HESI case study

What health promotion question is most important for the nurse to ask the client? "Do you tend to bite or chew your nails?" "What do you use to cleanse your skin?" "How often do you use a tanning booth?" "Do you use a hair coloring product?"

"How often do you use a tanning booth?"

What further assessment technique would the nurse consider to confirm a problem with the gallbladder? Murphy's signIl liopsoas test Obturator test The Alvarado score

Murphy's sign Pain is elicited when gallbladder inflammation is present.

The nurse observes that there are numerous blackheads around client's chin and nose. What action should the nurse take in response to this finding?

Note any pustules or nodules

The nurse tests cranial nerve XI by asking the client to shrug his or her shoulders. What action should the nurse perform?

Apply resistance to the client's shoulders. The nurse should test the client's ability to shrug his or her shoulders against resistance with equal strength bilaterally.

What action should the nurse perform if rapid facial flushing is observed?

Ask about any feelings of anxiety.

What follow-up question by the nurse provides the best information about the client's claudication distance? "When did you first notice you were having leg cramps?" "How long have you been walking this same distance?" "On a 10-point scale, how would you rank your pain?" "How far do you walk before the leg cramps begin?" Submit

"How far do you walk before the leg cramps begin?" Claudication distance refers to the distance, such as blocks walked, or stairs climbed, that produces pain.

Client reports feeling pressure on his chest sometimes, stating that it stops when he sits down and rests. He also tells the nurse that he feels tired a lot lately. He states, "I guess that's part of growing older." To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the nurse ask him?

"At what time of day do you feel most fatigued?" Fatigue related to stress or depression may be worse in the morning or may be present all day, while fatigue related to decreased cardiac output may worsen in the evening. Client tells the nurse that he gets progressively more fatigued throughout the day.

The nurse has already observed that both of the clients' feet are cool and pale. What questions should the nurse ask the client to obtain additional supporting data?

"Do your toes or toenails ever look blue?" "Do you feel tingling, numbness, or burning sensations in your legs and feet?"

The nurse observes multiple moles on the client's skin. What question is most important to ask the client?

"Have any of your moles changed in size or appearance?" Because a change in the size or appearance of a mole is a danger sign for skin cancer and warrants a referral for medical evaluation, this is the most important question for the nurse to ask.

To learn about any history of intermittent claudication, what question should the nurse ask? "When you first stand up, do you feel dizzy or light-headed?" "Can you feel your pulse pounding after vigorous activity?" "Have you experienced any leg cramping or pain in your legs?" "Do you have an urge to move your legs a lot during the night?" Submit

"Have you experienced any leg cramping or pain in your legs?" Claudication is cramp-like calf pain, associated with diminished blood supply to the leg muscles. When this pain occurs only at specific times, such as during activities, it is referred to as intermittent claudication.

The nurse questions the client about possible causes of fluid volume deficit. What are the priority questions that the nurse should ask? (Select all that apply. One, some, or all options may be correct.) "Have you experienced nausea or vomiting recently?" "How much water are you drinking per day?" "Have you experienced diarrhea recently?" "Are you feeling dizzy?" "Is your mouth dry?"

"Have you experienced nausea or vomiting recently?" "How much water are you drinking per day?" "Have you experienced diarrhea recently?"

The client reports that his son sleeps sometimes until noon in the summer. He often stays up very late at night. Which response by the nurse is accurate? "Sleeping until noon is unhealthy for anyone no matter what age they are." "Many adolescents start developing this type of pattern as they develop independence." "I would try enforcing a strict, earlier bedtime routine so he does not sleep so late." "Excessive daytime sleepiness is symptomatic of the sleep disorder narcolepsy." Submit Previous Section

"Many adolescents start developing this type of pattern as they develop independence." This is particularly common during the summer months, if there are no school obligations to make them rise earlier.

During the follow-up visit, the client states, "I'm a little worried about my older son. He is 16 and seems to be sleeping too much. If this keeps up, I'm afraid that I may have trouble sleeping due to the stress again!" Which initial response by the nurse is best? "Please tell me about your son's sleep habits." "Don't worry, it is normal for teenagers to sleep a lot. You are just hypersensitive about sleep." "Teens typically do not need as much sleep as adults, so there must be a problem." "You seem overly concerned about your son. You need to worry about yourself now."

"Please tell me about your son's sleep habits." This information is needed to determine what is "too much." The response also invites the client to continue expressing concerns.

After client stops coughing, the nurse continues the interview. To assess the client's history related to dyspnea on exertion (DOE), what question should the nurse ask? "Do you become short of breath while lying flat?" "What activities cause you to feel short of breath?" "How frequently do you experience difficulty breathing?" "Are you having trouble catching your breath right now?"

"What activities cause you to feel short of breath?" The type of activity and the amount of physical effort should elicit information about the client's DOE.

Which question that the client ask the nurse, indicate that more teaching needs to be done?

"Will I receive a diuretic for the swelling?" This answer requires more teaching because diuretics should not be used to help lymphedema. They draw off water in the interstitial spaces, and once the diuretic is out of the system, it will pull more water into the affected area.

While reviewing discharge paperwork with the client, he states, "I really need to get back to work. All of this has caused a great strain on my job." How should the nurse respond to the client's statement? "Right now you need to concentrate on getting better." "I will have a social worker call you to see if you need any financial help." "You seem concerned about missing work and the pressures of your job." "I know what you mean. I couldn't afford to miss very much work either." Submit

"You seem concerned about missing work and the pressures of your job." The nurse is therapeutically restating the client's feelings, which is likely to encourage the client to continue the conversation.

The client reports that a few years ago he took temazepam for sleep and it worked for a while. He asks if he can have a new prescription. Which response by the nurse is most appropriate? "You may resume the temazepam if you still have the prescription." "You really don't need a medication like this, do you?" "You should be reevaluated by a healthcare provider before resuming this medication." "Absolutely not! This type of drug is very addictive and should be avoided whenever possible."

"You should be reevaluated by a healthcare provider before resuming this medication." The client should always be reevaluated before resuming any medication. A new prescription needs to be filled if indicated. Continued evaluation is also needed if temazepam is used for more than 2 weeks or in high doses, both of which put the client at risk for tolerance and/or physical dependence.

The nurse obtains a health history that reveals the client is worried about the pressures of a growing family and a new job. The client has been unable to maintain his normal exercise routine and has gained 15 lbs. (6.8 kg) in the last 6 months. The client admits he frequently smokes when he cannot sleep. His spouse, who has accompanied on the visit to the clinic, states that her husband's snoring has worsened in both frequency and noise level over the last 3 months. The client has even resorted to taking one of his spouse's diazepam tablets before bedtime. How does the nurse respond to the client's disclosure that he used his spouse's diazepam tablets to help him sleep? "Do not take more of the diazepam than is prescribed." "You should not take someone else's prescription." "Let me note that in your chart." "Anti-anxiety medication can help you relax enough to fall asleep."

"You should not take someone else's prescription." This response directly addresses the issue without being condemning. It can be dangerous for clients to take someone else's prescription, due to the risk of contraindications or drug interactions.

The client's spouse inquires about the newly prescribed medication, which is a brand-name drug, and states, "When we fill this prescription, I hope we can get this in a generic form. Maybe it won't be as expensive." How should the nurse respond? "You shouldn't worry about the cost of medications right now. You should purchase whatever your spouse needs to get well." "Brand-name medications are generally more effective than generic drugs, so they are worth the additional cost." "Brand-name drugs and generic drugs are bioequivalent, so the client can safely take either form of the medication." "Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand-name drug."

"Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand-name drug." Although brand-name and generic medications are bioequivalent, the inert ingredients may vary, sometimes resulting in differing effects. Therefore, the healthcare provider must approve the substitution of a generic form for a prescribed brand-name medication.

Earlier, the client reported regular unilateral left knee pain. The nurse palpates the client's left knee and notes the presence of a small amount of swelling. Which sign should the nurse attempt to elicit? Bulge (fluid) sign. Battle sign. Allis sign. Tinel sign.

***Bulge (fluid) sign.*** A positive sign of fluid on the knee is found when very small amounts of fluid move across the joint. When swelling is palpated, the nurse may attempt to elicit this sign. Battle sign. A positive Battle sign is found in persons with certain brain injuries. Allis sign. A positive Allis sign may indicate hip dislocation in an infant. Tinel sign. A positive Tinel sign is found with carpal tunnel syndrome.

The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action? Select all that apply The presence of striae on the right and left lower quadrants. A protruberant shaped abdomen. A midline, inverted umbilicus. A large amount of pigmented nevi scattered accross the abdomen. Marked visible peristalsis.

-A protruberant shaped abdomen. A protruberant shaped abdomen indicates abdominal distention. -Marked visible peristalsis. Visible peristalsis may be seen in very thin people. Especially in the presence of a protruberant abdomen may indicate a bowl obstruction and would require the nurse to follow up.

While percussing the abdomen, the nurse hears tympany over most of the abdomen but notes a duller sound when percussing at the right costal margin. Which is the most appropriate follow up action the nurse should implement? (Select all that apply.) Note this location as the border of the liver. Ask the client if she is constipated. Document the presence of splenic dullness. Document the finding as normal. Make a note to notify the HCP of the findings.

-Note this location as the border of the liver. Dullness upon percussion is generally heard over organs, such as the liver. The right costal margin is the location at which abdominal tympany should change to dullness over the liver border. This location is useful in determining liver span. -Document the finding as normal. The right costal margin is the location at which abdominal tympany should change to dullness over the liver border.

While inspecting the client's abdomen, the nurse notes the following: Abdomen is rounded and symmetrical. No bulges or masses seen. Umbilicus is inverted and midline. No rashes noted. Silvery white striae noted on the lower abdomen. A four centimeter scar is noted on the right lower quadrant of the abdomen. No visible pulsations or perstalsis noted. No hair noted. What statements from the client's focused interview correlate to the abnormal inspection findings? (Select all that apply.) Daily bowel movements Past surgical history of an appendectomy. Nausea and vomiting. Food intolerance to spicy foods. Change in body mass index (BMI). Submit Previous Section

-Past surgical history of an appendectomy. Appendectomy scars will usually be present in the right lower quadrant. -Change in body mass index (BMI). Striae are the result of a change in skin pigmentation that occurs following significant stretching of the elastic fibers of the skin on the abdomen. Causes can include obesity or pregnancy.

The nurse is assessing for costo-vertebral angle (CVA) tenderness. Which statements best describe this percussion assessment? (Select all that apply.) It is normal for a client to feel pain with this percussion assessment. Percussion is completed over the 12th rib in the back bilaterally. Place one hand over the flank area and hit the hand with the ulnar side of the fist. Client will need to take a deep breath prior to completion of the percussion technique. Technique is used to assess for inflamation of the kidney.

-Percussion is completed over the 12th rib in the back bilaterally. -Place one hand over the flank area and hit the hand with the ulnar side of the fist. -Technique is used to assess for inflamation of the kidney.

After completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 6 mg by intravenous push every 6 hours. Morphine is available in 10 mg/1 mL vials. How many mL should the nurse administer?

0.6

The next day, the nurse initiates the feeding prescribed by the HCP. The prescription is for the formula to infuse at 30 mL/hour. The physician has ordered it to be "half-strength" (50/50 water and formula). The formula is available in 8-ounce cans. The nurse is preparing enough formula for 12 hours. How many cans of formula will the nurse need?

1

The nurse observes client for outward signs of hypoxemia. The nurse notes that his skin color to be normal and that his nail beds are pink. What additional assessment will provide supporting data related to hypoxemia? Select all that apply Color of palms and soles. Evidence of lower leg swelling. Presence and location of chest hair. Multiple thoracic hemangiomas. Shape of the fingers and fingertips. Submit Previous Section

1) Color of palms and soles. Cyanosis, a bluish tinge typically signifying tissue hypoxia, is most evident in the nail beds, lips, and buccal mucosa. In dark-skinned persons, cyanosis may also be evident in the palms of the hands and the soles of the feet. 2) Shape of the fingers and fingertips. Nail clubbing is associated with chronic hypoxemia. It develops in stages including fluctuation and softening of the nail, loss of the normal angle, increased convexity of the nail fold, thickening of the distal end of the finger, and a shiny aspect and striation of the nail.

The nurse places client supine in a Semi-Fowler's position. To inspect for jugular vein distention, what actions should the nurse take? Place the client in a Fowler's position with his head straight. Lower the head of the bed while observing the neck veins. Remove the client's pillow and turn his head away slightly. Assist the client to lean forward at a 30 to 45° angle. Place the client in a Semi-Fowler's position.

1) Remove the client's pillow and turn his head away slightly. Turning the client's head slightly away allows the nurse to best measure the height of any jugular vein pulsations. 2) Place the client in a Semi-Fowler's position. Raising the head of the bed to a 30 to 45° angle is the first step when assessing jugular vein distention.

To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.) 1. Auscultation. 2. Inspection. 3. Palpation. 4. Percussion.

1) inspection 2) auscultation 3) percussion 4) palpation The correct order of the assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation of the abdomen may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure an accurate assessment of peristalsis.

The nurse is preparing to test the client's pupillary response. (Place the steps in order from 1 to 6 from top to bottom.)

1. Have the client close both eyes and dim the lights in the room. 2. Bring a penlight in from the side of the client's head. 3. Have the client open both eyes. 4. Shine the light in the eye being tested as soon as the client opens his or her eyes. 5. Observe the eye being tested for constriction. 6. Note whether the other pupil constricts while the light shines into the eye being tested.

Before giving the initial dose of pain medication or antibiotic, which action should the nurse take first? Ask the client what liquid he would like to drink to swallow the pill. Teach the client the side effects of the medication. Ask the client if he is aware of any allergies to medications. Instruct the client to sit upright to swallow the medication.

Ask the client if he is aware of any allergies to medications.

Client was prescribed morphine IV 0.05mg/kg/dose now and every 2 hours as needed for moderate to severe pain. Morphine is available in parenteral dose of 2mg/mL. How much medication should the nurse draw up for administration? (Patient weighs 140 lbs on admission). (Enter the numerical value only. If rounding is necessary, round to the nearest tenth.)

1.6 mL

To determine the grade of the murmur, what action should the nurse take?

Note how easily the murmur is heard by gradually lifting the stethoscope. Murmurs are graded based on the intensity of the sound, ranging from a grade 1 murmur, which is barely audible, to a grade 6 murmur, which can be heard with the stethoscope lifted off the chest wall.

The antitussive medication label reads, "Take 2 teaspoonfuls every 4 hours as needed." The nurse gives the client some mL medication cups and teaches the client and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured?

10

The nurse prepares to administer diphenhydramine 50 mg orally. The tablet is supplied in a 25 mg dose. How many tablets should the nurse give? (Enter numerical value only. If rounding is necessary, round to the tenth.)

2

The nurse weighs client, who is 132 pounds. The nurse records the weight in kilograms. How many kilograms does he weigh? (Enter numerical value only. If rounding is necessary, round to the whole number.)

60

The client asks the nurse approximately how many lymph nodes an adult has. Which is the most factual answer the nurse can provide to the client about lymph nodes?

650. A healthy adult has approximately 600 to 700 lymph nodes.

The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup. Which is the best explanation for the HCP's prescription? A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. A CBC is obtained so that the HCP can rule out the possibility of appendicitis. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment

A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, trauma

The HCP determines that the client has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid antitussive. The client's mother questions the prescription for the antibiotic. The HCP states that the child should "Take 2 pills for the first dose, followed by 1 pill every 12 hours." The mother asks the nurse if this seems right. How should the nurse respond? This sounds like a mistake. Take 1 pill with each dose. Two pills every 12 hours is the usual dose. Let me contact the pharmacist to clarify these directions. A large first dose allows the medication to start working faster. Submit

A large first dose allows the medication to start working faster. A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.

After further examination and testing by the HCP, the client is referred to a surgeon and is scheduled for a uvulopalatopharyngoplasty (UPPP), the removal of tissue in the throat to treat the obstructive sleep apnea. The client is admitted to the hospital, and an apnea monitor is prescribed. The charge nurse should assign the client to which room? A semi-private room with another client. A designated isolation room with a double door. A private room near the nursing station and report room. A private room at the end of the hall. Submit Previous Section

A private room near the nursing station and report room. Due to the increased monitoring necessitated by the client's sleep apnea, the client's room should be near the nursing station.

When eliciting data about possible neurological problems, what information should the nurse obtain from the client? (Select all that apply. One, some, or all options may be correct.) Any difficulty speaking or swallowing. Ever hear voices that no one else hears. Headache frequency and location. Any numbness,tingling, or weakness of extremities. Did the head hit the floor with syncopal episode.

Any difficulty speaking or swallowing. Headache frequency and location. Any numbness,tingling, or weakness of extremities. Did the head hit the floor with syncopal episode. Rationale: psychosis, delusions, and hallucinations, which is are addressed in a psychosocial rather than a neurological assessment.

When the nurse demonstrates the use of the feeding equipment, the client's spouse looks away. The nurse observes the spouse crying. Which action should the nurse implement? Continue with the demonstration of the equipment while allowing the spouse time to control his emotions. Reassure the spouse that management of the feeding equipment can be easily mastered with some practice. Stop the demonstration and leave the room until the spouse states he is ready to continue with the session. Acknowledge the stressful nature of the situation and ask the spouse if he is ready to continue.

Acknowledge the stressful nature of the situation and ask the spouse if he is ready to continue. This is a therapeutic response, offering support and allowing the spouse to feel in control of the situation.

The client gradually weakens and is admitted to the medical unit. The healthcare provider (HCP) recommends the insertion of a feeding tube by means of a percutaneous esophageal gastrostomy (PEG). The client signs the consent form, and the procedure is scheduled for the next day. That evening, the nurse notes that the client's medical record contains an advance directive requesting no resuscitation (DNR) in the event of a cardiopulmonary arrest, which is confirmed in the prescriptions written by the HCP. While the nurse is conversing with the client and spouse, they both confirm that no heroic measures are to be implemented. What action should the nurse take to ensure the client's DNR status? Meet privately with client's spouse to discuss that a feeding tube can be considered a heroic means of keeping a client alive. Inform the client that the instructions in the advance directive cannot be followed if she receives a feeding tube. Ask the client why she wants to have a feeding tube inserted since she has an advance directive requesting no heroic measures. Advise the client that the healthcare provider will document in the medical record the do not resuscitate decision and any exception

Advise the client that the healthcare provider will document in the medical record the do not resuscitate decision and any exceptions. An order in the client's medical record is entered by the healthcare provider to inform the healthcare team how to respond when a resuscitation scenario happens. There may be an identifying wrist bracelet indicating that resuscitation status or form on the chart.

The nurse asks client about his history of cigarette smoking. He tells the nurse that he smoked two packs of cigarettes per day for more than 40 years, but then he quit smoking 10 years ago. He then looks away and remarks that he is very fatigued from answering all the interview questions. How should the nurse respond? Continue the interview and assessment, avoiding further questions related to cigarette smoking. Restrict visitors so that the client can rest, and return later to complete the interview and assessment. Advise the client to rest in the bed while the nurse performs a physical assessment of the client. Document that the physical assessment could not be performed because of the client's level of fatigue.

Advise the client to rest in the bed while the nurse performs a physical assessment of the client. Since it is important to obtain as much assessment data as possible to ensure the client's physiologic stability, the nurse should continue with the client's physical assessment but allow the client to rest by curtailing the interview.

During the interview, the nurse observes the client's speech patterns. The client seems to have difficulty choosing and forming some words. What action should the nurse take? Affirm the client's difficulty and ask about when this first started. Fill in the conversation with the words the client is attempting to say. Offer to complete the interview at a later time after the client has rested. Allow the client to respond and ignore any difficulty to avoid embarrassment.

Affirm the client's difficulty and ask about when this first started. This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client's symptoms.

Which statement is the best description of the sleep pattern for a normal adult? Sleep problems decrease in middle-aged adults. Most of the sleep cycle is made up of rapid eye movement (REM) sleep. An adult has four to six sleep cycles, each with non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, during a normal night's sleep. A middle-aged adult requires less sleep than an elderly adult. Submit

An adult has four to six sleep cycles, each with non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, during a normal night's sleep. Every 90 minutes REM sleep recurs. When a sleeper awakens at any stage of the sleep cycle it must start again at N1.

The nurse expresses concern regarding the client's bruise. What action should the nurse take to initiate the abuse assessment?

Ask the client if someone else caused the injuries. It is appropriate to first ask a direct question to elicit information about possible abuse. If the client is reluctant to respond to a direct question about possible abuse, the nurse may then choose to use an indirect approach to encourage further verbalization.

To determine what happened to the client prior to the loss of consciousness, the nurse should obtain what information from the client? Select all that apply Ask the client to stick out their tongue. Ask the client if they ever feel lightheaded or dizzy. Ask the client if they have any problems with smell. Ask the client if the dizziness occurs when they change positions. Ask the client if they felt like the room was suddenly spinning before the fell.

Ask the client if they ever feel lightheaded or dizzy. Ask the client if the dizziness occurs when they change positions. Ask the client if they felt like the room was suddenly spinning before the fell.

After the nurse reports the findings to the HCP, the client is scheduled for immediate removal of her gallbladder. Following surgery, the client returns to her room. During the nursing assessment on the first postoperative day, the client seems anxious and tells the nurse that she is in a lot of pain. In response to the client's statement that she is in a lot of pain, what action should the nurse take first? Explain to the client that post-operative pain is normal. Ask the client to describe her pain location and intensity. Ask the client if she has passed gas since surgery. Assess the client's heart rate and blood pressure. Submit Previous Section

Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality.

To assess muscle strength in the foot, the nurse asks the client to dorsiflex the foot. The client points the toes downward. What action should the nurse take next? Apply gentle pressure over the client's toes. Place one hand on the bottom of the client's foot. Ask the client to flex the foot upward. Help the client evert and then invert their foot.

Ask the client to flex the foot upward. Dorsiflexion involves pointing the toes upward, so the nurse should use language the client can understand to first position the foot correctly.

Client asks to sit on the side of the bed. After assisting him to this position, the nurse continues the assessment, facing client's back and placing both hands on his posterolateral chest at the level of T9. To assess chest excursion, what should the nurse do next? Ask the client to inhale deeply. Encourage the client to cough. Tap lightly over the middle finger. Instruct the client to hold his breath. Submit

Ask the client to inhale deeply. To assess chest excursion, the nurse observes the movement of the hands placed on the lower posterior thorax as the client inhales.

While assessing the spine, the nurse assesses the client's low back pain further. Which action will help determine the cause of the client's pain? Ask the client to lie supine and raise one leg, keeping it straight. Watch the client while they stand upright and slowly squats down. Instruct the client to balance on one foot with their arms at their sides. Help the client to a prone position, rotating both legs inward.

Ask the client to lie supine and raise one leg, keeping it straight. If sciatic pain occurs when raising a straight leg, the nurse should suspect the presence of a herniated disc.

To begin the assessment for vocal fremitus, what should the nurse do? Place one hand over each scapula. Locate the posterior axillary line. Assist the client to lie back in the bed. Ask the client to repeat a phrase aloud.

Ask the client to repeat a phrase aloud. Vocal fremitus is assessed by palpating for vibrations on the thoracic wall beginning at the apex and ending at the base of the lungs while the client repeats a word or phrase aloud.

Nursing Process: Assessment of Motor Function: The nurse continues the neurological assessment by assessing motor function. Since the client is lying in bed, which action should the nurse take to observe small muscle movement and coordination? Use a reflex hammer to elicit arm movement. Assist the client to sit on the side of the bed. Stroke the lateral sides of the sole of each foot. Ask the client to touch the thumb to each finger.

Ask the client to touch the thumb to each finger. While the client touches her thumb to each finger, the nurse observes for smooth, coordinated movement of the small muscles.

The client is seen in the surgeon's office for a follow-up evaluation 2 weeks after surgery. Which is the most effective method to evaluate improvement of the client's OSA? Ask the client how he has been sleeping for the last 2 weeks since surgery. Obtain current vital signs, including a pulse oximetry reading. Ask the client's spouse about the client's snoring and respiratory pattern at night. Assess lung sounds in the sitting and supine position. Submit Previous Section

Ask the client's spouse about the client's snoring and respiratory pattern at night. Speaking with the client's spouse about her observations regarding snoring, respiratory rate, and sleep pattern corroborates the nursing problem of ineffective respiratory patterns.

Of the client problems addressed on the nursing plan of care, which is the highest priority problem? Aspiration. Skin breakdown. Altered nutrition. Self-care deficit.

Aspiration. Aspiration, or the entry of foreign substances such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client's plan of care.

The nurse next palpates the axillary nodes. Using the pads of the fingers, the nurse moves over the node area in a circular motion. Two nodes are palpable and are easily movable. What actions should the nurse take in response to this finding? Document the assessment as within normal limits in the assessment record. Note the amount of pressure needed to occlude the nodes and prevent movement. Apply pressure more firmly until all the nodes in the area can be palpated. Assess the nodes further for consistency and any palpable matting. Ask the client if any there is any tenderness upon palpation of the nodes. Submit

Assess the nodes further for consistency and any palpable matting. Ask the client if any there is any tenderness upon palpation of the nodes.

The nurse is observing a student nurse perform a peripheral assessment on the client. Which action requires the nurse to intervene? Palpating bilateral pedal pulses. Assessing the capillary refill in the great toe. Assessing the Homan's sign in bilateral extremities. Applying light pressure in ankles to determine edema.

Assessing the Homan's sign in bilateral extremities. Homan's sign is "not a reliable indicator" and is a potentially dangerous method because of possible clot dislodgment.

Later that day, the UAP reports a change in client's vital signs, with an increase in temperature from 101° F to 103° (38.3 oC to 39.4oC) F. The UAP reports the information to the nurse, who goes to the client's room to assess the client. The nurse observes sputum in a tissue left at the bedside. The sputum is thick and purulent. What assessment should the nurse perform? Palpate for changes in vocal fremitus. Auscultate breath sounds bilaterally. Observe the thoracic diameter ratio. Percuss for diaphragmatic excursion.

Auscultate breath sounds bilaterally. Thick, purulent sputum is a sign of an infectious process. The nurse should auscultate the client's lungs to determine if a change from the previous assessment has occurred, reflecting a worsening of the client's condition.

Client denies any angina. After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate?

Auscultate the apical pulse for 1 minute. Auscultation of the apical pulse is the most accurate method to determine heart rate and rhythm because the nurse is listening directly over the heart, rather than depending on the transmission of the pulse to a distal site, such as the radial pulse site.

The nurse hears vesicular breath sounds when auscultating over the upper and middle lung fields posteriorly. What action should the nurse take? Encourage the client to cough and then auscultate these lung fields again. Stop the assessment immediately and administer a PRN dose of an inhaler. Continue the assessment after documenting the location of these abnormal sounds. Auscultate the lower lung fields to determine the presence of any adventitious sounds.

Auscultate the lower lung fields to determine the presence of any adventitious sounds. Since vesicular breath sounds are normally heard in the peripheral lung fields, the nurse should continue to auscultate the remaining lung fields, listening for any abnormal, or adventitious, sounds.

While client rests, the nurse continues the physical assessment. The nurse observes the appearance of his thorax and notes that the ratio of his anteroposterior and transverse chest diameters is 1:1. How should this finding be documented? Within normal limits. Funnel chest. Barrel chest. Thoracic scoliosis. Submit

Barrel chest. A barrel chest is the description for an increased anteroposterior (AP) to transverse ratio. The normal ratio is 1:2, so a 1:1 ratio represents an increased ratio.

he speech therapist is consulted to evaluate the client. The therapist determines that dysphagia precautions are needed and writes a prescription for pureed diet and honey-thickened liquids. The nurse and the unlicensed assistive personnel (UAP) enter the client's room shortly after the therapist's evaluation is completed. The UAP prepares to assist client with the noon meal and with personal care. Which instruction should the nurse provide to the UAP? Keep the client in a Sim's position while bathing and also while assisting with her meal. Help feed the client first and then allow the client to rest with the head of the bed lowered for 1 hour before bathing. Provide assistance with the meal then lower the head of the bed to bathe the client and change the bed linens. Bathe the client first and then place the client in a high Fowler's position during and after the meal.

Bathe the client first and then place the client in a high Fowler's position during and after the meal. The head of the bed should be elevated to a high Fowler's position while the client with dysphagia is eating, and it should be kept elevated for at least 1 hour following the meal to reduce the risk for aspiration.

When reporting to the supervisor, the nurse tells the supervisor that the client's pressure sore developed because the client had a stone in her shoe that she couldn't feel. How should the nurse summarize this initial report by the client?

Bilateral paresthesia in the feet. Paresthesia refers to abnormal sensation, such as numbness or tingling, so this is the best terminology to describe the client's report of numbness and lack of feeling in her feet.

Based on the client's recent history of loss of consciousness and falling, what additional assessment takes priority? Pedal pulse volume. Deep tendon reflexes. Two-point discrimination. Blood pressure and heart rate and rhythm.

Blood pressure and heart rate and rhythm. Hypotension and bradycardia can cause a loss of consciousness. Bradycardia may also be a sign of increased intracranial pressure.If the client has hypertension, it places the client at increased risk for a hemorrhagic stroke. If the client has cardiac irregularity, such as atrial fibrillation, the client should be evaluated and treated to prevent an embolic stroke.

The nurse next plans to determine the client's ankle brachial index. What equipment should the nurse obtain prior to completing this measurement?

Blood pressure cuff. A blood pressure cuff along with a Doppler probe is used to obtain the systolic blood pressure in the lower extremity. To calculate the ankle brachial index (ABI), this value is compare

When auscultating breath sounds, the nurse should demonstrate and ask the child to perform which action? Hold their breath for fifteen seconds while auscultating. Extend their arm to observe the color of the nailbeds. Cough deeply after each breath. Breathe deeply through the mouth.

Breathe deeply through the mouth. The child should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.

While assessing the client's nails, it is most important for the nurse to follow up on which assessment finding?

Brittle nail surface. Brittle or ridged nail surfaces may be the result of iron deficiency. This finding warrants follow-up assessment related to the client's nutritional status.

The nurse instructs the client to increase his intake of which foods to prevent a decrease in bone density? Any food that is high in calories. Foods that are rich in vitamin C. Calcium rich foods. High fiber foods.

Calcium rich foods. Calcium must be deposited in the bone to increase bone density.

Which assessment provides the most useful data related to the client's current nutritional status? Calculate the client's body mass index (BMI). Ask the client about any recent changes in his appetite. Assist the client to complete a 24-hour diet recall. Check the client's serum hemoglobin A1c level. Submit

Calculate the client's body mass index (BMI). Body mass index (BMI) is a marker of the client's optimal weight for his height and provides important data related to the client's current nutritional status.

Shortly after completing the admission assessment, the nurse returns to the client's room and notes a change in condition. The client has slurred speech. Further assessment reveals that the client is no longer able to move either the left arm or leg, and within a few minutes no longer responds to the nurse's questions. The nurse quickly assesses the client's level of consciousness by checking for a response to varying stimuli. What stimuli should the nurse use first to attempt to elicit a response from the client? Call the client's name. Lightly touch the client's arm. Pinch the client's trapezius muscle. Vigorously shake the client's shoulder. Submit

Call the client's name. The nurse should begin with the least amount of stimulus and progress to the greatest amount of stimulus, observing the amount of stimulus needed to evoke a response by the client.

A week later, the nurse notes a change in the client's weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports back to the nurse that the client weighs 110 lbs (50 kg), is 67 in (170.2 cm) tall, and is consuming 700 calories per day. How should the nurse explain the results of the calorie count to the client and the spouse? Client is taking in more calories than needed and may gain weight. Client is consuming an adequate number of calories for her height. Calorie consumption is insufficient and will result in weight loss. Since activity is limited, caloric intake is sufficient to meet needs.

Calorie consumption is insufficient and will result in weight loss. An average adult requires 20 to 35 calories per kilogram per day. The client, who weighs 110 pounds (50 kg), needs a minimum of 1000 calories per day to maintain her current weight.

The nurse questions the client if there are any foods she cannot eat. The client reports that she doesn't tolerate spicy foods. What questions should the nurse ask next? (Select all that apply.) Can you identify which spicy foods cause a problem? How often do you eat spicy foods? What happens when you eat spicy foods? Does anyone in your family have problems with spicy food? Why do you think spicy foods are a problem? Submit

Can you identify which spicy foods cause a problem? What happens when you eat spicy foods?

What is the best way for the client to identify the affected or at risk extremity?

Carry a wallet card or ID bracelet that identifies the affected extremity. This is the most effective way to remind healthcare professionals to avoid venipunctures, blood pressures, and fingersticks on the affected extremity.

The nurse's further assessment confirms the finding of an S3 heart sound. After determining that the client has an S3 heart sound, the nurse reassesses the client. What assessment should the nurse include?

Check for jugular vein distention. An S3 heart sound may be an early indicator of the onset of heart failure, so the nurse should assess the client for other signs of heart failure, including jugular vein distention.

Based on the client's assessment, what condition would the nurse suspect? Appendicitis Liver failure Cholecystitis Ureteral colic

Cholecystitis Characterized by right upper quadrant pain, nausea, and vomiting after eating.

The nurse observes that the dressing around the PEG tube insertion site is intact, with a small amount of serosanguineous drainage. Which action should the nurse implement? Apply a pressure dressing over the initial dressing. Circle the amount of drainage on the initial dressing. Remove the dressing and apply a new sterile dressing. Notify the HCP of the finding immediately.

Circle the amount of drainage on the initial dressing. Circling this small amount of drainage allows the nurse to compare any changes in the amount of drainage at a later time.

Which statements reflect potential expected outcomes for the nursing problem "disturbed sleep pattern related to stress from new job"? (Select all that apply.) Client can identify ways to relieve stress during the day and before bedtime. Client will report a 50% decrease in night awakenings within 1 week. Client establishes bedtime rituals, such as having a glass of wine before bed. Client maintains a sleep/wake log for 1 month. Client reports fewer incidences of dozing off during the day. Submit

Client can identify ways to relieve stress during the day and before bedtime. Client will report a 50% decrease in night awakenings within 1 week. Client reports fewer incidences of dozing off during the day.

The nurse considers which information to be subjective data? (Select all that apply.) Client states he only sleeps 3 or 4 hours per night. The client displays irritable behavior in front of the nurse, and yells at his wife when she points out he is irritable. The client has gained an additional five pounds. The client reports that the CPAP apparatus is uncomfortable. The client's wife states he has been yawning a lot at home.

Client states he only sleeps 3 or 4 hours per night. The client reports that the CPAP apparatus is uncomfortable. The client's wife states he has been yawning a lot at home.

The nurse is documenting the client's vomitus. Which documentation should be included in the client's medical record? (Select all that apply.) Client vomited green with undigested food particles. Vomit without odor. Vomit is soft in consistency. Approximately 250ml of vomit was noted. Client vomited x 1 lasting approximately 2 minutes. Submit

Client vomited green with undigested food particles. Vomit without odor. Approximately 250ml of vomit was noted. Client vomited x 1 lasting approximately 2 minutes. Submit

Before notifying the healthcare provider of the data reported by the nutritionist, what information is most important for the nurse to obtain? Type of vitamin supplement the client is taking. Percent of diet composed of carbohydrates. Client's calculated body mass index. Daily fat gram intake by the client.

Client's calculated body mass index. The body mass index is calculated based on the client's height and weight and provides a picture of the client's current nutritional status regarding over- or undernutrition.

To promote sleep for a hospitalized client, which intervention should the nurse implement? Avoid performing the prescribed assessments every 4 hours during the night. Withhold the client's pain medication during the day to decrease napping episodes. Ensure that the client's room is kept completely dark during the night with no outside lighting. Close the door to the client's room whenever possible to decrease the noise level and light coming into the room. Submit

Close the door to the client's room whenever possible to decrease the noise level and light coming into the room. Reducing the amount of light and the noise of call lights, hallway traffic, and overhead paging are important nursing interventions to facilitate sleep for a hospitalized client.

The nurse places a telephone call to client's HCP, an internist. How should the nurse report the assessment data? Provide the internist with a full report of the initial assessment data obtained upon the client's admission only. Describe only the most current assessment data and the changes observed after the client's temperature increased. Compare the current assessment of the client to the data obtained during the admission assessment of the client. Notify the internist that the client's condition has changed, but avoid giving specific data until the internist assesses the client.

Compare the current assessment of the client to the data obtained during the admission assessment of the client. This report will provide the most complete client data, enabling the internist to make the most effective decisions about any changes needed in the client's medical care.

The nurse percusses the client's lungs bilaterally and notes dullness in the lung bases. What follow-up action should the nurse implement? Compare this finding with the location of the client's pneumonia seen on x-ray. Review the client's medical history to determine how long he has had emphysema. Document this normal assessment finding in the client's admission assessment. Notify the healthcare provider (HCP) that the client may have developed a pneumothorax. Submit Previous Section

Compare this finding with the location of the client's pneumonia seen on x-ray. Dullness upon percussion should be anticipated over areas of abnormal density, including pneumonia. The nurse can confirm this assessment finding by reviewing the location of the client's pneumonia found on x-ray.

Because of the client's history of knee pain and current report of low back pain, which nursing action is most useful in developing an initial plan of care for the client? Obtain a family medical history. Complete a functional assessment. Observe for callus formation. Ask about any recent weight gain.

Complete a functional assessment. A functional assessment provides information about the client's ability to function and includes such areas as mobility and self-care. It is most important to gather this information to determine the client's level of safety in basic functioning.

To measure capillary refill, the nurse must first perform which action? Count the radial pulse rate. Compress the nailbed of one finger until it blanches. Place child supine while counting respirations. Elevate the extremity to be assessed. Submit Previous Section

Compress the nailbed of one finger until it blanches. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.

Although there is no visible swelling, the client's legs are large, so the nurse gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the nurse take next?

Compress the tissue more firmly for 5 seconds. To effectively assess for pitting edema, the RN should firmly depress the tissue for 5 seconds, release, and measure any resultant indentation.

The client returns to the clinic in 1 week and reports that her arm seems to be more swollen and inflamed. To validate this subjective report, the nurse assesses for edema in the client's arm, noting that 2+ pitting edema is present. During her previous visit, the edema in the client's arm was recorded as 1+. What action should the nurse implement?

Confirm that the clients' arm is more swollen than previously. Pitting edema of 1+ indicates mild pitting, or pitting of 2 mm.Pitting edema of 2+ indicates moderate edema, or pitting of 4 mm. This finding reflects that Lourdes' arm is more swollen than during the previous assessment.

The nurse observes that the client's skin pigmentation is deeply tanned. To evaluate the client for pallor, what area should the nurse assess?

Conjunctivae

Upon further observation, the nurse describes the child's sputum as tenacious. To what does tenacious refer? Color. Odor. Frequency. Consistency. Submit Previous Section

Consistency. Sputum with a thick consistency may be described as tenacious (sticking together).

The nurse observes that the nail surface is slightly curved and the angle of the nail base is 160 degrees. What action should the nurse take in response to this finding?

Continue the assessment, noting the color of the nail surface. A slightly curved nail surface is a normal finding. The normal nail base angle is 160 degrees. Since these findings are within normal parameters, the nurse should continue the assessment by observing the color of the nail surface.

The nurse auscultates the client's abdomen. The nurse notes eight high-pitched gurgling sounds occurring at irregular intervals in the right lower abdomen over 15 seconds. What action should the nurse take next? Move to the right upper quadrant (RUQ) to hear the sounds more distinctly. Continue to auscultate for bowel sounds in the right lower quadrant. Change to the bell of the stethoscope to listen. Listen for 5 minutes before documenting the activity of the bowel sounds. Submit

Continue to auscultate for bowel sounds in the right lower quadrant. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Expected amount of bowel sounds is between 8-30 over 1 minute. Need to assess if bowel sounds are hypoactive, hyperactive, or normal.

The couple discusses the decision together, and the client decides to have the procedure as scheduled. The client is taken to the procedure room, where a PEG tube is inserted. The client returns to her room following the insertion of the PEG tube. An IV of lactated Ringer's solution is infusing at 50 mL/hour. No feeding solution is attached to the PEG tube. Which initial actions should the nurse implement? Connect the lactated Ringer's solution to the PEG tube at the prescribed rate. Immediately check the PEG placement upon arrival to the room. Call the dietary department and request immediate delivery of the feeding solution. Continue to monitor the client without infusing any solution through the PEG tube.

Continue to monitor the client without infusing any solution through the PEG tube. Feeding supplements are initiated when bowel sounds are present, which may be several hours after PEG tube insertion.

The client is able to move the upper extremities through complete range of motion. In documenting full range of motion of the upper extremities, the nurse is able to note the absence of which abnormality? Arthritis. Kyphosis. Flaccidity. Contracture.

Contracture. A contracture is a shortening of a muscle resulting in limited range of motion. Full range of motion indicates that no contractures are present.

When recording the change in the client's assessment findings, how should the nurse document the breath sounds? Adventitious breath sounds present in the middle and lower lungs bilaterally. Client's posterior breath sounds have worsened from the earlier assessment. Crackles heard bilaterally in the middle and lower lung fields posteriorly. Bilateral normal breath sounds heard only in the upper lobes posteriorly.

Crackles heard bilaterally in the middle and lower lung fields posteriorly. This documentation provides a clear, concise picture of the current assessment findings.

The nurse continues assessment of the client's upper extremities, palpating the brachial and radial pulses. Which approach is best for the nurse to use when assessing for capillary refill?

Depress the client's nailbed. To assess capillary refill, the RN first compresses the nailbed for 3 seconds. This results in blanching of the nailbed. The RN then measures the amount of time necessary for return of normal color of the nailbeds: the capillary refill time.

To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the oxygen saturation continuously. What action should the nurse implement prior to applying the sensor? Determine if child has a latex allergy. Clean the site with an iodine solution. Milk the capillary blood flow of the site. Apply gauze padding to protect the skin. Submit

Determine if child has a latex allergy. The disposable sensor pads may be made of latex. If they are, the nurse should confirm that the client does not have a latex sensitivity or allergy.

Over time, the continuous feeding is increased to 80 mL/hour. The nurse plans to reinforce the education provided to the client's spouse on how to manage the continuous feeding once discharged. What information is most important for the nurse to collect prior to providing discharge instructions on how to manage the continuous feedings? Ask about the couple's financial resources. Learn the client's anticipated discharge date. Determine if the client and her husband feel ready to learn the skill. Obtain information about the couple's educational level.

Determine if the client and her husband feel ready to learn the skill. Readiness to learn is essential for effective teaching. If the client's spouse expresses a lack of readiness to learn, other resources will have to be initiated before the client is discharged home.

Based on client's report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform next?

Determine if the client is currently experiencing any angina. Because the client has a history of chest discomfort, the nurse should first determine if the client is currently experiencing angina. Angina should be treated immediately to reduce the risk for myocardial damage.

Prior to applying a nasal cannula in the ED, which action is most important for the nurse to implement to ensure client safety? Ensure the bed is in low position and the call light is within reach. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. Use aseptic technique to prevent contamination when applying the cannula. Use petroleum gel on the cannula prongs to prevent irritating the nostrils.

Determine that all electrical equipment in the room is functioning correctly and is properly grounded. An electrical spark in the presence of oxygen can result in a serious fire.

After ensuring that arterial circulation is present, the nurse next assesses the client's wound. The wound the client mentioned is located on the plantar surface of her right foot, on the ball of the foot. The nurse observes that the wound bed is red and the tissue immediately surrounding the wound is inflamed. The nurse plans to document the stage of the wound. What additional action should the nurse take to correctly stage the wound?

Determine the depth of the wound and underlying tissue damage. Pressure ulcers are staged based on the depth of tissue damage to the dermis and underlying tissues, which may include underlying tendons, joint capsules, bones, and muscles.

The nurse teaches the client about diphenhydramine. Which information should the nurse include?

Diphenhydramine blocks the effect of the histamine response to reduce itching. This medication may cause drowsiness. Blurred vision or loss of balance are potentially serious side effects of this medication.

What additional focused interview questions will be important for the nurse to ask the client?Select all that apply Do you have a history of any abdominal conditions or surgeries? Have you experienced any weight gain or weight loss? Are you have any difficulty with urination? Are you experiencing any shortness of breath? Do you have any difficulty swallowing your food?

Do you have a history of any abdominal conditions or surgeries? Have you experienced any weight gain or weight loss?

For the nurse to learn about the client's bowel patterns, which questions are most important to ask the client? (Select all that apply.) Have you had any recent onset of heartburn? Do you take any prescription or over-the-counter medications? Have you had any changes in your bowel movements? What is the color and consistency of your bowel movements? How often do you have a bowel movement?

Do you take any prescription or over-the-counter medications? Have you had any changes in your bowel movements? What is the color and consistency of your bowel movements? How often do you have a bowel movement?

After establishing priorities, the nurse should take which action next in preventing the client from aspirating? Obtain a prescription for placement of enteral feeding tube. Elevate the head of bed to 45 degrees. Ensure client participates with PT and OT exercises for strengthening. Ensure the client's meals are pureed.

Elevate the head of bed to 45 degrees. Positioning the client with head of bed elevated will decrease the risk for aspiration.

In selecting a site to draw the blood sample, the nurse observes that the client's left forearm is swollen. The client reports that she cut her left forearm a week earlier and reminds the nurse that she had left breast surgery 2 years previously. The nurse draws the blood samples from the client's right arm and then proceeds to assess the client's lymph nodes. To palpate the epitrochlear node, the nurse palpates the area above and behind the medial condyle of the humerus but is unable to palpate the node. What action should the nurse take next?

Document that the node is not palpable. The epitrochlear lymph node is located in the groove between the biceps and triceps muscles, above the medial epicondyle of the humerus and is not normally palpable.

The nurse observes a pulsation low and laterally on the neck at the area of the left internal jugular vein but is unable to palpate the pulsation. What action should the nurse take?

Document the level at which the pulsation is observed. Venous pulsations are not palpable. The nurse should document the level at which the pulsations are observed.

The nurse observes areas of petechiae surrounding some of the bruises. How should the nurse respond to this finding?

Document the location of the bruises and petechiae. Petechiae are very small areas of hemorrhage from superficial capillaries. They may be the result of a bleeding or clotting problem as well as an indication of superficial trauma. The presence of bruising and petechiae on the client's abdomen causes the nurse to suspect that the client may be the victim of abuse.

The nurse observes symmetric chest excursion. What action should the nurse take? Ask the client to cough before repeating the assessment. Document the normal finding on the assessment record. Question the client about a recent history of rib fractures. Stop the assessment and measure the client's vital signs.

Document the normal finding on the assessment record. Because chest excursion should be symmetric, i.e., equal on both sides, the nurse should document this normal finding on the assessment record. No additional intervention is warranted. If the chest excursion is asymmetric, the nurse should take further action to determine the cause of the asymmetry.

When observing the client from the side, the nurse notices a slightly convex thoracic curve and a slightly concave lumbar curve. What action should the nurse take in response to these findings? Ask the client how long they have had a dowager's hump. Record these symptoms of osteoporosis in the client's chart. Document the normal spinal curvature on the assessment form. Note the client's poor posture as a possible cause of their back pain.

Document the normal spinal curvature on the assessment form. The curvatures observed are normal spinal curvatures. No action is needed other than documentation of the finding.

The client's feet are pale and cool to the touch, consistent with the weak, thready pedal pulses palpated by the nurse. The nurse uses a Doppler ultrasound stethoscope to confirm the presence of the dorsalis pedis pulses. After applying gel to the transducer and placing the transducer over the middle of the dorsal surface of the foot, the nurse hears a regular swooshing sound. What action should the nurse take?

Document the presence of the pulse heard by Doppler ultrasound. A regular swooshing sound indicates that a pulse is heard with the Doppler ultrasound stethoscope. This finding should be documented.

The nurse hears crackles bilaterally in the posterior lung bases. After the nurse completes auscultation of the breath sounds posteriorly, client states he is ready to swing his legs back on the bed and rest. The nurse assists the client to a Semi-Fowler's position, ensuring that his oxygen remains in place. With client resting in bed in this position, the nurse auscultates the breath sounds anteriorly. The nurse hears high-pitched musical squeaking sounds in the upper lobes during expiration. What action should the nurse take? Document the presence of wheezes in the upper lobes and complete the assessment. Immediately assist the client to lean forward to reduce his respiratory effort. Note the location of these bronchial breath sounds before completing the assessment. Wait to assess these heart sounds until the respiratory assessment is complete.

Document the presence of wheezes in the upper lobes and complete the assessment. Wheezes may be present in clients with chronic emphysema when diffuse airway obstruction occurs.

The client's surgery is completed without complications. After a 2-hour stay in the postanesthesia unit, he returns to his room. The next day, the nurse observes the following vital signs: The client's heart rate drops from 80 bpm to 65 bpm while alseep. Oxygen saturation remains greater than 95% with regular respirations of 16 to 20 per minute. Which action should the nurse implement? Document this expected finding. Contact the HCP about this abnormality. Recommend the application of a cardiac monitor. Increase vital sign monitoring from every 8 hours to every 4 hours. Submit

Document this expected finding. A decrease of up to 20 bpm during NREM sleep is considered a normal finding and a part of the body's circadian rhythm.

The nurse asks the client to stand and assesses for the presence of varicose veins. A large, dilated, torturous vein is observed, so the nurse checks for valve competence by placing one hand at the lower end of the vein, and then compressing the vein with the other hand 20 cm higher. While the client is standing, the nurse notes the absence of any dependent rubor. What action should the nurse take in response to this finding?

Document this finding on the physical assessment form. Dependent rubor, a deep blue-red color when the legs are in a dependent position, occurs with severe arterial insufficiency. The absence of dependent rubor is a normal assessment finding, and should be documented in the physical assessment but requires no further intervention.

The nurse places the diaphragm of the stethoscope at the second right intercostal space. In listening at this site, what should the nurse attempt to distinguish first?

S1 and S2 heart sounds. The nurse should begin by listening for the normal heart sounds, S1 and S2, before attempting to distinguish abnormal heart sounds, such as S3 and S4 or heart murmurs.

While assessing shoulder range of motion, the nurse notes the absence of crepitation with movement. What action should the nurse take in response to this finding? Document this normal finding in the assessment. Ask the client about their intake of dietary calcium. Record the degree of range-of-motion loss. Review the client's record for a history of arthritis.

Document this normal finding in the assessment. Crepitation, a grating or crunching sound heard with joint movement, is an abnormal finding. Absence of crepitation is normal and should be documented in the assessment.

The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. After auscultating the client's bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds. What action should the nurse take in response to this finding? Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding. Take the client's blood pressure and heart rate after the assessment. Call another nurse to verify the finding. Document this normal finding on the client's assessment record.

Document this normal finding on the client's assessment record. Abdominal vascular sounds are not normally heard, so the only action necessary is to record this normal finding on the assessment record.

The nurse is able to distinguish the LUB-dup sequence of S1 and S2 and continues the assessment. After inching the diaphragm of the stethoscope to the left second intercostal space, the nurse hears a split S2 during the client's inspiration. What action should the nurse take in response to this finding?

Document this normal finding on the initial assessment record. A split S2 is a normal finding that can be heard in some people as the result of the slightly asynchronous closing of the aortic and pulmonic valves. A split S2 is heard best during inspiration at the pulmonic site, the left second intercostal space.

Although crackles could be heard bilaterally during the posterior auscultation of the lung bases, the nurse does not hear any adventitious sounds in the lung bases during anterior auscultation. What action should the nurse take? Reassure the client that his lung sounds are improving. Document that the lung bases are clear upon auscultation. Document what was heard both anteriorly and posteriorly. Record only the location of the abnormal breath sounds.

Document what was heard both anteriorly and posteriorly. Although abnormal breath sounds in the lung bases may be heard only from the posterior, it is important to document the sounds heard both anteriorly and posteriorly.

The nurse questions the client about anaphylaxis. What client cues would indicate the presence of an anaphylactic reaction? (Select all that apply. One, some, or all options may be correct.) Drooling Shortness of breath Diaphoresis Flushed or pale skin Tremors or seizures

Drooling Shortness of breath Flushed or pale skin

What cues support the nurse's assessment regarding the client's fluid status?

Dry mucus membranes. Dry or cracked mucus membranes can be the result of inadequate hydration, which, like inelastic skin turgor, validates the initial finding of fluid volume deficit.

The nurse observes the client as the arms rest on a table with the hands at a 90° angle to the table and the thumbs up. The client turns the hands upward with the back of the hands flat on the table and then downward with the palms flat on the table. What action is the nurse observing?

Elbow supination and pronation. The client's movements demonstrate a normal degree of elbow supination and pronation.

To gather data about client's history of chest pain, how should the nurse begin?

Encourage the client to describe his chest discomfort. (ASK THIS BEFORE ASKING FREQUENCY) Because chest pain can manifest in a number of different ways, the nurse should begin by obtaining information related to any type of chest discomfort so that further responses by the client include information related to any type of chest discomfort he has experienced.

The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.) Encourage the client to empty her bladder. Place a pillow under the client's knees. Inquire where the client is experiencing pain. Instruct the client to place her hands over her head. Discuss the sequence of steps performed during the abdominal assessment.

Encourage the client to empty her bladder. Place a pillow under the client's knees. Inquire where the client is experiencing pain. Discuss the sequence of steps performed during the abdominal assessment.

The feedings are changed to bolus feeding 3 times a day. After receiving instruction, the client's spouse demonstrates correct ability to perform the skill and states that he feels he can handle this responsibility. The client is discharged home and home healthcare services are initiated. During a home visit, the nurse observes the client's spouse administering a bolus feeding to the client, who is sitting upright in the bed. After checking the residual volume, the spouse pours the feeding into the syringe attached to the feeding tube. The spouse then holds the syringe upright while the feeding enters the stomach. In observing this procedure, which action should the nurse take? Tell the spouse to lower the syringe to increase the speed of the feeding. Lower the head of the bed until the feeding has all drained from the syringe. Remind the spouse to check for residual again after the feeding has entered the stomach. Ensure that he flushes the tubing with water after the syringe is empty of feeding.

Ensure that he flushes the tubing with water after the syringe is empty of feeding. Flushing the syringe and tubing with water reduces the risk for obstruction of the tubing.

After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care? Determine the need for client teaching. Reassess for any changes. Implement the priority nursing actions. Establish goals and expected outcomes.

Establish goals and expected outcomes. After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.

At 0300 the client awakes and requests a sleeping pill, stating he needs to make sure to get some sleep the night before surgery. His prescriptions include zolpidem tartrate 5 mg PO at bedtime PRN for sleep. His last respiratory rate while sleeping was 12 with an oxygen saturation level of 89%. Current vital signs are P 80 beats/min, BP 120/70 mmHg, R 22 breaths/min, T 98.9° F, and oxygen saturation 95%. How should the nurse proceed? Administer the PRN medication. Administer oxygen via facemask. Explain the oxygen saturation level is too low and that it wouldn't be safe. Administer half of the prescribed dose.

Explain the oxygen saturation level is too low and that it wouldn't be safe. The client's saturation level is too low in order to tolerate the hypnotic drug, which will likely drop the oxygen saturation level further.

The nurse observes contraction of the biceps muscle and flexion of the forearm in response to the attempt to elicit the biceps reflex. What action should the nurse take in response to this finding? Record the finding as a 4+ deep tendon biceps reflex. Document that clonus was elicited by the reflex testing. Explain to the client that the reflex response was normal. Repeat the test at the same location to confirm the finding.

Explain to the client that the reflex response was normal. The client's response is normal and should be documented as a 2+ response.

When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard? Femoral artery. Epigastric area. Umbilical area. Right quadrants.

Femoral artery. This area would produce a swishing sound that occurs during systole (vascular sounds).

The client tells the nurse that she has had 5 to 7 liquid diarrhea stools a day, for the last 2 days. What is the sequence of nursing actions? (Place in numerical order from first action through last action.) 1. Notify the HCP of the diarrhea. 2. Tell the spouse to hold the remaining feeding. 3. Assess the elasticity of the client's skin. 4. Auscultate for the presence of bowel sounds. Submit Previous Section

First initial action is to tell the spouse to hold the remaining feeding until further assessment can be obtained. Second, auscultate for bowel sounds to determine if there are hyperactive or hypoactive bowels. Third, assess skin elasticity to determine whether the client is dehydrated and will need further hydration. Finally, notify the HCP about the assessment findings for further instruction for the client.

The client follows the nurse's instructions to swing the arms forward and up in a wide arc and then back. This action allows the nurse to observe which shoulder range of motion? Internal and external rotation. Abduction and adduction. Flexion and hyperextension. Forward and reverse motion.

Flexion and hyperextension. Swinging the arms forward in a wide arc demonstrates forward flexion. Swinging the arms back behind the midline demonstrates hyperextension.

Once the client is settled in the exam room, which action by the nurse has the highest priority? Obtain more in-depth information about the client's osteoporosis management. Review the client's medical record for any history of bone or spinal fractures. Gather data about the nature, location, and duration of the client's back pain. Compare bilateral muscle strength and tone in the client's lower extremities.

Gather data about the nature, location, and duration of the client's back pain. Back pain can be a symptom of a variety of health problems. To ensure basic safety and homeostasis, it is most important for the nurse to obtain information related to the client's report of pain. Pain pattern gives clues about the cause of the pain directs its treatment.

While the nurse documents the findings related to the upper extremity assessment, the nurse and the client continue the conversation about the stiffness in the client's fingers after using the computer. The client laughs quietly and states that getting older is not much fun and often wonders how much longer the client can keep working before the body gives out. In responding to the client, the nurse recognizes that the client is dealing with issues related to which of Erikson's developmental stages? Initiative vs. guilt. Identity vs. inferiority. Generativity vs. stagnation. Integrity vs. despair.

Generativity vs. stagnation. According to Erikson's developmental framework, this is the central task of the adult and is supported by the client's expressed concern about continuing to work as the client gets older.

The client refuses to wear the CPAP mask while hospitalized. The night before their surgical procedure, the pulse oximeter alarms. The nurse enters the client's room and observes that the client is sleeping and that his oxygen saturation has decreased to 84%. Which priority action should the nurse implement? Quietly place an oxygen mask on the client without waking him. Gently shake the client to awaken him. Document the observation as an expected finding. Request that the HCP to reevaluate the client's status.

Gently shake the client to awaken him. Although the nurse wants to promote sleep, the client must be awakened to relieve the obstruction and increase oxygen saturation.

Health Promotion and Maintenance: Inspection of the PrecordiumThe nurse begins the physical assessment by inspecting the client's precordium. How should the nurse prepare the client for inspection of the precordium?

Help the client to a supine position on the bed with his chest exposed. A supine position with the chest exposed provides the best exposure for inspection of the precordium.

Which documentation best reflects the nurse's objective assessment? The client's mother reports that he has been coughing up large amounts of sputum. His deep cough produces a small amount of pale yellow sputum. The client seems anxious and short of breath. Cough is frequent, and the client produces some yellow sputum when he coughs.

His deep cough produces a small amount of pale yellow sputum. This is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.

The nurse assists with the creation of a plan of care. Which nursing diagnosis is most relevant to the client's current status? Excess fluid volume. Inability to sustain spontaneous breathing. Impaired gas exchange. Decreased cardiac output. Submit

Impaired gas exchange. Normal saturation is 95 to 100%. The child's oxygen saturation is well below normal, indicating that his gas exchange is impaired.

When the client's foot pain is controlled, which nursing diagnosis should take priority? Risk for caregiver role strain. Risk for social isolation. Impaired physical mobility. Imbalanced nutrition: more than body requirements.

Impaired physical mobility.

Which nursing diagnoses are a priority when developing the client's plan of care?

Impaired physical mobility. Lymphedema can make mobility difficult, especially lower extremity lymphedema. It is important to assess the client and refer to physical therapy for exercises and activity restrictions. Risk for infection. Infection may be common in lymphedema; pooling of protein-rich lymph fluid increases cellulitis. Risk for impaired skin integrity. Skin on the affected arm may be more dry than normal. Good skin care is essential to prevent infection; wraps and compression stockings may retain moisture against the skin. Disturbed body image. A client with lymphedema may have a disturbed body image from such things as wearing over-sized clothes or two different sized shoes. It is important to address these things with the client.

The nurse uses a stethoscope for auscultation of the client's heart and plans to begin auscultation at the aortic area. How should the nurse plan to continue auscultation from that site?

Inch the stethoscope across and down in a "Z" pattern. Inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard.

After infusing the formula at 30 mL/hour for 6 hours, the nurse checks the client's residual volume and obtains 75 mL. The prescription for the formula states that the rate should be increased by 10 mL/hour as long as the client's residual volume is less than half the previously infused total volume Which action should the nurse implement? Decrease the rate of the formula to 20 mL/hour. Maintain the rate of the formula at 30 mL/hour. Increase the rate of the formula to 40 mL/hour. Increase the rate of the formula to 75 mL/hour.

Increase the rate of the formula to 40 mL/hour. The client is tolerating the feedings. Follow the HCP instructions and increase as prescribed: The client has received 180 mL during the previous 6 hours. Half of that volume is 90 mL (180/2). The residual volume obtained was 75 mL, so the rate of formula should be increased by 10 mL/hour to 40 mL/hour.

The nurse next plans to palpate for vocal fremitus. Recalling the client's admission diagnosis of emphysema and an acute pulmonary infection, what finding should the nurse anticipate?

Increased fremitus over areas of consolidation. Increased fremitus, or vibration when the client speaks, is often felt over areas of consolidated lung tissue, such as in clients with pneumonia.

The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the presence of any undermining tracts, what action should the nurse implement?

Insert a sterile, cotton-tipped applicator to measure the depth. A sterile, cotton-tipped applicator can be gently inserted to measure the depth of the wound and any undermining tracts.

Since the child has a productive cough, the HCP orders a sputum specimen be obtained and sent to the lab for culture and sensitivity. When assisting the child to obtain a sputum specimen, what action should the nurse take? Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx. Insert a soft-tipped catheter through the nares to suction secretions. Use a hard-tipped Yankauer catheter device to remove oral secretions.

Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. This technique is the least invasive and will provide sputum rather than mucus. A client who is alert, able to follow directions, and has a productive cough can obtain a specimen without the use of an invasive catheter.

Considering the need for dysphagia precautions, what action should the nurse implement to intervene? Remind the UAP to keep track of the fluid intake and output. Advise the UAP to provide all fluids at room temperature. Instruct the UAP to add a thickening agent to all liquids per orders. Establish a fluid restriction for the client.

Instruct the UAP to add a thickening agent to all liquids per orders. Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is added to liquids to change the consistency, making swallowing easier.

The client then asks the nurse why the lymphatic system is so important. Which instruction is most important for the nurse to give a client who has lymphedema, when teaching about the importance of the lymphatic system?

It plays a major role in the body's defense against diseases. The 2 major functions of lymph nodes are (1) filtration of foreign material brought to the site and (2) circulation of lymphocytes. Lymphocytes, such as T, B and NK cells help prevent disease.

After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, the client's mother appears worried and nervous and states that her child has never been sick and this scares her. To encourage the mother to share more about her feelings, how should the nurse respond? Your child will be just fine. You don't need to worry. I worried just like you when my child was sick. Perhaps you would rather wait outside. It sounds like this has been a very frightening experience for you.

It sounds like this has been a very frightening experience for you. This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.

After preparing the client, the nurse visually inspects the precordium by first observing for an apical impulse. The nurse is unable to observe the apical impulse. The nurse next assesses for a left ventricular heave. The nurse should observe the force of the impulse at what location?

Left midclavicular line, 5th intercostal space. A left ventricular heave is seen at the apex, located at the left midclavicular line, 5th intercostal space. This forceful thrusting of the ventricle occurs with hypertrophy of the left ventricle.

The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first? Deeply palpate each abdominal organ. Carefully palpate areas of tenderness. Lightly palpate the abdominal surface. Gently palpate the edges of the liver. Submit

Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity.

Physical Assessment: PercussionSince client is still comfortable sitting on the side of the bed leaning over a bedside table, the nurse next prepares to percuss his thorax. In order to percuss the client's thorax posteriorly beginning at the apex of the right lung, how should the nurse begin? Palpate the space directly below the clavicle. Place one finger pad over the first rib. Locate the client's first intercostal space. Find the space directly above the diaphragm.

Locate the client's first intercostal space. Percussion should be performed systematically, percussing in the intercostal spaces to avoid the ribs and scapulae.

Which is the most important approach for the nurse to use when applying a nasal cannula? Ensure the cannula tubing stays snugly around the ears and under the chin. Make sure that the tip in the nasal prongs are aimed into the nares. Never allow the humidifier to run out of water. Keep some type of padding around the ears and over the cheekbones. Submit Previous Section

Make sure that the tip in the nasal prongs are aimed into the nares. This action directs the flow of oxygen into the client's upper respiratory tract.

Because of the client's dyspnea, the nurse is concerned that they may need to receive oxygen. Which action should the nurse perform that would be most indicative of the need for supplemental oxygen? Measure oxygen saturation. Auscultate breath sounds. Measure capillary refill. Observe chest expansion. Submit

Measure oxygen saturation. Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen, a valuable reflection of the client's overall oxygenation.

Which interventions should the nurse add to the client's plan of care? (Select all that apply.) Encourage an increase in carbohydrates and move the evening meal to 1 hour before bedtime to promote sleep. Monitor bedtime food and beverage intake, which might interfere with sleep. Instruct the client to keep reading material from work at the bedside to review when he awakens. Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy. Suggest the use of a soft, conforming mattress and pillow set for better body alignment. Submit Previous Section

Monitor bedtime food and beverage intake, which might interfere with sleep. Instruct the client to get out of bed if unable to fall back to sleep within 30 minutes and to do a quiet activity until becoming sleepy.

The nurse observes the overall hair distribution on the client's face and body. There is visible hair growth on the forearms but no visible hair on the lower extremities. The client has thin eyelashes and eyebrows and fine, downy facial hair. What action should the nurse take in response to these observations?

Move on to the next area of assessment since the findings are within normal limits. The findings are within normal limits, so the nurse should continue the assessment.

The nurse assesses the carotid artery pulse volume as +2. The nurse then listens for a carotid bruit by placing the bell of the stethoscope at the base of the neck on the right side. The nurse does not hear a bruit. What should the nurse do next?

Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. The nurse should auscultate each carotid artery systematically, including the base of the neck, the mid-cervical area, and the angle of the jaw.

Client remains seated on the side of the bed. The nurse begins to auscultate his breath sounds posteriorly by placing the diaphragm of the stethoscope over his left lung apex. After listening in this area, how should the nurse proceed? Move the diaphragm across to the apex of the right lung posteriorly. Listen again at the same location using the bell of the stethoscope. Stand in front of the client and listen to the left lung apex anteriorly. Inch down the left side posteriorly to listen to the left middle lobe.

Move the diaphragm across to the apex of the right lung posteriorly. Moving the diaphragm of the stethoscope across the posterior thorax provides the most systematic approach to comparing the lung sounds bilaterally.

After assessing the femoral artery, the nurse palpates the inguinal lymph nodes. What technique should be used?

Move the finger pads over the area using a gentle circular motion. This technique allows effective palpation of the lymph nodes.

After answering a few questions, the client begins to cough. What assessment should the nurse perform? Assess for the presence of nail bed clubbing. Review oral fluid intake for the last 24 hours. Observe for dryness of the oral mucosa. Note the amount and appearance of any sputum. Submit

Note the amount and appearance of any sputum. The amount and appearance of any sputum when the client coughs provides useful data related to the cause of the client's cough and any underlying problems.

To assess the client for signs of protein malnutrition, what action should the nurse take? Compress the client's nail beds. Observe the color of the conjunctiva. Note the texture of the client's hair. Measure the client's deep tendon reflexes.

Note the texture of the client's hair. Dull, dry, sparse hair may be an indication of nutritional deficiencies, including protein deficiency.

After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement? Notify the HCP of the findings. Assist the client to a semi-Fowler's position. Administer a pain medication. Place a warm moist pack on the client's abdomen.

Notify the HCP of the findings. Rebound tenderness and involuntary rigidity (guarding) are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation.

To learn about the intensity of the client's pain, what pain scale is most appropriate to use to assess the client's pain? FLACC behavioral pain scale Numeric pain scale Faces Pain scale Non-verbal cues

Numeric pain scale A numeric pain scale is an effective tool for measuring pain intensity.

A complete arterial circulation assessment includes a Modified Allen's Test. Which approach is best for the nurse to use to conduct this test?

Obliterate the ulnar and radial pulses. Instruct the client to make a fist several times for about 30 seconds. Document that the test results show inadequate circulation to the hand if pinkness fails to return within 6 seconds.

During the health history, the client reported that her feet and ankles swell occasionally. To assess for edema, what action the nurse take first?

Observe and compare the client's lower extremities. The RN should first assess for edema by observing a client's legs for any obvious swelling and by comparing the two extremities for differences in size.

The nurse monitors the client's postoperative lab values. The nurse notes that his white blood cell count (WBC) is 15,000 mm3 (15 × 109/L). Which observation should be documented in the nurse's assessment? (Select all that apply.) Select all that applyObserve for excessive drainage. Measure oxygen saturation. Determine skin turgor. Measure the tympanic temperature. Blood glucose level. Submit Previous Section

Observe for excessive drainage. Measure the tympanic temperature.

To continue to the cranial nerve VII assessment, the nurse asks the client to first smile, then frown, and then show his or her teeth. While the client performs these tasks, what should the nurse do? Apply light pressure over the facial nerve. Observe for symmetric facial movement. Gently palpate for swelling over the cheeks. Note how quickly the client completes each task.

Observe for symmetric facial movement. The nurse observes for symmetric movement when the client smiles, frowns, or shows his or her teeth. This assessment provides data related to the function of the facial nerve, cranial nerve VII.

During her initial clinic visit, the client radial pulse volumes were recorded as 3+ bilaterally. Assessment by the nurse finds that the left radial pulse volume is now 1+ and the right radial pulse volume is 3+. What additional assessment is most important for the nurse to implement?

Observe the appearance of the left hand. A 1+ pulse volume indicates diminished circulation, so further assessment of the left hand is a priority. The RN should assess the color, warmth, and capillary refill.

A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding? Reposition the client to her right side. Observe the area for bladder distention. Determine if the client feels bloated or gaseous. Assist the client to a sitting position immediately.

Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder.

The client states, "My scalp itches sometimes." What action should the nurse take first?

Observe the client's hair shafts and scalp. Loose white flecks may indicate dandruff. Itching may also be the result of head lice. The nurse should observe the scalp and hair shafts for the presence of nits, which adhere to the hair shaft.

The nurse completes an admission assessment. The client tells the nurse that she feels like she needs to vomit. The nurse helps the client to sit up at the side of the bed and provides her with an emesis basin. The client vomits into the emesis basin and then remains sitting on the side of the bed, stating that she may need to throw up again. Which assessment should the nurse complete first? Check the pulse. Listen to bowel sounds. Observe the color of the emesis. Obtain a STAT blood pressure. Submit

Observe the color of the emesis. Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client's homeostasis.

The client vomits 200 milliliters of yellow-green liquid. The client continues to feel nauseated. The nurse administers a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, the client states she feels better. The nurse offers to provide oral care with a mint-flavored foam swab and cool water. Which assessment takes priority while the nurse provides oral care? Assess for presence of dentures. Observe the condition of the mucus membranes. Evaluate the color of the gums Check for the presence of cavities. Submit Previous Section

Observe the condition of the mucus membranes. Because the client has a recent history of nausea, vomiting, and weight loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.

After receiving oxygen for a short while, the child is much less dyspneic. The nurse notes that the oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. Which actions should the nurse implement immediately? (Select all that apply.) Observe the sensor to ensure it is intact and obtain another reading. Assess for signs and symptoms of respiratory distress. Encourage coughing and deep breathing. Increase the oxygen flow to 3 to 4 L/min. Notify the HCP immediately. Submit Previous Section

Observe the sensor to ensure it is intact and obtain another reading. Assess for signs and symptoms of respiratory distress. Encourage coughing and deep breathing.

The client is uncomfortable lying on the exam table, so the nurse assists the client to a sitting position before completing assessment of the knees. The nurse begins by observing the anterior thighs and knees. How should the nurse assess for the presence of muscle atrophy? Gently apply pressure around the patella. Observe the size of the muscle. Palpate the tissues for edema. Measure the muscle with a goniometer.

Observe the size of the muscle. Atrophy, decrease in size, may first be observed in the medial portion of the anterior thigh muscle and is a sign of muscle disuse.

Which assessment is most important for the nurse to complete?

Observe the texture and distribution of hair growth on the scalp. Dull, dry, sparse hair may be the result of a nutrient deficiency, such as insufficient protein or zinc. These findings would support the nurse's concerns regarding the client's overall nutritional status.

To ensure the client receives adequate nutrition, which intervention should the nurse implement? Obtain and record a weekly weight. Obtain an order for a weekly complete blood count. Measure and record her abdominal girth every day. Perform capillary glucose measurements before every meal.

Obtain and record a weekly weight. Regular measurement of the client's weight provides a useful measurement of the client's general nutritional status. Assessment of the client's pattern of weight gain or loss should be combined with other measures, such as general assessment and dietary evaluation for a thorough picture of the client's nutritional status.

In managing the client's postoperative care, which task should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Complete a focused respiratory assessment every 4 hours. Obtain pulse oximetry and respiratory rate every 2 hours. Take vital signs and complete body systems assessment every 8 hours. Administer prescribed throat lozenges every 2 hours as needed. Serve the prescribed breakfast tray to the client. Submit

Obtain pulse oximetry and respiratory rate every 2 hours. Serve the prescribed breakfast tray to the client.

The nurse recognizes that the client's right-sided weakness is also a factor contributing to a risk for altered nutrition. With which member of the interprofessional team should the nurse consult regarding this problem? Clinical nutritionist. Occupational therapist. Rehabilitation counselor. Physical therapist.

Occupational therapist. Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self-care.

The spouse states that the client loves applesauce and asks if this is a good snack choice. Which response by the nurse is best? Do not offer her applesauce because it does not provide very many calories. Processed foods such as applesauce are often very high in sodium. Offer applesauce since that is what the client likes, along with higher calorie snacks. Applesauce is an excellent source of nutrients and calories.

Offer applesauce since that is what the client likes, along with higher calorie snacks. To improve the client's nutrition, the nurse needs to consider the likes and dislikes of the client in addition to the needed nutrients. Combining applesauce, which the client likes though not a high calorie snack, with snacks that contain more calories, best meets the needs of the client.

The nurse observes raised, pink wheals on the client's neck. How should the nurse respond to this observation?

Offer assurance that this is a temporary response. Urticaria, or hives, is an inflammatory response that is generally transient.

The client points out a small (1 mm), smooth, slightly raised bright red dot located on the abdomen. The client asks the nurse to examine that spot as well. How should the nurse proceed?

Offer assurance that this lesion is not an abnormal finding. Cherry angiomas are commonly seen on the abdomen, particularly in persons over the age of 30. Angiomas typically increase in number and size with aging and are not a cause for concern.

How should Cilostazole be taken?

One hour before, or two hours after a meal. The medication is most effective if taken on an empty stomach.

The client has a new prescription for an appetite stimulant. Which information about the drug should the nurse obtain prior to reinforcing the education provided to the client regarding the time the medication should be administered? Onset of action. Peak action. Duration of action. Plateau. Submit

Onset of action. Onset of action is when the medication begins to produce a therapeutic effect. The nurse should determine when the drug will start to take effect so that the medication can be taken when the greatest therapeutic effect can be achieved.

No carotid bruit is heard. After completing the assessment, the nurse reminds client to call if anything is needed and leaves the room. The nurse documents the findings and prepares to report the findings to the HCP. Which assessment data are important for the nurse to report to the client's HCP? (Select all that apply. One, some, or all options may be correct.) Presence of S1 and S2 heart sounds. Onset of an S3 heart sound. Observed jugular vein distention. Noted absence of a carotid bruit. Client's subjective report of dyspnea.

Onset of an S3 heart sound. Observed jugular vein distention. Client's subjective report of dyspnea.

What additional information related to end of life wishes is most important for the nurse to assess? Organ donor status. Desired funeral home. Wishes of other children. If the client prepared a will. Submit Previous Section

Organ donor status. It is essential for the nurse to assess the client's wishes regarding organ donation so that any necessary arrangements to preserve organs can be made prior to the client's death.

What data should the nurse obtain to complete the client's GCS rating? Select all that apply Orientation. Verbal response. Babinski reflex. Motor response. Pupillary response. Eye opening response. Submit Previous Section

Orientation Verbal Response Motor Response Eye Opening Response

Mental Status Exam: While continuing the interview, the nurse assesses the client's mental status. As the interview continues, the client occasionally struggles to choose and form words, but seems comfortable and relaxed. The nurse provides a quiet, calm environment, allowing ample time to respond to the interview questions. The client asks the nurse what the room number is, stating the need to let family know.

Oriented to situation. The client's statement describing the need to notify family that the client is in the hospital indicates an orientation to situation. Lack of knowledge of room number does not reflect disorientation or memory loss.

To ensure that the client's respiratory status is stable upon his arrival on the medical unit, the nurse should complete which assessment first? Breath sounds. Oxygen saturation. Level of fatigue. Chest excursion.

Oxygen saturation. Measurement of the client's oxygen saturation provides information about the effectiveness of gas exchange. A low oxygen saturation level requires immediate nursing intervention.

Which data indicate the need for the nurse to evaluate the client further for Pale conjunctivae. Smooth, thick finger and toe nails. Rough, dry, scaly, and pale skin. Flat abdomen, painful to palpate. The lips are dry and cracked.

Pale conjunctivae. The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia. Rough, dry, scaly, and pale skin. Skin becomes dry, scaly, and rough. Often the skin is pale and bruises easily. The lips are dry and cracked. This is an unexpected finding for someone with adequate nutrition and could be a sign of dehydration.

The nurse palpates the dorsalis pedis pulses bilaterally and determines that both pulses are weak and thready. What additional assessment information will validate this finding?

Pale, cool skin. Weak, thready pulses indicate diminished arterial circulation. Pale, cool skin is also likely to be present when arterial circulation is diminished, validating the finding of weak, thready pulses.

How should the nurse begin the carotid artery assessment?

Palpate one artery and then palpate the artery on the opposite side. This technique allows the nurse to effectively and thoroughly assess each artery.

During auscultation, the nurse has difficulty distinguishing S1 from S2 because of the client's irregular heart rhythm. While continuing to listen at the aortic site, what action should the nurse take?

Palpate the carotid artery pulse. S1 occurs simultaneously with the carotid artery pulsation. By gently palpating the carotid artery, the nurse can distinguish S1 as the sound that occurs with each pulsation.

The nurse reviews the client's initial complaint that her feet feel numb. Which assessment should the nurse perform first?

Palpate the dorsalis pedis pulses. Because the client has complained of numbness, it is important to assess for the presence and strength of the pedal pulses, a measure of the arterial circulation to the feet. The acute absence of arterial circulation would require immediate intervention.

The nurse begins her assessment of the integumentary system. Select the techniques the nurse should perform.

Palpation Inspection

The client's left upper extremity seems to be weaker than the right upper extremity. What additional assessment should the nurse perform to validate the finding of unilateral upper extremity weakness? Perform a palmar drift test. Complete a Romberg test. Check for a placing reflex. Observe for decorticate posturing.

Perform a palmar drift test. A palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and the eyes closed for 10 to 20 seconds. The weak arm will "drift" downward.

Next, the nurse asks the client to close his or her eyes. The nurse places the tuning fork in the palm of the client's left hand and asks to identify what it is. The client is unable to identify the tuning fork. What action should the nurse take in response to this finding? Document that the client is exhibiting left-sided astereognosis. Ask the client to open his or her eyes and identify the object being held. Place a comb in the client's left hand and ask him or her to identify the object. Hold the tuning fork on the back of the client's hand while trying to identify it. Submit

Place a comb in the client's left hand and ask him or her to identify the object. Stereognosis, the ability to recognize objects by touch, should be assessed by placing a familiar object in the client's hand. A tuning fork in not a familiar object to many people, so the nurse should replace the fork with a more familiar object, such as a comb.

The practical nurse (PN) evaluates the client's vital signs. Respirations are rapid and shallow. What technique should the nurse use to accurately evaluate the child's respirations? Observe chest expansion for 15 seconds and multiply by 4. Encourage the client to breathe as deeply and slowly as possible. Watch for nasal flaring and count the air exchanges with each movement. Place hands flat against the back or chest and observe the rise and fall of the chest.

Place hands flat against the back or chest and observe the rise and fall of the chest. This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow.

The nurse begins the assessment at the client's inguinal area, assessing the femoral artery and the inguinal lymph nodes. The nurse palpates the femoral artery and notes that it is weak. The nurse decides to assess for the presence of a bruit. What action should the nurse take?

Position a stethoscope over the artery. A bruit is a swooshing sound heard when blood flow through an artery is turbulent. It is heard by placing a stethoscope over the artery.

How should the nurse teach the student nurse to position the chair to ensure a safe transfer?

Position the chair at the head of the bed facing the foot on the client's left side close to the bed.

To gather data related to the pattern of abuse, what action should the nurse take first?

Provide a calendar for the client to mark the dates when any violent and abusive behavior by the client's partner occurred. A calendar is a useful visual aid in that it can help the client "see" the frequency of the abuse, and it can help the nurse determine if there is an escalation of violence toward the client. This is the first step when implementing a danger assessment for the client. The client may also be requested to complete a scale of violence to help the nurse assess the magnitude of the abuse.

The next morning, the nurse enters the client's room to prepare her for transport to the procedure room. The nurse states that the procedure is scheduled in 30 minutes. The client, who is lethargic, tells the nurse she has changed her mind and does not want the procedure performed. The client states that she would rather just go ahead and die. The client's spouse is in the room and is very upset by that comment. Which action should the nurse implement regarding cancellation of the procedure? Provide the couple with privacy to discuss the decision. Continue to prepare the client for the scheduled procedure. Remind the client that the consent form is already signed. Ask the client's spouse if the procedure should be cancelled.

Provide the couple with privacy to discuss the decision. The nurse must address the client's expressed desire to cancel the procedure. The nurse's initial actions should include allowing the couple privacy to discuss the decision, addressing any concerns of the client, and encouraging further communication. The client has a right to autonomy.

Three hours later, the client's husband calls the nurse, stating that she is reporting increased abdominal pain. The nurse asks the client where she is experiencing pain and she points to her right upper abdomen. When completing the pain assessment, how should the nurse assess for rebound tenderness? Position the client on her right side. Lightly palpate over the painful area. Ask the client to describe the pain. Push down on the left side of the abdomen. Submit

Push down on the left side of the abdomen. After applying pressure at a site away from the area of pain, the nurse quickly lifts and removes the hand from the client's abdomen. Pain upon release of the pressure is referred to as rebound tenderness.

To assess the client's recent memory more completely, what action should the nurse take? Encourage reminiscing about the birth of a child. Question how the client arrived at the hospital today. List four words and ask the client to repeat them back. Observe the client's cooperation in answering interview questions. Submit

Question how the client arrived at the hospital today. This action provides information related to the client's recent memory. The nurse should ask questions with verifiable answers to ensure the client does not make up responses.

How should the nurse document the information obtained when charting the client's abuse assessment?

Quote the client's responses to the questions as verbatim as possible. Documentation should be as verbatim as possible to provide the most detailed, accurate information.

Upon further questioning by the nurse, the client reports that this buckling of the knee has occurred several times previously. What additional information is most important for the nurse to obtain? Whether the client takes any pain medication for knee pain. The date the client last had bone density measured. Recent history of trauma or injury to the affected knee. How frequently the client performs weight-bearing exercises.

Recent history of trauma or injury to the affected knee. When the knee gives way suddenly, the nurse should determine if the client has experienced trauma to the area. This information is important in determining the cause of the symptom.

The child is discharged home with prescriptions for the medication and is instructed to follow up with his HCP in a week. The child and his mother return to the HCP's office one week later, after completion of the course of antibiotic therapy. The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take? Record the presence of clear breath sounds. Tell the client's mother that his lungs are still congested. Instruct the client to cough to clear his lungs and listen again. Notify the HCP of the abnormal lung sounds.

Record the presence of clear breath sounds. Vesicular breath sounds are a normal finding in the peripheral lung fields.

The mother of the client questions the nurse as to the purpose of an antitussive. The nurse explains that this medication should have what effect? Liquefy the respiratory secretions. Reduce the frequency of the cough. Decrease any pain with coughing. Prevent nausea due to the sputum.

Reduce the frequency of the cough. Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.

The nurse hears a grade 3 systolic murmur at the apical site but does not hear either an S3 or S4 heart sound. What action should the nurse take next?

Repeat auscultation across the chest using the bell of the stethoscope. After completing assessment with the diaphragm of the stethoscope, the nurse should repeat the sequence using the bell of the stethoscope. The bell of the stethoscope is used to listen for relatively lower pitched sounds than the diaphragm.

The nurse observes several bruises of various colors across the client's lower abdomen. How should the nurse interpret this assessment finding?

Repeated injury over a period of time. New bruises are generally red in color and change color over time. Bruises typically progress from purple-blue to blue-green to green-brown and finally to a brownish-yellow color before disappearing.

The nurse performs McMurray test and hears an audible click while maneuvering the client's left leg. In response to this finding, what action should the nurse implement? Observe the client's gait walking across the room. Explain to the client that the knee dislocation has resolved. Plan to instruct the client about knee strengthening exercises. Report the assessment to the clinic healthcare provider (HCP).

Report the assessment to the clinic healthcare provider (HCP). An audible click during McMurray test indicates that the client may have a torn meniscus. This finding should be reported promptly to the HCP for further evaluation and treatment.

Which nursing action should be included in the plan to promote skin integrity in a bed bound patient?

Reposition the client in bed from supine to a 30 degree side-lying position every 2 hours.

During the assessment, the nurse also observes that client is confused. During the admission interview and assessment, client was oriented to person, place, and time. The nurse auscultates his breath sounds and hears an increase in crackles posteriorly, now in both the lower and middle lung fields. Which data is most important for the nurse to obtain before contacting the HCP? Pedal pulse volume. Orientation to situation. White blood cell count. Respiratory effort. Submit

Respiratory effort. Confusion may be an indicator of decreasing oxygenation, especially in the older person. Based on the client's signs of worsening pneumonia coupled with the confusion, his respiratory rate and effort along with his oxygen saturation level should be obtained before the nurse contacts the HCP.

Which assessment finding further supports diagnosis? Restlessness and dyspnea. Skin is warm and flushed. Complaints of being thirsty. Blood pressure of 102/62 mmHg.

Restlessness and dyspnea. Restlessness and dyspnea are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.

After further conversation with the client's mother, the nurse needs to leave the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-client relationship? Teaching the child and his mother how to read the oximeter. Returning to the room at the time promised. Offering the mother reassurance that the child is stable. Providing a phone so that the child's mother can call home.

Returning to the room at the time promised. Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome.

Where should the nurse begin abdominal auscultation? They can begin anywhere. Right upper quadrant (RUQ). Right lower quadrant (RLQ) Left upper quadrant (LUQ)

Right lower quadrant (RLQ) Place the stethoscope lightly on the abdominal wall, beginning in the RLQ in the area of the ileocecal valve, where bowel sounds are normally present. Proceed with listening to other quadrants in a systemic manner.

To begin palpation at the base of the heart, where should the nurse palpate first?

Right sternal border, 2nd intercostal space. This is the location of the aortic site. The aortic and pulmonic sites are found at the base of the heart.

The nurse explains to the student nurse that the Braden Scale is used to measure which client parameter? Neurological status Risk for pressure sores. Risk for thrombophlebitis. Condition of the oral mucosa.

Risk for pressure sores. The Braden Scale assesses many risk factors that may contribute to pressure sores. The factors that are assessed are nutrition, the ability to move, the degree of activity, moisture on the skin, sensory perception, and friction and shear. A lower score indicates a higher risk for pressure sores.

Before attempting to palpate again, the nurse should give the client what instruction?

Roll half-way to his left side. Turning half-way to the left side moves the apex of the heart closer to the chest wall, so it is easier to palpate.

While palpating the client's hands, the nurse asks the client if there is any tenderness in the fingers. The client reports that sometimes the fingers get stiff after several hours of computer work, but states that there is currently no tenderness. When using the SOAP format of charting, how should the nurse document this finding? O: Client reports fingers are stiff. S: History of finger discomfort. S: Fingers get stiff after computer work. O: Denies finger tenderness at present.

S: Fingers get stiff after computer work. This notation correctly identifies the client's report of finger stiffness as a subjective (S) finding and accurately and concisely describes what the client reported.

Which breakfast selection(s) are good Oatmeal with a sliced banana. Pancakes with maple syrup. Hash browns and an English muffin. Scrambled eggs and sausage. Cheese and bacon omelet.

Scrambled eggs and sausage. Cheese and bacon omelet.

Locating the Angle of Louis is important to guide the nurse in next locating what area? Xiphoid process. Erb's point. Clavicle. Second rib.

Second rib. The second ribs attach to the sternum at the Angle of Louis, or sternal angle. This landmark is located at the bottom of the manubrium of the sternum, is felt as a bony ridge, and is the point where the treachea bifurcates into the right and left stem bronchi.

Priority Data Collection: The nurse interviews the client for subjective data regarding the itching. The nurse questions the client about her symptoms. What should the nurse ask about first?

Severity and location of the itching. This is the priority question. Itching may be a symptom of a more life threatening problem and the severity needs to be assessed as a priority.

The nurse assesses the client's elbows. When comparing the elbow joints bilaterally, for what should the nurse observe? (Select all that apply.) Skin color. Tympany. Contour. Resonance. Size.

Skin color. This is a characteristic that can be observed and provides data related to joints. Skin is visible and easily assessed. Contour. This is a characteristic that can be observed and provides data related to joints. Shape is visible and easily assessed. Size. This is a characteristic that can be observed and provides data related to joints. Size is visible and easily assessed.

The nurse visits with the client's spouse then observes as the unlicensed assistive personnel (UAP) assists the client with a meal. The UAP gives the client a glass of iced tea to drink and the client begins to cough. The nurse recognizes that the client's dysphagia may impact her fluid and nutritional status The nurse should obtain an order from which member of the interprofessional team? Case manager. Speech therapist. Registered dietician. Geriatric nurse practitioner. Submit

Speech therapist. Speech therapists have expertise in the evaluation and management of clients with dysphagia.

Which information in the client's history reflects a high risk for low back pain? Frequently travels with spouse to Korea by air visit relatives. Spends evenings working in a a large vegetable and flower garden. Often rides a bicycle to work as a history professor at a local college. Volunteers on the weekend as a tour guide at a historical city mansion.

Spends evenings working in a a large vegetable and flower garden. Gardening activities such as bending and pulling, lifting, and moving heavy objects increases the risk for low back pain.

The nurse observes that the client lacks coordination when touching the thumb to the fingers on the left side and decides to further assess upper extremity muscle strength. To assess upper extremity muscle strength, the nurse stands facing the client and holds out both hands toward the client. The nurse asks the client to grip two of the nurse's fingers with one hand and two fingers with the other hand. What instruction should the nurse provide next? Push my fingers back, using both hands at the same time. Squeeze my fingers with one hand, then with the other. Pull my fingers forward toward you, one hand at a time. Squeeze my fingers with both hands at the same time. Submit

Squeeze my fingers with both hands at the same time. When performing a hand grip test, the nurse asks the client to squeeze the nurse's fingers with both hands simultaneously, the nurse can compare muscle strength bilaterally.

The clinic supervisor enters the client's room, and the nurse gives the supervisor a brief report, based on the assessment completed up to this point. It is most important to report which finding to the supervisor? Lack of dependent rubor. Location of varicose veins. Stage 2 pressure ulcer. Bilateral cyanosis in both legs. Ankle brachial index of .94.

Stage 2 pressure ulcer. Bilateral cyanosis in both legs.

To check for scoliosis, the nurse provides which client instruction? Stand with the arms above the head in a diving position and bend forward at the waist. Place the hands on the hips and lean to one side and then to the other. Twist from one side to the other with the hands on the hips. Place the feet apart and slowly raise both arms above the head.

Stand with the arms above the head in a diving position and bend forward at the waist. Ask the client to place the hands together above the head as if diving into a swimming pool and slowly bend forward at the waist, allowing assessment of thoracic rib prominence or paravertebral muscle prominence in the lumbar spine.

The nurse begins by testing the client's biceps reflex. With the client's forearm resting on the nurse's forearm and the nurse's thumb over the biceps tendon, what action should the nurse take next to test the client's biceps reflex? Ask the client to contract the biceps muscle. Strike the thumb with the reflex hammer. Extend and externally rotate the client's forearm. Instruct the client to repeatedly clench the fist.

Strike the thumb with the reflex hammer. With the client's forearm slightly flexed and relaxed, the nurse should strike the thumb with the pointed end of the reflex hammer to elicit a response.

The client continues the conversation saying that they guess they may have to change the way they do certain things in order to continue to do the things they love. How should the nurse respond to this statement? Recognize that the client has regressed to an earlier developmental stage as a result of worrying about current physical problems. Offer encouragement to the client as the client struggles to find meaning in life despite current physical problems. Document on the assessment form that the client seems to be overly fixated on current physical problems. Support the client as the client considers strategies to adapt to the physiologic changes contributing to current physical problems. Explore with the client strategies used in the past to successfully adjust to changes in life. Submit

Support the client as the client considers strategies to adapt to the physiologic changes contributing to current physical problems. Explore with the client strategies used in the past to successfully adjust to changes in life. (Changing and adapting behavior to maintain control is emphasized by Erikson. A positive resolution to the client's developmental task of generativity vs. stagnation is the ability to be creative and productive. The nurse should support the client in efforts to adapt creatively to the physiologic changes causing current physical problems.)

The client lies down on the exam table in a supine position. The nurse assesses adduction and abduction of the hip by instructing the client to take what action? Bend the knee so the foot is flat on the table and allow the knee to drop inward then outward. Swing the entire leg laterally and then medially, keeping the knee straight while moving. Lift each leg straight above the body to a 90º angle. Turn both legs so the toes are pointed inward and then outward.

Swing the entire leg laterally and then medially, keeping the knee straight while moving. Lateral movement demonstrates abduction and medial movement demonstrates adduction.

Physiologic Adaptation: Before continuing the interview and assessment, the nurse enters the following initial data collected into a tablet: The client demonstrates difficulty speaking and previously reported feeling weak, passing out, and falling at home. Vital signs are currently T 97° F (36o C), Blood Pressure 140/88 mmHg, heart rate 92beats/min, and respirations 18 breaths/min. What terminology should be included in the nurse's documentation? Dysphagia. Tachycardia. Syncope. Paresis.

Syncope. Syncope is a sudden loss of strength or temporary loss of consciousness, which the client described as "passing out."

The nurse continues the assessment, ending at the apical site. The nurse hears a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope. How should the nurse identify this sound?

Systolic murmur. Murmurs are often heard as a swooshing sound. Systolic murmurs coincide with the S1 heart sound.

How should the nurse assess for orthostatic hypotension?

Take the client's blood pressure and pulse while the client is in the lying, sitting, and standing positions. Orthostaic hypotension can occur when the client has been lying or sitting for a prolonged period and quickly rises to an erect position. The systolic blood pressure must drop a minimum of 20 points to be considered orthostatic hypotension.

Which instructions should the nurse convey to help prevent venous thromboembolism (VTE) in the client's legs? (Select all that apply. One, some, or all options may be correct.)

Teach the client to dorsal flex and plantar flex his feet while in the bed and chair. Instruct the client to wear sequential compression stockings. Explain that enoxaparin injections will be administered routinely.

Which action should the nurse implement to a 40 year smoker who coughs in the morning?

Teach the client to take ten deep breaths an hour while awake. Deep breathing can help prevent atelectasis, which can lead to pneumonia.

What additional observation is important in assessing the mole?

The border of the mole is smooth Border regularity is an important finding because border irregularity may be a cancer danger sign.

Upon returning to the room, the nurse hears and sees the child coughing. She assesses the cough further. Which documentation reflects subjective data? Respirations are 36 breaths/min. The client appears anxious by repeatedly reaching for his mother's hand and asking, if he is okay. The client's mother is present in the room. The client and his mother state he has a cough. Submit

The client and his mother state he has a cough. This is subjective as it is the client and his mother's reported symptom.

Which interview data provides the nurse with information related to the client's judgment? Reminiscing about the birth of a child caused the client to cry gently. The client indicated the need to notify family about being in the hospital. Repeating back a list of four words made the client anxious and uncomfortable. The client was cooperative but vague in describing how the neighbor found her.

The client indicated the need to notify family about being in the hospital. The client's recognition of the need to notify family of being in the hospital is an indication of good judgment.

Which goal is correct for the client's diagnosis of impaired physical mobility? The client will transfer to the chair with assist of one person. The nurse will reposition the client every hour while the client is awake. The client will sit in the chair for each meal beginning on the day of admission. The nurse will assist the client to ambulate in the hall by the second hospital day.

The client will sit in the chair for each meal beginning on the day of admission. This is a correctly stated goal. The client is always the subject of the goal, and the action is always measurable. This goal includes what the client is to achieve and sets a realistic deadline.

In documenting the client's difficulty speaking, the nurse recalls that the client had difficulty forming some words and phrases. Before describing this finding on the assessment form, what additional data should the nurse consider? How many words per minute the client is able to speak. The client's ability to comprehend what is being asked. If any mouth drooping is observed when the client spoke. Whether the client is able to read the nurse's lips accurately. Submit

The client's ability to comprehend what is being asked. Aphasia should be assessed to determine if the client has lost the ability to comprehend information (receptive aphasia) or the ability to express herself (expressive aphasia). Most commonly, the client experiences both, referred to as global aphasia.

Which information is best to use for assessment of the client's functional ability related to nutrition? The client's food preferences. Types of food the client has eaten within the last 24 hours. The client's ability to feed herself with her left hand. The spouse's schedule for preparing meals.

The client's ability to feed herself with her left hand. Assessing the client's ability to self-feed is critical for understanding the client's ability to maintain nutritional needs.

In assessing the client's end-of-life wishes, the nurse remembers that the client's spouse is deceased. It is most important for the nurse to communicate with which person? The client's oldest child. The client's designated power of attorney for health care. The client's spiritual leader, such as a priest, rabbi, or pastor. The client's physician, with whom end of life wishes have been discussed. Submit

The client's designated power of attorney for health care. The person designated as a client's power of attorney for health care has been designated by the client to make health care decisions for the client if the client is unable to do so.

Thirty minutes later, the nurse returns to assess the client's response to the medication. Which findings provide the best data about the effectiveness of the medication? (Select all that apply.) The client's vital signs are within normal limits. The client is holding a pillow over her abdomen. The client's facial expression is calm and relaxed. The client states a lessening of her pain. The spouse reports that the client looks like her pain has improved.

The client's vital signs are within normal limits. The client's facial expression is calm and relaxed. The client states a lessening of her pain.

The nurse plans to measure the child's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, the client asks if it will hurt. Which response by the nurse is best? Yes, but the pain will only last a very short time. No, you will not even know the clip is on your finger. The clip feels like a clothespin squeezing your finger. You seem to be worried about experiencing pain. Submit

The clip feels like a clothespin squeezing your finger. This is an honest response to the child's question regarding pain and one that places the sensation they will feel in a context he can understand.

The client asks the nurse about the function of the lymph nodes. Which is the best answer the nurse can give in response to how the lymphatic system works?

The lymph system carries the lymphocytes throughout the body. They respond to foreign and abnormal substances, and communicate responses to other parts of the body.

The child's mother further states that she is worried her 2-year-old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? If you breastfed your daughter, she will have natural immunity. She will be protected from illness if she has had all her scheduled vaccinations. There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. She is young enough that she will not be as ill as her brother. There is nothing serious to worry about. Submit Previous Section

There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. Viral infections can spread from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first two to three days after symptoms appear, so the sibling is at risk and the mother should be informed.

The HCP conducts a physical exam. While the HCP agrees that job stress is likely exacerbating the disturbed sleep pattern, the spouse's report of increased snoring episodes is concerning. Diagnostic testing is prescribed.A polysomnogram (sleep study) reveals more than 200 episodes of sleep apnea during the night. A pulse oximeter is used during the testing, and the client's oxygen saturation level drops to 82% periodically. The client is diagnosed with obstructive sleep apnea (OSA) and is prescribed a nasal continuous positive airway pressure (CPAP) device to be used at night. Which is the best explanation by the nurse for educating the client about OSA? There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. There is a dysfunction of mechanisms that regulate the sleep and wake states, causing excessive sleepiness during the day. The airway remains open, but the brain fails to send messages to the diaphragm and chest muscles to initiate respirations. It is a syndrome characterized by chronic difficulty falling asleep with frequent awakenings at night. Submit

There is a lack of airflow through the nose and/or mouth for periods of 10 seconds or longer during sleep. This describes obstructive sleep apnea. Efforts by the brain and respiratory muscles continue, but airflow is obstructed.

The nurse assesses the patient's vomitus. Which finding would the nurse be the most concerned about? Green vomit with particles of food. Thick dark brown vomit White foamy vomit Yellow clear vomit

Thick dark brown vomit Thick dark brown vomit may indicate the presents of stool or blood. This is an abnormal finding that would need to be investigated and communicated.

The client's mother states that this is the third time in recent months she has brought her child to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections the child has had within the past year. What is the nurse's purpose for this question? To assess for suspected child neglect or abuse. To explore the possibility of antibiotic resistance developing. To assess for a possible immune deficiency disorder. To explore the need for a primary care provider to avoid ED visits.

To assess for a possible immune deficiency disorder. By 5 years of age a child should have developed immunity to many types of infections. It they continue to have reccurent infections it may be a sign of immune deficiency which will need further investigation.

When assisting with the planning of care for this client, the nurse's priority is focused toward what client goal? To maintain oxygen at 2 L/minute per nasal cannula. To monitor the child's oxygen saturation continuously. To maintain the child's oxygen saturation greater than 95% on room air. To ensure the child's respiratory function is stable. Submit Previous Section

To maintain the child's oxygen saturation greater than 95% on room air. This client-centered outcome statement describes the desired outcome in measurable terms.

The nurse reports the data about the client's nutritional status to the healthcare provider, who orders several lab tests. The nurse obtains a copy of the lab results the next day. Which statement best describes the value of obtaining laboratory values? To definitively diagnose the severity of the malnutrition. To rule out the cause of the malnutrition. To aid in supplements needed to correct the malnutrition. To use as objective measures in the diagnosis of malnutrition.

To use as objective measures in the diagnosis of malnutrition. No single laboratory test can diagnose malnutrition. There are many factors that should be considered, such as liver and kidney function, fluid balance, and any underlying disease process. Laboratory testing is just one component of the assessment to determine the client's risk and presence of malnutrition.

Nursing Process: Cranial Nerve Assessment: After completing the interview and mental status exam, the nurse tests the client's cranial nerves to determine if there is a deficit. The nurse observes the client moving through the six cardinal fields of gaze by following an object or fingers without the head moving. Which cranial nerves are tested when the nurse is evaluating the client's extra ocular movements? Select all that apply Optic (CN II). Facial (CN VII). Trochlear (CN IV). Trigeminal (CN V). Abducens (CN VI). Oculomotor (CN III).

Trochlear (CN IV). CN IV: Trochlear measures eye movement via superior oblique muscles. Abducens (CN VI). CN VI: Abducens measures eye movement via lateral rectus muscles. Oculomotor (CN III). CN III: Measures motor to eye muscles, eye movement via medial and lateral rectus and inferior oblique and superior rectus muscles; lid elevation via the levator muscle; pupil constriction; ciliary muscles.

The client is wearing thigh-high antiembolic hose prescribed by the Healthcare provider (HCP). The nurse assesses the client's legs every 8 hours. Which assessment finding reflects signs of possible thrombophlebitis that should be reported to the HCP? Paresthesia. Decreases hair growth in lower legs. Negative for pallor. Unilateral calf edema

Unilateral calf edema. Edema, or swelling of one calf, is a possible sign of thrombophlebitis that should be reported to the HCP.

What finding should the nurse expect in response to the client's itching?

Urticaria. Urticaria, or hives, are highly pruritic and can appear in response to many stimuli, including emotional stress.

The nurse prepares to palpate the joints in the client's wrist and hands. First, the nurse supports the client's hands. What action should the nurse take next? Use both thumbs to apply gentle pressure. Use the index fingers to lightly compress the pulses. Ask the client to spread the fingers apart. Instruct the client to make a fist with both hands. Submit Previous Section

Use both thumbs to apply gentle pressure. Both thumbs are used to apply gentle but firm pressure over the joints to palpate for swelling, thickening, nodules, and tenderness.

The initial assessment of client continues. The nurse measures the client's vital signs. His respiratory rate is 32 breaths per minute. What follow-up assessment data should the nurse obtain first? Cigarette smoking history. Use of accessory muscles. Cultural health beliefs. Color of sputum. Submit Previous Section

Use of accessory muscles. Use of accessory muscles indicates an increased respiratory effort by the client and indicates that the client may be experiencing respiratory distress.

While listening to the client's heart sounds at the apical site, the nurse now hears a dull soft sound following S2. What action will help the nurse confirm the presence of this sound?

Use the bell of the stethoscope to continue listening at the apical site. A soft dull sound heard after S2 is an abnormal heart sound. This S3 heart sound is low pitched and is heard best at the apex with the bell of the stethoscope.

When beginning palpation of the client's abdomen, the nurse uses a circular finger motion to depress the client's skin about a half centimeter. While palpating, the client's superficial abdominal muscles become tense and the client states she is very ticklish. What action should the nurse take? Use the client's own hand to assist with palpation. Switch to using the heel of the hand to palpate. Obtain an order for a muscle relaxant. Stop any further palpation immediately. Submit

Use the client's own hand to assist with palpation. The nurse will place their hand over the client's hand and fingers. People are not ticklish to themselves.

Which instruction should the nurse give to the nursing student for positioning the client's legs when he is sitting? Use two pillows and place one lengthwise under each calf. Let him position himself with pillows until he is comfortable. Allow him to use the bed controls to markedly flex his knees. Encourage him to keep his legs flat and not bend his knees.

Use two pillows and place one lengthwise under each calf. This method provides a slight elevation of the lower legs for comfort but avoids pressure behind the knees, which would adversely decrease venous return and decrease the risk for venous thrombosis.

The nurse uses a tuning fork to evaluate what sensory function? Pain. Vibration. Passive motion. Two point discrimination.

Vibration. The client's ability to sense vibration is assessed by placing a vibrating tuning fork on a bony surface.

The nurse notifies the healthcare provider of the elevation in WBCs and receives a prescription for an oral antibiotic. The client is to receive the first dose prior to discharge. Upon entering the client's room with the medication, the nurse observes the client is asleep. The spouse asks the nurse to leave the medication at the bedside for self-administration when he awakens. Which is the most important action for the nurse to implement? Honor the spouse's request and leave the medication capsule at the bedside. Let the client sleep for 1 more hour and return with the antibiotic. Wake the client and administer the first dose of the antibiotic. Allow the client to start the medication at home after discharge.

Wake the client and administer the first dose of the antibiotic. Although the client may need sleep, his need for the antibiotic is greater.

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? Wear clean gloves to carry the specimen to the lab. Wear clean gloves to place the specimen cup in a biohazard bag for transport. Wear gloves and a gown for the best protection. Wash hands after carrying the cup to the lab. Submit

Wear clean gloves to place the specimen cup in a biohazard bag for transport. This protects the person transporting the specimen, as well as the lab personnel receiving the specimen.

After assessing the client and verifying clear lung sounds and no cough, the HCP prescribes a CBC to completed. Which serum lab value confirms the resolution of infection? Red blood cell count (RBC) 4.5 x 106/mcL (4.5 x 1012/L).White blood cell count (WBC) 6000/mcL (6 x 109/L).Hemoglobin at 12 g/dL (120 g/L).Hematocrit at 40% (0.4 proportion of 1.0). Submit Previous Section

White blood cell count (WBC) 6000/mcL (6 x 109/L). This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing

The nurse uses the SBAR method when communicating with the primary HCP. Which are components of the SBAR method? (Select all that apply. One, some, or all options may be correct.) Assessment. Response. Recommendation. Action. Situation.

assessment recommendation situation

Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? (Select all that apply. One, some, or all options may be correct.) Creatine phosphokinase (CPK). Carotid ultrasound. Serum liver enzymes. Chest x-ray. Echocardiogram.

chest x ray echocardiogram

While the client moves the legs through various forms of range of motion, the nurse grades muscle strength. To indicate 100% muscle strength, the nurse assesses for movement against which of these? (Select all that apply.) Gravity. Compare at rest. Light touch. Pain. Resistance. Submit

gravity resistance *When assessing muscle strength, the nurse assesses for movement against resistance and gravity. Grade 5, or 100% muscle strength, is present when the client demonstrates full range of motion against gravity and resistance.

The nurse performs a focused assessment on the client, before he sees the healthcare provider (HCP). As part of the assessment, the nurse evaluates the client for which additional symptoms that are commonly associated with sleep deprivation? (Select all that apply.) Nocturia. Tachycardia. Euphoria. Paresthesia. Sleep apnea.

nocturia sleep apnea

The nurse begins the assessment as the client ambulates in the hallway. What observations should the nurse make while the client is walking to the exam room? Select all that apply Fine motor function. Posture. Gait. Bone density. Balance.

posture gait balance

The client shares with the nurse that knee pain is often experienced. The nurse asks the client about other common joint symptoms. On which symptoms should the nurse focus? (Select all that apply.) Stiffness. Swelling. Cramping. Numbness. Warmth.

stiffness swelling warmth *all are common joint symptoms related to acute inflammation or arthritis.