Intro to Prof. Nursing Final

The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP?

EBP emphasizes the use of best evidence with the clinicians experience.

. During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways?:

Listening to at least one full respiration in each location

Which technique is correct when the nurse is assessing the radial pulse of a patient?:

1 minute, if the rhythm is irregular.

The nurse is preparing to assess the visual acuity of a 16- year-old patient. How should the nurse proceed?

Use the Snellen chart positioned 20 feet away from the patient.

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least:

5 minutes.

The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?:

6

What is the range of urine the bladder can hold?

600-2000mL

A 65-year old man has noticed a change in his personality and his ability to understand. He also cries and becomes angry very easily. The cerebral lobe responsible for these behaviors is the ______________ lobe. A) Frontal B)Parietal C)Occipital D)Temporal

A) Frontal

The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using::

A set of rules.

A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to:

Ask the patient what medications he is currently taking

When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?:

Abnormal laboratory values

The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?:

Acute alcohol intoxication

A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called::

Adduction.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction?:

Air conduction is the normal pathway for hearing.

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these?:

Anteroposterior-to-transverse diameter ratio of 1:1

. The nurse is performing a general survey of a patient. Which finding is considered normal?:

Arm span (fingertip to fingertip) equals the patients height.

What step of the nursing process includes data collection by health history, physical examination, and interview?:

Assessment

The nursing process is a sequential method of problem solving that nurses use and includes which steps?:

Assessment, diagnosis, outcome identification, planning, implementation, and evaluation

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?:

Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation

When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior?:

Be silent, and allow him to continue when he is ready

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the::

Bell of the stethoscope at the apex with the patient in the left lateral position.

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:

Blood flow turbulence.

When expecting appendicitis what test can confirm?

Blumbergs

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?:

Cerebrum

Which critical thinking skill helps the nurse see relationships among the data?:

Clustering related cues

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?:

Dysfunction of the cerebellum

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n)::

Decreased level of consciousness.

oliguria

Decreased urine output

Which of these would be formulated by a nurse using diagnostic reasoning?:

Diagnostic hypothesis

When measuring a patients body temperature, the nurse keeps in mind that body temperature is influenced by::

Diurnal cycle.

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?:

Dullness across the abdomen

During report, the student nurse hears that the patient has "hepatomegaly" and recognizes that this term is?

Enlarged Liver

The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action?:

Evaluate the individuals condition, and compare actual outcomes with expected outcomes.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

Examine the patients lower arm and hand, and check for the presence of infection or lesions.

6. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?:

Examine the tender area last.

Which statement about the apices of the lungs is true? The apices of the lungs::

Extend 3 to 4 cm above the inner third of the clavicles.

The nurse is auscultating the chest in an adult. Which technique is correct?:

Firmly holding the diaphragm of the stethoscope against the chest

The nurse is checking the range of motion in a patients knee and knows that the knee is capable of which movement(s)?:

Flexion and extension

When assessing a patients pulse, the nurse should also notice which of these characteristics?:

Force

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?

Friction rub

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.:

Frontal

A patients annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called::

Functional scoliosis.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination?:

Gathering mental status information during the health history interview is usually sufficient.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the::

Glenohumeral joint.

The nurse is preparing to auscultate for heart sounds. Which technique is correct?:

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex

The nurse is performing an ear examination of an 80-yearold patient. Which of these findings would be considered normal?:

High-tone frequency loss

When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these?

Holistic health views the mind, body, and spirit as interdependent

During a mental status examination, the nurse wants to assess a patients affect. The nurse should ask the patient which question?:

How do you feel today?

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?:

Hyperactive reflexes

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

I know my name is John. I am at the hospital in Spokane. I couldnt tell you what date it is, but I know that it is February of a new year2010

the system for sensing the position and movement of individual body parts

Kinesthesis (Kinesthetic sense)

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?:

Level of consciousness, motor function, pupillary response, and vital signs

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would::

Listen with the bell of the stethoscope to assess for bruits.

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient:

May take a little longer to respond, but his general knowledge and abilities should not have declined.

For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?:

Measurement of weight and weight history

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _________ joint.:

Metacarpophalangeal

During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?:

Mild, even resistance to movement

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?:

Motor component of CN VII

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient::

Moves the head and shoulders against resistance with equal strength

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?:

Murmur at the second left intercostal space when supine

What test should be run if gallbladder is inflammed?

Murphy's

The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.: a

Nursing

During an examination, the nurse can assess mental status by which activity?:

Observing the patient and inferring health or dysfunction

The nurse is performing a general survey. Which action is a component of the general survey?:

Observing the patients body stature and nutritional status

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?:

Percuss and palpate the midline area above the suprapubic bone.

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurses best course of action?:

Perform a complete mental status examination.

The sac that surrounds and protects the heart is called the::

Pericardium.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing mental status in this patient?:

Please point to articles in the room and parts of the body as I name them.

The nurse knows that testing kinesthesia is a test of a persons:

Position sense

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as::

Presence of dysdiadochokinesia.

The nurse is examining the lymphatic system of a healthy 3- year-old child. Which finding should the nurse expect?

Presence of palpable lymph nodes

A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as::

Protuberant.

What is the consistency of your poop in the transverse colon?

Pudding (thick liquid)

A patient is complaining of pain in his joints that is worse in the morning, better after he moves around for a while, and then gets worse again if he sits for long periods. The nurse should assess for other signs of what problem?:

Rheumatoid arthritis

When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is:

Sensory-perceptive abilities

In assessing a patients major risk factors for heart disease, which would the nurse want to include when taking a history?:

Smoking, hypertension, obesity, diabetes, and high cholesterol

The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the::

Subjective report.

During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems?:

Teach the nurses how to conduct electronic searches for research studies.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a lazy eye and should::

Test for strabismus by performing the corneal light reflex test

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?

The flow of lymph is slow, compared with that of the blood

While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?:

These findings can all be normal in a child

A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is::

Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.

. During an abdominal assessment, the nurse would consider which of these findings as normal?:

Tympanic percussion note in the umbilical region

Which statement best describes a proficient nurse? A proficient nurse is one who::

Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient

what test as a nurse would you anticipate if pt has black tarry stools

Upper endoscopy

. A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, I buy obie get spirding and take my train. What is the best description of this patients problem?:

Wernickes aphasia

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?:

While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

In performing a voice test to assess hearing, which of these actions would the nurse perform?:

Whisper a set of random numbers and letters, and then ask the patient to repeat them.

The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

african american

Where does gas exchange occur?

alveoli

To test for stereognosis, you would: A) Have the person close his or her eyes, and then raise the person's arm and ask the person to describe its location. B) Touch the person with a tuning fork. C) Place a coin in the person's hand and ask him or her to identify it. D) Touch the person with a cold object

c. Place a coin in the person's hand and ask him or her to identify it.

A nurse is instructing the client about healthy sleep habits. Which of the following statements by the clients alerts the nurse that further teaching is indicated? A) "I don't take naps throughout the day." B) "I go to bed and get up routinely at the same time each day." C) "I have a small snack and take a bath before going to bed each day." D) "I watch television until I fall asleep at night."

D) "I watch television until I fall asleep at night." Environmental stimuli should be avoided to promote healthy sleep habits; therefore, additional teaching is indicated.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is:

Otosclerosis

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland.

Parotid

A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition?:

Prostatitis

A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to:

Provide culturally sensitive and appropriate care

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes?

Reflexes will be normal

A nurse who is caring for a client discusses strategies to promote rest and sleep. Which of the following statements indicates a need for further teaching? A) "I will walk briskly for 30 minutes before bedtime." B) "I will limit a glass of wine to 4 hours before bedtime." C) "I will avoid drinking large amounts of fluids immediately before bed." D) "I will engage in muscle relaxation techniques before bedtime."

A) "I will walk briskly for 30 minutes before bedtime." This statement indicates a need for further teaching. The client should avoid exercising right before bedtime because this can stimulate the client rather than relaxing the client. If the client wants to exercise in the evening, it should be 2 to 3 hr before bedtime, which allows the body to cool down and maintain a state of fatigue that promotes relaxation. Studies have shown that morning exercise may help set the client's circadian rhythm to alertness during the day and promote a full sleep cycle during the night.

A nurse is completing discharge teaching to a client with osteoarthritis. Which of the following statements by the client indicates the understanding of the teaching about this disease process? A) "It occurs due to the aging process and results in disintegration of cartilage in a joint." B) "It is due to loss of calcium in the bones and fractures can then occur." C) "It is caused by inflammation that affects both joints and other body tissues." D) "It happens in several phases when deposits of crystals develop in joints and soft tissues."

A) "It occurs due to the aging process and results in disintegration of cartilage in a joint." Aging and obesity are the leading factors that cause osteoarthritis, a disease of progressive loss of cartilage.

A client asks about the functions if the thymus, spleen, and lymph nodes. Which of the following responses by the nurse is appropriate? A) "These organs are for immunity." B) "These organs are used in digestion." C) "These organs regulate electrolyte balance." D) "These organs assist vitamin absorption."

A) "These organs are for immunity." The nurse informs the client that the function of the thymus, spleen, and lymph nodes are for immunity and to fight infection.

A nurse is preparing to collect health history data during a client admission. Which of the following questions by the nurse best promotes this discussion? A) "What brought you to the hospital?" B) "Would you tell me about all of your medical issues?" C) "Do you want to talk about your health concerns?" D) "Would it help to discuss your feelings about this hospitalization?"

A) "What brought you to the hospital? This response is a focused, open-ended statement. Open-ended questions allow a client to tell his or her story in detail and to relate what is important. It invites the client to communicate, while centering on the reason for seeking health care. This allows a nurse to focus on the client's priorities. Therapeutic communication is client-centered and goal-directed. It allows the client to explore thoughts and feelings and helps to establish a therapeutic relationship between the nurse and client.Components of the health history include demographic information, source of history, chief concern, history of present illness, past health history and current health status, family history, social history, and health promotion behaviors.

A nurse is caring for a client who has impaired renal function. The nurse should notify the provider if the client's hourly urine output falls below which of the following? A) 30mL B) 45mL C) 60mL D) 75mL

A) 30mL Output that is less than 30 ml/hr should be reported to the provider. This alerts the nurse to severe fluid imbalance and means the client has a decreased circulating fluid volume, and possibly inadequate renal perfusion.

While auscultating a clients heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A) A cardiac murmur B) A third heart sound (S3) C) An expected heart sound D) A fourth heart sound (S4)

A) A cardiac murmur

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A) Apply a moisture barrier ointment to the skin B) Clean with soap after each episode of incontinence C) Check the client's skin every shift for signs of breakdown. D) Request a prescription for the insertion of an indwelling urinary catheter.

A) Apply a moisture barrier ointment to the skin Skin that is left in contact with urine for prolonged periods of time is at risk for maceration and breakdown. Cleansing the skin and removing items that are wet (e.g., incontinence pads, sheets, undergarments) is a priority to prevent breakdown. Moisture-barrier ointments and creams also are useful to prevent the urine from coming in contact with the skin. Moisture barriers should be applied to the client's skin after cleansing, keeping the epidermis lubricated but not oversaturated.

When checking a clients capillary refill, the nurse finds that the color returns to usual in 10 seconds. The nurse understands that this finding indicates which of the following? A) Arterial insufficiency B) Venous insufficiency C) Within the expected range D) Thrombus formation in the vein

A) Arterial insufficiency To test capillary refill, the nurses presses on the client's nail beds to produce blanching and then measures the time it takes for the color to return. With adequate arterial capillary perfusion, the color should return within 3 seconds. Taking longer than 3 seconds indicates impaired arterial blood flow to the extremity.

A nurse is assessing a client who is 2 days postoperative auscultates bilateral breath sounds but absent sounds in the bases. The nurse should suspect which of the following postoperative complications? A) Atelectasis B) Crackles C) Rhonchi D) Pneumothorax

A) Atelectasis Atelectasis is an incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A charge nurse is making client care assignments. Which of the following tasks should the nurse plan ti delegate to AP?(Select all that apply.) A) Bathing a client who had an amputation 2 days ago. B) Assisting a client to ambulate using a gait belt. C) Reviewing low sodium diet for a client who has hypertension. D) Explaining oral hygiene to a client receiving chemotherapy. E) Feeding a client who had a stroke 3 months ago.

A) Bathing a client who had an amputation 2 days ago. B) Assisting a client to ambulate using a gait belt. E) Feeding a client who had a stroke 3 months ago.

The nurse is caring for a client who is receiving treatment following a motor vehicle crash. Which of the following is appropriate for determining the clients alertness? A) Check client's eye opening in response to verbal stimuli. B) Check pupillary response to light. C) Check client's motor response to nail bed pressure. D) Check client's response to questions about place and time.

A) Check client's eye opening in response to verbal stimuli. Checking the client's eye opening response to verbal stimuli is an appropriate method to check alertness.

The nurse is caring for a client who is having a colonoscopy. The client states, "I am so nervous about what the doctor might find during the test." The nurse responds by saying: "Are you feeling anxious about the results of your colonoscopy?" The nurse's response is an example of which of the following communication techniques? A) Clarification B) Paraphrasing C) Sharing observations D) Providing Information

A) Clarification Clarifying verifies whether the sender's message is clear and accurate and is a therapeutic communication technique.

A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident(CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A) Establish the ability to communicate effectively. B) Have a regular, formed stool at least every other day. C) Learn to control impulsive behavior. D) Improve left-side motor function.

A) Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

A nurse is providing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) A) Excessive laxative use B) Ignoring the urge to defecate C) Inadequate fluid intake D) Increased fiber in the diet E) Increased activity

A) Excessive laxative use B) Ignoring the urge to defecate C) Inadequate fluid intake

A nurse is preparing an older adult client for a physical examination to be preformed by a provider. Which of the following actions should the nurse implement? A) Explain to the client what is about to happen. B) Ensure the room is kept at a cool temperature. C) Provide music as an environmental distraction. D) Inform the client that sensitive areas will be examined first.

A) Explain to the client what is about to happen. Explaining assessment techniques decreases stress and anxiety. It also increases trust and promotes a therapeutic nurse-client relationship. Other therapeutic techniques used during physical assessment include the following:• Ensuring there is adequate lighting• Maintaining a quiet and comfortable environment• Providing privacy, using a gown or draping the client with a sheet and visualizing onlyone section of the body at a time• Inspecting before touching• Keeping nails short, and hands and stethoscope warm• Not palpating or auscultating through clothing (Clothing can obscure or create sounds.)• Having necessary equipment ready• Using standard precautions when in contact with body fluids, wound drainage, andopen lesions• DocumentingAdditional guidelines for performing a physical assessment of older adult clients include the following:• Allowing enough time for position changes• Performing assessments in several shorter segments to avoid overtiring the client• Having sensory aids available to use, such as eyeglasses or hearing aids

A nurse is caring for a client who sustained a large contusion on the head and a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following observations indicates to the nurse that the client could be developing serious complications? A) Increased respiratory rate from 18 to 44/min. B) Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). C) Increased blood pressure from 112/68 to 120/72 mm Hg. D) Increased heart rate from 68 to 72/min.

A) Increased respiratory rate from 18 to 44/min. This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances.

The nurse is caring for a patient who is actively bleeding. The physician orders blood transfusion. The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order. The patient states that she is a Jehovah's Witness and does not want blood products. The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories? A) Leininger's cultural care theory B) Roy's adaptation theory C) Watson's philosophy of caring D) Orem's self-care theory

A) Leininger's cultural care theory The goal of Leininger's theory is to provide the patient with culturally specific nursing care that integrates the patient's cultural traditions, values, and beliefs into the plan of care. The goal of Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. Watson's theory believes that the purpose of nursing action is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

A nurse is caring for a client who is postoperative following a cholecystectomy and is reporting pain. Which of the following actions should the nurse take?(Select all that apply.) A) Offer the client a back rub. B) Look for nonverbal pain indicators. C) Identify the client's pain level. D) Assist the client to ambulate. E) Change the client's position.

A) Offer the client a back rub. C) Identify the client's pain level. E) Change the client's position.

Nursing's metaparadigm includes which of the following? (Select all that apply). A) Person B) Disease C) Health D) Environment E) Nursing

A) Person C) Health D) Environment E) Nursing

A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to pain stimulus is within normal limits? A) Pushes the painful stimulus away. B) Extends the body part toward the stimuli. C) Shows no reaction to the painful stimuli. D) Flexes the upper and extends the lower extremities.

A) Pushes the painful stimulus away. The client who pushes the painful stimulus away is a normal response that is purposeful and appropriate.

A nurse is completing discharge teaching with a client. Which of the following is not a barrier to instruction? A) Repetition of information B) Client age C) The client's culture D) The client's illness

A) Repetition of information The repetition of information facilitates learning and is thus not considered a barrier to learning.

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following is an expected finding? A) Reports of exposure to a skin irritant B) Denial of pruritus C) Systemic symptoms including elevated temperature D) Reports of generalized joint discomfort

A) Reports of exposure to a skin irritant The most common cause of contact dermatitis is exposure to a topical irritant therefore identifying this irritant is an important component of treatment.

A nurse is caring for a client who is experiencing dysphagia. Which of the following referrals is appropriate at this time? A) Speech therapist B) Social worker C) Registered dietician D) Occupational therapist

A) Speech therapist A speech therapist assesses and makes recommendations for clients experiencing speech, language, and swallowing difficulties. It would be appropriate for a client who has dysphagia to be referred to a speech therapist for a swallowing evaluation.?

In reviewing literature for an evidence-based practice study, the nurse realizes that the most reliable level of evidence is the A) Systematic review and meta-analysis. B) Randomized control trial (RCT). C) Case-control study. D) Control trial without randomization.

A) Systematic review and meta-analysis. In a systematic review or meta-analysis, an independent researcher reviews all of the RCTs conducted on the same clinical question and reports whether the evidence is conclusive, or if further study is needed. A single RCT is not as conclusive as a review of several RCTs on the same question. Control trials without randomization may involve bias in how the study is conducted. Case control studies also have room for bias.

A nurse hears a low-pitched extra heart sound before what should be considered the first heart sound (S1) when auscultating a clients heart sounds with the bell of a stethoscope. The nurse should document this finding as which of the following heart sounds? A) The fourth heart sound (S4) B) A friction rub C) The third heart sound (S3) D) A split second heart sound S2

A) The fourth heart sound (S4) S4 is an extra sound that is best heard with the bell of a stethoscope. S4 occurs during the second phase of ventricular filling, near the end of diastole, when the atriums contract just before S1. The low-pitched sound is thought to be caused by the vibration of valves, supporting structures, and the ventricular walls. An abnormal S4 is heard in people who have conditions that increase resistance to ventricular filling, such as a weak left ventricle.

In collecting the best evidence, the gold standard for research is A) The randomized controlled trial B) The peer-reviewed article C) Qualitative research D) The opinion of expert committees

A) The randomized controlled trial Individual RCTs are the gold standard for research. A peer-reviewed article means that a panel of experts has reviewed the article; this is not a research method. Qualitative research is valuable in identifying information about how patients cope with or manage various health problems and their perceptions of illness. It does not usually have the robustness of an RCT. Expert opinion is on the bottom of the hierarchical pyramid of evidence

An RN is planning to delegate tasks to a (LPN). Which of the following is important for the nurse to understand when delegating task to the LPN? A) The state Nurse Practice Act B) The National Association for Practical Nurse Education and Services Standards C) The National Council of State Boards of Nursing Decision Tree D) The Omnibus Budget Reconciliation Act of 1987

A) The state Nurse Practice Act The state Nurse Practice Act identifies the skill or educational level needed by a nurse to complete a task as well as indicating items that can and cannot be delegated from a legal perspective.

A nurse is emptying a clients urinal when she notices the urine is a dark amber, cloudy and has an unpleasant odor. There findings are associated with which of the following ? A) UTI B) Urinary incontinence C) Urinary frequency D) Urinary retention

A) UTI These findings are associating with a urinary tract infection. The urine appears cloudy and concentrated because of the presence of WBC, RBC, and bacteria. Pus and bacteria can cause the unpleasant smell. These are all characteristics of a UTI.

A nurse is planning care for an older adult client who is at high risk for developing pressure ulcers. Which of the following is an appropriate measure for the nurse to include? A) Use a draw sheet to move the client up in bed. B) Apply cornstarch to keep sensitive skin areas dry. C) Massage the skin over the client's bony prominences. D) Elevate the head of the bed no more than 45 degrees.

A) Use a draw sheet to move the client up in bed. Using a draw sheet or a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

The nurse is caring for a patient who is known as a "frequent flyer," and who has been labeled as "noncompliant" by most of the staff because she does not follow her prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patients "noncompliance." This is because Orem's theory A) is useful in designing interventions to promote self-care. B) does not allow for environmental influences on care. C) allows for development of a plan of care that the patient must follow. D) is not useful in promoting self-care regimens.

A) is useful in designing interventions to promote self-care. Orem's theory explains the factors within a patient's living situation that support or interfere with the patient's self-care ability. This theory has value in helping nursing design interventions with the patient that will help to promote the patient's self-care in managing an illness, such as diabetes or arthritis

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change?:

Nerve degeneration in the inner ear

Barriers to incorporating EBP include::

Nurses lack of research skills in evaluating quality of research studies

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?:

Appendix

. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of being awakened from sleep with shortness of breath. Which action by the nurse is most appropriate?:

Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the nurse expect to find during the physical assessment?:

Asymmetric, hard, and fixed prostate gland

A charge nurse is planning care for 4 clients on a medical unit. Which of the following task should the nurse delegate to an AP(select all that apply.) A) Demonstrate the technique to instill eye drops. B) Ambulate a client who has a cane. C) Debride a wound. D) Transfer a client to a stretcher. E) Record urinary output.

B) Ambulate a client who has a cane. D) Transfer a client to a stretcher. E) Record urinary output.

A nurse notices an AP preparing to deliver a food tray to a client who is Orthodox Jewish. On the tray is a roast beef dinner with nonfat milk. Which of the following is an appropriate nursing action? A) Allow the AP to deliver the food tray to the client. B) Call the dietary department and ask for a kosher tray. C) Replace the nonfat milk with apple juice. D) Explain to the client that he needs the protein in the milk and the beef.

B) Call the dietary department and ask for a kosher tray. This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who are Orthodox Jewish do not eat meat and dairy together.

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? A) Brachial B) Carotid C) Femoral D) Popliteal

B) Carotid The nurse should avoid assessing the carotid pulse bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? A) Vital sign measurement B) Client's self-report of pain severity C) Visual observation for nonverbal signs of pain D) Nature of invasiveness of the surgical procedure

B) Client's self-report of pain severity Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.

A nurse is caring for several hospitalized patients. The nurse should perform the nursing process in which of the following sequences? A) Critically analyze data to determine priorities B) Collect and organize data about the client C) Set client-centered, measurable, and realistic goals D) Determine effectiveness of interventions

B) Collect and organize data about the client A) Critically analyze data to determine priorities C) Set client-centered, measurable, and realistic goals D) Determine effectiveness of interventions

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect? A) Necrotic foot ulcers B) Edema C) Hair loss D) Thick, deformed toenails

B) Edema An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema.

A client tells the nurse at the clinic that she thinks she might be developing rheumatoid arthritis(RA) because she has some stiffness in her joints. Which other early manifestation of the RA should the nurse expect to find when she assesses the client? A) Muscle atrophy B) Fatigue C) Temporomandibular joint pain D) Decreased range of motion

B) Fatigue Fatigue and joint swelling, pain, and stiffness are early manifestations of RA.

A nurse is planning care for a client who has end-stage renal disease. On assessment, the client has a 20 lb weight gain, crackle lung sounds, elevated blood pressure, and jugular neck vein distention. Which of the following findings explains the clients symptoms? A) Hypovolemia B) Hypervolemia C) Hyperkalemia D) Hyponatremia

B) Hypervolemia The client is experiencing hypervolemia, which is fluid overload and failure of the homeostatic systems that regulate fluid balance.

A client tells the nurse at an outpatient clinic that he has leg pains that begin when he walks but cease when he stops walking. Which of the following disorders should the nurse suspect? A) An acute obstruction in the vessels of the legs B) Peripheral vascular problems in both legs C) Diabetes mellitus D) Calcium deficiency

B) Peripheral vascular problems in both legs This describes intermittent claudication, an indication of vascular deficiencies, often peripheral arterial disease.

A nurse is caring for a client who is 36 weeks pregnant and has been admitted ti the obstetrical unit for continuous close observation. The client confides to the nurse that she doesn't think she will ever be a mother and begins to cry. Which of the following responses by the nurse is appropriate? A) Reassure the client that advanced medical knowledge will detect any problems with her pregnancy. B) Sit quietly with the client and follow her cues. C) Suggest that the client discuss her fears with her physician. D) Gently change the subject to something more ¬positive.

B) Sit quietly with the client and follow her cues. The client has indicated a need to talk and explore her feelings. Sitting with her and following her cues is an appropriate response by the nurse, and will assist in developing a therapeutic relationship.

A nurse is assessing a clients bowel sounds. The nurse understands that the bowel sounds should be auscultated A) after palpating the abdomen. B) prior to percussing the abdomen. C) after checking for kidney tenderness. D) prior to inspecting the abdomen.

B) prior to percussing the abdomen. Auscultation should be performed prior to percussing the abdomen to prevent altering the bowel sounds.

A nurse is assessing a client who has insomnia.Which of the following questions is the highest priority for the nurse to ask the client? A) "Are there any specific factors that you think is affecting your ability to sleep?" B) "Can you describe for me your bedtime routine?" C) "Do you have difficulty staying awake when you are driving?" D) "When did you begin to have trouble sleeping?"

C) "Do you have difficulty staying awake when you are driving?" This question addresses the greatest risk to the client which is safety and therefore is the priority question.

A nurse ids caring for a client who is 1 day postoperative following gynecological surgery and reports incisional pain. Which of the following actions should the nurse take first? A) Determine the time the client last received pain medication. B) Measure the client's vital signs, including temperature. C) Ask the client to rate her pain on a scale of 0 to 10. D) Reposition the client and offer her a back rub.

C) Ask the client to rate her pain on a scale of 0 to 10. The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse needs to know the severity of the client's pain before determining the appropriate interventions.

A nurse is giving a client a cold compress for episiotomy pain. Which of the following would be the best measurement of pain relief? A) Inspecting site for reduced swelling B) Monitor clients pulse rate C) Asking the client to rate the pain D) Assessing ability to urinate

C) Asking the client to rate the pain Pain is a subjective experience. Clients should be encouraged by the nurse to indentify pain and evaluate the response to pain management. This is done using pain scale from 1 to 10 at the time of the pain, and a relief rating is used after pain therapy. A pain diary may be used as a tool that documents the client's experience and helps the nurse evaluate the relief achieved. The client's pain rating, the relief rating 1 hour after cold compress, and other measures should be assessed by the client and nurse to evaluate the most effective pain relief measures.

A nurse is admitting a client for diagnostic testing. In which phase of the nursing process should the nurse ask the client about potential allergies? A) Planning B) Evaluation C) Assessment D) Implementation

C) Assessment The assessment phase is the appropriate time to ask the client about potential allergies.

A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse preform first? A) Reposition the client. B) Administer the medication. C) Determine the location of the pain. D) Review the effects of the pain medication.

C) Determine the location of the pain. Using the nursing process, assessment of the location of the pain is the priority action by the nurse.

A nurse is preparing a teaching plan for a client who has just found out that she has type 2 diabetes mellitus. What is the nurse's priority in preparing this plan? A) Establish short-term, realistic goals for the client. B) Give her access to a video about diabetes. C) Determine what the client knows about managing her diabetes. D) Evaluate the effectiveness of the client's admission teaching plan.

C) Determine what the client knows about managing her diabetes. The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should find out what the client knows before proceeding with the plan.

A nurse is caring for an older adult client who reports constipation. Which of the following is an appropriate nursing recommendations? A) Bear down hard when defecating. B) Drink 600 mL of water daily. C) Eat raw vegetables. D) Limit activity.

C) Eat raw vegetables. The client should eat raw vegetables to help provide fiber in the diet to increase stool bulk and move the stool through the colon to prevent constipation.

A nurse is planning care for a female client. Which of the following nursing actions is appropriate for helping to decrease the clients risk of a UTI while hospitalized? A) Cleanse the perineum from back to front. B) Obtain a prescription for an indwelling urinary catheter. C) Encourage fluid intake at and between meals. D) Offer the client the bedpan every 2 hr.

C) Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.

The nurse is caring for a client in an acute care facility. Which of the following actions by the nurse is appropriate? A) Determining the clients length of stay. B) Assigning roles to members of the interdisciplinary team. C) Ensuring the care plan meets individual needs of the client. D) Establishing the client's secondary medical diagnoses.

C) Ensuring the care plan meets individual needs of the client. The client's plan of care should be flexible to meet the changing needs of the client; the nurse should ensure the care plan meets individual needs of the client.

A nurse is caring for a client with a new diagnosis of diabetes mellitus type 1. Which of the following is an appropriate teaching intervention that focuses on affective learning? A) Ask the client to preform a return demonstration of insulin injection B) Review the action of insulin therapy C) Explore the clients feelings about dietary modifications D) Have a family member practice blood glucose monitoring using a glucometer

C) Explore the clients feelings about dietary modifications This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.

A nurse is assessing a client's abdomen who reports "stomach pain". Which of the following actions should the nurse do first? A) Auscultate B) Percuss C) Inspect D) Palpate

C) Inspect The nurse should inspect the abdomen for external abnormal conditions first.

When assessing a client who has atrial fibrillation, the nurse would expect his pulse to be A) Slow B) Not palpable C) Irregular D) Bounding

C) Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

A nurse is completing a clients history and physical examination. Which information should the nurse consider subjective data? A) Blood pressure B) Cyanosis C) Nausea D) Petechiae

C) Nausea Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

1. The nurse is making rounds and finds her older adult patient sobbing and obviously upset. She states that her doctor told her that she has cancer, and she does not want to die. "What's the sense?" she says. "I might as well die. I'm going to anyway. I guess that shows how useless I really am. Nobody wants an old lady around." The nurse notices that the patients respirations have increased, and the tip of her nose and ear lobes are becoming cyanotic. The nurse assesses the patient and finds that the patients pulse rate is over 150 beats per minute. According to Maslow's hierarchy of needs, the nurse should first A) Call the physician to request a psychiatric consult. B) Reassure the patient that she has value as a human being. C) Place the patient on oxygen and try to calm her. D) Call the patients family to help her realize that she is wanted.

C) Place the patient on oxygen and try to calm her. Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. These include physiological needs such as air, water, and food. Cyanosis and fast heart rate are indicators of physiological stress and must be dealt with first, or the patient may not survive. The second level includes psychological security. A psychiatric consult would come after physiological stabilization. The third level includes love and belonging needs that would also need to be addressed, and the family may be helpful in dealing with this, once the patient is stabilized. The fourth level involves self-esteem, which would also need to be addressed.

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? A) Reposition the client every 3 hr. B) Massage bony prominences to promote circulation. C) Provide the client with a diet high in protein. D) Apply cornstarch to keep the skin dry.

C) Provide the client with a diet high in protein. Inadequate protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse manager is assigning care responsibilities for the upcoming shift. A client is awaiting transfer back to the unit from the PACU following hip arthroplasty. To which staff member should the nurse assign to this client? A) Charge nurse B) LPN C) RN D) Assistive personnel (AP)

C) RN A client returning from a surgical procedure requires assessment and establishment of a plan of care. RNs are responsible for client assessment, establishment of an individualized plan of care, and identification of expected client outcomes. An RN is the appropriate choice.

A nurse is performing an admission assessment on a client. Which of the following findings is an indicator of dehydration? A) Red mucous membranes B) Jugular vein distention C) Skin tenting present D) Blood pressure 178/90 mm Hg

C) Skin tenting present A client who has dehydration has poor skin turgor, or skin tenting, which the nurse should observe for over the sternum or the back of the hand.

An older adult client in a long-term care facility has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for his incontinence, which of the following interventions should the nurse initiate to manage behavior? A) Remind the client to tell the nurse when he has to urinate. B) Use adult diapers to prevent frequent clothing changes. C) Take the client to the bathroom on an every- 2-hr schedule. D) Request a prescription for an indwelling urinary catheter.

C) Take the client to the bathroom on an every- 2-hr schedule. It is important to attempt measures that might help prevent incontinence before resorting to measures that can cause complications like infection and skin breakdown. For some clients, regular toileting can help manage this problem.

A nurse is talking with a client who has a new diagnosis of gout. When the client asks the nurse how she got this disorder, the nurse should explain, in terminology the client can understand, that gout develops when A) uric acid levels drop and calcium forms precipitates. B) tophi form in the kidneys and they impair the excretion of uric acid. C) the intra-articular deposition of urate crystals causes inflammation. D) articular cartilage thins, leading to splitting and fragmentation.

C) the intra-articular deposition of urate crystals causes inflammation.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is:

Candidiasis

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?:

Complete neurologic examination

. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:

Consider this finding as normal, and proceed with the examination.

A nurse is caring for a client who has recently fallen while getting out of bed and states, "I'm okay! I guess i should have called for help to the bathroom." After assessing the client, the nurses notifies the provider. Which of the following findings should the nurse include in her documentation in the chart? A) "There were no injuries sustained." B) "The incident report was completed." C) "The incident report was forwarded to risk management." D) "The provider was notified."

D) "The provider was notified." Notifying the provider is important, and this information needs to be documented in the chart.

A nurse is planning to prioritize client care after receiving report. Which of the following clients is a high priority for the nurse to see first? A) A client who is ambulatory and going for an x-ray at 10:00 A.M. B) A client who is to be discharged at 11:00 A.M. C) A client who received pain medication 30 minutes ago. D) A client who is short of breath.

D) A client who is short of breath. Using the airway, breathing, and circulation framework of care to determine the highest priority, the priority should be to visit the client who is short of breath.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients level of strength? A) Ask the client how strong they feel today. B) Ask the client if they have been up today. C) Check the pedal pulses and feet for edema. D) Ask the client to push their feet against the nurse's palms.

D) Ask the client to push their feet against the nurse's palms. Asking the client to push with the feet against the nurse's hands is an appropriate method of determining the client's level of strength.

A nurse is assessing a client who has COPD. The nurse should expect the clients chest to be which of the following shapes? A) Pigeon B) Funnel C) Kyphotic D) Barrel

D) Barrel Clients who have COPD chronically use accessory muscles to assist with respiratory effort. The chest wall eventually develops in an anterior-posterior diameter, making it appear barrel shaped.

A nurse is assessing a client who has a respiratory disorder. If the client has hypoxia, the nurse should expect which of the following findings? A) Bradycardia B) Bradypnea C) Pallor D) Cyanosis

D) Cyanosis Cyanosis Hypoxia is too little oxygen anywhere in the body. A client who is hypoxic will eventually develop cyanosis, unless the client also has severe anemia or certain other conditions that prevent the manifestation of cyanosis.

A nurse is admitting a client with a partial hearing impairment. Which of the following is the priority action by the nurse? A) Speak using a normal tone of voice B) Stand directly in front of the client C) Rephrase statements as needed D) Determine if the client uses a hearing aid

D) Determine if the client uses a hearing aid Using the nursing process, assessment is the first action by the nurse.

A nurse in the emergency department is assessing a client who has multiple injuries of the abdomen. Which of the following findings require further investigation by the nurse? A) Symmetry of the lower quadrants B) Concave umbilicus C) Bilateral bowel sounds of lower quadrants D) Ecchymosis

D) Ecchymosis Ecchymosis is an abnormal finding of the abdomen and may indicate internal injury.

A nurse is preparing an inservice for a group of a newly licensed nurses about client confidentiality. The nurse should explain that they may share a clients protected health information with which of the following groups? A) The client's immediate family members B) Clergy affiliated with the facility C) The facility's administrators D) Health care team members caring for the client

D) Health care team members caring for the client To coordinate safe and effective care delivery, the nurse may share details of a client's health status and treatment plan with others who are responsible for delivering client care. The Health Insurance Portability and Accountability Act (HIPAA) allows sharing of information necessary for treating clients.

An acute nurse id caring for an adult client who is undergoing evaluation for a possible brain tumor. When preforming a neurological examination, which of the following is the most reliable indicator of cerebral status? A) Pupil response B) Deep tendon reflexes C) Muscle strength D) Level of consciousness

D) Level of consciousness The nurse should examine the client's level of consciousness as the most reliable indicator of cerebral status.

A nurse in a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following task should the charge nurse avoid assigning to the volunteer? A) Delivering meal trays to clients in their rooms B) Assisting a client who has difficulty seeing the foods on the tray while eating C) Delivering a routine urine specimen to the laboratory D) Observing a postoperative client who is confused

D) Observing a postoperative client who is confused A volunteer does not have the training to intervene if this client tries to get out of bed or starts pulling at tubes. The observation of this client should be assigned to a member of the nursing staff.

A nurse id caring for a client who was found to have a spinal cord transection at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? A) Paresthesia B) Hemiplegia C) Quadriplegia D) Paraplegia

D) Paraplegia Paraplegia, paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is assessing a client who has respiratory insufficiency. Which of the following findings should the nurse recognize as an early sign of inadequate oxygen? A) Diaphoresis B) Combativeness C) Oliguria D) Restlessness

D) Restlessness Early signs of inadequate oxygenation include unexplained apprehension, restlessness, irritability; tachypnea, tachycardia, dyspnea on exertion, and mild hypertension.

A nurse is assessing a client who has a left sided heart failure. Which of the following findings should the nurse expect? A) Jugular venous distention B) Right upper quadrant pain C) Pitting edema of the lower legs D) Shortness of breath while laying down

D) Shortness of breath while laying down Orthopnea, or shortness of breath when the client lies down, is a characteristic manifestation of left-sided heart failure. Increased lung pressures from interstitial and alveolar edema cause it.

Qualitative nursing research is valuable in that it A) Excludes all bias. B) Uses randomization in structure. C) Determines associations between variables and conditions. D) Studies phenomena that are difficult to quantify.

D) Studies phenomena that are difficult to quantify.

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should make the nurse suspect deep-vien thrombosis (DVT)? A) Coolness of the leg B) Decreased pedal pulses C) Pain in the ankle and foot D) Unilateral leg edema

D) Unilateral leg edema Clients who have DVT may have no symptoms at all or may have unilateral leg edema, extremity pain, warm skin, erythema, or fever.

A nurse id auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following? A) Crackles B) Rhonchi C) Stridor D) Wheezes

D) Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

A client tells the nurse that he is concerned because his doctor told him he has a heart murmur. The nurse should explain to the client that a murmur A) is a high-pitched sound due to a narrow valve. B) is an extra sound due to blood entering an inflexible chamber. C) means that there is some inflammation around your heart. D) indicates turbulent blood flow through a valve.

D) indicates turbulent blood flow through a valve.

A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure(ICP) is A) bradycardia B) ipsilateral pupil dilation C) widening pulse pressure D) lethargy

D) lethargy Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy.

A nurse is monitoring a client who is at risk for increased intracranial pressure. While assessing the clients cranial nerves, the nurse should check the function of cranial nerve III by A) testing visual acuity. B) observing for facial asymmetry. C) eliciting the gag reflex. D)checking pupillary response to light.

D)checking pupillary response to light. Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great, and then I wake up and feel like I cant get my breath. The nurses best response to this would be:

Do you have any history of problems with your heart?

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

Enlarged and tender inguinal nodes

During a cardiac assessment on a 38-year-old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings?:

Heart failure

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?:

Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting:

Tinea capitis

During a cardiovascular assessment, the nurse knows that a thrill is:

Vibration that is palpable.