NUR 204 ATI Health Assessment Chap. 26-31
A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable?
-Education -Gender -Perception
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
-Poor skin turgor -Hypotension -Flat neck veins
A nurse is admitting a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?
Shivering
A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?
Tachycardia
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?
Temporary urinary retention
A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?
Ventricular gallop
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?
-Contractures of the extremities -Crackles in the lungs -Pressure ulcers
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes?
-Decreased gastric motility -Decreased skin elasticity -Increased pain threshold
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?
"Do you have any difficulty staying awake when you are driving?"
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
"Information about a client can be disclosed to family members at any time."
A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection?
-An increase in neutrophils -Localized edema
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client?
-Water heater temperature 54.4 degrees C (130 degrees F) -Throw rugs
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?
Albumin
A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?
Ask the client to rate her pain on a scale from 0 to 10
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?
Attach a humidifier bottle to the base of the flow meter
A nurse is assessing a client who is receiving bolus enteral feedings. Which of the following laboratory values indicates the client needs a change in the formula?
BUN 28 mg/dL
A nurse is caring for a client who came to the emergency department with abdominal distention and is not on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?
Check to see if the suction equipment is working
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?
Checking the pupillary response to light
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client?
Client concerns
A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?
Ecchymosis
A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration?
Edema in the palm of the hand
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?
Shakiness and diaphoresis
A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?
Increased calcium excretion
A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?
Laceration
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?
Report of exposure to a skin irritant
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 pain?
The client's self-report of pain severity
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?
The client's sociocultural background influences nonverbal communication
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsation in the pulmonic area, at which anatomical location should the nurse place her fingers?
The left second intercostal space
A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?
Third square
A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
To identify delayed gastric emptying
A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?
"The area surrounding the insertion site feels warm to the touch"
A nurse is caring for an adult client who is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter
-Cephalic vein -Basilic vein
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect?
-Report of feeling pressure -Tenderness over the symphysis pubis -Distended bladder -Voiding 30 mL frequently
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain?
-Restlessness -Grimacing -Clenching
a nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect?
-Sudden attacks of sleep -Hallucinations at the onset of sleep
A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?
28%
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?
3+
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?
300 mL
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?
35 mg/dL
A nurse on a medical unit assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?
A client who reports urinary frequency
A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?
Asking the client to rate the pain
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess the apical pulse for a full minute
A client receives the wrong medication. The nurse who made the medication error should take which of the following actions first?
Assess the client
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?
Assessment
A nurse is assessing a client who has chronic respiratory insuffiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation?
Clubbing of the fingers
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?
Conjunctivae
A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings, should the nurse assess first?
Date of client's last tetanus immunization
A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?
Determine the location of the pain
A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse plan to take first?
Determine what the client knows about managing diabetes
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?
Kyphosis
A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?
Nausea
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?
Nausea and vomiting
A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?
Necrotic subcutaneous tissue
A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?
Palpates the abdomen prior to performing auscultation
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Perform a bladder scan
A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an interventions should the nurse complete?
Pinch up a fold of skin to check for turgor
A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?
Prior to percussing the abdomen
A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect?
Scaling and redness between the client's toes
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
Self-report of pain
A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?
The client's current weight-bearing status
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values an an indication that the client has developed an infection?
WBC count
A nurse is 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 adventitious breath sounds?
Wheezes
A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors?
When asking if the client took his medications this morning
