NUR-210 Exam 1
A nurse who coordinates care in a public health unit is teaching staff how best to communicate with the older clients who dominate the demographic area. Which of the following directives should the nurse provide?
"Allow your client's stamina and abilities to guide the pace and content of your interactions."
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
"Are you taking any medications on a regular basis?"
The nurse is conducting the health interview of an adult client who has sought care because of a "wicked cough" leading to dyspnea. When trying to differentiate between pathologic lung changes and an infection as the etiology of the client's cough and resultant dyspnea, what interview question should the nurse ask?
"How long have you been experiencing your cough?"
The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment?
"What have you eaten in the last 24 hours?"
A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?
"What is your major health concern at this time?"
A nurse is receiving report from the night shift about four clients. Which client would the nurse see first?
A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min
When assisting a patient with health promotion, what must the nurse also nurture?
A healthy environment
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
A large amount of exudate in the sinuses
A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?
Allow the child to place the hand under the examiner's hand
When performing a physical assessment on an older adult client, what should the nurse consider offering this client?
An extra blanket
Which nursing action is most appropriate when providing care to the older adult with impaired vision?
Announce presence every time by identifying self by name.
What are nurses able to detect through the health assessment?
Areas in need of health adjustments
A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
Ask the client about the most recent experiences of pain.
An older adult client has come to the clinic with new complaints of fatigue, constipation, and cold intolerance. The nurse would refer the client for what type of testing?
Assessment of thyroid function
During an assessment of an elderly client, the nurse notes a decrease in pupil size and a slowed reaction of the pupil to light. Accommodation and convergence are normal. Based on these findings, what should the nurse emphasize with client education?
Avoid driving at night
When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?
Cigarette smoking
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate.
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?
Fever.
During the health history of an 8-month-old patient, the nurse asks the mother to list the immunizations that the patient has received. This information is important for which part of the history?
Health maintenance
The thoracic cavity contains which of the following organs? Select all that apply.
Heart Lungs Most of the esophagus
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
Heart murmur
The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply.
Inc cardiac output Inc blood pressure Inc heart rate
When assessing a newborn, the nurse observes that the infant's hands and feet are bluish in color. How would the nurse interpret this finding?
Ineffective temperature regulation
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
A nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight
pulse ox monitor tests what....
Oxygen saturation
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
Reduce all environmental noise.
What must occur before a client will be willing to teach the nurse about her culture?
The nurse needs to establish rapport and trust
The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?
The right lung has three lobes, while the left lung has two lobes.
When inspecting the toenails of an elderly client, an expected finding is:
Yellowed, thickened, lusterless nails
When the nurse is conducting the health history, when would be the most natural time to ask the client about alcohol use?
after asking about cigarette smoking
A sign of infection in the elder that is more common than fever is
confusion.
After conducting a physical examination of a client, the nurse suspects hypertrophy of the left ventricle. What is a characteristic of the apical impulse that is useful in confirming this suspicion?
duration
objective data
information that is seen, heard, felt, or smelled by an observer; signs
During a comprehensive assessment, the primary technique used by the nurse throughout the examination is
inspection.
The nurse hears a murmur in a patient with a known mitral valve prolapse. The murmur most likely occurs in
late systole
The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?
light
In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?
murmur
Bradycardia
slow heart rate
The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?
stethoscope bell
Which question asked by the nurse is appropriate when assessing instrumental activities of daily living (IADLs)?
"Are you able to prepare meals for yourself?"
An older client asks why the leg muscles have become flabby over the last few years. What should the nurse respond to this client?
"It occurs with aging but is encouraged by sitting too much."
A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?
"What diseases did you have as a child?"
Which of the following techniques are used in a physical assessment? Select all that apply.
1. Inspection 2. Palpation 3. Auscultation
Which client most likely has the greatest need for a folic acid supplement?
A 31-year-old woman trying to become pregnant
The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral?
A 50-year-old client newly diagnosed with diabetes
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
A grey-white line
How do many older adults define their health?
Ability to function independently
An older adult client presents with cramping leg pain when walking, which is relieved by rest; cool pale feet; capillary refill in the toes of 4 to 6 seconds; negative Homans' sign bilaterally; no edema; and inability to palpate dorsalis pedis and posterior tibial pulses bilaterally. Which of the following would the nurse suspect?
Arterial insufficiency
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Ashen gray
During an examination of the oral cavity, which technique by the nurse is appropriate to examine the anterior portion of the tongue?
Ask the client to stick the tongue out between the lips.
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?
Assist the client to walk as soon and as often as possible.
A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding?
Auscultate for the presence of a bruit
The nurse is planning to assess for the presence of lower pitch sounds when examining a patient's heart. Which item of equipment would the nurse use to make this assessment?
Bell of a stethoscope
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of what condition?
Chronic obstructive pulmonary disease
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
Chronic obstructive pulmonary disease
When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?
Collect subjective data
Assessment of a client's lower extremities reveals unilateral edema of the right extremity. Which of the following would be most appropriate for the nurse to do next?
Compare measurements of both extremities.
Which of the following accompanies decreased ovarian function?
Decreased vaginal secretions
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
Dyspnea
You are caring for a patient with hypertension. What dietary change would be appropriate to recommend?
Eat more spinach
The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?
Either side of frenulum on floor of the mouth
A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?
Expansion of health care networks
Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client?
Extent of tobacco use and exposure
A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?
Gastrointestinal
A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data?
Impaired Skin Integrity
During the health interview, a client reports an occasional blockage in the upper portion of the nasal passage. The nurse understands the most pronounced effect this would have on the client would be what?
Impaired sense of smell
A nurse is caring for a client diagnosed with cystic fibrosis. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most appropriate?
Ineffective Airway Clearance related to respiratory secretions
A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?
Involuntary facial or head movements
The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?
It is likely a breast but which is a normal finding at this age.
When discussing the nursing process with a group of students, which of the following statements best describes it?
It is ongoing and continuous.
A client is receiving an intradermal injection to evaluate general immunity during a nutritional assessment. What conclusion is suggested if the client has no reaction?
It may be immunosuppression resulting from undernourishment.
What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?
Latex allergy
During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?
Lungs
A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?
Making incorrect nursing judgments or diagnoses
A nurse needs to record the height of a client who refuses to stand because of blisters on the feet. What alternative method should the nurse implement to obtain the client's height?
Measure the arm span to estimate height
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?
Observe the client's respiratory rate and pattern
When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?
One deep inspiration and expiration through the open mouth
After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?
Ongoing
When assessing a client's pulse, the nurse should be alert to which of the following characteristics?
Rate, rhythm, amplitude and contour, and elasticity.
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
Resonance
A client has a pulse rate of 28 beats/15 seconds. How should the nurse document this finding?
Tachycardia
A patient has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?
Teach deep breathing and coughing.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
The ability of the arteries to stretch
During palpation of a young child's abdomen, the nurse assesses the liver. What would the nurse expect to find?
The liver is located 2 cm below the right costal margin.
The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. The nurse interprets this finding as indicating which of the following?
The pattern is expected with this condition
The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
Use Doppler ultrasonography to locate the pulse.
Which intervention should the nurse suggest to a client to improve the condition of dry skin?
Use lanolin-based products
apnea
cessation of breathing.
Kyphosis
excessive outward curvature of the spine, causing hunching of the back.
The result of a nursing assessment is the
formulation of nursing diagnoses.
Light palpation is most appropriate to assess the
inflamed areas of skin
A client says that food is not important and meals are not enjoyable. Where should the nurse document this information?
nutrition health pattern
The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse?
perianal lacerations extending to external sphincter
A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?
reflex hammer
An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?
"Are you currently taking any diuretic medications?"
The nurse is preparing to perform a nutritional assessment for a client. Which of the following questions would be most appropriate to use when initiating the assessment?
"Can you tell me what you've eaten in the last 24 hours?"
During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development?
"Can your child run, hop, and skip?"
A client complains of knee pain on the nurse's arrival in the room. What should the nurse's first sentence be after greeting the client?
"Could you please describe what happened?"
A parent of an ill infant states, "We gave him ibuprofen for a fever, and he had an allergic reaction." Which response would be most appropriate?
"Describe what happens to him when he takes ibuprofen."
The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?
"Do you have any pain or discomfort in your chest?"
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?
"Do you have family who visit you regularly?"
A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?
"Do you perform any sustained or continually repetitive motions with that arm?"
The nurse notes thrush on the palate of a patient. The most appropriate question the nurse should ask is
"Have you been on antibiotics recently?"
The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?
"Have you ever had a problem with mental or emotional illness?"
During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?
"How does that make you feel right now?"
The nurse is assessing a client with chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?
"How often do you use over-the-counter nasal sprays?"
The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors as they help to provide care to him. How should the nurse best respond?
"I will be back with your pain medication."
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
"I'm going to assess the client now so that I can begin formulating the care plan."
The nurse measures a male client's waist circumference as 43 inches (109 cm). Which statement is most appropriate for the nurse to make given this finding?
"Let's discuss your risk factors for heart disease."
The nurse is discharging a 9-year-old child from the hospital and is transporting him via wheelchair to the parents' car. The father states, "Go ahead and put him in the front seat." What response from the nurse would be most appropriate?
"The child should sit in the back seat until 12 years old or of adult size. The air bags can cause harm if deployed."
A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?
"They make sure that any microorganisms on my hands do not touch your skin."
What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status?
"What do you eat in a typical day?"
Which of the following nutritional guidelines should a nurse provide to a patient who is entering the second trimester of her pregnancy?
"You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients."
The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?
1+
The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.
1. "I feel so tired sometimes." 2. Client complains of a headache 3. "My father died of a heart attack."
The triage nurse is assessing a 7 year old child brought to the emergency department complaining of abdominal pain. Which findings would prompt the nurse to have the child evaluated as soon as possible? (Select all that apply.)
1. Acute intense pain with vomiting 2. Child isolates pain in right lower quadrant 3. Child unable to stand due to pain
In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that the client may have an infection in the hand or forearm. The nurse understands that which of the following are functions of the lymphatic system? Select all that apply.
1. Drains excess fluid and plasma proteins from tissues and returns them to the venous system 2. Traps and destroys microorganisms and foreign materials filtered from lymph 3. Absorbs fats from the small intestine into the bloodstream
The thoracic cavity contains which of the following organs? Select all that apply.
1. Heart 2. Lungs 3. Most of the esophagus
The nurse notes that a client has decreased fremitus in the left upper lung lobe. What should the nurse consider as causing this assessment finding? Select all that apply.
1. Pneumothorax 2. Pleural effusion 3. Bronchial obstruction
Which of the following are part of the preinterview of the nurse-patient interview? Select all that apply.
1. setting goals for the interview 2. taking time for reflection 3. setting goals for the interview 4. taking notes
An older client who typically weights 160 lbs. appears withdrawn and disheveled and causes the nurse to be concerned since the last visit a month ago. For which body weight should the nurse conduct a complete nutritional assessment?
152 lbs.
The nurse assesses a client's carotid pulse and finds it to be of normal amplitude. How would the nurse document this finding in the client's electronic medical record?
2+
The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next?
2nd intercostal space left sternal border
An individual is considered obese when his or her BMI is:
30-39
Which of the following wounds is most likely attributable to neuropathy?
A painless wound on the sole of the client's foot, which is surrounded by calloused skin
When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe this heart sound? S2 is:
Accentuated
A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status?
Accessibility
A nurse is planning a program to address measures to reduce the leading cause of mortality in children age 1 to 14 years. Which of the following would the nurse include?
Accident prevention
The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child?
Actively engage the child in play.
The nurse is assessing an older adult with intact cognition. A younger family member is present. The client is slightly hearing impaired, so the nurse must speak up. What should the nurse never do in relation to the client in this situation?
Address the family member if the client hesitates when answering a question
A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?
Adequate lighting
An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action?
Administer oxygen
The nurse is reviewing a client's medical history before surgery. The client has been taking ginseng, garlic, and aspirin daily. What's the nurse's best action?
Advise the client to notify his or her healthcare provider about stopping the supplments and aspirin.
When assessing a patient, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a patient from what background?
African American
The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?
Air passing through constricted passageways
What are various measurements of the human body, including height and weight, called?
Anthropometric
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?
Anxiety
The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the following should the nurse suspect?
Appendicitis
After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?
Application of an alcohol-based hand rub
An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect?
Arterial insufficiency
A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?
Ask about any medications being used for hypertension.
The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, "I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies." What would the nurse do next?
Ask the client about the timing of his allergy symptoms.
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
Asthma
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?
Asthma
The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding?
Auscultate the client's apical pulse.
A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
B12 deficiency
The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply.
Bathing Climbing stairs Getting in and out of bed
The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?
Begin above the right clavicle and percuss each section comparing the right chest with the left chest.
An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition?
Benign prostatic hypertrophy
What can the nurse assess using percussion?
Borders of the heart
A nurse auscultates a client's heart sounds and obtains a rate of 56 beats per minute. How should this rate be documented by the nurse?
Bradycardia
A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?
Bradycardia
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?
Bradypnea
When assessing adolescent girls, the nurse should know that what usually appears first?
Breast buds
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?
Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.
A group of students is reviewing information about general indicators for nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator for good nutritional status?
Brittle hair
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
Bronchitis is characterized by excess mucus production and chronic cough.
Which question by the nurse is most appropriate to assess for risk factors for malnutrition?
"Do you eat alone most of the time?"
In order to let an older adult client establish his or her cultural identity, which statement would be most appropriate for the nurse to make first?
"Tell me your beliefs about the illness you are experiencing."
What included in personal protective equipment? Select all that apply.
1. Gloves 2. Gown 3. Mouth, nose, eye protection
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?
A baseline for comparison with future findings
A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?
Airway
When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
Bronchitis
A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding?
Client has an increased chest diameter
An elderly client's history reveals the use of antihistamines. When inspecting the client's mouth, what would the nurse expect to find?
Decreased saliva
A 70-year-old retired auto mechanic comes to the office because his neighbour is concerned about the client's memory. The client admits to misplacing his keys more often and forgetting what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different provinces; and he has limited his activities because the people he interacted with were "his wife's friends, not his." He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. The nurse performs a mini-mental state examination and obtains a total score of 24 out of 28. Based on this information, what is the most likely diagnosis?
Depression
A nurse assesses a newborn with bruising on the head. How should the nurse document this finding?
Ecchymoses
Learning about the effects of the illness does what for the nurse and the patient?
Gives them the opportunity to create a complete and congruent picture of the problem
The nurse understand the molars are responsible for what?
Grinding
Which strategy can the nurse use to effectively approach the older adult client during the health history?
Have the room well-lit with minimal background noise.
A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?
History of breast surgery
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?
Imbalanced nutrition
The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?
Immobility
A nurse cares for a client who suffered a myocardial infarction two (2) days ago. A high pitched, scratchy, scraping sound is heard that increase with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?
Inflammation of the pericardial sac
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
Instruct the client to cough forcefully
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
Light palpation
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patient's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgments or diagnoses
If palpable, superficial inguinal nodes are expected to be:
Nontender, mobile, and 1 cm in diameter
Which method should a nurse use when assessing respirations in a newborn?
Observe the respiratory effort for one full minute
How can a nurse best assess a client's dietary habits?
Obtain a 24 hour dietary recall of all foods and fluids consumed
The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?
On the parent's lap
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal health history
Older adults tend to get arteriosclerosis. What is the cause of this disease process?
Calcification of the arteries
A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following?
Cardiac cycle
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?
Characteristic
During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. What would be most important for the nurse to assess?
Checking for a deviated nasal septum
A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?
Cheyne-Stokes
A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe?
Children typically have higher pitched heart sounds.
A nurse has completed an assessment of a school-age child. The nurse has identified several "soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?
Recognize that the findings may or may not indicate the presence of a neurologic problem.
Which of the following is the most accurate method of determining the length of a child under 24 months of age?
Recumbent length measured in the supine position
The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes the main points of what the client has just said. What type of communication is the nurse using?
Reflection
A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?
Sinus arrhythmia
A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?
Skinfold thickness
During an interview, a patient tells the nurse about spending time out of doors and hiking to connect with the earth and observe the activities of small animals. The nurse would document this patient's hiking behavior as supporting:
Spirituality
Which murmur meets the criteria of a innocent murmur? Select all that apply.
Still Pulmonary flow Venous hum
During an interview, the patient begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the patient is providing?
Stop documenting in order to maintain eye contact with the patient.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
Stridor
A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?
Summarization
A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify?
The client's feelings of happiness
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?
The client's range of motion in her right arm
A nurse has assessed an elderly client and is preparing to analyze the assessment data. What would the nurse need in order to accurately perform data comparison?
Usual daily pattern
During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?
Venous insufficiency
Dorsalis pedis
at the top of the foot arch
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
health maintenance
A nurse is providing nutritional instruction to a client with cardiovascular disease. The nurse mentions a nutrient that is a necessary component of bile salts (which aid in digestion), serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone. The nurse warns the client, however, that this nutrient when consumed in excess can lead to heart attacks and strokes. To which of the following nutrients is the nurse referring?
Cholesterol
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
Chronic obstructive pulmonary disease (COPD)
The nurse plans time to sit with a client to help address the client's spiritual needs. Why is this important?
Clients are holistic beings consisting of body, mind, and spirit
When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?
Coarse crackles
This type of assessment includes a health history and physical assessment.
Comprehensive
A child is admitted to the hospital after an injury during a school field trip. The child's parents arrive shortly afterwards and refuse to allow their child to receive needed antibiotics to fight off infection and analgesics to lessen the child's severe pain. Which of the following should the nurse do?
Consult the hospital's ethics committee
During a spiritual assessment the nurse realizes that personal beliefs differ significantly from those of the client. What should the nurse do?
Continue with the assessment
Which of the following assessment findings is most congruent with chronic arterial insufficiency?
Cool foot temperature and ulceration on the client's great toe
A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?
Cool skin
When auscultating a client's heart sounds the nurse detects a murmur that is initially loud and then gets softer. The nurse determines the pattern of this murmur to be which of the following?
Crescendo-decrescendo
A nurse is participating in an educational exercise in which she is conducting a self-examination of her own biases. This activity addresses what construct of cultural competence?
Cultural awareness
A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?
Cyanotic
During a physical examination of the older adult client, which of the following should the nurse consider an abnormal age-related finding of the musculoskeletal system?
Decreased arm swing with walking
A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?
Depression
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Determine any changes from the baseline data
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client
The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?
Document the finding
A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding?
Document the finding in the child's chart
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?
Dorsal hand surface
A nurse is assessing a client before administration of an antibiotic. The nurse should be aware that which of the following represents a biochemical variation that may exist between clients of different cultures?
Drug metabolism
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
Dyspnea
The nurse is assessing a client's cardiovascular status within the comprehensive health history. What should the nurse include in this section of the assessment? (Select all that apply.)
Dyspnea Edema BP pattern
The nurse is collecting the history on a child and discovers that the child has missed a recommended vaccination. What is the nurse's best recommendation?
Encourage a catch up dose as soon as possible.
A woman consumes pasta, grains, and other carbohydrates for
Energy
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?
Ensuring that contact with the skin is maintained
The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?
Erb point
A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?
Establish a baseline for the comparison of future health changes.
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
Evaluation
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says "Absolutely not! There's no way I'll let you do that to me!" Which response by the nurse would be most appropriate?
Explain the importance of the pelvic exam and Pap smear, but respect the client's wishes and omit the exam.
Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?
Extremely obese
What is the most common reason for admission of the older adult to the emergency department (ED)?
Falls
The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?
Family history
Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?
Females with 88.9 cm (35 in) or greater waist circumference.
The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?
Fifth intercostal space, left midclavicular line
A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?
Flat neck veins
A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Focused assessment
If a client does not speak English, when is a trained interpreter required?
For any meaningful communication, including pain assessment or client teaching
When the nurse palpates the neck of an infant, he notices crepitus at the right clavicular area. The infant also exhibits decreased movement in the right arm. Which of the following would the nurse suspect?
Fractured clavicle
When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve patient care?
Gaining relevant information about the patient's spirituality.
A home care nurse is teaching a patient's daughter meal planning for her mother who is recovering from a hip replacement surgery. Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid?
Ham sandwich with tomato on rye bread with peaches and yogurt
The nurse obtains the following data about a 3-year-old child during an assessment at the neighborhood health clinic. Which finding would indicate a need for further evaluation of the child?
Has an undescended testes.
Prior to assessing the spirituality of the patient, what is important for the nurse to do?
Have knowledge of his/her own spirituality.
Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child?
Have the child blow a pinwheel.
While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. What action would the nurse do first?
Have the client cough, then listen again.
How does the nurse differentiate a pleural friction rub from a pericardial friction rub?
Have the client hold his or her breath; if the rub persists, it is pericardial
When assessing a client for possible varicose veins, which of the following would the nurse do?
Have the client stand for the exam
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?
History of allergies
The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?
History of present illness
A new mother wants to give her baby honey. The nurse tells her that it is potentially dangerous to do this. Why is this practice potentially dangerous?
Honey is a known reservoir for the botulism bacterium
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include?
Hypertension is more prevalent in African Americans than among Caucasians.
A nurse is preparing to conduct a community assessment. Upon completing the assessment, which of the following would the nurse expect as the primary outcome?
Identification of health-related concerns
A nurse is preparing to conduct a community assessment. Upon completing the assessment, what would the nurse expect as the primary outcome?
Identification of health-related concerns in the community
When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?
Identify in what areas the patient needs the most care
A nurse assesses the spirituality of a client who is terminally ill with pancreatic cancer. Which of the following is the best rationale for this action, from the nurse's perspective?
Identifying possible coping mechanisms
The nurse has just finished assessing a 48-year-old female client who is morbidly obese. The client claims that she overeats as a way to cope with stress. The client underwent a divorce 3 years ago and is currently single. She works 50 hours a week and cares for both her teenaged daughter and her elderly mother. When the nurse suggests changes to her nutrition, the client is resistant. Which of the following nursing diagnoses would be most appropriate for this client?
Imbalanced nutrition: more than body requirements
When teaching a nutrition class, what would you recommend for adults older than the age of 50?
Increase foods rich in vitamin B12 and calcium
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?
Inspection
A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
Intermittent claudication is leg pain that occurs with walking and is relieved by rest.
A nurse is working with a client who is Buddhist. Based on what the nurse knows of the common dietary practice of this religion, which nutrient should the nurse make sure that the client is not deficient in?
Iron
The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is "unable to hold her urine," and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence?
Is this something that has begun to happen just recently?
A client asks the nurse about the function that the lymph system plays in the body. Which of the following would be most appropriate for the nurse to include when responding to the client?
It filters harmful substances from the body.
The nurse auscultates the base of the lungs to assess for what reason?
It is where fluid occurs with with pulmonary edema.
A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?
It will be slightly lower than standing readings.
A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment?
Katz Activities of Daily Living tool
A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?
Knowing the person's baseline functional status and recognizing deviations from it
The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?
Kyphosis
The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?
L
A nurse obtains a client's blood pressure (BP) on admission in both arms: Right arm BP 130/75 mmHg and left arm BP 140/80 mmHg. Which arm should the nurse use for subsequent blood pressure reading?
Left arm
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?
Left side-lying
A nurse performs the Trendelenburg test for a client with varicose veins. What care should the nurse take when performing this test?
Legs should be elevated for 15 seconds.
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia is white patches inside of the mouth.
Before completing the physical examination, the nurse determines that the patient is awake, alert, and oriented. This information would be important for which part of the general survey?
Level of consciousness
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?
Lifestyle and health practices profile
A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next?
Lightly palpate the client's leg veins for tenderness
The nurse is conducting an assessment of a rural community. What community assessment finding is most characteristic of rural communities?
Limited access to specialized health care
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
Listen at each site for at least one complete respiratory cycle
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?
Lithotomy
You should use the bell of the stethoscope when auscultating what type of sounds?
Low-frequency sounds
A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?
Lower arm and hand for erythema and swelling
Which of the following indicates that an elderly client has been affected by polypharmacy?
Medications are used to counteract side effects of other prescribed medications.
The nurse is preparing to obtain a client's mid-arm circumference. Which equipment would the nurse need to gather?
Metric tape measure
A nurse assesses a newborn of African American descent and observes a bluish pigmented area on the sacrum. The nurse recognizes this as what type of skin variation?
Mongolian spot
A nurse is working with a client who recently suffered a heart attack. As a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. This layer of muscle is known as which of the following?
Myocardium
Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?
Narrowing or partial obstruction of an airway passage
A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group?
Native Americans
The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?
Native Americans
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?
Neuropathic
The nurse assesses chest expansion in a 30-year-old man and finds it to be 8 cm. How would the nurse document this finding?
Normal expansion
During a busy shift, Nurse R. admitted a post-surgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?
Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.
You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered?
Obese
A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kilograms (534.6 pounds). Upon extubation, the client's oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems?
Obesity, which can limit chest wall expansion and compromise breathing
A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?
Opiates, which may cause hypoventilation
A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?
Orthopnea
A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?
Orthopnea
A nurse is filling out an incident report after an older adult patient fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when patient falls occur?
Orthostatic hypotension
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?
Over the client's thigh
The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate?
Palpate each artery individually to compare
When the nurse palpates the abdomen of a preschool boy, he begins to giggle and draw his legs up onto his abdomen. What would be most appropriate for the nurse to do?
Palpate with the child's hand under the nurse's hand.
Nurses provide both direct and indirect care. What is an example of indirect care?
Participating in a client care conference
A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Past health history
A triage nurse is working in the emergency department of a busy hospital. Four patients have recently been admitted. Patient A has an arrhythmia diagnosed as atrial fibrillation; Patient B is in chronic congestive heart failure; Patient C is assessed and found to have a probable pulmonary embolism; Patient D complains of chest pain relieved by nitroglycerin and rest. Which patient would be the nurse's highest priority?
Patient C
The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?
Pay attention to the details while observing
A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?
Perform a focused assessment of the client's musculoskeletal system
While the nurse is interviewing a newly admitted older adult client, the client repeats the same story to the nurse several times. What is the nurse's next, best action?
Perform mini mental status exam
The nurse is exhibiting critical thinking in which client care situation?
Performing a focused assessemt on a client who is complaining of shortness of breath.
While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. How would the nurse document the findings?
Pericardial friction rub
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?
Peripheral arterial disease
The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which finding would the nurse interpret as being normal?
Pinkish, spongy soft palate
What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client?
Plan for additional time to allow as much independence as possible
A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?
Pneumonia
A nurse is preparing a health education class for a group of older adult clients at a local senior center. The nurse is focusing on health promotion and disease prevention. Which condition would the nurse cite as a common cause of infection-related deaths in the elderly?
Pneumonia
A young adult female presents at the clinic with fatigue and long, heavy periods. Blood is drawn for laboratory testing, and findings include both low hemoglobin and hematocrit levels. What can these low levels indicate?
Poor iron absorption
Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?
Preparing food
A nurse assesses a client's blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education?
Prevention of falls
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?
Provide simple and organized information.
The nurse is caring for a client who is 48 hours post-op from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?
Pulmonary embolism
The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?
Pulmonary embolism
Which instructions should the nurse provide to the client taking a sublingual medication?
Put the medication underneath your tongue.
The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?
Quitting smoking and keeping good control of your blood sugar levels are important.
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?
Quote the client's words.
A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?
Raise head of bed and apply oxygen
The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?
Reassess previously detected problems
A patient asks the nurse if there are church services in the hospital because the patient attends mass every Sunday. The nurse realizes that this patient is demonstrating:
Religion
A child brought to the clinic is observed to have malformed ears. The nurse recognizes that this finding requires what further testing?
Renal function testing
When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern?
Reports of constipation
When percussing the posterior lung fields, which of the following findings is expected?
Resonance over all lung fields
An older adult client is brought to the ED. The client tells the nurse, "I feel like something really heavy is sitting on my chest." The nurse then says to the client, "You feel as if something heavy is sitting on your chest?" Of what type of nurse-client communication is this an example?
Restatement
When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?
S1
Which of the following dishes should the nurse cite as an example of a way for clients to integrate more omega-3 fatty acids into their diets?
Salmon pan-fried in canola oil
While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate?
Shortness of breath
A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in what location?
Sinoatrial node
A nurse is preparing perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
Skinfold calipers
The nurse is assessing the apices of the client's lungs. The nurse should locate them at which position?
Slightly above the clavicle
Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.
Smoking Overweight Lack of exercise
A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?
Snellen chart
A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding?
Solar lentigines
In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?
Some herbal supplements may interact with prescribed medications.
Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working?
Standards of care often set the time frame for assessing the clients on the unit
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?
Stress
The school nurse is in the talking to a group of students about sexually transmitted diseases. One of the students says, "I know that most of the 10th grade has already had sex. There's drinking and parties, and this is where a lot of it happens." What type of data is the nurse collecting?
Subjective
The nurse assesses a client's spiritual dimension, documenting the primary source of information at which location?
Subjective data
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?
Suggest methods and provide resources to assist with smoking cessation
The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?
Teaching strategies to reduce complications of existing diagnoses
An older adult client has been admitted for assessment related to decreased cognition. What assessment finding is most suggestive of delirium as the cause of the client's cognitive changes?
The client recently began a new medication regimen.
A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?
The client will have a loss of involuntary respiratory control.
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
A 14-year-old girl comes to the clinic and requests to be seen for suspicion of a sexually transmitted disease (STD). What is the nurse's responsibility for treatment of this adolescent?
The nurse understands that it is not necessary to have parental consent to treat an STD in a child 13 years or older.
Which observation confirms to the nurse that the client is experiencing a normal inspiration?
The thoracic cavity enlarges.
The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer?
The ulcer is superficial and pale.
A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?
There is loss of involuntary respiratory control.
While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?
Thin, shiny, atrophic skin
A group of students is reviewing information about general assessment indicators of nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator of adequate nutritional status?
Thinning, dry hair
A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook?
To assess if the patient has the ability to obtain or prepare food
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?
To see the client before the client assumes a social face or behavior
The nurse auscultates the apical pulse and then palpates the PMI (point of maximal impulse). To best palpate the PMI, the nurse places two fingers at the left border of the heart in the 5th intercostal space.
True
The nurse might expect the patient admitted with dehydration to have tachycardia.
True
The radial pulse is palpated over the lateral flexor surface.
True
The student nurse examines a 62-year-old patient and reports to the preceptor that the patient appears to have an infection in an untreated laceration on the calf. The student is unsure of the assessment because the patient does not have a fever. The preceptor correctly explains that the older adult often does not have a fever with an infection.
True
The nurse is preparing to perform the physical examination of an older adult client who will begin rehabilitation from an ischemic stroke. Which nursing action would be most appropriate?
Try to minimize position changes.
A nurse in the community is completing a manual blood pressure assessment. Which action should the nurse take to ensure the assessment is accurate?
Turn down the television volume.
A health care organization is preparing posters about childhood mortality for a community health fair. What should be identified as the leading cause of mortality for children of all ages?
Unintentional injuries
Within all age groups from 1 to 44 years, a nurse knows that the most common cause of mortality is from what source?
Unintentional injuries
The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?
Unstable gait
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record?
Urge
The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?
Venous insufficiency
The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?
Venous insufficiency
The nurse is able to identify which vertical reference line of the thorax as a reference line for the posterior thorax?
Vertebral line
Which vitamin is found only in animal foods?
Vitamin B12
A nurse has just determined a client's body mass index (BMI). Which measurement should the nurse add to the BMI to increase the predictive ability for health risk to the client?
Waist circumference
What is the most common measurement used to determine abdominal visceral fat?
Waist circumference.
Which action by a nurse is appropriate before beginning a physical examination of a client?
Wash hands before examination in the examination room
Which action by a nurse demonstrates the correct application of the principles of standard precautions?
Wearing gloves when palpating the tongue, lips, & gums
A Muslim teenager is in the hospital for surgical repair of a severe fracture in the leg during the month of Ramadan, which the client says he would like to observe during his stay. Which of the following interventions should the nurse be prepared for in caring for this client?
Withhold all food and drink between sunrise and sunset
The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient as being:
Within normal limits
tachypnea
abnormally rapid breathing.
A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom?
acute bacterial rhinosinusitis
A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?
acute bacterial sinusitis
capillary refill
after blanching nail bed, color should return to normal withing <3 secs
The posterior tibial pulse can be palpated at the
ankle
The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has?
aortic aneurysm
The apex of each lung is located at the
area slightly above the clavicle.
While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing
arterial insufficiency.
Posterior tibial
artery supplying the foot, behind the medial ankle
A nurse is conducting a health assessment. How will the information collected from the patient be used?
as a basis for the nursing process
The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?
ask the mother to leave the room
The bicuspid/mitral valve is located
between the left atrium and the left ventricle.
Raynaud's disease
causes the blood vessels to narrow when you are cold or feeling stressed
dyspnea
difficulty breathing
While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand.
The nurse is preparing to inspect a newborn's inner ear with an otoscope. The nurse should pull the pinna
down and back.
A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?
dyspenea
An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium?
experiencing visual hallucinations
Tachycardia
fast heart rate
A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?
focused
A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
focused assessment
Common conditions or problems that accompany aging are often called
geriatric syndromes
A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.
gloves, gown, face shield
The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?
head to toe
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?
head to toe
Within the 65-year-old and older age group, a nurse knows that the most common cause of mortality is from what source?
heart disease
arterial insufficiency
inadequate blood flow through the arteries
The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of
increased central venous pressure.
Because the nurse realizes that spirituality varies, information gained will assist the nurse in
individualizing interventions to meet specific needs.
thrombophlebitis
inflammation of a vein associated with a clot formation
While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of
iron
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
manubrium.
Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the patient's quality of life. When assessing ADLs, the nurse asks if the patient can grasp small objects and open jars. This is an example of assessing the patient's:
mobility
eupnea
normal breathing
While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting
normal changes that occur with the aging process.
The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan
nutritional information specifically for the client's culture.
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?
open-ended questions to encourage the client to tell his or her story
what is the peripheral vascular system?
part of the circulatory system that consists of the veins and arteries not in the chest or abdomen (i.e. in the arms, hands, legs and feet).
Cheyne-Stokes
periods of rapid breathing and no breathing, coughing or noisy breaths. When a person is just hours from death, you will notice changes in their breathing
The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?
peripheral vascular
After assessing pitting edema below the knee in a patient, the nurse would suspect that which vein may be occluded?
popliteal
The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to
position the handle of the otoscope to one side.
When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?
postural orthostatic hypotension
A client has just had abdominal surgery and the nurse is consulting with the patient about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?
protein
The nurse is performing an assessment of a hospital client at the beginning of a shift. When assessing the client's heart rate, the nurse will most likely palpate what artery?
radial artery
Shared practices and rituals used to express one's faith can be called
religion
The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?
right cervical node
An elderly patient arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the patient appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:
sensory deficits
components of the peripheral vascular system
temp edema capillary refill tenderness pulses
The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing
tertiary prevention
A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is
the degree to which dyspnea affects daily function.
A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if
the provider is not bilingual
subjective data
things a person tells you about that you cannot observe through your senses; symptoms
The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the
third to fifth intercostal space at the left sternal border.
The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom?
treatment
Which terms are used to identify the lobes of the right lung? Select all that apply.
upper lobe middle lobe lower lobe
Any new onset of incontinence in the frail elder should be investigated for
urinary tract infection.
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?
use as a drape
A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?
venous insufficiency
Which finding noted during assessment of the oral cavity of an older adult alerts the nurse that the older adult may be neglecting oral care?
white patchy plaque on the tongue
