Nurs 4 - Nursing Process: Assessment - NCLEX RN EAQ's

Which assessment question is appropriate when collecting a developmental history for an adolescent who is new to the pediatric practice? 1 "What grades do you get in school?" 2 "Have your wisdom teeth erupted yet?" 3 "What was your approximate height at 4 years of age?" 4 "What was your approximate weight at 5 years of age?"

1 - "What grades do you get in school?" While all of these assessment questions are appropriate, only the question regarding scholastic performance (grades in school) is a question that is appropriate for a developmental history. Asking questions regarding wisdom tooth eruption and approximate height and weight at 4 and 5 years of age respectively is more appropriate when collecting a growth history.

While interacting with a client, the nurse notices a lack of coordination in the client's speech. What could be the reason behind this condition? 1 Cranial nerve lesion 2 Occipital lobe lesion 3 Parietal cortex lesion 4 Limbic lobe lesion

1 - Cranial nerve lesion Cranial nerve lesions can cause a lack of coordination in articulating speech, as the cranial nerves are responsible for speech coordination. Occipital lobe lesions may lead to loss of vision. Parietal cortex lesions can cause an inability to recognize spatial or body positioning perception. Limbic lesions could interfere with emotions, learning, and memory.

Which findings indicate chronic osteomyelitis? Select all that apply. 1 Elevated white blood count 2 Presence of avascular scar tissue 3 Cold sensation at the infection site 4 Constant bone pain relieved by rest 5 Elevated erythrocyte sedimentation rate

1 - Elevated white blood count 2 - Presence of avascular scar tissue 5 - Elevated erythrocyte sedimentation rate Chronic osteomyelitis is manifested by an elevated white blood count, the presence of avascular scar tissue, and increased levels of erythrocyte sedimentation rate due to an infection. Chronic osteomyelitis is characterized by warmth at the infection site and constant bone pain not relieved by rest.

Which Korotkoff sound represents systolic blood pressure in children? 1 First 2 Second 3 Fourth 4 Fifth

1 - First The first Korotkoff sound represents the systolic pressure in everyone. A blowing or swishing sound occurs in the second Korotkoff sound. The third Korotkoff sound involves crisper and more intense tapping sounds. The fifth Korotkoff sound is the point at which sound disappears and represents the diastolic pressure in adults and adolescents.

A client is recovering from a myocardial infarction. Which action should the nurse take before developing the client's teaching plan? 1 Identify the learning needs of the client. 2 Determine the nursing goals for the client. 3 Explore the use of group teaching for the client. 4 Evaluate the community resources available to the client.

1 - Identify the learning needs of the client. For teaching to be meaningful, the client must have a need to learn and a readiness to learn. These factors need to be identified before a teaching plan is formulated. Determining the nursing goals for the client eliminates the client from the goal-setting process; active participation by the client increases motivation and retention. Exploring the use of group teaching for the client is not the initial step; learning needs must be determined first to see if group learning is appropriate; also, group learning must be available as an option. Evaluating community resources is not the initial step; assessment of learning needs comes first.

Which actions should the nurse perform while collecting subjective data from a client during a focused urinary assessment? Select all that apply. 1 Inquire about painful urination 2 Ask the client about changes in characteristics of urination 3 Assess the levels of blood urea nitrogen and creatinine 4 Palpate the abdomen for bladder distention or masses 5 Inspect the urinary meatus for inflammation or discharge

1 - Inquire about painful urination 2 - Ask the client about changes in characteristics of urination While collecting subjective data from a client during the focused urinary assessment, the nurse should ask the client about painful urination and also about any changes in the characteristics of urination (diminished, excessive). This information indicates the presence or absence of urinary disorders. The nurse should palpate the abdomen for bladder distention or masses while collecting objective data during the physical examination. The blood, urea, nitrogen, and creatinine values are included in the objective diagnostic data. The nurse inspects the client's urinary meatus for inflammation or discharge while collecting objective data during the physical examination.

A nurse is assessing an older adult male client. Which clinical findings are expected responses to the aging process? Select all that apply. 1 Slowed neurologic responses 2 Lowered intelligence quotient 3 Long-term memory impairment 4 Forgetfulness about recent events 5 Reduced ability to maintain an erection

1 - Slowed neurologic responses 4 - Forgetfulness about recent events 5 - Reduced ability to maintain an erection Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired.

A client is scheduled for a cholecystectomy and asks the primary nurse about the function of the gallbladder. What should the nurse identify is the function of the gallbladder when providing preoperative teaching? 1 Stores and concentrates bile 2 Releases bile into the pancreatic duct 3 Connects the common bile duct and the pancreas 4 Controls the flow of fat through the sphincter of Oddi

1 - Stores and concentrates bile The gallbladder concentrates and stores about 90 mL of bile, which is discharged in response to the entrance of fatty food into the duodenum. The gallbladder releases bile into the cystic duct. The common bile duct is connected directly to the pancreas. The sphincter of Oddi controls the release of bile into the duodenum; dietary fat progresses from the stomach to the duodenum and then to the rest of the intestinal tract.

Which leadership theory focuses on the role of leaders in relational and contextual terms? 1 Style theory 2 Two-factor theory 3 Expectancy theory 4 Transformational theory

1 - Style theory Style theories focus on what leaders do in relational and contextual terms. The two-factor leadership theory refers to using motivator factors to inspire work performance. The expectancy theory of leadership refers to providing specific feedback about positive performance. The transformational theory of leadership refers to a process in which the leader attends to the needs and motives of followers.

A nurse educates a mother who complains that her preschool-aged child suffers from bedtime fears and insomnia. Which of these statements should the nurse tell the mother? 1 "You should avoid keeping the lights on in the child's room." 2 "You should comfort the child after he or she experiences a bedtime fear and leave the child in his or her own bed." 3 "You should feed the child some tea, coffee, or chocolate before the child goes to bed." 4 "You should start sleeping with the child in order to calm the child."

2 - "You should comfort the child after he or she experiences a bedtime fear and leave the child in his or her own bed." The nurse should teach the mother to discuss any fears with her child, provide comfort to the child, and then leave the child in his or her own bed. This way, the child's fears are not used as excuses to delay bedtime. To reduce bedtime fears in children, a small light can be kept on. Coffee, tea, colas, and chocolate act as stimulants that can keep the child awake throughout the night. American culture promotes independence in childhood. One belief is that co-sleeping does not promote this independence; thus healthcare providers discourage it.

Which nurse has the following authorizations: change plans whenever necessary; function as part of the interprofessional team by communicating, planning, and implementing care directly to the client; and assess the cohort risks? 1 Nurse manager 2 Clinical nurse leader (CNL) 3 Licensed practitioner nurse (LPN) 4 Advanced practice registered nurse (APRN)

2 - Clinical nurse leader (CNL) A CNL is a nurse who has successfully completed the CNL certification examination. A CNL functions as part of the interprofessional team by communicating, planning, and implementing care directly with healthcare professionals. A CNL has the authority to access the cohort group as well as change the plan of care wherever required. Nurse managers are involved in managing a team of nurses and other staff. LPNs are trainers and work under a registered nurse, gain experience, and learn the basics of nursing. The APRN perspective is supported by in-depth education in physiology, physical assessment, pharmacology, and a broad healthcare systems perspective.

What would the nurse say is the difference between triage under usual conditions and triage under mass casualty conditions? 1 Urgent care 2 Expectant care 3 Emergent care 4 Nonurgent care

2 - Expectant care Expectant care includes critical care to the clients who are expected to die or are dead. This condition is not included in the triage under usual conditions. Urgent care includes care to clients with major injuries that require immediate treatment. This condition is included in triage under usual and mass casualty conditions. Emergent care is provided when there is immediate threat to life. This condition is included in triage under usual and mass casualty conditions. Nonurgent care is when there are minor injuries that do not require immediate treatment. This is included in triage under usual and mass casualty.

What was the underlying purpose of the national health information technology infrastructure that originated from the Executive Order Incentives for the Use of Health Information Technology issued by President George W. Bush in 2004? 1 To create a new subspecialty of nursing informatics 2 To improve the quality, safety, and efficiency of health care 3 To have a process for formulating pertinent nursing diagnoses 4 To provide a set of tools in order to achieve quality client outcomes

2 - To improve the quality, safety, and efficiency of health care President George Bush issued the Executive Order Incentives for the Use of Health Information Technology with the ultimate goal of improving the quality, safety, and efficiency of health care. This was to be achieved by mandating that most health care facilities implement an Electronic Health Record for client information. The underlying purpose of the Executive Order Incentives for the Use of Health Information Technology was not for creating a new nursing subspecialty. Nursing informatics happened as a result of the order. The North American Nursing Diagnosis Association (NANDA) International organization is a classification system for developing nursing diagnoses. Clinical information systems offer a set of tools for the clinician to achieve quality client outcomes.

Which statement of the nurse at the time of discharge would reflect the decision-making skill called autonomy? 1 "I accept the task of providing a discharge teaching plan." 2 "I understand my task of preparing a discharge teaching plan." 3 "I may independently develop and implement a discharge teaching plan." 4 "I will consult with other team members to find out why the discharge teaching plan is delayed."

3 - "I may independently develop and implement a discharge teaching plan." The decision making skill of autonomy is demonstrated when the nurse independently develops and implements a discharge teaching plan. When the nurse accepts the commitment of providing the discharge teaching plan, he or she demonstrates accountability. The nurse takes responsibility when he or she declares that he or she understands the task of preparing a discharge teaching plan. The nurse is in an authoritative role if he or she consults other team members to find out more information about why the discharge teaching plan is delayed.

Through which organization can a registered nurse apply for certification as an informatics nurse? 1 National Institutes of Health 2 American Medical Informatics 3 American Nurses Credentialing Center 4 Office of the National Coordinator for Health IT

3 - American Nurses Credentialing Center To apply for a certification as an informatics nurse, a registered nurse should apply to the American Nurses Credentialing Center. The National Institutes of Health is an organization that is involved in widespread health care research using information technology. The American Medical Informatics is an organization which was solely founded for the development of biomedical and health care informatics. The Office of the National Coordinator for Health IT is an organization which is responsible for developing policy infrastructure that supports health care information technology.

Which nursing action is appropriate to determine conservation for the 9-year-old client who has mastered the expected conservation for age prior to the current health maintenance visit? 1 Asking the child to compare mass 2 Asking the child to compare length 3 Asking the child to compare weight 4 Asking the child to compare numbers

3 - Asking the child to compare weight The nurse would assess for conservation of weight for the 9-year-old school-age client who has mastered the expected conservation for age up until the current visit. Conservation of mass is expected between 5 and 7 years of age. Conservation of length is expected at 6 to 7 years of age. Conservation of numbers is expected at 5 to 7 years of age.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? 1 Bruising 2 Tachycardia 3 Hyperkalemia 4 Hypoglycemia

3 - Hyperkalemia Spironolactone is a potassium-sparing diuretic that is used to treat clients with ascites; therefore the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin? 1 It is used to suppress hunger in individuals trying to lose weight, so the client should stop taking the medication. 2 It is often used to treat migraines associated with hormonal changes and should be safe for continued use as needed. 3 It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. 4 It is an atypical antipsychotic, and the woman needs to make an immediate appointment with her mental healthcare provider to discuss alternative medications.

3 - It is teratogenic and associated with major fetal malformations, so the client should stop the medication immediately. Isotretinoin is used to treat severe acne that has not responded to other forms of treatment. It is teratogenic, and pregnancy should be avoided by female clients taking the medication. Isotretinoin is not used to treat migraines, is not an antipsychotic, and is not used in a weight-loss program.

The nurse should be concerned about a client's mother-infant bonding if the client is reluctant to do what on the first postpartum day? 1 Undress the newborn 2 Breast-feed her newborn 3 Look at her newborn's face 4 Attend classes for newborn care

3 - Look at her newborn's face Looking at the face or seeking eye-to-eye contact with the infant is an early sign of the initiation of bonding with the infant. The mother may feel inept or worry about upsetting the nurse by undressing her infant; new mothers need encouragement to undress their infants. Refusing to breast-feed her newborn may indicate that the mother is worried that she does not have enough milk, a common concern. The client may have attended prenatal classes, may be otherwise occupied, may not be feeling well enough to attend the class, or may feel that she has enough experience to care for her infant without attending a class for newborn care.

A young woman who is receiving treatment for premenstrual syndrome visits the primary healthcare provider and reports a headache and dry mouth. Which drugs would be responsible for these side effects? Select all that apply. 1 Danazol 2 Ibuprofen 3 Sertraline 4 Fluoxetine 5 Escitalopram

3 - Sertraline 4 - Fluoxetine 5 - Escitalopram Drugs used to treat premenstrual syndrome include sertraline, fluoxetine, and escitalopram. The side effects of these drugs are headaches, dry mouth, dizziness, and sleep disturbances. Danazol is used to treat endometriosis. Side effects are edema and oily skin. Ibuprofen is used to treat primary dysmenorrhea. The side effects include nausea, vomiting, and indigestion.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. 1 Back of the neck 2 Back of the hand 3 Palm of the hand 4 On the sternal area 5 Back of the fore arm

4 - On the sternal area 5 - Back of the fore arm Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

4 - Gangrenous necrosis Gangrenous necrosis is a condition that may occur after prolonged frostbite or inadequate treatment of frostbite. Frostbite occurs when there is damage to body tissues from extreme cold. This may result in the formation of ice crystals in the tissues and cells. The involvement of muscle, bone, and tendon freezing results in deep frostbite. Superficial frostbite involves skin and subcutaneous tissue, usually the ears, nose, fingers, and toes.

After getting stranded during a blizzard, a client is found with the condition depicted in the image. From which condition is the client suffering? 1 Frostbite 2 Deep frostbite 3 Superficial frostbite 4 Gangrenous necrosis

4 - Secondary The image depicts mucous patches in the mouth, which is present in the secondary stage of syphilis. Gummas on the skin are present in the late stage of syphilis. Clinical manifestations are absent in the latent stage of syphilis. Painless indurated lesions are present in the primary stage of syphilis.

The image illustrates the mouth of a client with syphilis. Which stage of syphilis is present? 1 Late 2 Latent 3 Primary 4 Secondary

The nurse can identify the most commonly demonstrated comorbid disorders associated with generalized anxiety disorder (GAD) by assessing the client for which of the following? Select all that apply. 1 Obesity 2 Phobias 3 Suicidal ideations 4 Impaired cognitive function 5 Signs of alcohol withdrawal

2 - Phobias 3 - Suicidal ideations 5 - Signs of alcohol withdrawal The most frequent comorbid conditions associated with GAD include alcohol abuse, simple phobias, and suicidal ideations. Obesity and impaired cognitive function generally are not identified as being comorbid conditions associated with GAD.

A 58-year-old client is planning to retire. Which action would be appropriate in this situation? 1 Assessing the activity level 2 Assessing issues related to income 3 Assessing the family to conduct an environmental check 4 Assessing the options of public transportation and number of community activities

2 - Assessing issues related to income When an older adult is planning for retirement, the nurse should assess issues related to income to ensure that the client can properly support himself or herself. When assisting older adults with housing needs, the nurse should assess their activity level. Assessing the family to conduct an environmental check should be done to consider the client's housing needs. Assessing public transportation options and community activities should be done when planning for a client's housing needs.

The registered nurse suggested that a newly hired registered nurse delegate tasks to nursing assistants. Which is an element that fosters effective delegation decisions by the newly hired registered nurse? 1 Skills 2 Stability 3 Practice 4 Environment

2 - Stability Stability along with safety, critical thinking, and time for decision-making creates an integrative process, which fosters effective delegation decisions. Skills are important for making decisions based on critical thinking. Practice accomplishes safety in delegation. Environment with feedback about performance is the best strategy for shaping the future behavior of individuals.

During a health promotion and maintenance program, the nurse explains the mother-infant relationship to a group of adolescents. Which statement by one of the adolescents indicates effective teaching? 1 "A child raised by his grandmother has more developmental problems." 2 "A child raised by an adult mother has more developmental problems." 3 "A child raised by a midlife mother has more developmental problems." 4 "A child raised by an adolescent mother has more developmental problems."

4 - "A child raised by an adolescent mother has more developmental problems." Adolescents often have unrealistic expectations, viewing their infants as playthings or love objects. The children of adolescent mothers experience more developmental problems than do children of adult mothers. Many children of adolescents are raised by a grandparent. Living with a grandparent may have positive effects on child outcomes, but this may not be the case if the mother and grandparent are in conflict. Adult and midlife mothers are more mature than adolescent mothers.