Test 1 questions

A nurse at an ambulatory clinic is preparing to begin the collection of objective assessment data from a female client. After meeting the client and bringing her into the examination room, what instruction should the nurse provide? a. "I'll get you to lay down flat on the exam table, please." b. "I'll start the assessment with you standing up and then help you onto the table." c. "Please have a seat on the edge of the exam table." d. "Where would you like me to conduct your health assessment."

"Please have a seat on the edge of the exam table."

A client asks why the nurse is asking how the client's family experiences and tolerates pain. Which of the following would be the most appropriate response by the nurse? a. "It helps me to determine how the family understands and perceives pain." b. "It is just a way for me to more fully understand you and your upbringing." c. "It will allow me to see if you are more likely to react to pain in a negative manner." d. "It helps me to direct interventions toward your cultural history."

a. "It helps me to determine how the family understands and perceives pain."

A nurse is working with a client whose ideal body weight is 172 lb. At what weight would this client first be considered obese? a. 206.4 lb b. 223.6 lb c. 240.8 lb d. 189.2 lb

a. 206.4 lb

A nurse working at a health clinic performs nutritional assessments on a variety of clients in one day. Which of the following clients would be at increased risk for malnutrition? Select all that apply. a. An elderly woman with Alzheimer's disease b. A teenaged girl who typically snacks on carrots and apple slices c. A single mother of three who makes $20,000 per year d. A 12-year-old girl with Crohn's disease e. A 33-year-old smoker who says that food has lost its taste f. A 45-year-old man who regularly works 8-hour days

a. An elderly woman with Alzheimer's disease c. A single mother of three who makes $20,000 per year d. A 12-year-old girl with Crohn's disease e. A 33-year-old smoker who says that food has lost its taste

During a new client's nutritional assessment, the nurse asks the client's height and usual weight. The client states that he has no idea how much he weighs. How should the nurse respond? a. "How would you describe your feelings around your body type and body mass?" b. "Has your weight increased, decreased, or stayed the same lately?" c. "Why do you feel that it's not important to monitor your weight?" d. "Can you tell me what you eat and drink in a typical day?"

b. "Has your weight increased, decreased, or stayed the same lately?"

A nurse is conducting a health history interview for an older adult. Which of the following questions or statements would be important for nutritional assessment? a. "Why don't you eat more meat? You need protein." b. "What prescribed and over-the-counter medicines do you take?" c. "What kinds of foods did you prepare when your husband was alive?" d. "When did you first notice that you had this sore on your heel?"

b. "What prescribed and over-the-counter medicines do you take?"

A nurse is assessing a client for possible fluid overload. Which assessment finding is most consistent with this diagnosis? a. Moist, plump tongue b. Distended neck veins with head elevated 45 degrees c. Venous filling of 3 seconds d. Boggy eyeball

b. Distended neck veins with head elevated 45 degrees

The nurse analyzes the data obtained from a client's nutritional assessment and develops a health promotion diagnosis related to nutrition for a client. Which nursing diagnosis would best for this client? a. Imbalanced nutrition: more than body requirements related to excessive caloric intake b. Health-seeking behaviors related to desire and request to alter amount of food intake c. Imbalanced nutrition: less than body requirements related to inadequate caloric intake d. Ineffective thermoregulation related to decreased adaptability to cold secondary to decreased subcutaneous tissue

b. Health-seeking behaviors related to desire and request to alter amount of food intake

Based on analysis of assessment data from a client with pain, the nurse writes a wellness diagnosis. Which diagnosis would be most appropriate? a. Bathing self-care deficit related to severe pain b. Readiness for enhanced spiritual well-being related to coping with prolonged physical pain c. Risk for activity intolerance related to chronic pain and immobility d. Chronic pain related to chronic inflammatory process of rheumatoid arthritis

b. Readiness for enhanced spiritual well-being related to coping with prolonged physical pain

The nurse notes that a client has thinning hair, a non-healing sore, lower extremity edema, and ascites. Which nutritional deficiency should the nurse suspect this client is experiencing? a. Vitamin C b. Vitamin A c. Protein d. Priboflavin

c. Protein

An emergency department nurse is assessing a client's complaint of upper abdominal pain. To assess the character of the pain, the nurse would begin with what assessment question? a. "Can you describe to me how your pain feels?" b. "Is your pain affecting your ability to cope?" c. "Would you describe your pain as acute, or as chronic?" d. "How would you rate your pain on a 10-point scale?"

a. "Can you describe to me how your pain feels?"

The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies: a. "Pain is a natural part of aging." b. "Patients are reluctant to report pain because they want to be considered as 'good' clients." c. "Older clients may worry that reporting pain will lead to costly tests." d. "Patients may fear that uncontrolled pain will affect their independence."

a. "Pain is a natural part of aging."

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? a. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 b. Bowel sounds are present in all four quadrants, all organ within normal limits c. Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits d. Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation

a. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

What is one way nurses use critical thinking in regard to the nursing process? a. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions b. Nurses do not need to think critically; they just need to follow the doctor's orders c. Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions d. Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client

a. Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing a. Deep palpation b. Moderate palpation c. Very deep palpation d. Light palpation

a. Deep palpation

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? a. Expansion of health care networks b. The shrinking cost of medical care c. Public mistrust of physicians d. Decrease in client participation in care

a. Expansion of health care networks

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should a. Explain the role and purpose of the nurse b. Allow the client time to calm down c. Avoid discussing sensitive issues d. Set time limits with the client

a. Explain the role and purpose of the nurse

The review of systems component of the health history is best described as a. Focus on common questions and issues related to each of the different body systems b. Series of questions that start at the head and finish at the feet c. Focus on diseases of the major body systems d. Detailed investigation of questions about major body systems

a. Focus on common questions and issues related to each of the different body systems

A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? a. General b. Rest and sleep c. Gastrointestinal d. Appetite

a. General

A client has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this client? a. Knowledge deficit b. Ineffective copping c. Acute pain d. Nutritional: less than body requirement

a. Knowledge deficit

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? a. Making incorrect nursing judgment or diagnoses b. Validating information that is already correct c. Relying on objective and subjective information d. Interjection of the nurse's thoughts or feelings into the data

a. Making incorrect nursing judgment or diagnoses

The nurse is performing a pain assessment on a client with cancer pain. What consideration(s) should the nurse take into account while performing this assessment? Select all that apply. a. Multiple types of pain may be present b. Phantom pain does not occur in cancer pain c. Treatments for cancer may cause their own pain responses d. The pain may cause acute or chronic e. Pseudoseizures may result in the client's pain

a. Multiple types of pain may be present c. Treatments for cancer may cause their own pain responses d. The pain may cause acute or chronic

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following? a. Palpitation b. Dyspnea c. Pulse pressure d. Apical beats

a. Palpitation

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply. a. Perspiration b. Hypoglycemia c. Increased heart rate d. Sleeplessness e. Increased intestinal motility

a. Perspiration c. Increased heart rate d. Sleeplessness

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? a. Progress notes b. POC c. Problem list d. Data base

a. Progress notes

During the interview of an adult client, the nurse should a. Provide the client with information as questions arises b. Complete the interview as quickly as possible c. Read each question carefully from the history form d. Use leading questions for valid responses

a. Provide the client with information as questions arises

Which of the following factors affect blood pressure? Select all that apply. a. Stress b. Eye color c. Ethnicity d. Weight e. Smoking

a. Stress c. Ethnicity d. Weight e. Smoking

Which describes the nurse using the technique of palpation? a. The nurse notes increased warmth surrounding an abdominal incision. b. The nurse notes gurgling sounds over the individual's abdomen. c. The nurse notes tympany over the individual's lower abdomen. d. The nurse notes asymmetry of the individual's abdomen.

a. The nurse notes increased warmth surrounding an abdominal incision.

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action? a. Wearing gloves to palpate the tongue and buccal membranes b. Performing hand hygiene between examinations of each body part c. Discarding the trash can the safety pin that was used to assess sensory perception d. Wearing a gown, gloves, and mask during the physical exam

a. Wearing gloves to palpate the tongue and buccal membranes

The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model? a. "What changes do you have to make in order to accommodate your chest pain?" b. "Do you have any other symptoms together with your chest pain, such as nausea, sweating?" c. "In your experience, what kinds of activities tend to cause your chest pain?" d. "Would you describe your chest pain as being acute, or is it chronic?"

b. "Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client? a. 23 b. 18 c. 11 d. 12

b. 18

A nurse assesses the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute? a. 85-100 b. 45-60 c. 65-80 d. 105-120

b. 45-60

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? a. A blood pressure reading of 110/70 mm Hg in a competitive athlete b. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight c. A pulse rate of 98 in a 10-year-old boy d. A temperature of 97 degrees in an elderly woman

b. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

A client has a BMI of 28. The nurse should assess which areas for additional risk factors for heart disease? Select all that apply. a. Medication b. Activity level c. Cholesterol d. Temperature d. Blood pressure

b. Activity level c. Cholesterol d. Blood pressure

The nurse is conducting a health assessment on a client presenting to the emergency room with a critical condition. The nurse should initially ask questions regarding which topic(s) during the initial assessment? Select all that apply. a. Stress at work b. Allergies c. Medications d. Adverse reactions e. Lifestyle changes

b. Allergies c. Medications d. Adverse reactions

A nurse reviews the vital signs of a new client: temperature 99.3° F (37.38° C), pulse 105 beats/min, blood pressure 143/83 mm Hg, and respiratory rate 22 breaths/min. What action should the nurse take first? a. Notify the health care provider of the abnormal vital signs. b. Ask the client if they are experiencing any discomfort. c. Ask the client to rest quietly and then retake the vital signs. d. Ask the client if they have a history of high blood pressure.

b. Ask the client if they are experiencing any discomfort.

A nurse reviews the vital signs of a 77-year-old client: temperature 99.2 F° (37.33° C), heart rate 90 beats/min, blood pressure 130/50 mm Hg, respiratory rate 22 breaths/min and shallow, and oxygen saturation rate 93% on room air. Which action should the nurse take next? A. Notify the health care provider regarding tachypnea b. Assess the client for infection c. Apply oxygen d. Chart findings as normal

b. Assess the client for infection

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed? a. Use of moderate palpation with gloves b. Auscultation of the heart with the stethoscope bell c. Use of light palpation with an ungloved hand to sense murmur d. Auscultation of the heart using the stethoscope diaphragm

b. Auscultation of the heart with the stethoscope bell

During an assessment the nurse suspects that a client has a vitamin C deficiency. What information did the nurse use to make this clinical determination? a. Paresthesias b. Bleeding gums c. Bone pain d. Dry flaky skin

b. Bleeding gums

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following? a. Reliability b. Personal and social history c. Identifying data d. Review of systems

b. Personal and social history

The nurse is caring for a post-operative client with an order for morphine sulfate 2 mg IV push every 4 hours. The client's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take? a. Administer another dose of the morphine sulfate immediately. b. Call the prescribing physician see about changing the pain medication. c. Instruct the client that it is too soon for another dose of morphine. d. Wait and medicate the client when the next dose of morphine is due.

b. Call the prescribing physician see about changing the pain medication.

The nurse conducts an assessment of an older adult. Which of the following findings indicates the client is at risk for malnutrition? (Select all that apply.) a. Receives monthly pension b. Confusion c. Difficulty ambulating d. Ill-fitting dentures e. Lives at home with family

b. Confusion c. Difficulty ambulating d. Ill-fitting dentures

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? a. Erase the incorrect statement and write the correct one. b. Cross out the incorrect statement with a single line. c. Use correction fluid to obliterate what has been written. d. Cross out the wrong statement in a way that is not readable.

b. Cross out the incorrect statement with a single line.

The nurse is assessing a client who is experiencing a great deal of pain. Which assessment data would be considered normal under those circumstances? a. Hypoglycemia b. Decreased gastric motility c. Decreased heart rate d. Increased urinary output

b. Decreased gastric motility

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview? a. Do you currently have a cough? b. Describe how you breathe for me? c. Do you experience any pain when you breathe? d. Do you have difficulty producing sputum?

b. Describe how you breathe for me?

A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error? a. Place correcting tape over the error and enter the correct data on top of the tape. b. Draw a line through the error, write "error," and initial the entry. c. Obliterate the entry with a marking pen. Write "error" and write the correct data beside it. d. Use an eraser to erase the mistake and then write in the correct data

b. Draw a line through the error, write "error," and initial the entry.

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? a. Using the diaphragm to listen to low-pitched sounds b. Ensuring the contact with the skin in mandated c. Application of firm pressure when using the bell d. Using the bell to detect high-pitched sounds

b. Ensuring the contact with the skin in mandated

The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation? a. Pt is confused and combative b. Hyperactive bowel sounds are heard in all four quadrants c. Pt is overweight d. Pt's pain is tolerable

b. Hyperactive bowel sounds are heard in all four quadrants

Pain is whatever the client says it is. Self-report is the gold standard for assessing pain; however, nurses learn when assessing pain to assess the following as well: (Check all that apply.) a. Increased urine output b. Increased heart rate c. Grimacing d. Increased blood pressure e. Rocking f. Decreased urine output

b. Increased heart rate c. Grimacing d. Increased blood pressure e. Rocking f. Decreased urine output

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client? a. Lying quietly b. Kicking c. Occasional grimace or frown d. Whimpering

b. Kicking

When assessing an older adult client with osteoporotic thinning and vertebral collapse, which of the following would the nurse expect to find? a. Increased arm swinging b. Kyphosis c. Lordosis d. Narrowed gait

b. Kyphosis

The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location (via body diagram), and verbal descriptors, and which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool? a. Visual Analog Scale b. McGill Pain Questionnaire c. Numeric Pain Intensity Scale d. Combined Thermometer Scale

b. McGill Pain Questionnaire

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? a. Past health history b. Objective data c. Family history data d. A genogram

b. Objective data

Which would the nurse recognize as a barrier to assessing pain in the older adult? Select all that apply. a. Treatment of pain can lead to greater quality of life. b. Older adults with pain may fear becoming dependent on others. c. The belief that pain is a normal part of the aging process. d. Older adults may not display an outward reaction to pain. e. The unavailability of pain assessment tools for the older adult.

b. Older adults with pain may fear becoming dependent on others. c. The belief that pain is a normal part of the aging process. d. Older adults may not display an outward reaction to pain.

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply a. Core body temperature b. Onset and character of the clients chest pain c. Blood pressure d. List of all of the client's current medications e. Respiratory rate f. Date and location of the clients last blood pressure check

b. Onset and character of the clients chest pain d. List of all of the client's current medications f. Date and location of the clients last blood pressure check

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area? a. Auscultation b. Palpation c. Percussion d. Inspection

b. Palpation

For which assessment would the nurse plan to use light palpation? a. Pulsation of abdominal aorta b. Papular rash c. Size of liver d. Shape of abdominal mass

b. Papular rash

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form a. Establishes comparability of data across populations b. Prevents missed questions during data collection c. Clusters the assessment data with nursing diagnoses d. Covers all the data that a client may provide

b. Prevents missed questions during data collection

What information concerning a client's respirations should the nurse record after completing a general physical assessment? a. Client's understanding of the factors that can affect respirations b. Rate, rhythm, and depth of respiration taken for a full minute c. Client's understanding of the assessment d. Any existing chronic condition that can affect respiration

b. Rate, rhythm, and depth of respiration taken for a full minute

The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following? a. Hearing test confirmed hearing loss. Consultation were made b. Recent changes in hearing: client states, "I cannot hear high-pitched sounds"; Weber and Rinne test confirmed sensory hearing loss c. Interview was conducted on the client with new-onset hearing loss; tests were abnormal. d. Client was interviewed for changes in hearing; tests were performed.

b. Recent changes in hearing: client states, "I cannot hear high-pitched sounds"; Weber and Rinne test confirmed sensory hearing loss

A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse document this information in the comprehensive assessment? a. History of present illness b. Review of systems c. Past history d. health maintenance

b. Review of systems

The nurse is assessing the client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating? a. Behavioral b. Sensory c. Cognitive d. Physical

b. Sensory

The nurse is explaining the difference between acute pain and chronic pain to the client. Which should the nurse include in the explanation? a. The duration of chronic pain is short. b. The cause of acute pain can be identified. c. Acute pain lasts longer than 3 to 6 months. d. Chronic pain is caused by damage to nerves.

b. The cause of acute pain can be identified.

Which is an example of percussion? SATA a. The nurse notes rustling over the client's thorax b. The nurse notes resonance over the client's thorax c. The nurse notes gurgling throughout the client's abdomen d. The nurse notes dullness over the client's liver e. The nurse notes tympany over the client's lower abdomen

b. The nurse notes resonance over the client's thorax d. The nurse notes dullness over the client's liver e. The nurse notes tympany over the client's lower abdomen

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? a. Follow the ABC approach b. Uses evidence-based techniques c. Focuses on the system that caused the hospitalization d. Ask unlicensed staff to measure vitals signs

b. Uses evidence-based techniques

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? a. "Reddened area noted on skin surface superficial to client's coccyx." b. "Impaired skin integrity related to decreased mobility." c. "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm." d. "Possible pressure ulcer observed over client's coccyx region."

c. "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

During a nutritional assessment, the client asks the nurse for suggestions to improve her diet. The nurse identifies a nursing diagnosis of health-seeking behaviors related to desire to improve diet. Which of the following suggestions would be most appropriate? a. "Eat fewer orange vegetables and more dark green vegetables daily." b. "Drink at least 2 to 3 glasses of fruit juices a day." c. "Choose low-fat versions of milk products such as yogurt." d. The majority of your diet should consist of whole grains.

c. "Choose low-fat versions of milk products such as yogurt."

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? a. "Are you friendly with your neighbors?" b. "Have you tried to schedule a cleaning service?" c. "Do you have family who visit you regularly?" d. "What amount of cleaning have you been doing in the past?"

c. "Do you have family who visit you regularly?"

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information? a. "Has your congestive heart failure been affecting your activities of daily living recently?" b. "Do you ever find yourself SOB when you're carrying out your daily routines?" c. "Has this been having an effect on your ability to carry out your routines and get around your home?" d. "Has your heart failure been causing you any dyspnea lately?"

c. "Has this been having an effect on your ability to carry out your routines and get around your home?"

A nurse is performing a general survey on a new client who is reporting new onset headaches and blurred vision. Which of the following statements by the client would require further follow-up?PRIORITY URGENT ASSESSMENT a. "I had an adverse reaction to penicillin and cephalosporins." b. "My mother had a history of hypothyroidism." c. "My father had a stroke due to uncontrolled hypertension." d. "I eat at fast food restaurants occasionally."

c. "My father had a stroke due to uncontrolled hypertension."

Which of the following clients would be classified as having chronic pain? a. A client with pneumonia b. A client with the flu c. A client with rheumatoid arthritis d. A client with controlled hypertension

c. A client with rheumatoid arthritis

A post-operative client is observed breathing 24 breaths/minute while complaining of 10/10 abdominal pain. The client's oxygen saturation is 90% on 2 liters nasal cannula. What is the nurse's priority action? a. Teach and encourage incentive spirometry use. b. Explain why deep breathing and coughing is important. c. Administer prescribed analgesia as ordered. d. Manually ventilate client with ambu bag at bedside.

c. Administer prescribed analgesia as ordered.

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? a. Risk for self-directed violence b. Impaired verbal communication c. Anxiety d. Imbalanced nutrition: less than body requirements

c. Anxiety

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed a. Focused b. Entry c. Comprehensive d. Exploratory

c. Comprehensive

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen? a. Moderate palpation b. Direct palpation c. Deep palpation d. Light palpation

c. Deep palpation

The nurse is caring for an 88-year-old man hospitalized with a fractured hip and asks for a dietary consult because assessment findings indicate that the client is malnourished. The client has a diagnosis of early-stage Alzheimer disease. In conducting a comprehensive dietary assessment, what would be the method of choice for determining this client's dietary intake? a. Food-frequency questionnaires b. 24-hour recall c. Direct observation d. A 3-day food diary

c. Direct observation

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? a. Finger pad surface b. Ulnar hand surface c. Dorsal hand surface d. Palmar hand surface

c. Dorsal hand surface

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain? a. Verbal Descriptor scale b. Numeric Rating Scale c. Faces Pain Scale d. Visual Analog Scale

c. Faces Pain Scale

Which of the following statements best conveys the rationale for health promotion in a school setting? a. Children contract numerous communicable diseases in the school environment. b. Children younger than 13 years are some of the most common consumers of acute health care services. c. Healthy child development is a critical health determinant because of its implications for lifelong health. d. Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents.

c. Healthy child development is a critical health determinant because of its implications for lifelong health.

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? a. Chief complaint b. Past health history c. History of present illness d. Review of symptoms

c. History of present illness

An instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession? a. Biomedical knowledge b. Simple technology c. Natural senses d. Critical pathways

c. Natural senses

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? a. Document the findings b. Cluster the data c. Perform a physical examination d. Determine a problem list

c. Perform a physical examination

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? a. Have the UAP retake the blood pressure b. Recheck blood pressure in 30 minutes c. Reassess blood pressure d. Notify the physician

c. Reassess blood pressure

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique? a. Risk for impaired skin integrity b. Risk for chronic pain c. Risk for injury d. Risk for infection

c. Risk for injury

A nurse assigns an unlicensed assistive personnel (UAP) to take vital signs on a client. The nurse intervenes when which of the following is observed? a. Using a temporal arterial thermometer without touching the client's skin b. Allowing a client to rest for 5 to 10 minutes before taking blood pressure c. Taking blood pressure with the client's arm elevated above the heart d. Holding rectal thermometer in place for 3 minutes

c. Taking blood pressure with the client's arm elevated above the heart

The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize? a. The client's rating on a 0 to 10 visual analog scale b. The client's explanation of how her pain feels c. The client's report on a 0 to 10 numeric scale d. The client's facial expressions

c. The client's report on a 0 to 10 numeric scale

Which of the following describes how the health history interview differs from a social conversation? a. The interview allows more time for the client to demonstrate self-awareness b. The interview permits the clinical to express his or her needs and interests c. The interview focuses on the client's needs to improve health and well-being d. The interview is restricted to actual or potential illnesses

c. The interview focuses on the client's needs to improve health and well-being

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table? a. Pad the table b. Serves as a head support c. Use as a drape d. Collect body fluids

c. Use as a drape

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event? a. "Client visibly agitated during assessment and unwilling to continue." b. "Client became upset and terminated assessment." c. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." d. "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

d. "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client? a. "It means I need to have the physician come in and look over your chart to make sure I didn't miss anything." b. "It means that I need you to sign a statement in which you confirm that everything you have shared with me today is true." c. "It means I need to take all of your vital signs one more time." d. "It means I need to make sure that all the information I gathered today is reliable and accurate."

d. "It means I need to make sure that all the information I gathered today is reliable and accurate."

The nurse prepares to update the care plan of a client recovering from abdominal surgery. Which client need should the nurse meet that most appropriately addresses the client's pain? a. Chronic pain associated with surgical procedure b. Activity intolerance associated with abdominal pain c. Altered breathing pattern associated with abdominal pain d. Acute pain associated with abdominal wound

d. Acute pain associated with abdominal wound

What are various measurements of the human body, including height and weight, called? a. Datum b. Anthropomorphic d. Vital measurement d. Anthropometric

d. Anthropometric

When physically assessing for malnutrition in a child, the nurse would also observe for which of the following? a. Mental disorders b. Personal likes and dislikes c. Swallowing deficiencies d. Child abuse

d. Child abuse

A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data? a. Blood pressure was 130/85 3 months ago but 120/80 today. b. Resting heart rate was 65 bpm 3 months ago but 70 bpm today. c. Client's temperature was 98.6°F (37°C) 3 months ago but is 99.2°F (37.3 °C) today. d. Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today.

d. Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today.

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation? a. Current physiological status b. Motivation for adherence to treatment c. Past medical history d. Effect of health on functional status

d. Effect of health on functional status

In which disease process should a nurse expect to see a client with the presence of pitting edema? a. Colon cancer b. Diabetes mellitus c. Liver disease d. End stage renal disease

d. End stage renal disease

A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess? a. Posture b. Behavior c. Mood d. Feelings of happiness

d. Feelings of happiness

The most commonly used method of percussion is a. Mild percussion b. Blunt percussion c. Direct percussion d. Indirect percussion

d. Indirect percussion

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing? a. Planning b. Implementation c. Evaluation d. Nursing diagnosis

d. Nursing diagnosis

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should a. Administer tylenol b. Instruct the client to drink more fluid c. Refer the client to a primary care provider d. Record vital signs

d. Record vital signs

A client has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The client always explains having fallen and tripped. The nurse suspects abuse. The next step should be to: a. Call social services b. Confront the client c. Call the police d. Report the findings to a supervisor

d. Report the findings to a supervisor

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? a. Dullness b. Tympany c. Flatness d. Resonance

d. Resonance

The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first? a. Irrational cognition b. Severe phobias c. General intelligence d. Sensory abilities

d. Sensory abilities

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? a. The thickness of the circulating blood b. The volume of air entering the lungs c. The oxygen levels in the blood d. The ability of the arteries to stretch

d. The ability of the arteries to stretch

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary? a. The client's medical record b. The client's wife c. The physician d. The client

d. The client

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing? a. Rectal b. Oral c. Axillary d. Tympanic

d. Tympanic

An adolescent client presents to the health clinic for a routine physical examination. Which observation by the nurse needs validation by collection of objective data? a. Body ordor from the axilla area b. Skin warm and flushed appearance c. Clean and well groomed appearance d. Wearing long sleeve clothing in july

d. Wearing long sleeve clothing in july