test prepu

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature."

A normal pulse pressure range for an adult client is typically

30 to 50 mm Hg.

For which of the following clients should a nurse perform a focused assessment?

Client with 4-day history of sore throat and fever with enlarged lymph nodes

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive

The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching?

Dispose of tissues directly into trash cans

Which of the following is not released during the stress response?

Dopamine

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family history

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

A diagnostic finding which is unrelated to nutritional deficiency is

High serum albumin

the nurse explains to the client that smoking has what effect on the body? Select all that apply.

Hypertension Vasoconstriction Peripheral vascular disease

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?

Perspiration Increased heart rate Sleeplessness

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?

Primary

What is the main issue that a nurse should consider when choosing a pain assessment tool to collect objective data?

Produce accurate results each time it is used

the nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

What is the element of pain transmission that causes nociceptors to perceive a nerve impulse?

Transduction

When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient?

Vitamin B

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client?

anemia

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

bmi underweight range

below 18.5

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive

A teenaged client is seen by the nurse for report of excessive thirst and weight loss despite high food intake. Which health condition is most likely responsible for these symptoms?

diabetes mellitus

Revising the plan as needed occurs in what part of the nursing process?

evaluation

An assessment that concentrates on patterns of role performance that all humans share is called what?

functional

What is the most commonly accepted theory of pain?

gate control theory

physical assessment order abdominal

inspect, auscultate, percuss, then palpate

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment?

prone

he nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

-Heart rate 115 beats/minute. -Blood pressure 180/75.

The nurse recognizes the value of the Healthy People 2020 guidelines when creating a plan of care that addresses which client-centered goals? Select all that apply

-living a healthy lifestyle -disease prevention -improving one's quality of life -increasing the longevity of one's life

A nursing student is caring for a male client who has been admitted in a severely malnourished state. For what signs of malnutrition would the student observe?

Bleeding of the gums

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?

Client sitting with arm slightly flexed and even with the heart

On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity?

Fluid accumulation

An assessment that concentrates on patterns of role performance that all humans share is called what?

Functional

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

Functional

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order.

Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Confirm or rule out nursing diagnoses

At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

Immediate

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

Prior to inflating the cuff to measure the client's blood pressure, the nurse has palpated the radial artery, inflated the cuff, and noted the point at which the radial pulse disappears. What is the rationale for the nurse's action?

It prevents client discomfort and an auscultatory gap.

A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading?

Left arm

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

What can cause edema in a client with a weak heart?

Overhydration

Purposeful hourly rounding by the nurse should include which assessments? (Select all that apply.)

Pain Personal needs Position Fall prevention

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?

Palpitation

Your lab instructor explains that physical examination relies on what cardinal assessment technique?

Percussion

You are educating your client on taking blood pressure at home. What would be important to include in your client education?

Routine recalibration of the device

for which assessment would the nurse plan to use direct percussion?

Sinuses

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

What is one of the broad goals within nursing?

To treat human responses

a nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

Transduction

A nurse begins a comprehensive physical examination on a client and notes that the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply.

Type II diabetes mellitus Hypertension Stroke

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

When inspecting structures such as the jugular venous pulse, what would be the best lighting to use?

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?

Wood's light

before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health

bmi healthy weight range.

between 18.5 and 24.9

bmi overweight range

between 25 and 29.9

bmi obese range

between 30 and 39.9

While assessing an older adult client's respirations, the nurse can anticipate that the respiratory pattern may exhibit a

shorter inspiratory phase

At what percent of weight over ideal weight is a person considered obese?

20%

A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client?

46

A nurse is calculating the ideal body weight for a female client who 5 feet 2 inches tall and has a small body frame. Which of the following is this client's ideal body weight?

99

Which of the dimensions of pain listed is being assessed by the question "How does the pain treatment you are getting affect your overall mood?"

Affective.

the nurse is seeing an older client who has not had medical care for many years. Vital signs are T 37.2, HR 78, BP 118/92, RR 14. The client denies pain. The nurse notices that the client has some hypertensive changes in her retinas; a urine test reveals mild proteinuria. The nurse expected the client's BP to be higher. The client is not taking any medications. What do you think is causing this BP reading?

An auscultatory gap

after assessing a client's radial pulse, the nurse determines that an apical pulse needs to be assessed. What will the nurse do when assessing the apical rate? (Select all that apply.)

Assess the rate for 1 minute. Place the stethoscope at the apex of the heart.

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

Body temperature is not impacted by which of the following factors?

Diet

A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?

Goniometer

during a shift assessment, the nurse suspects the client with a urinary tract infection may be experiencing sepsis. What symptoms might alert the nurse to this? Select all that apply.

Hypotension Tachycardia Elevated temperature

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

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply

Increased heart rate Increased blood pressure Increased cardiac output

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan syndrome

Which of the following best describes neuropathic pain?

May be labelled as central pain

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?

Nursing diagnosis

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

Palmar surface

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

The client's acuity

When assessing a client's pulse, the nurse is able to palpate the pulse for some time before losing it upon exerting a little bit more pressure. The pulse is beating at 80 bpm. Which of these should the nurse document as the character of the client's pulse?

Thready pulse

A client is concerned that a blood pressure reading of 180/78 mm Hg is extremely high when the readings usually are around 130/60 mm Hg. What could have caused this elevation in blood pressure?

arm below the level of the heart

a client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take?

auscultate the heart rate for a full minute

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?

bleeding gums

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

blunt percussion.

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next

check for the presence of defining characteristics.

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

constipation

A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?

consult with the healthcare provider about increasing the dose of medication.

The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?

head to toe

The nurse wants to elicit a sound from a client's abdomen. Which technique should the nurse use?

indirect percussion

physical assessment order

inspection, palpation, percussion, and auscultation

he nurse is preparing to assess the respirations of an alert adult client. The nurse should

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

perform a physical examination

During a health assessment, a client shares, "I get a little dizzy when I get up from my chair too quickly." Which question will the nurse ask the client first when attempting to identify client needs and potential health risks?

"What do you mean by 'a little dizzy'?"

What are the areas of independent nursing practice? Select all that apply.

-Deciding when physical procedures should be performed on a client -Deciding what client teaching is necessary -Deciding when a client needs to be turned

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones? Select all that apply.

-Eliminate distracting noises from the environment -Readjust the ear pieces to ensure a snug fit -Angle the binaurals towards the nose

A nurse is calculating the ideal body weight for a female client who 5 feet 5 inches and has a medium body frame. Which of the following is this client's ideal body weight?

125

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis?

A clinical judgment about client responses to health difficulties

when making rounds, the RN should prioritize follow-up care for which client?

An oncology client with a cough but no fever

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

The nurse would assess for positive Blumberg sign how?

Applying and releasing pressure to the abdomen

A client has arrived to the clinic for a routine physical examination. Prior to assessing the client's blood pressure, what should the nurse do?

Ask the client to sit quietly in a chair for 5 minutes.

During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process?

Chronic obstructive pulmonary disease

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?

Diagnosis

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan syndrome. What assessment finding would the nurse expect to find?

Elongated fingers

A nurse is working with a client who has just been given a prescription for warfarin (Coumadin). Which foods should the nurse warn this client to avoid due to its interference with the effectiveness of warfarin?

Green, leafy vegetables

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what?

Higher than normal

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension

A student nurse learns that especially in the very young and very old pain can be inadequately treated. What else would the student learn about inadequate pain treatment in the very young?

It can lead to neurodevelopmental problems

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

Modulation

A 12-year-old boy has reported to the emergency department after having fallen off his bicycle and sustained what appear to be minor injuries. The nurse is assessing him for pain. Which of the following objective findings would most tend to indicate pain?

Nodding up and down in response to questions

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate the carotid arteries

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Parkinson's disease

The admitting nurse has just met a new client. As the nurse introduces himself, he begins the process of inspection on this client. 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

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

Tachycardia

For which client should the nurse wear gloves to provide care? Select all that apply.

The client with Clostridium difficile The client with vancomycin-resistant enterococci The client requiring oropharyngeal suctioning

Why is the nurse always reassessing the client for changes?

To achieve the best results

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviors

The nurse reviews information obtained from the admission's department about a client seeking medical care for a chronic problem. What should the nurse expect to complete when assessing this client? Select all that apply.

Validate data Document data Collect objective data Collect subjective data

The nurse documents that a 45-year-old male is 177.8 cm (5 ft 10 in) tall and weighs 97.5 kg (215 lb). He tells the nurse that he "has a good appetite, but doesn't get much exercise because of his busy work schedule." An appropriate NANDA nursing diagnosis for this client is

altered nutrition, more than body requirements related to intake greater than calories expended.

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

kyphosis

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?

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

the client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

-Increased heart rate -Increased blood pressure -Increased cardiac output

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply.

-Neurotransmitters like endorphins and histamines regulate this pain. -The pain is associated with the inflammatory process. -This form of pain can be either chronic or acute in nature.

Which is an example of inspection? Select all that apply.

-The nurse notes a fine rash covering the individual's thorax. -The nurse notes symmetry of the individual's thorax. -The nurse detects foul odor of the urine.

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? Select all the apply. (select all that apply.)

-Who will be there to help the client with ADLs? -How will the client get home from the hospital? -How will the client cook and eat?

A client had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route?

102.4°F

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mm Hg

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb

a nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this client's ideal weight?

145 lb

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?

18

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1½-inch diaphragm

Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.)

Has body mass index of 16 Discusses feeling fat in clothes

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

When beginning a height measurement on a 14-year-old, the nurse should instruct the client to stand on the scale with heels together. T or F

T

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

Temperature, pulse, respirations, and blood pressure

a client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

The blood pressure is elevated

During a general survey, the nurse asks if the client is feeling cold. What did the nurse most likely observe in the client?

The client is wearing clothing that is inconsistent with warm weather.

A client recovering from a motor vehicle crash sustained right rib fractures and a fractured pelvis. The nurse is reviewing the client's metabolic panel lab results and notes a blood glucose of 130 mg/dL; the client has no history of diabetes. What is the nurse's best initial action?

ask the client if she was in pain when the labs were drawn