.-2

5. The home health nurse assesses capillary refill time on a middle-aged adult. Which of the following results is considered to be within normal range? a. 1-3 seconds b. 4-6 seconds c. 6-8 seconds d. 8-10 seconds

a. 1-3 seconds

4. The nurse assesses the cardiac status of a patient and identifies and increased pulse pressure. Pulse pressure can best be described as which of the following? a. The difference between systolic and diastolic blood pressure readings b. The intensity of peripheral pulses c. The difference between apical pulse and radial pulse d. The volume of the stroke and the heart rate.

a. The difference between systolic and diastolic blood pressure readings This also represents stroke volume

10. When communicating with a client who speaks a different language, which best practice should the nurse implement? a. Speak loudly and slowly b. Arrange for an interpreter to translate c. Speak to the client and the family together d. Stand close to the client and speak loudly

b. Arrange for an interpreter to translate Rationale- An interview with a non-English- speaking person requires a bilingual interpreter for full communication.

13. The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? a. Ask the client why he started taking illegal drugs b. Ask the client about the amount of drug use and its effect c. Ask the client how long he thought that he could take drugs without someone finding out. d. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

b. Ask the client about the amount of drug use and its effect Rationale- By asking the client about the amount of drug use and its effect, the nurse can adequately assess the situation without belittling the patient or making them feel as if they have done something wrong. It is a very specific yet nonjudgmental way to gather information about the drug use.

6. The nurse in an outpatient clinic receives a phone call from a patient complaining of a rash. Which of the following actions should the nurse take FIRST? a. Make an appointment for the patient to see the physician b. Determine if the patient is taking any new medications c. Ask the patient how he is feeling d. Instruct the patient to apply cream to the rash.

b. Determine if the patient is taking any new medications Rationale- Drugs may cause allergic skin eruptions, especially if these are new medications such as antibiotics, barbiturates and aspirin

8. When performing a physical assessment, the home health nurse notes that the eyes of the client involuntarily move rapidly from side to side. Which of the following terms should the nurse use to describe the observation? a. Strabismus b. Nystagmus c. Photophobia d. Ptosis

b. Nystagmus A nystagmus is the "back and forth oscillation of the eye"

1. To assess the pedal pulse, the nurse should palpate in which area? a. The region in the back of the knee b. The top of the foot c. The groin area d. The inner side of the ankle below the medial malleolus

b. The top of the foot

12. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and she is seen at your clinic every week." Which is the most appropriate nursing response? a. " I cannot discuss any client situation with you." b. "If you want to know about Carol, you need to ask her yourself." c. "Only because you are worried about your friend, I'll tell you that she is improving." d. "Being her friend, you know she is having a difficult time and deserves privacy."

a. "I cannot discuss any client situation with you." Rationale- By stating that she (or he) cannot discuss any client information, the nurse is following HIPAA guidelines. If they were to answer with b, c or d, they are implying that Carol is indeed a patient which is against HIPAA privacy practices.

11. The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care, a staff member asks the nurse educator to describe the concept of acculturation. Which of the following responses if the most appropriate for the nurse educator to make? a. "It is the process of learning a different culture to adapt to a new or changing environment." b. "It is a subjective perspective of the person's heritage and a sense of belonging to a group" c. "It is a group of individuals in a society who are culturally distinct and have a unique identity." d. "It is a group that shares some of the characteristics of the larger population group of which it is a part."

a. "It is the process of learning a different culture to adapt to a new or changing environment"

2. The nurse prepares to conduct a physical exam on a new client in the assisted living facility. The nurse determines which of the following observations will have the MOST impact on the nursing assessment? a. Presence of assistive devices for vision and hearing b. Indications of anxiety c. Appearance and appropriateness of clothing and grooming d. Posture, height, and weight

c. Appearance and appropriateness of clothing and grooming Inattention to hygiene or appropriateness of clothing may indicate mental disorders such as depression, or unilateral neglect may indicate early dementia

15. The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for this client, which is the priority nursing action? a. Adhering to mandatory abuse-reporting laws b. Notifying the case worker of the family situation c. Removing the client from any immediate danger d. Obtaining treatment for the abusing family member

c. Removing the client from any immediate danger

9. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the LIP of the incident, and completes and incident report. Which statement should the nurse document on the incident report? a. The client fell out of bed b. The client climbed over the side rails. c. The client was found lying on the floor. d. The client became restless and tried to get out of bed.

c. The client was found lying on the floor Rationale-There is no evidence that 1) The client fell out of bed because they could have already gotten out of bed and fallen. There is no evidence that 2) the client climbed over the side rails because there was no witness to the actual incident itself, and 3) there was no evidence as to why they tried to get out of bed.

14. The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? a. Hypotension, ataxia, hunger b. Stupor, lethargy, muscular rigidity c. Hypotension, coarse hand tremors, lethargy d. Hypertension, changes in level of consciousness, hallucinations

d. Hypertension, changes in level of consciousness, hallucinations Rationale- Alcohol withdrawal delirium symptoms include coarse, irregular tremors, vivid hallucinations, agitated behavior, tachycardia and fever

7. Which of the following assessment findings in a young adult patient indicates to the nurse that there is a problem with fluid volume deficit? a. Taut, shiny skin b. Perspiration in the axillae c. Warm, smooth, elastic skin d. Tenting of the skin

d. Tenting of the skin A fluid volume deficit occurs with dehydration, and tenting of the skin occurs when the individual is dehydrated