Assessment PrepU #2

The mental health nurse assesses for the most common mental health disorder found in children when asking which question?

"Do you ever get scolded at school for not sitting still?

A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status?

"What did your child eat for breakfast?"

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

15mm induration

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects the assessment to reveal:

3+ edema in the lower extremities.

A client weighs 215 lbs and is 5' 8" tall. What would the nurse calculate this client's body mass index (BMI) as being?

32.7

A patient comes to the clinic at 8 a.m. for a scheduled visit. The nurse obtains the patient's temperature orally. Which finding would the nurse interpret as a potential indicator of a problem?

99.6 degrees F; A diurnal variation of 1 or 2 degrees in body temperature is normal throughout the day. Temperature is usually lowest in the morning and increases during the day to betweeen 99 to 99.5 degrees F and then decreases during the night. Therefore, an early morning temperature of 99.6 degrees would suggest a potential problem, because this temperature would then increase as the day goes on. Early morning temperatures of 97.2 degrees, 98.0 degrees, and 98.4 degrees would not be a cause for concern.

Which symptoms may a client with Ménière disease report before an attack?

A full feeling in the ear

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

A positive reaction indicates that the client has been exposed to the disease.

The nurse is preparing an elderly hospitalized client for discharge to home within the hour. What should be the priority for the nurse?

Assess the need for pneumococcal and influenza vaccinations.

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Count the rate of respirations.

A client who is blind is admitted for treatment of a small bowel obstruction and has been vomitting for days. Which nursing diagnosis takes highest priority for this client?

Deficient fluid volume

The nurse needs to carefully monitor a client with traumatic injuries. How often should the nurse check and document the client's pain?

Every time the client's vital signs are assessed

What must the nurse do to identify actual or potential health problems?

Gather data from sources

Which assessment finding would cause the nurse to suspect compartment syndrome in the client following a bone biopsy?

Increased diameter of the calf

The nurse is caring for an older adult client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

Loss of arterial elasticity

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds

According to Wright & Leahey (2005), which family function incorporates the use of power and decision making about resources?

Management

An older adult resident of an assisted living facility has been inconsistently continent of urine until the last several weeks. Which intervention by the care providers at the facility is the most likely priority?

Performing a physical examination and history to determine the exact cause and character of the incontinence.

The nurse is conducting a preoperative assessment of a girl 5 years of age who is scheduled for surgery later that day. The nurse should be aware that the client's imminent surgery is likely to cause what?

Separation anxiety and fear of pain.

A client is receiving a cephalosporin and an aminoglycoside as combination therapy. What assessment should the nurse prioritize?

Serum BUN and creatinine levels

The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock?

Shallow, rapid respirations

The nurse is caring for a client with dysrhythmia. What would be an important procedure to teach a client with dysrhythmia to perform to evaluate his or her response to treatment?

Technique for palpating and counting the radial pulse

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

The Hemovac drain isn't compressed; instead it's fully expanded.

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output of 20 ml/hour

A nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. The nurse administers acetylcysteine every 4 hours for 72 hours. Which laboratory findings confirm the effectiveness of the drug therapy?

alanine aminotransferase and aspartate aminotransferase

What data indicates to the nurse that placental detachment is occurring?

an abrupt lengthening of the cord

A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal?

body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)

A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:

check the client's pedal pulses frequently.

Asking the client to complete serial sevens assesses what?

concentration

A nurse is caring for a client with illness anxiety disorder. Which behavior is the nurse most likely to encounter?

expression of fear of colorectal cancer following 3 days of constipation

A fourth heart sound (S4) indicates a

failure of the ventricle to eject all blood during systole.

Immediately after a birth, a nurse assesses the neonate's head for signs of molding. Which factors determine the type of molding?

fetal body flexion or extension

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

hoarseness of the voice

The classic lesions of impetigo manifest as

honey-yellow crusted lesions on an erythematous base.

A client with Down syndrome is admitted to the pediatric unit with asthma. The client does not enunciate words well and holds onto furniture when walking. The nurse should ask the caregiver

how the client's condition today differs from their normal condition.

A nurse is caring for a veteran, who exhibits signs and symptoms of posttraumatic stress disorder (PTSD). Signs and symptoms of posttraumatic stress disorder include:

hyperalertness and sleep disturbances.

The nurse determines one or two bowel sounds in 2 minutes should be documented as

hypoactive.

A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an infant?

irritability

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis?

joint stiffness that decreases with activity

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra; For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

muscle weakness;Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren't seen in hyperkalemia.

A client is diagnosed with a conductive hearing loss. When performing a Weber test, the nurse expects that this client will hear sound:

on the affected side by bone conduction.

A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple myeloma are at risk for

pathologic bone fractures.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

tetany

When caring for an adolescent diagnosed with depression, the nurse should remember that depression manifests differently in adolescents than it does in adults. In an adolescent, signs and symptoms of depression are likely to include:

truancy, a change of friends, social withdrawal, and oppositional behavior.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.

The nurse determines the client's temperature through palpation by

using the back of the hand.