ATI: Fundamentals (Chapter 26), ATI: Fundamentals (Chapter 27), ATI Fundamentals Chapter 28, ATI Fundamentals Chapter 29, ATI: Fundamentals (Chapter 27), ATI: Fundamentals (Chapter 30) Integumentary and Peripheral Vascular Systems, ATI Fundamentals C...

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16

A client asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 ft what visually unimpaired eyes see at 20 ft. " D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A A. Correct: The first number is the distance (in feet) the client stands from the chart. The second number is the distance in which a visually unimpaired eye can see the line clearly. B. Incorrect: Each eye has it own visual acuity, which includes both numbers. C. Incorrect: The numerator of visual acuity results is a constant. It does not change with the client's ability to see clearly. D. Incorrect: Each eye has its own visual acuity, which includes both numbers.

A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

A. Posture B. Skin lesions C. Speech

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A, B A. Correct: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach. B. Correct: Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min. C. Incorrect: Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods. D. Incorrect: Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings. E. Incorrect: Bruits indicate narrowed blood vessels and are unexpected findings.

A nurse assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply) A. Palpating the thyroid in the lower half of the neck. B. Visualizing the thyroid on inspection of the neck. C. Hearing a bruit when auscultating the thyroid. D. Feeling the thyroid ascend as the client swallows. E. Finding symmetric extension of the trachea on both sides of the midline.

A, D, E A. Correct: The thyroid gland lies in the anterior portion of the lower half of the neck, just in front of the trachea. B. Incorrect: An average-sized thyroid gland is not visible on inspection. C Incorrect: A bruit indicates increased blood flow, possibly due to hyperthyroidism. D. Correct: When the client swallows a sip of water, the nurse should feel the thyroid move upward with the trachea. E. Correct: The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline.

A nurse in a provider's office is preparing to test a "client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V. (Select all that apply.) A. "Close your eyes" B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

A,C,E A. Incorrect: The first step of testing cranial nerve V, trigeminal nerve, is to have the client close his eyes. B. Incorrect: Testing cranial nerve VII, the facial nerve, involves testing the mouth for taste sensations. C. Correct: Testing cranial nerve V, the trigeminal nerve, involve testing the strength of muscle contraction by asking the client to clench his teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. D. Incorrect: Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise his eyebrows, puff out his cheeks, and perform other facial movements. E. Correct: Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when he feels a gentle touch on his face from a wisp of cotton.

A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

A,D,E A. Correct: In older adulthood, the nipples become smaller and flatter. B. Incorrect: Older adults have more adipose tissue and less glandular tissue in their breasts. C. Incorrect: Older adults have no nipple discharge, unless there is some underlying pathophysiology. D. Correct: In older adulthood, the breasts become softer and more pendulous. E. Correct: Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day and cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply) A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you sleep?" E. "Tell me about any personal stress you are experiencing."

A. "Have your working hours changed recently?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you sleep?" E. "Tell me about any personal stress you are experiencing."

A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? (Select all that apply.) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test

A. CORRECT: For the Romberg test, the client stands with his eyes closed, arms at his side, and feet together. The nurse verifies balance if he can stand with minimal swaying for at least 5 seconds. B. CORRECT: For the heel-to-toe walk, the client places the heel of one foot in front of the toes of the other foot as he walks in a straight line. The nurse verifies balance if he can walk in a straight line without losing his balance. C. INCORRECT: A Snellen eye chart tests visual acuity, not balance. D. INCORRECT: Testing spinal accessory function verifies that cranial nerve XI is intact by asking the client to shrug his shoulders and turn his head against resistance. E. INCORRECT: A Rosenbaum eye chart tests visual acuity, not balance.

A nurse is caring for a client who has several risk factors for hearing loss. As the nurse reviews the client's medication history, which of the following medications the client takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide (Lasix) B. Ibuprofen (Advil) C. Cimetidine (Tagamet) D. Simvastatin (Zocor) E. Amiodarone (Cordarone)

A. CORRECT: Furosemide, a loop diuretic, can cause hearing loss as well as blurred vision. B. CORRECT: Ibuprofen, a nonsteroidal anti-inflammatory agent, can cause hearing loss as well as vision loss. C. INCORRECT: Cimetidine, a medication that decreases gastric acid secretion, is unlikely to cause hearing loss. D. INCORRECT: Simvastatin, a medication that helps lower cholesterol, is unlikely to cause hearing loss. E. INCORRECT: Amiodarone, an antidysrhythmic medication, is more likely to cause blurred vision than hearing loss.

A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Slower superficial pain sensation

A. CORRECT: With aging, light touch sensation decreases for the client who is aging B. CORRECT: With aging, losses in vision, hearing, taste, and smell decline. C. CORRECT: With aging, fine finger movement slows, along with some reflex and motor responses. D. CORRECT: With aging, some decline in short-term memory is an expected finding. Major cognitive decline is an expected finding. E. INCORRECT: With aging, superficial pain sensation typically remains the same.

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. No signs of obstruction in the left ear canal D. Rinne test showing less for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear

A. CORRECT: With sensorineural hearing loss, the Weber test demonstrates lateralization to the unaffected ear. D. CORRECT: With sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction. B. INCORRECT: A light reflex at 10 o'clock in the left ear indicates that air or fluid has displaced the tympanic membrane, but it does not indicate sensorineural hearing loss. C. INCORRECT: Signs of obstruction in the ear canal indicate conductive, not sensorineural, hearing loss. E. INCORRECT: With sensorineural hearing loss in the left ear, air conduction is greater than bone conduction in the left ear.

A nurse is instructing an assistive personnel about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client?

A. Do not measure the clients temperature rectally.

A nurse is caring for an 82 year old client in the emergency department who has an oral body temperature of 101, pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity D. Allow the client to shiver the dispel excess heat E. Assist the client with oral hygiene frequently

A. Obtain culture specimens before initiating antimicrobials C. Encourage the client to rest and limit activity E. Assist the client with oral hygiene frequently

A nurse is caring for an 82 year old client in the emergency department who has an oral body temperature of 101, pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity D. Allow the client to shiver the dispel excess heat E. Assist the client with oral hygiene frequently

A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity E. Assist the client with oral hygiene frequently

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (select all that apply) A. Place the client in semi-fowlers position. B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate D. Count the rate for 30 seconds if it is irregular. E. Count and report any sighs the client demonstrates

A. Place the client in semi-fowlers position. B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate

A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply) A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake at least 2 hr before bedtime

A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake at least 2 hr before bedtime

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply) A. REM sleep provides cognitive restoration B. REM sleep lasts about 90 mins C. It is difficult to awaken a person in REM sleep D. Sleepwalking occurs during REM sleep E. Vivid dreams are common during REM sleep

A. REM sleep provides cognitive restoration C. It is difficult to awaken a person in REM sleep E. Vivid dreams are common during REM sleep

A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? A. "I will make sure the menu includes kosher options." B. "I will ask the client if they want to schedule some times to pray during the day." C. "I will avoid discussing care when the client's family is around." D. "I will make sure daily communion is available for this client."

B A. INCORRECT Jewish culture, not Islam, requires food to be kosher. B. CORRECT: Islamic practices include praying five times per day. Work with the client to establish a schedule for the day, noting which times the client prefers to pray, and scheduling treatments around those times when possible. C. INCORRECT American culture appreciates direct eye contact. In Middle Eastern cultures, direct eye contact can be perceived as rude, hostile, or sexually aggressive. D. INCORRECT Daily communion is a ritual to consider for a Catholic client, not for a Muslim client.

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Closure of the tricuspid valve E. Murmur

B, D A. Incorrect: To auscultate a ventricular gallop (an S3 sound), the nurse places the bell of the stethoscope at ech of the auscultatory sites. B. Correct: To auscultate the closure of the mitral valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. C. Incorrect: To auscultate the closure of the pulmonic valve, the nurse places the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space. D. Correct: To auscultate the closure of the tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. E. Incorrect: To auscultate a murmur, the nurse places the bell of the stethoscope at various auscultatory sites.

A nurse is caring for a client who recently had a stroke and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply.) A. Speak fast and loudly. B. Make sure only one person speaks at the time C. Write down what the client does not understand. D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words.

B, D, E A. INCORRECT: The client is not hearing impaired, so speaking loudly will not promote communication. B. CORRECT: Make sure only one person speaks at the time because trying to understand more than one voice at a time is challenging C. INCORRECT: Writing down what the client does not understand provides the same information in a format the client can understand, provided he is literate. D. CORRECT: Allowing ample time for the client to respond helps enhance communication. Rushing ahead to the next question would be demeaning and could cause frustration. E. CORRECT: Brief sentences with simple words are generally easy to understand.

A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family members? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room. B. Determine client understanding several times during the conversation. C. Look at the interpreter when asking the family questions. D. Use lay terms if possible. E. Do not interrupt the interpreter and the family as they talk

B, D, E A.INCORRECT Talking to the interpreter about the family while the family is in the room would hinder communication between the family and the nurse/interpreter. B. CORRECT: Determining client understanding throughout the conversation ensures the client comprehends the information and the nurse will know how to direct the conversation. C. INCORRECT Looking at the interpreter instead of the family while the family is in the room would hinder communication between the family and the nurse/interpreter. D. CORRECT: Using lay terms will promote effective communication between the family and the nurse/interpreter. E. CORRECT: Not interrupting will promote effective communication between the family and the nurse/interpreter.

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.

B,D,E A. Incorrect: The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years old. B. Correct: Inserting the speculum slightly down and forward follows the natural shape of the ear canal. C. Incorrect: The nurse should insert the speculum 1 to 1.5cm (0.4-0.6 in). D. Correct: The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. E. Correct: Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle.

A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instruction? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am ay my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B. "I'll take a short nap whenever I feel a little sleepy."

A nurse who is admitting a client who has a fractured femur obtains a blood pressure of 140/94. The client denies any history of hypertension. Which of the following actions should the nurse take first?

B. Ask the client if he is having pain

A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

B. Auscultation

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and her last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.

B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. E. Perform the general survey before the examination.

A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply) A. Collect the data in one continuous session B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time answering questions E. Invite the client to use the bathroom before beginning the examination

B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time answering questions E. Invite the client to use the bathroom before beginning the examination

A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital's spiritual services. B. Ask what is making the client cry. C. Ensure no visitors or staff enter the room for a short time period. D. Turn on the television for a distraction

C A. INCORRECT Contacting the hospital's spiritual services presumes there is a problem and should not be done without asking the client's permission. B. INCORRECT Asking the client about the crying could be interpreted as discounting or being disrespectful of the client's beliefs. C. CORRECT: Providing privacy and time for the reading of religious materials supports the client's spiritual health. D. INCORRECT Providing a distraction could be interpreted as discounting or being disrespectful of the client's beliefs.

A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religion share similar feelings about their religion. B. A shared religious background generates mutual regard for one another. C. The same religious beliefs can influence individuals differently. D. The nurse and client should discuss the differences and commonalities in their beliefs

C A. INCORRECT It would be stereotyping to assume that all members of a specific religion had the same beliefs. Feelings and ideas about religion and spiritual matters can be quite diverse, even within a specific culture. B. INCORRECT Mutual regard does not necessarily follow a shared religious background. C. CORRECT: Members of any particular religion should be assessed for individual feelings and ideas. D. INCORRECT Due to boundary issues, the nurse's beliefs are not part of a therapeutic client relationship. It is the client's beliefs that are important.

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention(bloating). The protrusion(protuberancia) is at midline, the skin over the area is taut(tenso), and the nurse notes no involvement of the flanks (costado). Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

C A. Incorrect: With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut. B. Incorrect: With fluid, the flans also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. C. Correct: With flatus, the protrusion is mainly midline, and there is no change in flanks. D. Incorrect: With hernias, protrusions through the abdominal muscle wall are visible, especially when the client raises her head.

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C, D, E A. Incorrect: The nurse should expect an older adult's gums to be pale. B. Incorrect: The nurse should expect an older adult's vocal pitch to rise. C. Correct: Tooth loss and gum disease are common in older adults. D. Correct: Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. E. Correct: Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals.

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

C, E A. Incorrect: Rhonchi are coarse sounds that result from fluid or mucus in the airways. B. Incorrect: Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways. C. Correct: Resonance is the expected percussion sound over the the thorax. It is a hollow sound that indicates air inside the lungs. D. Incorrect: Tactile fremitus is an expected vibration the nurse can expect to feel as the client vocalized. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall. E. Correct: Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

A nurse in a provider's office is preparing to test a "client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V. (Select all that apply.) A. "Close your eyes" B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

C, E A. Incorrect: The first step of testing cranial nerve V, trigeminal nerve, is to have the client close his eyes. B. Incorrect: Testing cranial nerve VII, the facial nerve, involves testing the mouth for taste sensations. C. Correct: Testing cranial nerve V, the trigeminal nerve, involve testing the strength of muscle contraction by asking the client to clench his teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. D. Incorrect: Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise his eyebrows, puff out his cheeks, and perform other facial movements. E. Correct: Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when he feels a gentle touch on his face from a wisp of cotton.

A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime B. Offer the client warm milk and crackers at 2100 C. Allow the client to take a bath in the evening D. Ask the provider for a sleeping medication

C. Allow the client to take a bath in the evening

A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. A concave thoracic spine posteriorly B. An exaggerated lumbar curvature C. A concave lumbar spine posteriorly D. An exaggerated thoracic curvature E. Muscles slightly larger on his dominant side

C. CORRECT: A concave lumbar spine posteriorly (with the concavity moving inward from the back of the body) is an expected finding. E. CORRECT: Muscle size equal on both sides or slightly larger on the dominant side is an expected finding. A. INCORRECT: A convex thoracic spine posteriorly (with the convexity arching toward the back of the body) is an expected finding. B. INCORRECT: Although lordosis, an exaggerated lumbar curvature, is common among toddlers and pregnant women, it is an unexpected finding in most adults. D. INCORRECT: Although kyphosis, an exaggerated lumbar curvature, is common among older adults, it is an unexpected finding in younger adults.

A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink

C. CORRECT: Fastening a bra from behind requires internal rotation of the shoulder, so this activity will elicit pain. A. INCORRECT: Mopping the floor requires flexion and extension of the shoulder. B. INCORRECT: Brushing the back of the hair requires external rotation of the shoulder. D. INCORRECT: Reaching for something up high requires external rotation of the shoulder.

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. Immediately complete a thorough assessment. B. Put the client in a room with a client who is hearing impaired. C. Provide a private room, and limit stimulation. D. Talk loudly to the client, and encourage ambulation.

C. CORRECT: Minimizing stimuli helps clients who have sensory overload. A. INCORRECT: Immediately completing a thorough assessment might overwhelm the client at this time. Therefore, brief assessments during the course of the shift are better. B. INCORRECT: Rooming with a client who is hearing impaired would increase environmental stimuli. D. INCORRECT: Talking loudly would increase environmental stimuli.

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

C. Dorsal surface

A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. "I believe in this case you should really make an exception and accept the blood transfusion." B. "I know your family would approve of your decision to have a blood transfusion." C. "Why does your religion mandate that you cannot receive any blood transfusions?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution

D A. INCORRECT: Do not impose an opinion onto the client and ask them to go against their religious beliefs. B. INCORRECT: Do not make an assumption on behalf of the client's family. C. INCORRECT Asking a "why" question can appear judgmental or accusatory. D. CORRECT: Involving the client's religious and spiritual leaders is a culturally responsive action at this point. Alternative forms of blood products can be discussed, and a plan reasonable to all can be reached.

A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand

D. CORRECT: Identifying a familiar object in the hand confirms the client's sense of stereognosis, which is tactile recognition. A. INCORRECT: Identifying a whispered word confirms that CN VIII is intact. B. INCORRECT: Identifying a tracing on the palm confirms the client's sense of graphesthesia, which is the ability to use only the sensation of touch to recognize writing on the skin. C. INCORRECT: Identifying the vibration of a tuning fork confirms the client's vibratory sense.

A nurse is reviewing instructions with a client who is hearing impaired and has just started wearing hearing aids. Which of the following statements by the client indicates understanding of the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned up so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night."

D. CORRECT: To conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use. A. INCORRECT: The client should keep the hearing aids completely dry at all times. B. INCORRECT: The client should clean the ear molds with mild soap and water. C. INCORRECT: To avoid feedback noise, the client should keep the volume on the lowest setting that allows her to hear.

A nurse is instructing an assistive personnel about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client?

Do not measure the client's temperature rectally.

Under Management of Client Care, list at least six interventions for clients who are hearing impaired (hearing loss)

Hearing impairment Sit and face the client. Avoid covering the mouth while speaking. Encourage the use of hearing devices. Speak slowly and clearly. Do not shout. Try lowering vocal pitch before increasing volume. Use brief sentences with simple words. Write down what clients do not understand. Minimize background noises. Ask for a sign language interpreter if necessary.

Under Management of Client Care, list at least six interventions for clients who are visually impaired. (vision loss)

Vision impairment Call clients by name before approaching to avoid startling them. Identify yourself. Stay within the clients' visual field if they have a partial loss. Give specific information about the location of items or areas of the building. Explain interventions before touching clients. Before leaving, inform clients of your departure. Carefully appraise clothing and suggest changes if soiled or torn. Make a radio, television, compact disc (CD) player, or digital audio file player available. Describe the arrangement of the food on the tray before leaving the room

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 2 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous light brown macules on the face

a. Capillary refill less than 2 seconds d. Thick skin on the soles of the feet e. Numerous light brown macules on the face

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor b. Cyanosis c. Jaundice d. Erythema

b. Cyanosis

A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) a. Thin, parchment-like skin b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity e. Excessive wrinkling

b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity (Tenting is a delay in the skin returning to its normal place after pinching.)

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply.) a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature

b. Skin color c. Edema e. Skin temperature

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) a. Acne b. Warts c. Psoriasis d. Herpes simplex e. Varicella

d. Herpes simplex e. Varicella

A nurse is reviewing the expected range of motion of joint movement with a group of nursing students. What information should the nurse include in the review? Use the ATI Active Learning Template: Basic Concept to complete this item. Under Related Content, list the 13 common types of motion along with the actions that demonstrate them.

● Related Content ◯ Flexion - a movement that decreases the angle ◯ Extension - a movement that increases the angle ◯ Hyperextension - an extreme extension ◯ Supination - the ventral surface facing up ◯ Pronation - the ventral surface facing down ◯ Abduction - the movement of an extremity away from the midline ◯ Adduction - the movement of an extremity toward the midline ◯ Dorsiflexion - flexing the foot and toes upward ◯ Plantar flexion - bending the foot and toes downward ◯ Eversion - turning the body part away from midline ◯ Inversion - turning the body part toward the midline ◯ External rotation - rotating a joint outward ◯ Internal rotating - rotating a joint inward