Chapter 35: Next Generation NGN

The nurse in a community health clinic is preparing to assess the thyroid gland of a 22-year-old female client.

1. Position self to complete the assessment: Stand behind the client 2. Identify landmarks by palpation: Identify thyroid and cricoid cartilages and thyroid isthmus 3. Displace the thyroid gland for palpation: Ask the client to swallow

A 75-year-old male client is admitted to the hospital with confusion. The client's adult child states that their father has been becoming more confused for the past few months. The child states "they keep forgetting to pay their bills and are unable to manage a budget, and they are constantly making poor decisions. I don't know what to do." The client is able to state their name and date of birth but appears confused about where they are and why, and the current date. The client also has difficulty with word finding and carrying on a conversation. For each finding, click to specify if the finding indicates an age-related change or Alzheimer Disease. Findings may support more than one classification.

Forgetful at times: Age-Related Change and Alzheimer Disease Unable to manage a budget: Alzheimer Disease Constantly making poor decisions: Alzheimer Disease Unable to state where they are or why or the current date: Alzheimer Disease Difficulty carrying on a conversation: Alzheimer Disease

A 33-year-old female client is being seen in the clinic for changes in the right breast. The nurse performs a focused breast assessment. Findings include a small (less than 1-cm) nodule that is nontender, smooth, and movable. benign or maligmant?

all benign

A nurse in a community clinic is attempting to collect a health history on a 26-year-old female new client who appears anxious. To help reduce the client's anxiety, the nurse should

decrease environmental stimuli, introduce oneself, ask simple, concise questions, and explain the nurses role

A nurse is administering medications to a newly admitted 85-year-old male client in the hospital. The client starts coughing harshly after taking a sip of water. The client states they have lost weight in the past few months because of difficulty eating and drinking. The nurse is concerned that the client may have

dysphagia as evidenced by difficulty drinking

A 33-year-old female client seeks medical attention at a community clinic for an intermittent frontal headache. The nurse prepares to assess the client's sinuses. To palpate the sinuses, the nurse will sit

facing the client, and press up on the frontal sinuses, under the brow bone. Then, the nurse will palpate over the cheek bones to assess the maxillary sinuses, Afterward, the nurse will tap lightly over the sinus areas to assess for tenderness

A community health nurse is conducting a community assessment on an inner city neighborhood. The assessment reveals predominantly young single parents, higher than expected birth with higher infant mortality, affordable public transportation, several small convenience stores in a 5-mile radius, one grocery store within a 20-mile radius, several small health clinics within a 10-mile radius, and major medical centers within a 20-mile radius. The nurse determines that the findings of

higher birth rates with higher rates of infant mortality, one grocery store in a 20-mile radius, medical centers within a 20-mile radius, and single parents require follow-up.

A nurse is caring for a 59-year-old female client admitted with suspected gastrointestinal (GI) bleeding. The nurse anticipates the following vital signs related to the loss of blood volume:

increased heart rate and decreased blood pressure

A nurse in a clinic performs a head-to-toe assessment on a 62-year-old male client. The assessment reveals the following: alert and cooperative, lungs diminished in the bases, increased secretions in the larger airway, respirations 22 breaths/min, pulses 1+, capillary refill greater than 3 seconds, abdomen soft and nontender, skin warm and dry with cool lower extremities, and client moves all extremities well with full range of motion. The nurse should first address the client's

respiratory function followed by the client's cardiovascular system

A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Prior to meeting the new client, the nurse should first

review the client's medical record and then explain the purpose of the interview

A 76-year-old female client visits the primary care doctor for an annual physical. The client's spouse recently died and the client lives by themselves with no adult children nearby. The client's appearance is clean but disheveled and the client has lost weight since the last visit 3 months ago. The nurse is concerned about the client being able to care for themselves at home. Based on the client's findings and history, the client is at risk for

self-neglect and the nurse should complete the lawson scale for instrumental activities of daily living IADLs

The nurse in a community health clinic performs a comprehensive assessment on a new client. The 33-year-old male client is awake, alert, and moves all extremities well. Vital signs include: temperature, 101.2°F (38.4°C); heart rate, 100 beats/min; blood pressure, 90/60 mm Hg. The client reports burning when urinating. The client's last bowel movement was 2 days ago. Based on the client's findings, the nurse should follow up on

temp and burning during urination

The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Upon inspection, the client is in the

tripod position, has a barrel chest and nails are clubbed, crackles heard on auscultation