Fundamentals 2020 Part 3
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/min The pulse deficit is the difference between the apical and radial pulse rates.
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 is instructing an assistive personnel (AP) 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 client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting her respirations." D. "Let the client rest for 5 minutes before you measure her blood pressure."
A. "Do not measure the client's temperature rectally."
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling."
A. "Would you like me to contact the chaplain to come speak with you?" D. "You know, it is quite normal to feel anger toward your husband at this time." E. "Tell me more about how you are feeling."
A nurse is caring for a client who asks what her Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? 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 feet what visually unimpaired eyes see at 20 feet." 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. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet."
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 3 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 3 seconds D. Thick skin on the soles of the feet E. Numerous light brown macules on the face
A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass B. Decrease fluid intake to prevent urinary incontinence C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation
A. Increase protein intake to increase muscle mass C. Increase calcium intake to prevent osteoporosis D. Limit sodium intake to prevent edema E. Increase fiber intake to prevent constipation
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3* C (101* F), 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 to 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 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 off the trachea on both sides of the midline
A. Palpating the thyroid in the lower half of the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline
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-Fowler's 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 sec if it is regular E. Count and report any sighs the client demonstrates
A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate
A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain
A. Role conflict
A nurse is performing a neurosensory examination for a client. Which of the following assessments 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. Romberg test B. Heel-to-toe walk
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. Decreased risk of depression
A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline
A nurse in a provider's office is preparing to perform a breast examination for an older adult client 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. Smaller nipples D. More pendulous E. Nipple inversion
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. Borboygmi D. Friction rubs E. Bruits
A. Tympany B. High-pitched clicks
Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply.) A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Respond positively when giving feedback
A. Use an open posture C. Establish and maintain eye contact E. Respond positively when giving feedback
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 caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my wife when I get home." Which of the following statements should the nurse make? A. "Sounds like something you should discuss with her when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."
B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns."
A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A. "I will make sure the menu includes kosher options." B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer." C. "I will make sure to use direct eye contact when speaking with this client." D. "I will make sure daily communion is available for this client."
B. "I will discuss the daily schedule with the client to make sure the client will have time for prayer."
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my wife was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and he taught me a few things." D. "It may take me a while to get the hang of this. I have to admit, I am pretty nervous."
B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?"
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following responses should the nurse make? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. "It's still too soon to expect to feel normal. Give it a little more time."
B. "I'm interested in finding out more about how your body feels to you."
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."
B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling."
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at risk for body image disturbances? (Select all that apply.) A. 30-year-old male client following laparoscopic appendectomy B. 45-year-old female client following mastectomy C. 20-year-old female client following left above-the-knee amputation D. 65-year-old male client following cardiac catheterization E. 55-year-old male client following stroke with right-sided hemiplegia
B. 45-year-old female client following mastectomy C. 20-year-old female client following left above-the-knee amputation E. 55-year-old male client following stroke with right-sided hemiplegia
A nurse is caring for a client who has a new diagnosis to type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns
B. Allow the client to provide input in the treatment plan C. Assist the client with time management, and address the client's priorities E. Encourage the client in the expression of feelings and concerns
A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mmHg. The client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication B. Ask the client if she is having pain C. Request a prescription for an antianxiety medication D. Return in 30 min to recheck the client's blood pressure
B. Ask the client if she is having pain
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 his family? (Select all that apply.) A. Talk to the interpreter about the family while the family is in the room B. Ask the family one question at a time 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. Ask the family one question at a time D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk
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
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. Closure of the mitral valve D. Closure of the tricuspid valve
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 collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity
B. Decreased height D. Nail thickening E. Decreased bladder capacity
Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally reciprocal between the nurse and the client B. Encourage the client to communicate his thoughts and feelings C. Give the nurse-client communication no time limits D. Allow communication to occur spontaneously throughout the nurse-client relationship
B. Encourage the client to communicate his thoughts and feelings
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 should the nurse take? (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. Insert the speculum slightly down and forward D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape
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
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 is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test
A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
B. Reflecting
A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture
B. Sit at eye level with the child
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 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 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. "Clench your teeth." E. "Tell me when you feel a touch."
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."
C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply.) A. "I will remove the dentures from the body." B. "I will make sure the body is lying completely flat." C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room."
C. "I will apply fresh linens and place a clean gown on the body." D. "I will remove all equipment from the bedside." E. "I will dim the lights in the room."
A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used to it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about your support system you'll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."
C. "Your daily routines will be different when you get home." D. "Tell me about your support system you'll have after you leave the hospital." E. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction
C. Alarm reaction
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughter's wedding." Based on Kubler-Ross' model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance
C. Bargaining
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. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side
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 reports pain with internal rotation of her right shoulder. This discomfort can affect the client's ability to perform which of the following activities? 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. Fastening her bra behind her back
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is a midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias
C. Flatus
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospital's spiritual services B. Ask him what is making him cry C. Provide quiet times for these moments D. Turn on the television for a distraction
C. Provide quiet times for these moments
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. Resonance E. Bronchovesicular sounds
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote healing B. The client needs to be given privacy at times for self-reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute care facility
C. The client's sense of loss can be lessened through retaining control of certain areas of her life
A nurse is caring for a client who shares the nurse's religious background. Which of the following information should the nurse anticipate? 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. The same religious beliefs can influence individuals differently
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. Tooth loss D. Glare intolerance E. Thickened eardrums
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing."
D. "I don't even want to look at my leg. You can check the dressing."
A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my son to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."
D. "I keep forgetting which medications I have taken during the day."
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive blood transfusion. 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 transfusion?" D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."
D. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."
A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse 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. A familiar object she places in his hand
A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting
D. Convening a family meeting
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone
D. Decreased muscle tone