Fundamentals of Success Physical Assessment
A nurse is performing a psychosocial assessment. Which assessment should be identified as a subtle indicator of depression? A. Unkempt appearance B. Anxious behavior C. Tense posture D. Crying
Answer: A Rationale: A. When people are depressed, they frequently do not have the physical or psychic energy to perform the activities of daily living and often exhibit an unkempt appearance. A disheveled, untidy appearance is a covert, subtle indication of depression. B. Anxious behavior is overt, not covert and subtle. C. Tense posture is overt, not covert and subtle. D. Crying is overt, not covert and subtle.
A nurse is assessing a client who states, "I feel cold." Which mechanism that helps regulate body temperature will increase body heat? A. Vasodilation B. Evaporation C. Shivering D. Radiation
Answer: C Rationale: A. Vasodilation brings warm blood to the peripheral circulation, where it is lost through the skin via radiation; this produces heat loss. B. Evaporation (vaporization) is the conversation of a liquid into a vapor. When perspiration on the skin evaporates, it promotes heat loss. C. Shivering generates heat by causing muscle contraction, which increases the metabolic rate by 100% to 200%. D. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact; this produces heat loss.
A client has an elevated temperature and reports feeling cold. Which additional physical change should the nurse expect during the onset phase (cold or chill phase) of a fever? Select all that apply. A. Restlessness with confusion B. Decreased respiratory rate C. Profuse perspiration D. Warm skin E. Shivering
Answer: E Rationale: A. Restlessness with confusion may indicate the beginning of delirium associated with high fevers that alter cerebral functioning. Delirium is associated with the course phase (plateau phase) of a fever. B. During the onset phase (cold or chill phase) of a fever, the pulse and respiratory rates increase as the body attempts to achieve the new set-point. C. Profuse diaphoresis (sweating) occurs during the defervescence phase (fever abatement, flush phase) of a fever. D. Pale, cold skin occurs during the onset phase of a fever. Warm skin occurs with the flushing due to vasodilation during the defervescence phase (fever abatement, flush phase) of a fever. E. Shivering occurs during the onset phase (cold or chill phase) of a fever. Fever is caused by the release of inflammatory mediators (pyrogens) that cause the hypothalamus to reset the set-point of temperature. When this happens, the body feels cold, and shivering occurs. Shivering involves muscle contraction that produces heat, which increases the temperature to the new hypothalamic set-point.
A nurse refers to the Glasgow Coma Scale when assessing a client's level of consciousness. Place the following statements related to verbal response in the Glasgow Coma Scale in order from behaviors that support alertness to those that support unresponsiveness. 1. No response 2. Oriented, converses 3. Disoriented, converses 4. Uses inappropriate words 5. Makes incomprehensible sounds
Answer: 2, 3, 4, 5, 1 Rationale: 1. No response is rated 1, the lowest level of the five levels of functioning, and is after makes incomprehensible sounds, level 2 in the Best Verbal Response category of the Glasgow Coma Scale. 2. Oriented and converses is rated 5, the highest level of functioning of the five levels in the Best Verbal Response category of the Glasgow Coma Scale. 3. Disoriented and converses is rated 4 out of five levels of functioning and is after oriented and converses, level 5 in the Best Verbal Response category of the Glasgow Coma Scale. 4. Uses inappropriate words is rated 3 out of five levels of functioning and is after disoriented and converses, level 4 in the Best Verbal Response category of the Glasgow Coma Scale. 5. Makes incomprehensible sounds is rated 2 out of five levels of functioning and is after uses inappropriate words, level 3 in the Best Verbal Response category of the Glasgow Coma Scale.
A nurse is assessing the characteristics of a client's urine. Which of the following can cause urine to appear red? A. Beets B. Strawberries C. Red food dye D. Cherry gelatin
Answer: A Rationale: A. Betacyanin, a pigment that gives beets their purplish red color, is excreted in the urine and feces of some people when it is nonmetabolized (a genetically determined trait). This bright red pigment turns the urine and feces red for several days after eating beets. B. Strawberries will not turn the urine red. However, they can cause an allergic reaction (reason is unknown), producing the cellular release of histamine and hives. C. Red food dye does not turn the urine red. Red dye No. 3, found in foods such as maraschino cherries, is a suspected carcinogen. D. Red food dye does not turn the urine red. However, red dye No. 3, found in foods such as gelatin desserts and maraschino cherries, is a suspected carcinogen.
Which method of examination is being used when the nurse's hands are used to assess the temperature of a client's skin? A. Palpation B. Inspection C. Percussion D. Observation
Answer: A Rationale: A. Gross temperature assessments (e.g., cold, cool, warm, hot) can be obtained by palpation. Palpation is the examination of the body using the sense of touch. Sensory nerves in the fingers transmit messages through the spinal cord to the cerebral cortex, where they are interpreted by the nurse. B. Inspection cannot assess skin temperature. Inspection uses the naked eye to perform a visual assessment of the body. C. Percussion cannot assess skin temperature. Percussion is the act of striking the body's surface to elicit sounds that provide information about the size and shape of internal organs or whether tissue is air filled, fluid filled, or solid. D. Observation cannot assess skin temperature. Observation uses the naked eye to perform a visual assessment of the body.
A nurse plans to take a client's radial pulse. Which method of examination should be used by the nurse? A. Palpation B. Inspection C. Percussion D. Auscultation
Answer: A Rationale: A. Palpation, the examination of the body using the sense of touch, is used to obtain the heart rate at a pulse site. When measuring a pulse, an artery is compressed slightly by the fingers so that the pulsating artery is held between the fingers and a bone or firm structure. B. A pulse is not measured by using the sense of sight. Inspection uses the naked eye to perform a visual assessment of the body. C. Percussion cannot measure a pulse. Percussion is the act of striking the body's surface to elicit sounds that provide information about the size and shape of internal organs or whether tissue is air filled, fluid filled, or solid. D. Auscultation is used to obtain an apical, not radial, pulse. Auscultation is the process of listening to sounds produced in the body. It is performed directly by just listening with the ears or indirectly by using a stethoscope that amplifies the sounds and conveys them to the nurse's ears.
A client is admitted to the emergency department with difficulty breathing. Which client response identified by the nurse causes the most concern? A. Low pulse oximetry B. Wheezes on expiration C. Shortness of breath on exertion D. Use of accessory muscles of respiration
Answer: A Rationale: A. Pulse oximetry is a noninvasive procedure to measure the oxygen saturation of the blood. The expected value is 95% or more. If a client's pulse oximetry result is low, the client is hypoxic and needs medical intervention. B. Although wheezing on expiration, which is associated with bronchial constriction, requires continuous monitoring, it is not as critical an assessment as is a clinical manifestation presented in another option. Wheezing on exhalation that increases in severity or wheezing on both inhalation and exhalation becomes a priority in relation to the situation presented. C. Shortness of breath is an expected response to exertion and is not a cause for concern. D. Although using accessory muscles of respiration requires monitoring, it is not as critical an assessment as low pulse oximetry. Some people with chronic respiratory problems always use accessory muscles of respiration when breathing.
A nurse is unable to palpate a client's brachial pulse. Which pulse should the nurse assess to determine adequate brachial blood flow in this client? A. Radial B. Carotid C. Femoral D. Popliteal
Answer: A Rationale: A. The brachial artery splits (bifurcates) into the radial and ulnar arteries. When there is an adequate radial pulse, the brachial artery must be patent. B. This information will not provide information about brachial artery blood flow. The carotid arteries are in the neck, whereas the brachial arteries are in the arms. A carotid pulse site is located on the neck at the side of the larynx, between the trachea and the sternomastoid muscle. C. This information will not provide information about brachial artery blood flow. The femoral arteries are in the legs, whereas the brachial arteries are in the arms. A femoral pulse site is in the groin in the femoral triangle. It is in the anterior, medial aspect of the thigh, just below the inguinal ligament, halfway between the anterior superior iliac spine and the symphysis pubis. D. This information will not provide information about brachial artery blood flow. The popliteal arteries are in the legs, whereas the brachial arteries are in the arms. A popliteal pulse site is in the lateral aspect of the hollow area at the back of the knee (popliteal fossa).
Which nursing action is common to all instruments when taking a temperature? A. Ensure that the instrument is clean. B. Place a disposable sheath over the probe. C. Wash with cool soap and water after use. D. Check that it is below ninety-six degrees before insertion.
Answer: A Rationale: A. This is an acceptable medical asepsis practice. All instruments, regardless of their type, must be clean before and after use. B. This is true only for electronic thermometers and sometimes used for plastic thermometers. C. This is true only for plastic thermometers. D. This is not true for all thermometers, such as chemical disposable thermometers, temperature-sensitive tape, and electronic thermometers. This is true for plastic thermometers.
A nurse is assessing a postoperative client for signs of hemorrhage. Which clinical manifestation is indicative of shock? Select all that apply. A. Hypotension B. Tachycardia C. Fast respirations D. Cold, clammy skin E. Prolonged capillary refill
Answer: A, B, C, D, E Rationale: A. The circulating blood volume is reduced by 25% to 35% during the compensatory stage of shock and by 35% to 50% during the progressive stage of shock as the peripheral vessels constrict to increase blood flow to vital organs. This shunting of blood causes hypotension. B. The heart rate increases (tachycardia) during the compensatory stage of shock to maintain adequate blood flow to body tissues. C. During the compensatory stage of shock, the respiratory rate increases to maintain adequate oxygenation of body cells. D. With hemorrhage, there is a decrease in blood pressure as a result of hypovolemia, which in turn stimulates the sympathetic nervous system. The sympathetic nervous system stimulates vasoconstriction, which moves blood from the periphery of the body to vital organs. The decrease in circulation to the skin causes it to become cold and clammy. E. Prolonged capillary refill occurs with shock because of reduced circulating blood volume (hypovolemia) due to blood loss.
A nurse identifies that a client is exhibiting signs of the onset phase (cold or chill phase) of a fever. Which client assessment supports this conclusion? Select all that apply. A. Goose bumps on the skin B. Decreased heart rate C. Cyanotic nail beds D. Flushed skin E. Sweating
Answer: A, C Rationale: A. Contraction of the arrector pili muscles (goose bumps), an attempt by the body to trap air around body hairs, is associated with the onset phase (cold or chill phase) of a fever. During this phase, the body responds to pyrogens by conserving heat to raise the body's temperature and reset the body's thermostat. B. During the onset phase (cold or chill phase) of a fever, the heart and respiratory rates increase, not decrease. C. Cyanosis of the nail beds occurs during the onset phase (cold or chill phase) of a fever. Vasoconstriction and shivering are the body's attempt to conserve heat. D. Flushed skin occurs during the defervescence phase (fever abatement, flush phase) of a fever as the hypothalamus attempts to lower the body's temperature. Quick vasodilation occurs, which helps to cool the body. E. Profuse diaphoresis (sweating) occurs during the defervescence phase (fever abatement, flush phase) of a fever as the hypothalamus attempts to lower the body's temperature. During this phase, the fever abates and the body's temperature returns to the expected range.
A nurse in the clinic must obtain the vital signs of each client via an electronic thermometer before clients are assessed by the primary health-care provider. Which client characteristic indicates that the nurse should take the client's temperature via the rectal, rather than the oral, route? Select all that apply. A. Mouth breather B. History of vomiting C. Presence of confusion D. Intolerance of the semi-Fowler position E. Intelligence at the level of a seven-year-old child
Answer: A, C Rationale: A. Mouth breathing allows environmental air to enter the mouth, which may result in an inaccurately low reading. To take an oral temperature, the instrument must remain under the tongue of a closed mouth until the reading is obtained. This can take as little as several seconds (electronic thermometers) or as long as 3 to 4 minutes (plastic thermometers). B. A history of vomiting does not negate the use of an oral thermometer. If the client should begin to vomit, the nurse can remove the thermometer. C. Taking an oral temperature when a client is confused is unsafe. A client who is confused may bite down on an oral thermometer and cause injury to the mouth. D. An oral thermometer can be used with a client maintained in any position. E. A 7-year-old child understands cause and effect and can follow directions regarding the use of an oral thermometer.
A nurse concludes that a client has inadequate nutrition. Which client adaptation supports this conclusion? Select all that apply. A. Beefy red and smooth tongue surface B. Reddish-pink mucous membranes C. Cachectic appearance D. Spoon-shaped nails E. Shiny eyes
Answer: A, C, D Rationale: A. The tongue usually is pink, moist, and smooth, with papillae and fissures present. A beefy red or magenta color, smooth appearance, and increase or decrease in size indicate nutritional problems. B. This is the usual color of mucous membranes because of their rich vascular supply. Pale mucous membranes or the presence of lesions indicates nutritional problems. C. Cachexia is general ill health and malnutrition marked by weakness and excessive leanness (emaciation). D. Fingernails that curve inward like spoons can be caused by iron deficiency, vitamin B12 deficiency, or anemia. E. The eyes are always moist and shiny because lacrimal fluid continually washes the eyes. Pale or red conjunctivae, dryness, and soft or dull corneas are signs of nutritional problems.
A client with hypertension is given discharge instructions to take the blood pressure every day. A nurse is evaluating a family member taking the client's blood pressure as part of the client's discharge teaching plan. Which behavior indicates that the family member needs additional teaching? Select all that apply. A. Positions the arm higher than the level of the heart B. Places the diaphragm of the stethoscope over the brachial artery C. Applies the center of the bladder on the cuff on the lateral aspect of the arm D. Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat E. Inserts the earpieces of the stethoscope into the ears so that they tilt slightly backward
Answer: A, C, D, E Rationale: A. A blood pressure reading should be taken with the arm supported at the level of the heart. If the arm is above the level of the heart, the blood pressure reading will be inaccurately decreased, and if the arm is below the level of the heart or not supported, the blood pressure reading will be inaccurately increased. B. This is a correct action when obtaining a blood pressure reading. The brachial artery is close to the skin's surface, and the diaphragm of the stethoscope is used for low-pitched sounds of a blood pressure reading. C. This is an incorrect placement of the center of the bladder cuff. The bladder of the cuff should be directly over the brachial artery. This ensures an accurate reading because it provides uniform and complete compression of the brachial artery. D. This may result in an inaccurate reading. The value on the manometer should be opened to allow the gauge to drop 2 to 3 mm Hg per heartbeat. E. The earpieces of the stethoscope should be placed into the ears so that they tilt slightly forward, not backward. This ensures that the openings in the earpieces of the stethoscope are facing toward the ear canal for uninterrupted transmission of sounds.
A nurse obtains the blood pressure of several adults. Which blood pressure result should cause the most concern? A. 102/70 mm Hg B. 140/92 mm Hg C. 125/78 mm Hg D. 135/85 mm Hg
Answer: B Rationale: A. A BP of 102/70 mm Hg is within the acceptable ranges for an adult, which are a systolic of less than 120 mm Hg and a diastolic of less than 80 mm Hg. B. A BP of 140/92 mm Hg is considered high-stage II hypertension and is the BP that should cause the most concern. A systolic more than 139 mm Hg or a diastolic more than 89 mm Hg is high-stage II hypertension. C. A BP of 125/78 mm Hg is within the parameters of an elevated BP, which is a systolic of 120 to 129 mm Hg and a diastolic of less than 80 mm Hg. This BP is not as high as a BP in another option. D. A BP of 135/85 mm Hg is considered high-stage I hypertension. A systolic between 130 and 139 mm Hg or a diastolic between 80 and 90 mm Hg is considered high-stage I hypertension. This is not as high as a BP in another option.
A nurse is caring for a client receiving contact isolation. The nurse must take the client's rectal temperature with a plastic thermometer. Which should the nurse do? A. Take the temperature for 5 minutes. B. Wear gloves throughout the procedure. C. Place the client in the right lateral position. D. Insert the thermometer 2 inches into the client's anus.
Answer: B Rationale: A. A plastic rectal thermometer must remain in place 2 to 4, not 5, minutes to obtain an accurate reading. An electronic thermometer usually will obtain a reading within several seconds. B. Gloves, personal protective pieces of equipment, are the best way the nurse is protected from contracting or transmitting a pathogen. C. The left, not right, lateral position is the best position to place a client in when obtaining a rectal temperature because it utilizes the anatomic position of the anus and rectum for safe, easy insertion of the thermometer. D. Inserting the thermometer 2 inches into the anus can cause damage to the mucous membranes. A lubricated thermometer should be inserted 1.5 inches into the anus to ensure a safe, accurate reading.
A nurse is planning care for a client who has intolerance to activity. Which is the first assessment that should be made by the nurse? A. Range of motion B. Pattern of vital signs C. Impact on functional health patterns D. Influence on the other family members
Answer: B Rationale: A. Activity intolerance is related to the cardiovascular and respiratory systems, not the nervous and musculoskeletal systems. B. Activity intolerance is related to the inability to maintain adequate oxygenation to body cells, which is associated with respiratory and cardiovascular problems. Obtaining the vital signs (e.g., pulse, respirations, and blood pressure) will provide valuable information about these systems. C. Although the impact on functional health patterns might eventually be assessed, it is not the priority. D. Although the influence on the other family members might eventually be assessed, it is not the priority.
A nurse in the emergency department is engaging in an initial assessment of a client. Which assessment takes priority? A. Blood pressure B. Airway clearance C. Breathing pattern D. Circulatory status
Answer: B Rationale: A. Although important, blood pressure is related to circulation, which is not the priority. B. Client assessment must always be conducted in order of priority of needs. In an emergency, the ABCs of assessment use airway, breathing, and circulation. A clear airway is essential for life and therefore has priority. C. Although important, assessment of a breathing pattern is not the priority. D. Although important, circulation is not the priority.
A nurse is caring for a client who had surgery for a hysterectomy 2 days ago. After the nurse reviews the client's medical record, which piece of data should cause the nurse the most concern? CLIENT'S CLINICAL RECORD Primary Health-Care Provider's Prescriptions - Hydromorphone 6 mg PO every 4 hours for severe incisional pain - Acetaminophen 325 mg PO every 4 hours prn for mild incisional pain or 650 mg PO every 4 hours prn for moderate incisional pain - Diet: Clear liquids, progress to regular as tolerated - Activity: OOB three times a day, ambulate in hallway - Vital signs every 4 hours Progress Notes - Client progressed to full liquids; full liquids not well tolerated, vomited after eating 6 ounces of soup; ambulated in hallway 30 feet, tolerated well without signs of activity intolerance. Administer hydromorphone 6 mg at 4 p.m. for incisional pain reported at level 7 out of 10. Abdominal dressing dry and intact. IV 0.9% sodium chloride at 100 mL per hour infiltration in left hand, discontinued and moved to right hand. Warm soak applied 20 minutes to left hand as per protocol. Vital Signs 6 p.m. - Temperature: 99.4F, orally - Pulse: 68 beats per minute, regular - Respirations: 10 breaths per minute - Blood pressure: 110/68 mm Hg A. Vomited after eating 6 ounces of soup B. Respirations: 10 breaths per minute C. IV infiltration in left hand D. Temperature: 99.4F
Answer: B Rationale: A. Although vomiting is a concern, it is not as important as information presented in another option. The client is receiving 100 mL of fluid hourly; therefore, the client is most likely adequately hydrated. B. A respiratory rate of 10 or below is a concern. The client is receiving hydromorphone, an opioid, which depresses the central nervous system. A respiratory rate is depressed when an opioid medication is excessive. The dose of hydromorphone may need to be reduced. C. Although an IV infiltration is a concern, it is not as important as data presented in another option. The IV was discontinued and replaced in the other hand, and a warm soak was applied to the site of the infiltration. D. Although an increase in temperature after surgery is a concern, an oral temperature of 99.4F is within the expected range of 97.5F to 99.5F.
When evaluating the vital signs of a group of clients, the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its lowest? A. 4 p.m. to 6 p.m. B. 4 a.m. to 6 a.m. C. 8 p.m. to 10 p.m. D. 8 a.m. to 10 a.m.
Answer: B Rationale: A. Body temperature is rising between 4 p.m. and 6 p.m. B. Diurnal variations (circadian rhythms) vary throughout the day, with the lowest body temperature usually occurring between 4 a.m. and 6 a.m. The metabolic rate is at its lowest while the person is sleeping. C. Body temperature is at its highest between 8 p.m. and 10 p.m. D. Body temperature is rising between 8 a.m. and 10 a.m.
A nurse is assessing a client's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time? A. Radial B. Carotid C. Femoral D. Brachial
Answer: B Rationale: A. There are no contraindications for palpating both radial arteries at the same time. B. It is unsafe to palpate both carotid arteries at the same time. Slight compression of both carotid arteries can interfere with blood flow to the brain. In addition, excessive compression of the carotid arteries can stimulate the carotid sinuses, which causes a reflex drop in the heart rate. C. There are no contraindications for palpating both femoral arteries at the same time. D. There are no contraindications for palpating both brachial arteries at the same time.
A client has had a 101F fever for the past 24 hours. How often should the nurse monitor this client's temperature? A. Every 2 hours B. Every 4 hours C. Every 6 hours D. Every 8 hours
Answer: B Rationale: A. This is too frequent for routine monitoring of body temperature. Although the set-point for body temperature changes rapidly, it takes several hours for the core body temperature to change. B. This is an appropriate interval of time for routine monitoring of body temperature. it is frequent enough to identify trends in changes in body temperature while limiting unnecessary assessments. C. Every 6 hours is too long an interval for monitoring a client with a fever and is unsafe. D. Every 8 hours is too long an interval for monitoring a client with a fever and is unsafe.
The nurse is obtaining a client's blood pressure. Which information is most important for the nurse to document? A. Staff member who took the blood pressure B. Client's tolerance to having the blood pressure taken C. Client's body position if the client is not in a sitting position D. Which head of a dual-head stethoscope was used to obtain the reading
Answer: C Rationale: A. Although this should be done, it is not the most important information. B. This is necessary only if the client did not tolerate the procedure. C. The client's position when the blood pressure is measured may influence results. Generally, systolic and diastolic readings are lower in the horizontal than in the sitting position. There is a lower reading in the uppermost arm when a person is in a lateral recumbent position. A change from the horizontal to an upright position may result in a temporary decrease (5 to 10 mm Hg) in blood pressure; when this decrease exceeds 25 mm Hg systolic or 10 mm Hg diastolic, it is called orthostatic hypotension. D. Either the bell or diaphragm of a dual head stethoscope can be used to obtain a blood pressure reading.
A nurse concludes that a client is experiencing pyrexia. Which client assessment precipitated this conclusion? A. Mental confusion B. Increased appetite C. Rectal temperature of 101F D. Heart rate of 50 beats per minute
Answer: C Rationale: A. Mental confusion is not a common human response to pyrexia (fever). B. Loss of appetite (anorexia), not an increased appetite, is a common human response to pyrexia (fever). C. A rectal temperature of 101F (38.3C) or an oral temperature of 100F (37.8C) is a common human response that indicates pyrexia (fever). D. An increased heart rate (tachycardia), not a decreased heart rate (bradycardia), is a common human response to pyrexia.
A nurse is teaching a community health class about cancer prevention for people who are asymptomatic and not at risk for cancer. Which screening guideline for this group of people should the nurse include? A. Pap smear annually for females 13 years of age and older B. Mammogram annually for women 30 years of age and older C. Colonoscopy at 50 years of age and every 10 years thereafter D. Prostate-specific antigen yearly for men 30 years of age and older
Answer: C Rationale: A. The American Cancer Society recommends Pap smears screening every 3 years for women between the ages of 21 and 65. B. The American Cancer Society recommends that women with average breast cancer risk begin yearly mammograms at 45 years of age until 55 years of age and then continue with biennial screening if the client is in good health or has a life expectancy of at least 10 years. However, clients have the option to continue annual screening if desired. C. A colonoscopy should be performed at age 50 and every 10 years thereafter for individuals at average risk for developing colorectal cancer. This is the age when the risk for colon cancer increases. D. The American Cancer Society recommends that screening for cancer of the prostate be conducted at 50 years of age yearly or on an individual basis. Individuals who are African American or have a family member with the disease before the age of 65 should discuss the need for screening with a primary health-care provider starting at age 40 or 45.
Which assessment requires the nurse to assess the client further? A. 18-year-old woman with a pulse rate of 140 after riding 2 miles on an exercise bike. B. 50-year-old man with a BP of 112/60 mm Hg on awakening in the morning C. 65-year-old man with a respiratory rate of 10 D. 40-year-old woman with a pulse of 88
Answer: C Rationale: A. This is an acceptable increase in heart rate with strenuous aerobic exercise. B. This is an acceptable blood pressure with the body at rest. The expected blood pressure in an adult is a systolic value of less than 120 mm Hg and a diastolic value of less than 80 mm Hg. C. A respiratory rate of 10 is below the expected respiratory rate for an adult and should be assessed further. The expected respiratory rate for an adult is 12 to 20 breaths per minute. D. This is within the expected range of 60 to 100 beats per minute.
Which is common to the collection of all specimens for culture and sensitivity tests regardless of their source? A. Preservative media must be used. B. Two specimens should be obtained. C. Surgical asepsis must be maintained. D. A morning specimen should be collected.
Answer: C Rationale: A. This is not necessary for all specimens. B. Generally, if a specimen is collected using proper technique, one specimen is sufficient for testing for culture and sensitivity. C. The results of culture and sensitivity tests are faulty and erroneous if the collection container or inappropriate collection technique introduces extraneous microorganisms that falsify and misrepresent results. Surgical asepsis (sterile technique) must be maintained. D. This is not necessary for any culture and sensitivity specimen.
A nurse is assessing a client's heart rate by palpating the carotid artery. Which action should the nurse implement when assessing a pulse at this site? A. Monitor for a full minute. B. Palpate just below the ear. C. Press gently when palpating the site. D. Massage the site before assessing for rate.
Answer: C Rationale: A. This is unnecessarily long, and even slight compression can interfere with blood flow to the brain. B. This is not the site to access the carotid artery. A carotid pulse site is located on the neck at the side of the larynx, between the trachea and the sternomastoid muscle. C. The carotid artery should be palpated with a light touch to prevent interference to blood flow to the brain and stimulation of the carotid sinus that can cause a reflex drop in the heart rate. D. This is contraindicated. Massage can stimulate the carotid sinus located at the level of the bifurcation of the carotid artery, and this results in a reflex drop in the heart rate.
A nurse must assess for the presence of bowel sounds in a postoperative client. Which technique should the nurse employ to obtain accurate results when auscultating the client's abdomen? A. Listen for several minutes in each quadrant of the abdomen. B. Place a warmed stethoscope on the surface of the abdomen. C. Perform auscultation before palpation of the abdomen. D. Start at the left lower quadrant of the abdomen.
Answer: C Rationale: A. This is unnecessary. Bowel sounds may be hyperactive (1 every 3 seconds) or hypoactive (1 every minute). After a few sounds are heard, the stethoscope can be moved to the next site. For sounds to be considered absent, there must be no sounds for 3 to 5 minutes. B. This is done for client comfort, not to influence the accuracy of the assessment. C. Bowel sounds are auscultated before palpation and percussion because these techniques stimulate the intestines and thus cause an increase in peristalsis and a false increase in bowel sounds. D. A systematic assessment can begin in any of the four abdominal quadrants. However, many people do begin the systematic four-quadrant assessment in the lower right quadrant over the ileocecal valve, where the digestive contents from the small intestine empty through a valve into the large intestine.
A client has a serious vitamin K deficiency. For which clinical manifestation should the nurse assess this client? Select all that apply. A. Bone pain B. Skin lesions C. Bleeding gums D. Ecchymotic area E. Muscle weakness
Answer: C, D Rationale: A. A deficiency in vitamin D, not vitamin K, causes bone pain associated with osteoporosis. B. Vitamin K deficiency is not associated with skin lesions. Ascorbic acid (vitamin C) deficiency causes small skin hemorrhages and delays wound healing. Riboflavin (vitamin B2) deficiency causes lip lesions, seborrheic dermatitis, and scrotal and vulval skin changes. C. A disruption in the clotting mechanism of the body can result in bleeding. Vitamin K plays an essential role in the production of the clotting factors II (prothrombin), VII, IX, and X. D. An ecchymotic area is caused by extravasation of blood into skin or mucous membranes. In this client's situation, it is caused by a disruption in the clotting mechanism of the body as a result of a vitamin K deficiency. E. A deficiency in thiamine (vitamin B1), not vitamin K, causes muscle weakness.
A nurse is interviewing a newly admitted client. Which word used by the client describes information associated with the defervescence phase (fever abatement, flush phase) of a fever? Select all that apply. A. Cold B. Achy C. Warm D. Sweaty E. Thirsty
Answer: C, D Rationale: A. Feeling cold occurs during the onset phase (cold or chill phase) of a fever because of vasoconstriction, cool skin, and shivering. B. Feeling achy occurs during the course phase (plateau phase) of a fever. Generally, this is the result of extra energy being exerted by the body fighting the infection, as well as a response to activation of the immune system. C. Feeling warm is associated with the defervescence phase (fever abatement, flush phase) of a fever because of sudden vasodilation. D. Feeling sweaty occurs during the defervescence phase (fever abatement, flush phase) of a fever because of the body's heat loss response. E. Feeling thirsty is associated with the course phase (plateau phase) of a fever because of mild to severe dehydration.
A nurse is monitoring the status of postoperative clients. Which vital sign will change first when a postoperative client has internal bleeding? A. Body temperature B. Blood pressure C. Pulse pressure D. Heart rate
Answer: D Rationale: A. Although the body temperature decreases as shock progresses because of a decreased metabolic rate, it is not one of the first signs of shock. B. Two other vital signs will alter before blood pressure as the heart attempts to compensate for decreased circulating blood volume. C. Although the pulse pressure will narrow during shock, other vital signs will change first. Pulse pressure is the difference between the systolic and diastolic pressures. D. The initial stage of shock begins when baroreceptors in the aortic arch and the carotid sinuses detect a drop in the mean arterial pressure. The sympathetic nervous system responds by constricting peripheral vessels and increasing the heart and respiratory rates. During the compensatory stage of shock, the effects of epinephrine and norepinephrine continue with stimulation of alpha-adrenergic fibers, causing vasoconstriction of vessels supplying the skin and abdominal viscera, and beta-adrenergic fibers, causing vasodilation of vessels supplying the heart, skeletal muscles, and respiratory system.
Which usually is unrelated to a nursing physical assessment? A. Posture and gait B. Balance and strength C. Hygiene and grooming D. Blood and urine values
Answer: D Rationale: A. Assessing posture and gait is within the scope of nursing practice because posture and gait reflect human responses. B. Assessing balance and strength is within the scope of nursing practice because balance and strength reflect human responses. C. Assessing hygiene and grooming is within the scope of nursing practice because hygiene and good grooming reflect human responses. D. Prescribing and assessing urine and blood values are not in the independent practice of nursing. These assessments are dependent or interdependent functions of the nurse and are covered by specific prescriptions or standing prescriptions.
A nurse in the emergency department is caring for a client who is diagnosed with hypothermia. Which factor present in the client's history may have precipitated this condition? A. Heatstroke B. Inability to sweat C. Excessive exercise D. High alcohol intake
Answer: D Rationale: A. Hyperthermia, not hypothermia, is associated with this condition. Heatstroke (heat hyperpyrexia) is failure of the heat-regulating capacity of the body that results in extremely high body temperatures (105F). B. Hyperthermia, not hypothermia, can result from the lack of sweat. The inability to perspire does not allow the body to cool by the evaporation of sweat (vaporization). C. Hyperthermia, not hypothermia, can result from excessive exercise. Exercise increases heat production as carbohydrates and fats break down to provide energy. Body temperature temporarily can increase to as high as 104F. D. Excessive alcohol intake interferes with thermoregulation by providing a false sense of warmth, inhibiting shivering, and causing vasodilation, which promotes heat loss. In addition, it impairs judgment, which increases the risk of making inappropriate self-care decisions.
Which physical examination method should a nurse use when assessing a client for borborygmi? A. Palpation B. Inspection C. Percussion D. Auscultation
Answer: D Rationale: A. Palpation may stimulate intestinal motility, which increases bowel sounds, but it is not the assessment method used to hear bowel sounds. Palpation is the examination of the body using the sense of touch. B. Inspection cannot assess bowel sounds. Inspection uses the naked eye to perform a visual assessment of the body. C. Percussion may stimulate intestinal motility, which increases bowel sounds, but it is not the assessment method used to hear bowel sounds. Percussion is the act of striking the body's surface to elicit sounds that provide information about the size and shape of internal organs or whether tissue is air filled, fluid filled, or solid. D. Auscultation is the process of listening to sounds produced in the body. It is performed directly by just listening with the ears or indirectly by using a stethoscope that amplifies the sounds and conveys them to the nurse's ears. Active intestinal peristalsis causes rumbling, gurgling, and tinkling abdominal sounds known as bowel sounds (borborygmi).
When evaluating the vital signs of a group of clients, the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its highest? A. 12 a.m. to 2 a.m. B. 6 a.m. to 8 a.m. C. 4 p.m. to 6 p.m. D. 8 p.m. to 10 p.m.
Answer: D Rationale: A. The body temperature is on the decline during this time. B. The body temperature is just beginning to rise from its lowest level, which occurs between 4 a.m. and 6 a.m. C. Although the body temperature is rising, it has not reached its peak at this time. D. Diurnal variations (circadian rhythms) vary throughout the day, with the highest body temperature usually occurring between 8 p.m. and midnight.
A nurse is caring for a client who is experiencing an increase in clinical manifestations associated with multiple sclerosis. Which term describes this recurrence of clinical manifestations? A. Variance B. Remission C. Adaptation D. Exacerbation
Answer: D Rationale: A. The word "variance" is not a term that describes recurrence of clinical manifestations of a chronic illness. Variance occurs when there is a deviation from a critical pathway. This occurs when goals are not met or interventions are not performed according to the stipulated time period. B. The word "remission" is not a term that describes recurrence of clinical manifestations of a chronic illness. A remission is a period during a chronic illness of lessened severity or cessation of clinical manifestations. C. The word "adaptation" is not a term that describes recurrence of clinical manifestations of a chronic illness. An adaptation is a physical or emotional response to an internal or external stimulus. D. An exacerbation is the period during a chronic illness when clinical manifestations reappear after a reduction or absence of clinical manifestations.
An adult client's vital signs are: oral temperature 99F, pulse 88 beats per minute with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 182/100 mm Hg. Which sign should cause concern? A. Pulse B. Respirations C. Temperature D. Blood pressure
Answer: D Rationale: A. This is within the expected adult pulse range of 60 to 100 beats per minute and the rhythm is regular; the client should be assessed further and the information compared with the client's baseline data. B. This is within the expected adult respiratory range of 12 to 20 breaths per minute. C. This is within the expected adult temperature range of 97.5F to 99.5F for an oral temperature. D. The blood pressure is more than the expected systolic value of less than 120 mm Hg and a diastolic value of less than 80 mm Hg and, of the options presented, should cause the most concern. A systolic blood pressure of 180 or more and/or a diastolic pressure of 121 or more is in the blood pressure category of Crisis.
A client has lost approximately 2 units of blood during a vaginal delivery. For which response to this blood loss should the nurse assess this client? Select all that apply. A. Increased urinary output B. Slow, shallow breathing C. Hypertension D. Tachycardia E. Bradypnea
Answer: D Rationale: A. With a reduction in blood volume, there will be less blood circulating through the kidneys, resulting in a decreased, not increased, urinary output. B. With a decrease in circulating red blood cells, the respiratory rate will increase to meet oxygen needs. C. With a reduction in blood volume, the blood pressure will be decreased, not increased. D. Tachycardia occurs with hemorrhage as the body attempts to bring more oxygen to cells via the circulation. E. Rapid breathing, not bradypnea, occurs with hemorrhage as the respiratory rate increases to meet oxygen needs.