holistic health EAQ

While assessing a client's hair, the nurse notices the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which client statement indicates an understanding of the teaching? select all that apply. One, some, or all responses may be correct. A. " I will clean my comb in ammonia water." B. "I should use lindane- containing shampoo." C. " I should shampoo my hair in a tub or shower." D. "I should use a dilute vinegar solution to loosen the nits." E. "I should use a shampoo treatment once every 24 hours."

A. " I will clean my comb in ammonia water." D. "I should use a dilute vinegar solution to loosen the nits." E. "I should use a shampoo treatment once every 24 hours." LINDANE: May be used to treat lice and scabies, but it may cause serious side affects. -Clients with lice are instructed not to wash their hair in a tub or shower because this action may cause lice to migrate to other sites. -AMMONIA WATER: Should be used to clean combs and other hair accessories to enhance lice control. -Nits are loosened by the use of dilute vinegar solution. -Shampooing should be continued once every 24 to 48 house.

Which nursing assessment questions assess the faith, belief, fellowship, and community aspect of a clients spirituality? Select all that apply. one, some, or all responses may be correct. A. "What gives meaning to your life?" B. "What is your source of power, hope, and belief during difficult times?" C. "In what way do your beliefs help or strengthen you for coping with illness?" D. "How has the illness affected you capability to express what is essential in life?" E. "How do you feel the changes caused by the illness are affecting or will affect your life?"

A. "What gives meaning to your life?" B. "What is your source of power, hope, and belief during difficult times?" C. "In what way do your beliefs help or strengthen you for coping with illness?"

Which PRIORITY assessment would the nurse include when providing care for a client who is experiencing depression? select all that apply, one, some or all responses may be correct. A. Appetite B. Irritability C. Restlessness D. Active status E. Emotional status

A. Appetite D. Activity status E.Emotional staus These helpto determine the level of depression

When assessing a client reporting shortness of breath, which activity BEST ensures the nurse obtains accurate and complete date to prevent a nursing diagnostic error? A. Assess the client's lung B. Assess the client for pain C. Obtain details of smoking habits D. Ask about the onset of shortness of breath

A. Assess the client's lung Nurse would assess the client's lung to gather objective data that will support the subjective data provided by the client.

How can the nurse evaluate the effectiveness of communication with a client? A. Client feedback B. Medical assessment C. Health care team conferences D. Client's physiological response

A. Client feedback Feedback permits the client to ask questions and express feelings and allow the nurse to verify client understanding. -Medical assessments: do not always include nurse-client relationships. -Team conferences: Are subject to all members evaluations of clients status. -Nurse-client communications should be evaluated by the client's verbal and behavioral responses.

Which is the correct nursing intervention when assessing a client with anxiety? A. Divide the assessment and do it over shorter amounts of time B. Complete the client assessment in shorter amount of time C. Postpone the client assessment until a more beneficial time D. Do the assessment in soft-spoken voice for a longer duration

A. Divide the assessment and do it over shorter amounts of time The client with anxiety easily gets irritated, even over small issues. To reduce any aggressive behavior the nurse does the assessment in smaller appointments.

When would the nurse observe a client to assess their level of functioning? Select all that apply. One, some, or all responses may be correct. A. Durning mealtime B. When talking about pain C. When preparing medication D. During the assessment interview E. When administering insulin injections

A. Durning mealtime C. When preparing medication E. When administering insulin injections An observe of the functional level of the client often occurs during a return demonstration. The nurse may observe the client while eating to determine if the client is able to eat w/o assistance. The nurse teaches the client to prepare medications and asks for return demonstration to assess the clients understanding. The nurse also observes the client administering insulin injections to ensure that the client is able to perform it properly.

Within which component of nursing process would the nurse note evidence of swelling and skin discoloration of the client's lower extremities? A. Input B. Output C. Content D. Feedback

A. Input -Input: Is the data or information that comes from a client's assessment, such as how the client interacts with the environment and the client's physiological function. -Output: End product of a system. -Content: Information about nursing interventions for clients with specific health care problems -Feedback: Involves the assessment of how a system functions.

The nurse is advised to join a community health center that mainly caters to Latino clients. Which would the nurse develop to help reduce health disparities? Select all that apply. one, some, or all responses may be correct. A. Learning to speak basic medical Spanish B. Updating paper supplies at the health care facility C. Learning about the health literacy rate of the community D. Incorporating the health beliefs of the community in any nursing care plans E. Learning about respect and unique beliefs and values prevalent among the group

A. Learning to speak basic medical Spanish C. Learning about the health literacy rate of the community D. Incorporating the health beliefs of the community in any nursing care plans E. Learning about respect and unique beliefs and values prevalent among the group A. This promotes communications and develops trust between the nurse and clients. C- Can help the nurse identify areas of opportunity for the clients education and health promotion D. Makes care more effective E.Nurse will learn unique values and beliefs of the ethic group &. respect them to deliver equitable healthcare.

Upon noticing a client with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis? A. Lips B. Sclera C. Conjunctiva D. Mucus membrane

A. Lips Cyanosis is the medical term for when your skin, lips or nails turn blue due to a lack of oxygen in your blood. Lips and nail beds are best to assess for cyanosis. -Sclera & mucous membrane: assessed in jaundice -Conjunctiva: Assessed for the presence of pallor

When providing comfort to a client the last house of life, which would be the nurse's primary concern? Select all that apply. One, some, or all responses may be correct. A. Pain B. Nutrition C. Elimination D. Respiratory status D. Cardiovascular status

A. Pain D. Respiratory status

During a newborn assessment the nurse identifies that the temperature, pule, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the electric health record. In which way would the nurses action be interpreted? A. The nurse preformed the actions correctly B. This is a medical procedure, and the nurse overstepped scope of practice C. Nursing assessments are not equivalent to a primary health care providers assessment D. The initial assessment of the infant's physical status is the responsibility of the client's primary health care provider.

A. The nurse preformed the actions correctly

Which assessment finding of the skin refers to elasticity? A. Turgor B. Edema C. Texture D. Vascularity

A. Turgor -Turgor: refers to the elasticity of the skin. -Edema: Indicates fluid buildup in the tissues. -Texture: Refers to the character of the skin. -Vascularity: Refers to the circulation of the skin.

The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the clients temperature. Which action is the nurse taking? A. Validation B. Assessment C. Interpretation D. Documentation

A. Validation Validation: Process of gathering more assessment data; it involves clarifying vague or unclear data. Assessment: First step of the nursing process involves collecting information from the client and secondary sources Interpretation: Nurse recognizes that further observations are needed to clarify information Documentation: Last part of the complete assessment

Which intervention reflects the nurse's approach of "family as a context'? A. Working to make the client comfortable B. Evaluating the clients family's coping skills C. Determining the clients family's energy level D. Trying to meet the clients family's nutritional needs

A. Working to make the client comfortable "Family as context"=the focus is on the client. This focuses on the family's needs as a whole to determine their coping skills.

Which respiration rate would the nurse expect for a 2year old child? A. 20 breaths/min B. 30 breaths/min C. 40 breaths/min D. 50 breaths/min

B. 30 breaths/min Normal range for the respiratory rate for a 2year old (toddler) is between 25 and 32 breaths/min. -20breaths/min is normal respiratory rate in adolescents and adults. -40breaths/min is normal respiratory rate in newborns. -50breaths/min is normal respiratory rate in infants

Which factor would elevate a client's oxygen saturation? A. Nail polishes B. Carbon monoxide C. Intravascular dyes D. Skin pigmentation

B. Carbon monoxide -Carbon monoxide artificially elevates the oxygen saturation during assessment. -Nail polishes: interfere with the ability of the oximeter. -Intravascular dyes: Will artificially lower the oxygen saturation. -Skin pigmentation: Will over estimate the saturation.

Which part of the client's body would the nurse asses to confirm a diagnosis of frostbite?Select all that apply. one, some or all responses may be correct. A. Axilla B. Fingers. C.Ear lobes D. Forehead E. Upper thorax

B. Fingers. C.Ear lobes Particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. -Axila(armpit): determine the body temperature this site is used to diagnose a fever -Forehead & Upper thorax: are assessed to detect diaphoresis

Which factor would the nurse use to assess the quality of health care provided a client? A. Fall-prevention measures employed for the client B. Functional health status of the client after discharge C. Hand hygiene practiced by the health care personnel D. Teamwork and coordination among healthcare personnel

B. Functional health status of the client after discharge Health care providers determine the quality of care provided to the client by measuring outcomes that show how the client's heath status has changed.On method of measuring the quality of health care provided to the client is the functional health status of the client after discharge.

The nurse is assessing four infants. Currently, which infant has an abnormal weight? A. Infant 1 B. Infant 2 C. Infant 3 D. Infant 4 INFANT 1- Age(Months)= 4 Weight in birth= 2.9kg Current weight = 6.1 kg INFANT 2- Age(Months)=5 Weight at Birth= 3.3 kg Current Weight= 8.5kg INFANT 3- Age(Months)=12 Weight at Birth= 3.35kg Current weight= 10 kg INFANT 4- Age(Months)=11 Weight at birth= 3.4 kg Current weight= 10.3kg

B. Infant 2 The average birth weight of a new born is 3.2 to 3.4 kg. The infant usually doubles his or her birth weight by 4 to 5 months of age. Infant 2 weight of 8.5kg at 5 months is abnormal. Infant 1, weighing 6.1 kg is a normal weight. An infant has usually tripled his or her birth weight by around 1 year. Infants 3 & 4 are experiencing normal weight gain.

Upon entering an examination room for assessment of a confused client, which action would the nurse take? A. Perform an assessment quickly. B. Plan a focused physical assessment C. Skip the examination until the client is reoriented D. Leave the room to find the health care provider

B. Plan a focused physical assessment.

The nurse performs a respiratory assessment and auscultates high-pitch, creaking, and accentuated breath sounds on expiration. Which term describes the findings? A. Rhonchi B. Wheezes C. Pleural friction rub D. Bronchoveslicular

B. Wheezes -Wheezes are most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Ronchi- are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airway. -Pleural friction rub: An abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. -Bronchovesicular: sounds are intermediate between bronchial (upper) & vesicular (lower) breath sounds they are normal when heard between the first and second intercostal spaces anteriorly & posteriorly between scapular.

Which documentation is MOST informative for an assessment of drainage on a surgical dressing? A. "Moderate amount of drainage?" B. "No change in drainage since yesterday?" C. "A 10 mm-diameter area of drainage at 1900." D. "Drainage is doubled in size since last dressing change."

C. "A 10 mm-diameter area of drainage at 1900." Is objective and gives specific details regarding the assessment and a time frame

Which step of the nursing process involves the nurse interviewing a client about a current health problem an obtaining the client's vital signs? A. Planning B. Diagnosis C. Assessment D. Implementation

C. Assessment Assessment: collection of comprehensive data pertinent to the client's health.During the planning step the nurse develops a plan to prescribes strategies & alternative to attain expected outcomes. Then analyzes the assessment to determine the diagnoses during the diagnosis step of nursing practice. Then the implementation step of standards, this step may include administering prescribe d medications.

The nurse assesses the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever? A. Client A B. Client B C. Client C D. Client D CLIENT A DAY I- 100F DAYII- 100.4F DAY III- 100.8 DAY IV- 100.6F CLIENT B DAY I- 102F DAY II- 98.5F DAY III- 103F DAY IV- 99F CLIENT C DAY I- 103F DAY II- 101F DAY III- 104F DAY IV- 102F CLIENT D DAY I- 102F DAY II- 98.5F DAY III- 99.9F DAY IV- 103F

C. CLIENT C Remittent fever: Body temperature spikes and falls without a return to normal temperature levels.

During an assessment, which finding prompts the nurse to don a protective gown? A. Open sore B. Abrasions of the skin C. Excessive wound drainage D. Productive, moist coughing

C. Excessive wound drainage -Excessive wound drainage may require more protection than gloves, so a protective gown should be donned by the nurse. -Open sore & Abrasions: To the skin should be approached with gloved hands. -Moist productive cough: Should prompt the nurse to provide a mask to the client.

Which objective is the MOST important prerequisite for measuring health care quality delivered in the hospital? A. To implement the root cause analysis tool B. To review all the incident reports documented C. To collect all the medical records of the hospital D. To prepare nurse performance evaluation forms

C. To collect all the medical records of the hospital -The most important prerequisite for assessing the quality of health care delivery system is to collect the medical records of the clients admitted and discharged from the hospital.

During a health history, an older client reports having fallen three times in the past months. Which would the nurse ask to obtain other risk factors? A. Assessing the level of education attained B. Evaluating respiratory status C. Subscribing to a call alert system D. Asking the client to walk across the room

D. Asking the client to walk across the room The nurse must obtain further information to determine risk factors. Asking the client to walk across the room, will determine any abnormalities in the gait or loss of balance.

Which physical assessment technique involves listening to the sounds of the body? A. Palpation B. Inspection C. Percussion D. Auscultation

D. Auscultation -Palpation: Using the sense of touch to assess and collect data. -Inspection: Involves the nurse carefully looking to collect data. -Percussion: Tapping the skin with the fingertips to vibrate underlying tissues and organs

Which step in the nursing process would involve promoting a safe environment for the client? A. Planning B. Diagnosis C. Diagnosis D. Implementation

D. Implementation The nurse promotes a safe environment during the implementation stage of the the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment date to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.

Which nurse action during a psychosocial assessment of a transgender client may contribute to health disparities? A. Asking specific questions about ender and sexual practices used B. Reporting any physical or mental abuse of the client to the appropriate authority C. Assuring the client that the confidentiality of the information gathered during the assessment will be maintained D. Insisting on using the name listed on the client's driver's license

D. Insisting on using the name listed on the client's driver's license.

When preparing to assess a client with active tuberculosis, which piece of personal protective equipment would the nurse put on before entering the client's room? A. Isolation gown B. Surgical mask C. Show covers D. N95 respiratory mask

D. N95 respiratory mask Active TB places a client on airborne precautions, so the nurse must wear an N95 respiratory mask to prevent personal respiratory exposure to infectious droplets.

The nurse assess a client's nails and finds a slight convex curve at the angle from the skin to nail base of about 160 degrees. Which condition would the nurse suspect? A. Clubbing B. Paronychia C. Koilonychia D. Normal finding

D. Normal finding -Clubbing: There is a change in the angle between the nail and the nail base larger than 180 degrees. -Paronychia: Inflammation of the skin at the base of the nail. -Koilonychia: Concave curves on the nail.

Which statement describes the percussion technique? A. Listening to sounds that the body makes B. Using the sense of touch to assess and collect data C. Carefully looking for abnormal findings D. Tapping the skin with the fingers to vibrate underlying tissues

D. Tapping the skin with the fingers to vibrate underlying tissues

Where is the carotid site found?

Medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest when other sites are not palapable

Where is the ulnar site found?

Ulnar side of the forearm at the wrist. It is used to assess the status of circulation to the hand and to perform the Allen test.

Where is the posterior tibial site found?

below the medial malleolus. It is used to assess the status of circulation in the foot.

Where is the Dorsalis pedis located?

top of foot. This site is used to assess the status of circulation in the foot.