N125: Hesi Adaptive Quizzing #3

When the defining characteristics of al client's assessment data apply to more than one diagnosis, which action would the nurse take?

Gather more information Identify related factors Review all defining characteristics

Which condition would the nurse suspect upon finding a bluish coloration of the skin during assessment?

Heart disease

Which condition would the nurse suspect when an older adult is unable to see nearby object?

Hyperopia Presbyopia Hyperopia = farsightedness Presbyopia= impaired vision with aging

When measuring a client's blood pressure during a physical examination, which error will result in false high diastolic reading?

Inflating the cuff too slowly

A client weighs 150 lb and is 5 feet 7 inches tall. What is this client's body mass index (BMI)?

23.53 150lb=68kg 5f7in = 1.7 m BMI = 68/1.7 (squared) 23.53

A client who does not understand English requires an interpreter. Which action by the nurse may exacerbate health disparities?

The nurse talks only to the interpreter about the client

A recent immigration from china is critically ill and dying. To meet this client's emotional needs, which question would the nurse ask when collecting data?

Which family member do you prefer to receive information?

Which assessment item needs to be documented on a client with restraints?

- Pulse near the restrained area - Temperature of the restrained area - Skin integrity surrounding the restraint - Behavior leading to the need for restraint

Upon entering an examination room for assessment of a confused client, which action would the nurse take?

Plan a focused physical assessment. do not rush through the assessment or leave the patient

Which client would experience impaired near vision?

Presbyopia Hyperopia A loss of elasticity of the lens causes impaired near-vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina.

While providing care for a client with heat stroke, the nurse measured and noted the temperature as 39C which temperature would the nurse document in F?

102.2 F Calculation : Celsius X (9/5) + 32

A client weighed 210 pounds on admission to the hospital. After two days of diuretic therapy, the client weighs 205.5 pounds. How many liters of fluid has the client excreted? Record the answer using a whole number. Record your answer using a whole number. __________ liters

2 L

After presenting information about falls risk assessment to nursing staff, which participant's statement needs review for corrective action?

We will use the admission fall assessment for the entire stay

While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client ?

Abducens nerve The abducens nerve is the VI cranial nerve , which helps in lateral movement of the eyeballs. NOT optic= vision Oculomotor = puil dilation Facial= facial expression

While assessing a client, the nurse identifies the ration of eh anteroposterior diameter and transverse diameter of the chest as 1:1. Which finding supports this conclusion?

Client is an older adult Client has history of smoking Client has chronic lung disease

Which client would the nurse suspect as having an increased risk of hyperlipidemia?

Client with corneal arcus Client with yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia.

For the client with a closed chest tube drainage system connected to suction, which assessment findings require additional evaluation by the nurse?

Constant bubbling in the water seal chamber This is indicative of an air leak

When preparing to assess a client with Clostridium difficile, which piece of personal protective equipment would the nurse put on before entering the client's room?

Full placates gown

A registered nurse teacher a new employee about precautions taken during a client's physical examination. Which employee's statement indicates effective learning?

I would examine the client in a noise free area I would wear eye shields while examining a client with excessive drainage.

In which sequential order would the nurse assess the visual level of a client?

1. Direct the client to stand or sit 60 cm away from eye level 2. Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye 3. Close the opposite eye to superimpose the field of vision 4. Move a finger equidistant between the nurse and the client outside the field of vision 5. Ask the client to report when he or she is able to see the finger

While performing a physical assessment of a client, the nurse notices patchy areas with pigmentation loss on the skin, hands, arms. With which probable cause would the nurse associate this finding?

Autoimmune disease

A client reports difficulty breathing and the nurse auscultates bilateral wheezing in the anterior upper lobes. Which potential rationale would explain this sound?

High velocity airflow through an obstructed airway Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.

When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a deep vein thrombosis DVT?

Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT.

An assessment of an 89 yr old client yields a history of severe congenital spinal deformity. Which condition would describe the nurse's finding?

Kyphosis

A client in the 2nd trimester of pregnancy arrives at the clinic for a general health checkup, including a pelvic examination. For which position would the nurse prepare the client?

Lithotomy Position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region; this position is recommended for examining pregnant women.

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?

N95 respiratory mask

While providing care for a client who is postoperative, the nurse observed a pulse deficit during physical assessment. Which pulses would the nurse use to assess the pulse deficit?

Radial and Apical

After a home assessment of an older adult's fall risk, which intervention would the nurse suggest?

Securing rugs to prevent movement Removing excessive pieces of furniture Wearing corrective lenses for distance vision Performing exercises to strengthen lower extremities

Which question would the nurse ask the client when obtaining their health history?

Tell me about your food habits Do you use alcohol or tobacco? have you ever experienced any allergic reactions?

In which sequential order would the nurse perform the assessment of a lesion?

The first step in assessing the lesion is to collect standard information about the lesion. This information includes the color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). The next step is to observe for any exudate, odor, amount, and consistency. After this step, the size of the lesion is measured in centimeters by using a small, clear, flexible ruler. Finally, each lesion is measured for height, width, and depth.

After reviewing otoscope use for assessment of ear with the nursing staff, which participant's response reflects safe follow up care for when earwax covers the tympanic membrane?

perform warm water irrigation to remove wax

Which priority assessment would the nurse include when providing care for a client who is experiencing depression ?

Appetite activity status emotional status

which condition would the nurse suspect when an older adult has thin white ring around the margin of her iris?

Arcus Séniles IN older adults the iris becomes faded and a thin white ring appears around the margin of the iris.

When assessing risk factors, which question would the nurse ask a client who has developed pneumonia?

Are you diabetic? Chronic diseases are a risk factor for developing infections such as pneumonia.

While preparing to teach a client about self-injection of insulin, which nurse action wold increase the effectiveness of the teaching session?

Assess the client's barriers to learning self-injection techniques

During a falls and risk assessment, which action would the nurse take after learning the client experienced a recent fall?

Assessing the circumstances of the fall, including feelings and setting

The adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later the client is admitted to the hospital with a diagnosis of tetanus. Which statement describes the nurses responsibility in this situation?

Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.

After conducting a falls risk assessment education session for the staff and observing falls risk assessment on the unit, which staff action needs review for corrective action?

Delegating falls assessment to assistive personnel

When the nurse completes a thorough assessment to identify the reason for a client's anxiety, which critical thinking attitude is involved in this situation?

Discipline

Which nurse's action is important for establishing good communication with the client who has impaired hearing?

Obtaining the clients attention before speaking The first step that the nurse should take for starting a communication with a client with impaired hearing is getting client's attention before speaking.

A client arrives at a health clinic report, " I am here to have y tuberculin skin test read." the nurse noted a 7-mm indurated area at the injection site. Which nurse's statement best describes the results?

The results indicated that you are infected with the tuberculosis organism

While assessing a client the nurse finds inflammation of the skin at the bases of the clients nails. Which event or disorder would the nurse associate with the reason behind the condition?

Trauma Paronychia is an abnormality of the nail bed. This condition is marked by inflammation of the skin , this condition may be caused by trauma or a local infection.

The nurse documents auscultation of coarse rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which condition would the nurse associate with these sounds?

Turbulence due to muscular spasms and fluid or mucus in the larger airways

While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong order of ammonia?

Urinary tract infection

While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery?

Expectoration of Blood After a submucosal resection (SMR), hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva.

When interviewing and assessing a 17 yr old client , which finding alerts the nurse to explore substance abuse with the adolescent?

Failing grades Blood spots on clothing Absenteeism from school Long sleeved shirts in warm weather

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? 1 Spiritual belief 2 Family practices 3 Emotional factors 4 Cultural background

Family Practices Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care.

Upon entering the examination room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse?

Find a way to interview the client privately

When conducting an assessment of a client who does not speak English and an interpreter is unavailable, which action would the nurse NOT utilize?

Using medical terminology Use more simple words