NU273 Week 1 PrepU: Assessment
While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: do nothing; the client's skin is intact. give the client a donut ring to reduce pressure on the affected area. contact the client's family. document the condition of the client's skin.
document the condition of the client's skin. The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 10: Principles and Practices of Rehabilitation, p. 181. Chapter 10: Principles and Practices of Rehabilitation - Page 181
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? decreased cough and gag reflexes heart rate of 94 beats/minute oxygen saturation (SaO2) of 89% blood-tinged stools
oxygen saturation (SaO2) of 89% Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy. Reference: Oximetry
A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride, an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within 1 to 2 minutes after I.V. bolus administration. 1 to 2 minutes after continuous I.V. infusion. 10 to 15 minutes after continuous I.V. infusion. 10 to 15 minutes after I.V. bolus administration.
1 to 2 minutes after I.V. bolus administration. Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine's antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped. Reference: N/A
The nurse is auscultating the heart of a client diagnosed with mitral valve prolapse. Which is often the first and only manifestation of mitral valve prolapse? An extra heart sound Fatigue Syncope Dizziness
An extra heart sound Often the first and only sign of mitral valve prolapse is identified when a physical examination of the heart reveals an extra heart sound, referred to as a mitral click. Fatigue, dizziness, and syncope are other symptoms of mitral valve prolapse. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 28: Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders, p. 793. Chapter 28: Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders - Page 793
During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? Sebum deficiency Fluid retention Dehydration Protein deficiency
Fluid retention Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 60: Assessment of Integumentary Function, Assessing Vascularity and Hydration, p. 1801. Chapter 60: Assessment of Integumentary Function - Page 1801
While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion? Christianity Judaism Islam Hinduism
Islam According to the Islamic religion, neither food nor drink is taken between sunrise and sunset during the holy days of Ramadan. There are no special or universal food beliefs common to Christianity. According to Judaism, Kosher food is eaten, meat cannot be mixed with dairy, and separate cooking and eating utensils are used for food preparation and consumption. According to Hinduism, beef is forbidden and other meats must meet ritual requirements. Reference: Chapter 46: Spirituality - Page 1797
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Semisolid food with thick liquids Thin liquids only Solid food with thin liquids Pureed food with water
Semisolid food with thick liquids A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient. Reference: N/A
The nurse is conducting a morning assessment of an 80-year-old female patient who has a longstanding diagnosis of heart failure (HF). The nurse notes an elevation in jugular venous pressure (JVP) greater than 4 cm above the woman's sternal angle, a finding that did not exist the day before. What conclusion should the nurse draw from this assessment finding? The woman is demonstrating the early signs of cardiogenic shock. The woman has left-sided heart failure. The woman is also likely to experience shortness of breath. The woman may be experiencing an exacerbation of right-sided HF.
The woman may be experiencing an exacerbation of right-sided HF. Increased JVP is associated with right-sided HF. Dyspnea may or may not be present, but is more closely associated with left-sided HF. Increased JVP is not necessarily indicative of impending shock. Reference: N/A
Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified? an increase in fetal heart rate variability episodes of nausea and vomiting a decrease in intensity of contractions an increased sense of rectal pressure
an increased sense of rectal pressure An increased sense of rectal pressure indicates that the client is moving into the second stage of labor. The nurse should be able to discern that information by the client's behavior. Contractions don't decrease in intensity, there isn't a change in fetal heart rate variability, and nausea and vomiting don't usually occur. Reference: Labor, Care During
A 10-year-old boy is taking dextroamphetamine (Dexedrine) daily for ADHD. At each clinic visit, the nurse must assess the child. The priority assessment since he is on this medication would be which? body temperature. Vision. height and weight. blood pressure.
height and weight. The nurse should assess blood pressure, body temperature, and vision at each clinic visit as routine nursing measures in caring for a pediatric client. However, the priority assessment would be of height and weight. Monitoring the growth and development of children taking amphetamines is extremely important because these drugs have been associated with growth suppression. Reference: Chapter 22: Psychotherapeutic Agents - Page 386
A hospitalized client requests a magnesium citrate "bisacodyl pill" every night to "stay regular." The nurse should initially be most concerned about what potential health risk for this client? laxative abuse bulimia-induced purging poor intake of dietary fiber effective knowledge related to laxative use
laxative abuse Stimulant laxatives such as bisacodyl are generally useful and safe for short-term treatment of constipation, cleansing the bowel prior to endoscopic examinations, and treating fecal impaction. However, they are not safe for frequent or prolonged usage and are often overused in older adults. Although the nurse should confirm that the client's fiber intake is adequate, the possibility of laxative abuse should first be investigated and addressed. The request is not an indication of purging or effective knowledge of laxative use. Reference: Chapter 58: Drugs Affecting Gastrointestinal Motility - Page 1021
During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data? medical objective secondary source subjective
objective Physical examination techniques such as auscultation provide objective data, which reflect findings without interpretation. The client and client's family report subjective data to the nurse. The family and members of the healthcare team provide secondary source information. The nurse obtains medical data from the physician and medical record. Reference: Health History Interview And Physical Assessment
A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? after induction therapy is completed within hours within 1 month within 2 weeks
within 2 weeks Bone marrow depression is most likely to occur 10 days after methotrexate is administered. Reference: Methotrexate
A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.
36 The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%. Reference: Burn Care, Burns
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? 9% 18% 27% 36%
36% According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 62: Management of Patients with Burn Injury, Rule of Nines, p. 1848. Chapter 62: Management of Patients with Burn Injury - Page 1848
The school nurse is conducting health assessments for a group of children. Which of the following situations encountered by the nurse raises suspicion of child neglect? A child reports of constant hunger. A child tries to get attention from the nurse. A child states, "I don't like my mother." A child doesn't want to play with others.
A child reports of constant hunger. Constant hunger is a possible indicator that a child is being neglected. The other options would all be considered relatively age appropriate behaviors rather than being indicative of a more serious situation. Reference: Suspected Child Abuse Assessment, Child Abuse
A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it is slightly concave. Additional assessment should proceed in which order? palpation, percussion, and auscultation palpation, auscultation, and percussion percussion, palpation, and auscultation auscultation, percussion, and palpation
auscultation, percussion, and palpation The correct order of assessment for examining the abdomen is inspection, auscultation, percussion, and palpation. The reason for this approach is that the nurse would perform the less-intrusive techniques before the more-intrusive techniques. Percussion and palpation can alter natural findings during auscultation. Reference: Assessment Techniques
The most common symptom of esophageal disease is nausea. vomiting. dysphagia. odynophagia.
dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 45: Management of Patients With Oral and Esophageal Disorders, p. 1279. Chapter 45: Management of Patients With Oral and Esophageal Disorders - Page 1279
A child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage? vomiting of dark brown emesis refusal to drink clear fluids decreased heart rate frequent swallowing
frequent swallowing Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate. Reference: Ostanesthesia Care, Pediatric & Tonsillectomy And Adenoidectomy
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: right lower quadrant. right upper quadrant. left upper quadrant. left lower quadrant.
left lower quadrant. The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 14: Nursing Management During Labor and Birth, p. 490. Chapter 14: Nursing Management During Labor and Birth - Page 490
A client asks the nurse how to identify rheumatoid nodules with rheumatoid arthritis. What characteristic will the nurse include? tender to the touch nonmovable located over bony prominence reddened
located over bony prominence Rheumatoid nodules usually are nontender, movable, and evident over bony prominences, such as the elbow or the base of the spine. The nodules are not reddened. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, Clinical Manifestations, p. 1094. Chapter 38: Assessment and Management of Patients With Rheumatic Disorders - Page 1094
The primary objective in the immediate postoperative period is controlling nausea and vomiting. relieving pain. maintaining pulmonary ventilation. monitoring for hypotension.
maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 19: Postoperative Nursing Management, p. 457. Chapter 19: Postoperative Nursing Management - Page 457
A client had been withdrawn in the client's room for 3 days, not eating or sleeping, prior to his admission to the inpatient unit. Upon interview, the client demonstrates difficulty answering questions, appears to have no facial expressions, and cannot follow simple instructions. This cluster of symptoms can be described as what? Negative symptoms Delusions Thought disorder Positive symptoms
Negative symptoms Common negative symptoms of schizophrenia include alogia, affective blunting, avolition, anhedonia, and attentional impairment. Reference: Chapter 16: Schizophrenia - Page 256
A nurse is performing an otoscopic examination on a client. Which finding would the nurse document as abnormal? Umbo in the center of the tympanic membrane External auditory canal erythema Tympanic membrane pearly gray Manubrium superior to the umbo
External auditory canal erythema An erythematous external auditory canal would be considered an abnormal finding. The tympanic membrane is normally pearly gray and translucent. The umbo, which is located in the center of the eardrum, extends from the superior manubrium. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders, Clinical Manifestations, p. 1926. Chapter 64: Assessment and Management of Patients With Hearing and Balance Disorders - Page 1926
A nurse is beginning to apply the nursing process during a new client interaction. What activity should the nurse perform? Obtain a medication history. Identify potential client problems related to drug therapy. Educate the client about basic medication safety. Confirm or rule out nursing diagnoses.
Obtain a medication history. History and physical examination are completed during assessment, the first step of the nursing process. Problem identification is completed during the nursing diagnosis step, the second step of the nursing process. Education is a form of intervention. Confirming or ruling out nursing diagnoses would be part of the diagnosis stage. Reference: Chapter 4: The Nursing Process in Drug Therapy and Patient Safety - Page 47
The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification? Ophthalmoscope Retinoscope Tonometer Amsler grid
Ophthalmoscope The nurse is correct to provide an ophthalmoscope to the surgeon for examination of the optic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders, Direct Ophthalmoscopy, p. 1881. Chapter 63: Assessment and Management of Patients With Eye and Vision Disorders - Page 1881
Which is the leading cause of disability and pain in the elderly? Osteoarthritis (OA) Rheumatoid arthritis (RA) Systemic lupus erythematosus (SLE) Scleroderma
Osteoarthritis (OA) Osteoarthritis is the leading cause of disability and pain in the elderly. RA, SLE, and scleroderma are not leading causes of disability and pain in the elderly. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 38: Assessment and Management of Patients With Rheumatic Disorders, p. 1104. Chapter 38: Assessment and Management of Patients With Rheumatic Disorders - Page 1104
The nursing instructor is talking with a group of senior nursing students about shock. When caring for a patient at risk for shock what assessment finding would the nurse consider a potential sign of shock? Elevated systolic blood pressure Elevated mean arterial pressure Shallow, rapid respirations Bradycardia
Shallow, rapid respirations A symptom of shock is shallow, rapid respirations. Systolic blood pressure drops in shock; mean arterial pressure is less than 65 mm Hg. Bradycardia occurs in neurogenic shock, but other states of shock are normally accompanied by tachycardia. Reference: N/A
A nurse is caring for a preterm newborn who has developed rapid, irregular respirations with periods of apnea. Which additional assessment finding should the nurse identify as an indication of respiratory distress syndrome (RDS)? Deep inspiration Expiratory lag Sternal retraction Inspiratory grunt
Sternal retraction The nurse should identify sternal retraction as a sign of respiratory distress syndrome in the preterm newborn. Deep inspiration is not seen during respiratory distress; rather, a shallow and rapid respiration is seen. There is an inspiratory lag, instead of an expiratory lag, during respiratory distress. There is a grunting heard when the air is breathed out, which is during expiration and not during inspiration. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 23: Nursing Care of the Newborn with Special Needs, p. 899. Chapter 23: Nursing Care of the Newborn With Special Needs - Page 899
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness? The upper abdominal quadrants on the left and right side The costovertebral angle Above the symphysis pubis Around the umbilicus
The costovertebral angle The nurse is correct to assess the kidneys for tenderness at the costovertebral angle. The other options are incorrect. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 53: Assessment of Kidney and Urinary Function, Table 53-2: Identifying Characteristics of Genitourinary Pain, p. 1556. Chapter 53: Assessment of Kidney and Urinary Function - Page 1556
A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. The client admits drinking excessively over the previous 48 hours. This behavior is an example of: alcoholism. a manic episode. situational crisis. depression.
situational crisis. A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks. Reference: Depression
An adolescent becomes increasingly withdrawn, is irritable with family members, and has been getting lower grades in school. After giving away a stereo and some favorite clothes, the adolescent is brought to the community mental health agency for evaluation. This adolescent is at risk for: suicide. anorexia nervosa. school phobia. schizophrenia.
suicide Changes in academic performance and familial communications, social withdrawal, and giving away treasured possessions suggest that this adolescent is contemplating suicide. Anorexia nervosa would cause weight loss and other related symptoms. This adolescent's signs and symptoms don't suggest fear of school and they typify depression, not schizophrenia. Reference: N/A
A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding? "My child can't eat wheat, rye, oats, or barley." "My child needs a gluten-rich diet." "My child must avoid potatoes, rice, and cornstarch." "My child can safely eat frozen and packaged foods."
"My child can't eat wheat, rye, oats, or barley." A child with celiac disease must follow a gluten-free diet. If the child eats foods containing gluten, changes in the intestinal mucosa will prevent the absorption of fats and other foods. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch may be included in a gluten-free diet. Frozen and packaged foods, which may contain gluten fillers, should be avoided. Reference: Malabsorption
The nurse is assessing the client's mental status . Which question will the nurse include in the assessment? "Can you write your name on this piece of paper?" "Can you count backward from 100?" "Who is the president of the United States?" "Are you having hallucinations now?"
"Who is the president of the United States?" Assessing orientation to time, place, and person assists in evaluating mental status. Does the client know what day it is, what year it is, and the name of the president of the United States? Is the client aware of where he or she is? Is the client aware of who the examiner is and why he or she is in the room? "Can you write your name on this piece of paper?" will assess language ability. "Can you count backward from 100?" assesses the client's intellectual function. "Are you having hallucinations?" assesses the client's thought content. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, p. 1959. Chapter 65: Assessment of Neurologic Function - Page 1959
A client has undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy as treatment for endometrial cancer. When providing postoperative care to this client the nurse would be alert for signs and symptoms of which of the following? Leukopenia Neurotoxicity Bladder dysfunction Clotting deficiencies
Bladder dysfunction After a total abdominal hysterectomy and bilateral salpingo-oophorectomy, the client is at risk for several complications, especially bladder dysfunction because the surgical site is close to the bladder. Leukopenia and neurotoxicity are adverse effects of chemotherapy agents such as paclitaxel and carboplatin used to treat ovarian cancer. Deep vein thrombosis, not clotting deficiencies are a potential complication after this type of surgery. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 57: Management of Patients With Female Reproductive Disorders, Bladder Dysfunction, p. 1715. Chapter 57: Management of Patients With Female Reproductive Disorders - Page 1715
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which finding suggests that the decongestant has been effective? Increased salivation Increased tearing Reduced sneezing Headache
Reduced sneezing Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, the client shouldn't experience increased salivation or tearing. Because decongestants alleviate congestion, they also relieve headaches, which may be caused by congestion. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 37: Assessment and Management of Patients With Allergic Disorders, Pharmacologic Therapy, p. 1068. Chapter 37: Assessment and Management of Patients With Allergic Disorders - Page 1068
The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. Reports of abdominal pain of 4 on a 0 to 10 point scale Hypoactive bowel sounds in all four quadrants The client states, "I feel nauseated." Peripheral pulses +3 Skin warm and dry Client informs the nurse there is a floater in the left eye
Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated." Client informs the nurse there is a floater in the left eye Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team. Reference: Chapter 26: Health Assessment - Page 692
The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system? Integumentary Neurologic Cardiovascular Respiratory
Respiratory Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 12: Pain Management, p. 235. Chapter 12: Pain Management - Page 235
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Thin liquids only Pureed food with water Solid food with thin liquids Semisolid food with thick liquids
Semisolid food with thick liquids A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient. Reference: N/A
A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child? hypokalemia hyperphosphatemia hypercalcemia hypernatremia
hypokalemia Hypokalemia occurs when insulin administration causes glucose and potassium to move into the cells. Insulin administration doesn't directly affect calcium levels. Hypophosphatemia — not hyperphosphatemia — may occur with insulin administration because phosphorus enters the cells with insulin and potassium. Insulin administration doesn't directly affect sodium levels. Reference: Diabetic Ketoacidosis
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? platelet count, prothrombin time, and partial thromboplastin time platelet count, red blood cell count, and hemoglobin thrombin time, fibrinogen, and hemoglobin level D-dimer, red blood cell count, and partial thromboplastin time
platelet count, prothrombin time, and partial thromboplastin time The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, fibrinogen level, and D-dimer, as well as client history and other assessment factors. Red blood cell count and hemoglobin are not utilized in this diagnosis. Reference: Disseminated Intravascular Coagulation
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? Decreased acetylcholine level Increased acetylcholine level Increased norepinephrine level Decreased norepinephrine level
Decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 11: Health Care of the Older Adult, p. 211. Chapter 11: Health Care of the Older Adult - Page 211
A client whose partner has left is admitted to the hospital with severe depression. The nurse suspects that this client is at risk for suicide. Which question is most appropriate and helpful for the nurse to ask during an assessment for suicide risk? "Are you sure you want to kill yourself?" "If my partner left me, I know I would want to kill myself. Is that how you feel?" "How do you think you would kill yourself?" "Why don't you just look at the positives in your life?"
"How do you think you would kill yourself?" To determine if a client is at risk for suicide, the nurse should ask, "How do you think you would kill yourself?" If there is a plan, the client may be closer to carrying out the act than an individual who has thought about, but hasn't planned, suicide. Asking "Are you sure?" requires a "yes" or "no" response and is self-limiting. The nurse stating a desire to commit suicide if placed in the client's situation is inappropriate because the statement tells the client what to think and feel. Telling the client to look at the positives in life dismisses the client's feelings. Reference: Major Depression
A client receiving drug therapy develops numbness and tingling in the extremities and muscle cramps. What assessment should the nurse perform? Check the client's blood glucose level. Review the client's most recent potassium level. Check the client's urine output. Assess the client's level of orientation.
Review the client's most recent potassium level. Hypokalemia is suggested by numbness and tingling in the extremities, muscle cramps, weakness, and irregular pulse. Fatigue, drowsiness, hunger, tremulousness, and cold clammy skin would suggest hypoglycemia. Renal injury would be manifested by elevated BUN and creatinine concentration, decreased hematocrit, and electrolyte imbalances, fatigue, malaise, decreased urine output and irritability. Neurologic dysfunction would most likely be manifested by confusion, delirium, insomnia, drowsiness, and changes in deep tendon reflexes. Reference: Chapter 3: Toxic Effects of Drugs - Page 40
A nurse is caring for a client with acute mitral regurgitation related to an acute myocardial infarction. The nurse knows to monitor the client carefully for symptoms of which initial complication or result? Cerebral vascular accident (CVA) Severe heart failure Kidney failure Infarcted bowel
Severe heart failure Acute mitral regurgitation usually manifests as severe congestive heart failure, resulting from blood flowing backward from the left ventricle to the left atria and eventually into the lungs. Kidney failure could become a problem later if cardiac output is too low, but not initially. CVA and an infarcted bowel would not be caused by mitral regurgitation. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 28: Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders, Clinical Manifestations, p. 793. Chapter 28: Managements of Patients With Structural, Infectious and Inflammatory Cardiac Disorders - Page 793
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? Intractable Variant Unstable Refractory
Unstable Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 27: Management of Patients With Coronary Vascular Disorders, Chart 27-2, p. 757. Chapter 27: Management of Patients With Coronary Vascular Disorders - Page 757
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: evaluation of the corneal reflex response. examination of the fundus of the eye. assessment of the client's gait. evaluation of bowel and bladder functions.
evaluation of the corneal reflex response. During an acute crisis, the nurse should check the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in the arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn't include fundus examination unless the client has sustained direct eye trauma. The client shouldn't be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren't vital, so the nurse should delay their assessment. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 65: Assessment of Neurologic Function, Superficial Reflexes, p. 1964. Chapter 65: Assessment of Neurologic Function - Page 1964
The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant's pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant's pulse rate? This infant will need a home cardiac monitor set up. The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. The parents will not be able to check the pulse accurately; the nurse will need to do home health checks on this infant on a periodic basis. The parents should be encouraged to get a neighbor or family member to help them check their infant's pulse.
The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant's apical pulse. If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant's pulse accurately. Reference: Chapter 25: Vital Signs - Page 654
A client has been receiving chlorpromazine to treat psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? restlessness, difficulty sitting still, and pacing involuntary rolling of the eyes tremors, shuffling gait, and masklike face extremity and neck spasms, facial grimacing, and jerky movements
tremors, shuffling gait, and masklike face Pseudoparkinsonism may appear 1 to 5 days after starting an antipsychotic and may also include drooling, rigidity, and "pill rolling." Akathisia may occur several weeks after starting antipsychotic therapy and consists of restlessness, difficulty sitting still, and fidgeting. An oculogyric crisis characterized by uncontrollable rolling back of the eyes and, along with dystonia, should be considered a medical emergency. Dystonia may occur minutes to hours after receiving an antipsychotic and may include extremity and neck spasms, jerky muscle movements, and facial grimacing. Reference: Extrapyramidal Symptom Assessment Chlorpromazine Hydrochloride
