NUR 3306 Final Study Guide: Quizzes 1-4

The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. The instructor explains that SBAR charting is based on?

A. The client's background B. Information that the nurse obtains from the family CorrectC. Complete and accurate assessment findings D. Data in old medical records

An adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Mark all that apply.)

A. Aggressiveness CorrectB. Intensity CorrectC. Quality CorrectD. Functional goal E. Quantity Response Feedback: In addition to pain intensity, other basic elements of a pain assessment are location, duration, intensity, quality/description, alleviating/aggravating factors, pain management goal, and functional goal. Aggressiveness and quantity are distracters for this question.

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

A. Ask the doctor for an order for an MRI CorrectB. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment Response Feedback: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students knows that this type of information is assessed in what type of assessment?

A. Comprehensive CorrectB. Functional C. Head to toe D. Body systems

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

A. Decreased intake of grains B. Weight loss CorrectC. Variety D. Increased intake of meats Response Feedback: Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and grains, particularly from plant sources; and meeting individual nutritional needs while avoiding either deficiencies or excesses in nutrient intake.

A middle aged client is admitted to the observation unit with right lower quadrant pain. The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

A. Deficient knowledge related to disease process B. Pain related to an inability to tolerate food C. Potential for malnutrition (deficit) related to an inability to tolerate food CorrectD. Fluid volume less than body requirements related to an inability to tolerate fluids Response Feedback: Fluid volume is generally affected faster than anything else when a client cannot keep fluids down. A knowledge deficit can only occur once a medical diagnosis is established. Pain is not a nutrition-related nursing diagnosis. Malnutrition does not occur during a hospitalization but over a long period.

How does the nurse use critical thinking when accurately assessing vital signs?

A. Evaluating assessment techniques CorrectB. Developing nursing diagnoses C. Monitoring evaluations D. Planning assessment techniques

The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.)

A. Female gender CorrectB. Male gender C. Coffee drinker CorrectD. Tobacco use CorrectE. Age older than 50 years Response Feedback: Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For clients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include female gender or being a coffee drinker.

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

A. MRI CorrectB. Physical examination for neurologic changes C. CT scan CorrectD. Focused history E. EEG Response Feedback: A client with severe headaches may be unable to provide a complete history, but a focused history and physical examination looking for neurologic changes are critical nursing behaviors. Nursing behaviors do not include MRIs, CT scans, or EEGs.

What tool does the nurse use to auscultate the client's abdomen?

A. None B. Fetoscope CorrectC. Stethoscope D. Sonoscope

A nurse, who suffers from a respiratory infection is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse's best action?

A. Perform hand hygiene before coughing into hands B. Cover the mouth and nose with her hands while coughing C. Cough into the air away from the client toward the hallway CorrectD. Cough into the inner aspect of the elbow

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the client's is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

A. Pinch a fold of skin on the client's abdomen B. Pinch a fold of skin on the client's cheek C. Pinch a fold of skin on the client's upper thigh CorrectD. Pinch a fold of skin on the client's forearm Response Feedback: To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the patient's hand or lower arm. The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

A. Shape of the ears B. Shape of the chin CorrectC. Shape of the lips CorrectD. Shape of the nose CorrectE. Shape of the eyes Response Feedback: The most noticeable difference among racial groups is skin color. Shape of the eyes, nose, and lips also varies based on background and genetics. Variations in skull or neck shape or size relate more to height and weight than to specific racial or cultural background. Shape of the chin and ears is not related to cultural differences.

When caring for clients in any health care environment, what is the most important technique for preventing infection?

A. Sterile technique B. Standard precautions CorrectC. Hand hygiene D. Use of gloves

When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?

A. Strain B. Vertebral injury C. Lymph node enlargement CorrectD. Limitations in movement Response Feedback: During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection. Therefore, the other options are incorrect.

Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?

A. The evaluation of financial reimbursement B. The evaluation of client nutrition CorrectC. The evaluation of care for continual improvement D. The evaluation of timely documentation of pain

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

A. To establish rapport with the client and family. B. To gather information for specialists to whom the client might be referred. CorrectC. To establish a database against which subsequent assessments can be measured. D. To quantify the degree of pain a client may be experiencing.

A school age child is brought to the pediatric clinic by her mother, who tells the nurse that the child has a sore on her leg that "just keeps getting bigger." On examination, the nurse practitioner notes an area of vesicles and bulla, some of which have ruptured and are oozing serous fluid. A honey-colored crust covers the area. What would the nurse suspect the lesion is?

A. Varicella B. Scabies CorrectC. Impetigo D. Rubella Response Feedback: Impetigo is a highly contagious superficial skin infection commonly caused by Staphylococcus aureus or Group A beta-hemolytic streptococci. It is characterized by vesicles or bullae that eventually rupture and ooze serous fluid that forms the classic honey-colored crust. The scenario does not describe varicella, scabies, or rubella.

The triage nurse on the adolescent unit knows that puberty can contribute to what?

A. Violence B. Suicidal ideation CorrectC. Depression D. Bipolar disorder Response Feedback: Adolescence may be difficult because of hormonal changes as well as growth and developmental stage. Onset of menarche and puberty can contribute to depression. The other options are distractors to the question.

Parents bring a school age child to the emergency department after a bicycle accident. The father tells the nurse that the child was not wearing a helmet when thrown over the handlebars, striking the child's head on the sidewalk. What would be the most important information for the nurse to include in education for this child and family?

A. Where to find bike safety courses CorrectB. Use of safety equipment C. Use of hand signals when bike riding D. Measuring for the right size bicycle Response Feedback: The nurse may include all the listed information in client teaching for this client and family, but the most important information would be the use of safety equipment.

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?

A. Work with medical team to evaluate possible surgery B. Discuss pharmacologic interventions C. Chronic pain related to cervical spine injury CorrectD. Assess characteristics of the pain Response Feedback: The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. Option C represents a nursing diagnosis, not an intervention.

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

A. "Is your spouse living with you?" B. "Are you living with your spouse?" CorrectC. "Do you live alone or with someone?" D. "Are you married, divorced, or widowed?" Response Feedback: An inclusive, sensitive, and ultimately better question by which to determine the client's marital status is, "Do you live alone or with someone?" This phrasing provides a more direct avenue for finding out about support at home. The other options list questions that would not be the most appropriate question to ask the client about their marital status.

A nurse in the emergency department is caring for a nonverbal client. What would be the best way for the nurse to assess this client's level of pain?

A. Ask the client to draw a picture of the pain B. Ask the paramedics what they think is the client's pain level C. Ask the client to describe the pain CorrectD. Ask the family if they have noticed any changes in the client's behavior Response Feedback: When attempting to perform a pain assessment on a client who cannot self-report pain, the nurse should try to identify any potential causes for pain, observe client behaviors, ask the family or other caregivers if they have noticed any changes in the client's behavior, and attempt an analgesic trial. A nonverbal client cannot describe the pain in spoken words. Asking the client to draw a picture of pain while in the emergency department would not be the best way to assess the client's level of pain, nor would asking paramedics what they think about the client's pain.

The nurse is gathering a complete history of the client's present illness. The nurse knows that the most appropriate way to begin to gather this information is what?

A. Assessing the client's vital signs B. Gathering a complete list of the client's medications CorrectC. Asking open-ended questions D. Asking focused questions Response Feedback: The nurse collects information about the present illness by beginning with open-ended questions and having the client explain symptoms. The most appropriate way to collect data about the present illness is not to assess the client's vital signs, gather a complete list of the client's medications, or ask focused questions.

The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

A. Assists in keeping the skin intact CorrectB. Assists in friction protection C. Assists in protection from infection D. Assists in keeping skin dry Response Feedback: Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

In the Hispanic culture, a common rite of passage for a female teenager is called what?

A. Bar Mitzvah B. Confirmation CorrectC. Quinceanera D. Menstruation Response Feedback: A Hispanic rite of passage is the quinceanera. A Jewish rite of passage is bar mitzvah for boys and bat mitzvah for girls. Confirmation is a Catholic rite for boys and girls. Menstruation is a physical process for all girls.

The nursing instructor is discussing the different types of pain with the nursing class. What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site?

A. Chronic pain B. Cutaneous pain CorrectC. Referred pain D. Somatic pain Response Feedback: Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. Chronic pain is pain referred to as persistent. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues and is felt at its origination. Somatic painoriginates from skin, muscles, bones, and joints and is felt at its origination.

A nursing instructor is discussing therapeutic versus nontherapeutic responses with nursing students. Which of the following would the nurse identify as nontherapeutic?

A. Clarification CorrectB. Distraction C. Summarizing D. Focusing Response Feedback: Distractions in the environment contribute to nontherapeutic communication. Clarification, summarizing, and focusing are all important aspects of therapeutic communication.

HIPAA gives clients greater control over their medical records. What else does HIPAA provide?

A. Copying of medical records B. Education of lay people about medical records CorrectC. Client recourse if privacy protections are violated D. Legal use of medical records Response Feedback: HIPAA provides for client education on privacy protection, client access to medical records, client consent prior to disclosing information from the record, and client recourse if privacy protections are violated. HIPAA does not address copying of medical records, education of lay people about medical records, or legal use of medical records.

The nursing instructor is explaining to students the difference between the language used when a nurse talks to the client and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?

A. Document according to the orders of the physician B. Talk to the client and document exactly the same CorrectC. Use medical terminology when documenting in the medical record D. Document exactly as the client talks Response Feedback: The nurse documents in the medical record using appropriate medical terminology. When speaking with clients, the nurse uses common lay language so the client better understands the questions. The nurse would not document according to the orders of the physician, nor would the nurse document exactly as speaking to the client. The nurse would not document exactly as the client talks, as this could be incorrect information to include in the medical record.

In what life stage, defined by Erikson, is group identity important?

A. Early adulthood B. School age CorrectC. Adolescence D. Young adult Response Feedback: Adolescents tend to cling together in cliques and crowds. Doing so helps to protect against the loss of identity through the assumption of a group identity that temporarily defines for the adolescent how to dress, act, and belong. Erikson explained that this behavior will eventually fall away as the individual defines his or her own identity. The other options are distracters for this question.

What term is this quote describing? "__________ encompasses the evolutionary development which has made man the teaching, instituting, and learning animal."

A. Ego integrity B. Despair CorrectC. Generativity D. Stagnation Response Feedback: Generativity "encompasses the evolutionary development which has made man the teaching, instituting, and learning animal." The three distractors are also terms from Erikson's Model of Individual Development. In the late adulthood stage ego integrity versus despair is paired. Ego integrity is when one comes to terms with one's life choices. When one does not reach this developmental mark, despair can result. In the middle adult stage generativity is paired with stagnation. Stagnation results when one does not meet generativity as described above.

What type of family violence is among the most common type that children experience?

A. Financial abuse CorrectB. Sibling violence C. Munchausen's syndrome D. Traumatic stress Response Feedback: Sibling violence is among the most common type of violence that children experience. The other options do not describe the most common type of family violence that children experience.

What is egocentrism?

A. Internalized sets of actions that permit children to do mentally what they once did physically B. Centering attention on one aspect of a problem and failing to consider other dimensions C. The belief that inanimate objects are capable of action and have lifelike qualities CorrectD. The inability to distinguish one's own perspective from another person's Response Feedback: Egocentrism is the inability to distinguish one's own perspective from another person's. Animism is the belief that inanimate objects are capable of action and have lifelike qualities. Centration is the child centering attention on one aspect of a problem and failing to consider other dimensions. Piaget defined operations as internalized sets of actions that permit children to do mentally what they once did physically.

A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus?

A. Just above the thyroid cartilage B. Between the thyroid and the cricoid cartilages CorrectC. Just below the cricoid cartilage D. In front of the sternocleidomastoid muscle Response Feedback: Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. the other three options are distracters for the question.

To make a legal entry into the medical record, the nurse must document what?

A. Laboratory tests ordered B. Attending physician CorrectC. Time of the assessment D. Nature of the assessment Response Feedback: The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.

The nurse is in the client's room after she has given birth one day ago and observes a family member offering the baby a bottle after the infant has breastfed. The family member states to the new mother, "This baby is not fat enough and needs to eat double the first few weeks." What is the nurse's best action?

A. Offer the client formula and bottles to keep at bedside when needed. CorrectB. Provide information to the client and family about newborn nutritional needs. C. Reassure the mother that the baby will gain more weight with bottle feeding. D. Remind the mother to decrease her caloric intake while increasing the baby's. Response Feedback: Culturally based postpartum practices are diverse. Generally, most cultures recognize that, after childbirth, women must rest, take care of the baby, and eat for two when breastfeeding. In some cultures, people may believe that a fat baby is a healthy baby, and new parents might be advised to offer their baby a bottle after breastfeeding to ensure that the infant is not starving and puts some meat on the bones fast. In these situations the nurse must provide facts about infants' nutritional needs and weight-gain patterns, as well as health risks associated with infant formula consumption and overfeeding (Riordan and Auerbach, 2005).

An older adult is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?

A. Older adults have fewer nerve fibers; therefore, they feel less pain CorrectB. Older adults may be reluctant to report pain C. Older adults are always in chronic pain D. Older adults are stoic and expect to be in pain Response Feedback: Although pain is prevalent in older clients, some of them see pain as just part of natural aging. They may be reluctant to report pain, because they want their providers to consider them "good clients," or they may fear that complaints of pain may lead to costly tests or expensive medications that they cannot afford. Older adults do not have fewer nerve fibers, they are not always in chronic pain, and they are not always stoic or expecting to be in pain.

A caregiver brings a handicapped client to the ED reporting altered level of consciousness and refusal to eat by the client. The client is found to be severely dehydrated. The nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

A. Psychological B. Intentional CorrectC. Unintentional D. Direct Response Feedback: Physical, sexual, psychological, and financial abuse and neglect may be intentional or unintentional. The scenario does not describe psychological abuse or intentional abuse. Direct abuse is a simple distracter for this question.

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what?

A. Rest and improve health CorrectB. Provide accurate answers C. Talk about their feelings D. Communicate verbal concern Response Feedback: The nurse uses silence purposefully during the interview to allow clients time to gather their thoughts and provide accurate answers. The nurse also uses silence therapeutically to communicate nonverbal concern. Silence also gives clients a chance to decide how much information to disclose. Silence is not used to rest and improve the client's health, have the client talk about their feelings, or communicate verbal concern.

The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?

A. Rush B. Gurgle C. Murmur CorrectD. Bruit Response Feedback: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. Rush and gurgle are distracters for this question. A murmur is assessed during a cardiac assessment.

The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what?

A. Safety CorrectB. State of health C. Growth pattern D. Past surgeries Response Feedback: Anthropometric measurements are the various measurements of the human body, including height and weight. They provide critical information about the adult's state of health. Accurate measurements do not provide critical information about safety, past surgeries, or growth pattern in the adult client.

The nurse can best practice effective care by exhibiting which behavior during a cultural assessment?

A. Set a focused time limit for collecting data. B. Stay focused on the computer screen to remain neutral. C. De-emphasize nonverbal communication cues. CorrectD. Acknowledge own prejudicies that might create barriers to care. Response Feedback: Leininger suggests that the attributes and behaviors of a nurse practicing effective care within the patient's cultural context include the following: - Genuine interest in a patient's culture and personal life experiences - Active listening and awareness of meanings behind the patient's verbal communication (storytelling) - Nonverbal communication (body language, eye contact, facial expressions, interpersonal space, and preferences regarding touch) - Acknowledgement that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care.

A nursing student is helping with a group presentation on social assessment. What would be most important for the student to include in the group presentation?

A. Social assessment emphasizes the interconnectedness of physical, physiologic, and educational dimensions of health B. Social assessment emphasizes the interconnectedness of physical, family, and social dimensions of health C. Social assessment emphasizes the interconnectedness of physical, spiritual, and psychic dimensions of health CorrectD. Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health Response Feedback: Social assessment, integral to quality nursing care at every level, emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health for individuals, communities, and populations studied. Psychic, social, and educational dimensions are not dimensions of health emphasized in the social assessment. The other options are distracters to the question.

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?

A. Society B. Community C. System CorrectD. Culture Response Feedback: At the most basic level, culture can be defined as a shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world. Society is defined as a group of people bound by a common culture. Community is defined as a group of people having a common interest. System is defined as a group of interrelated elements forming a complex whole.

What does the nurse knows about normal blood pressure?

A. Stays level throughout the day CorrectB. Follows a diurnal rhythm C. Rises with the early morning fall of blood glucose D. Follows the same cycle as the sun Response Feedback: A daily, circadian (diurnal) cycle of blood pressure occurs, with it increasing late in the afternoon and decreasing in the early morning. Blood pressure does not stay level throughout the day. Blood pressure does not rise with the early morning fall of blood glucose. Blood pressure does not follow the same cycle as the sun.

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

A. Suicide attempts B. Suicide means CorrectC. Suicide ideation D. Suicide plan Response Feedback: Suicide ideation is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" This question does not assess attempts at suicide, means of suicide, or plans of suicide.

A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

A. The blood pressure is lower than normal B. There would be no need to assess the blood pressure CorrectC. The blood pressure is elevated D. The blood pressure is within normal limits Response Feedback: Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale. It would be expected that the nurse would assess the blood pressure upon arrival to the emergency department for this client.

The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger.". How would the nurse note these findings in the client's medical record?

A. The client has abnormal thinning of skin B. The client's integumentary system is within normal limits CorrectC. The client states that wounds are taking longer to heal D. The client has an abnormal inability to maintain temperature Response Feedback: Replacement of the epidermal layer decreases with aging, resulting in rougher skin texture and prolonged time for wound healing. The other options are distracters. It would be incorrect to state that the client has abnormal thinning of skin from the information given in the question. The nurse would not document that the integumentary system is within normal limits if the client states the wounds take an excessive time to heal. There is no information in the question that addresses the client have an abnormal inability to maintain temperature.

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

A. The research supporting intravenous medications given for pain take half as long to work as oral medications CorrectB. The time it takes a pain medication to decrease pain intensity C. The time it takes a pain medication to block pain in a client D. The median half-life of an intravenous pain medication Response Feedback: Most healthcare facilities have a standard time frame for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously. Standards are based on the time it takes a pain medication to provide a noticeable decrease in pain intensity. The mandate from The Joint Commission does not look at the half-life of the pain medication, because the half-life would differ from drug to drug, and no drug is listed in the question. The pain medication does not block pain, but decreases the pain intensity. Research does not support that intravenous medication take half as long to work as oral medication, because this information depends on the individual drug and the chemical makeup of the drug.

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

A. The sister may not tell the client exactly what the nurse says B. The client's sister may not understand medical terminology C. The sister may not be there every time the nurse needs to talk to the client CorrectD. The client may not want her sister to know her private information Response Feedback: Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because clients may not want to share personal information with others. HIPAA guidelines address privacy issues such as this scenario. Even when the client gives permission for the family member to be present, an official interpreter should be present per facility policy. The other options could be true in some situations, but the priority answer addresses privacy, both the client's right to privacy, and the facility's handling of private information.

When using Gordon's framework for a functional health assessment, the nurse asks a client, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing?

A. Vision B. Hearing C. Coping CorrectD. Cognition Response Feedback: A question to include in review of cognition and perception is whether the client has made any environmental changes because of vision, hearing, or memory decrease. The options of vision or hearing individually would not be complete as a response. The option of coping is not addressed in the question posed by the nurse.

What does examination of the skin involve? (Select all that apply)

Correct Palpation Auscultation Percussion Nutritional Assessment Correct Inspection

The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? (Mark all that apply.)

CorrectA. Atrophied tongue CorrectB. Temporal muscle wasting CorrectC. Generalized muscle weakness CorrectD. Dry eyes E. Productive cough Response Feedback: Clinical findings of malnutrition can occur throughout the body. Visible signs include muscle wasting, particularly in the temporal area; muscle weakness and decreased muscle size; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, gums, lips, tongue, eyes, and, in men, genitalia. A productive cough is not a visible sign of malnutrition.

The student nurse would learn that there are what types of family violence? (Mark all that apply.)

CorrectA. Child maltreatment CorrectB. Elder abuse C. Sibling rivalry CorrectD. Intimate partner violence E. Spousal neglect Response Feedback: Types of family violence include child maltreatment, sibling violence, intimate partner violence, and elder abuse. They do not include sibling rivalry or spousal neglect.

When inspecting the hair, what would the nurse note? (Select all that apply.)

CorrectA. Color CorrectB. Condition of hair shaft C. Length of hair D. Hair breakage of more than 6 hairs CorrectE. Hair shafts that are shiny Response Feedback: During hair inspection, the nurse notes color, consistency, distribution, areas of hair loss, and condition of the hair shaft. Length of hair and hair breakage of more than 6 hairs are distractors for this question.

A couple adopts an 8-month-old infant. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this infant/family?

CorrectA. Consider visits by a home health nurse to assess the environment for safety and comfort B. Teach parents to discipline the infant C. Teach parents to stimulate the infant as needed D. Consider a visit by a home health nurse to assess parenting skills Response Feedback: The most appropriate intervention for risk for delayed child development related to recent adoption is to consider a home health nurse visit to assess the environment for safety and comfort. Infants are too young for discipline, and this has no connection to the nursing diagnosis. All children need stimulation. Nothing in the scenario indicates that the couple's parenting skills are in question.

An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.)

CorrectA. Depth CorrectB. Location C. Other lesions on body CorrectD. Size CorrectE. Texture Response Feedback: A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body

While assessing a new client, the nurse asks about a family history of genetic illnesses The client states that her mother has diabetes. For which of the following is the patient at increased risk?

CorrectA. Diabetes B. Hypertension C. Cancer D. Seizures

The nursing instructor is discussing with the nursing students different types of health histories. A student asks when it would be appropriate to take a comprehensive health history. What would be the instructor's best answer? (Select all that apply.)

CorrectA. During a hospital admission B. At a clinic visit for a fall C. In the emergency department after a car accident CorrectD. During an annual physical examination CorrectE. At a screening for sports participation Response Feedback: The comprehensive health history takes place during an annual physical examination, for sports-participation screenings, and during a hospital admission. An emergency history would be done after a car accident. A focused history would be done in the clinic after a fall.

A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?

CorrectA. Follow the cues of the client during the interview B. Use a written checklist to make sure you cover all necessary areas C. Use a head-to-toe approach to make sure you do not miss anything D. Use a focused approach, asking only about symptoms of the present illness Response Feedback: Regardless of the order of data, the nurse guides the conversation following the cues of the client and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and the nurse would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness.

Clients in health care settings often are anxious. What behaviors would lead a nurse to believe that a client is anxious? (Select all that apply.)

CorrectA. Rapid speech CorrectB. Nail-biting CorrectC. Defensive tone D. Steady voice CorrectE. Sweating Response Feedback: Behaviors that indicate anxiety are nail-biting, foot-tapping, sweating, and pacing. Voice may quiver, speech may be rapid, and language or tone may be defensive. These behaviors are an attempt to relieve anxious feelings. A steady voice is not an indication of anxiety.

Nursing students are learning about different methods of charting in clinical. What method is the model for improving communication between and among clinicians?

CorrectA. SBAR B. CBE C. SOAP D. PIE

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

CorrectA. Systolic pressure 180 mm Hg B. Apical pulse 70 beats/minute C. Respirations 12 breaths/minute D. Oxygen saturation 95% on room air

The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

CorrectA. The client exhibits no signs or symptoms of infection B. The client changes position every 2 hours C. The client keeps the area clean and dry D. The client knows prevention measures for pressure ulcers Response Feedback: All options are appropriate outcomes for this client, but the most important outcome is that the client exhibits no signs or symptoms of infection.

As part of the general survey, the nurse should shake hands with the client when first meeting him or her as long as doing so in culturally appropriate. Why is this action so important?

CorrectA. The handshake portrays caring B. The handshake shows how professional the nurse is C. The handshake allows the nurse to get physically close to the client in a nonthreatening way D. The handshake allows the nurse to assess how nervous the client is

An Afghani woman is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

CorrectA. Assess if the client speaks and understands English B. Remember that Afghani women were not allowed an education in their home country C. Get a translator D. Speak only with the client's husband Response Feedback: The most important transcultural assessment to make with this client is whether she speaks and understands English. The nurse would need this information prior to asking for a translator, assuming the client was not allowed an education, or talking only with the husband.

A college football player has been hospitalized with a knee injury. When sending his diet orders to the hospital kitchen, the nurse knows what to include?

CorrectA. Extra servings of protein B. Extra servings of carbohydrates C. Extra servings of grains D. Extra servings of fats Response Feedback: Athletes may require additional protein for muscle building and maintenance. Hospitalized athletes do not generally require extra servings of carbohydrates, grains, or fats.

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

CorrectA. Seated in a chair at eye level with the client B. Sitting on the side of the bed, looking down at the client C. Leaning on the nightstand at eye level with the client D. Standing beside the bed, looking down at the client Response Feedback: To facilitate optimal eye contact, the nurse needs to be at eye level with the client. Those who stand while clients are in bed will be taller than clients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level with clients who are in bed during interviews. The other options listed do not promote therapeutic communication.

The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain?

CorrectA. Sleep patterns B. Family history C. Genetic history D. Elimination pattern Response Feedback: When assessing pain in older adults, the nurse should be sure to also review the effects of pain on diet, sleep, and mood. Unrelieved pain may lead to insomnia or depression and seriously affect the client's quality of life. It would not be necessary to assess the family history, genetic history, or elimination pattern to gain insight into the client's pain level.

A nurse conducting a comprehensive nutritional assessment is assisting the client in completing a 24-hour food recall. What does the research show regarding the client's ability to recall intake?

CorrectA. The client often underestimates high intakes B. The client often overestimates high intakes C. The client often underestimates liquid intake D. The client often overestimates liquid intake Response Feedback: In the 24-hour food recall, the client tends to overestimate low intakes and underestimate high intakes. To control this tendency, it is important for the nurse to use prompts such as "golf-ball size" or "the size of your fist or thumb."

The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?

CorrectA. To remember the elements that are important to assess with a symptom B. To remember the parts of a focused assessment C. To remember the order of the assessment D. To remember how to document assessment findings Response Feedback: Some providers use a mnemonic to remember the elements that are important to assess for the presenting symptom. OLDCARTS is one example and stands for onset, location, duration, character, associated/aggravating factors, relieving factors, timing, and severity. OLDCARTS does not help a nurse remember the parts of a focused assessment, order of assessment, or how to document findings.