NURS 212 final exam

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse asks a client how he is feeling. The client states, I'm feeling a bit nervous today." Which of the following responses should the nurse make?

"Please explain what you mean by the word 'nervous.'"

A nurse is providing education to a male client about health promotion screenings. Which of the following information should the nurse include in

A digital rectal examination can detect enlargement of the prostate gland.

46. A 24-year-old client has a blood pressure of 95/70, and asks the nurse whether this blood pressure is okay. Below, identify all assessment findings that are consistent with adequate tissue perfusion. (Select all that apply.) A. Brisk capillary refill B. Extremities show symmetrical warmth and color C. Intact mental status without weakness D. Elevated heart rate E. Pallor or cyanosis

A. Brisk capillary refill B. Extremities show symmetrical warmth and color C. Intact mental status without weakness

55. What must the nurse do in response to the unexpected vital signs? (Select all that apply) A. Consider if the vitals are measured accurately. B. Assess the client for other relevant findings. C. Proceed to electrical cardioversion and warming protocols. D. Do nothing for now, but be sure to recheck in one hour.

A. Consider if the vitals are measured accurately B. Assess the client for other relevant findings

47. A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations she the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

Agitation

56. A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

Agitation

A nurse is inserting a urinary catheter for a female adolescent. Which of the following findings should the nurse report to the provider?

An area of tenderness on the labia majora

A nurse is providing a bed bath for an older adult client who is immobile. Which of the following findings should the nurse report to the provider?

An inability to retract the foreskin

41. From the options below, identify the proper order of listening to heart sounds. A. Erb's point, tricuspid, mitral, pulmonic, aortic B. Tricuspid, mitral, pulmonic, aortic, Erb's point C. Aortic, pulmonic, Erb's point, tricuspid, mitral D. Mitral, tricuspid, Erb's point, pulmonic, aortic

Aortic pulmonic erbs point tricuspid mitral

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands

8. During the assessment interview with a 26-year-old male client, he states "the world would be better off if I weren't around." Which of the following is the nurse's priority response? A. "Do you really think the world would be better off if you weren't around?" B. "Are you having thoughts about harming yourself?" C. "Tell me why you would say that." D. "Has something happened to make you feel this way?"

Are you having thoughts about harming yourself

45. A client who has major depressive disorder states to the nurse that he and his family would be better off if he we gone. Which of the following is the nurse's priority response? A. "Do you really think your family would be better off without you?" B. "Are you thinking of harming yourself?" C. "Tell me what is happening right now." D. "When did you first start feeling this way?"

Are you thinking of harming yourself

14. A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions nurse take to check cranial nerve XII? A. Ask the client to stick out their tongue and observe if it is midline. B. Observe for the ability of the client to turn their head side to side. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

Ask the client to stick out their tongue and observe if it is midline.

Wearing boots and hardhat.

BMI and oral temperature

Wearing leather vest and pants.

BMI and oral temperature

20. A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority? A. Blood pressure 92/50 mm Hg B. Heart rate 72/min C. Abdominal pain rated 4 on a scale of 0 to 10 D. Respiratory rate 20/min

Blood pressure 92/50mm Hg

38. A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid

During an initial interview, the examiner asks: "have you taken anything to try to help the pain?" This question is seeking information about which of the 8 critical variables (OLDCART)?

Clients perception of the problem

48. What must the nurse do in response to the unexpected vital signs? (Select all that apply)

Consider if the vitals are measured accurately Assess the client for other relevant findings

39. A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make? A. Right radial pulse 5/5, 80/min, palpated B. Left radial pulse 4+, 80/min, palpated C. Left radial pulse absent, 80/min, palpated

D. Right radial pulse 4+, 80/min, palpated

2. A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve lI? A. Testing extra ocular movements (EOMs) B. Observing for facial symmetry C. Eliciting the gag reflex D. Checking the pupillary response to light

D. checking the pupillary response to light

9. A nurse is caring for an infant who has been vomiting and had decreased oral intake. Which of the following is the most reliable indicator of fluid loss in this client? A. Decrease in body weight from last week B. Irritability and fussiness C. Low blood pressure D. Increased heart rate

Decrease in body weight from last week

46. A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client. B. Administer the medication. C. Determine the location of the pain. D. Review the effects of the pain medication.

Determine the location of the pain

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first

Determine the location of the pain

23. A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation? A. Different blood pressures in the upper limbs. B. Different apical and radial pulses. C. Differences between oral and axillary temperatures. D. Differences in upper and lower lung sounds.

Different apical and radial pulse

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer? (Select all that apply.)

Dilation of hair follicles Nipple retraction A small bulging module lateral to one breast

A nurse is performing a breast inspection on a client. Which of the following findings should the nurse report to the provider?

Dimpling

A nurse is completing the initial admission assessment and history for a client. Which of the following is the oriority action for the nurse to take:

Document the client's allergies in the elegonic medical record.

29. A nurse is measuring the radial pulse of a 19-year-old client. The pulse rate is 55/min, regular. Which of the following actions should the nurse take

Document this as an expected finding

A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance? (Select all that apply.)

During an interview about the client's health history When introducing themselves to the client While collecting the client's vital signs

secondary prevention

Early detection and treatment Eg: screenings and family counseling

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the followinz actions should the nurse take

Explain to the client what is about to hapagn.

A nurse is preparing to assess a client for the presence of a hernia. Which of the following areas should the nurse plan to inspect? (Select all that apply)

Femoral area Inguinal area

30. A nurse is conducting a focused interview of ear health. Which of the following questions should be included in this interview? (Select all that apply.) A. "Have you noticed any trouble with hearing?" B. "Have you noticed any problems with balance?" C. "Have you noticed any problems with your sense of smell?" D. "Do you use hearing protection when working with power tools?" E. "Have you noticed any hair loss?"

Have you noticed any trouble with hearing Have you noticed any problems with balance Do you use hearing protection when working with power tools

Consumed energy drinks and cigarettes at breakfast and lunch

Heart rate and blood pressure

27. During a health assessment interview, a client identifies smoking cigarettes. Below, identify the priority follow-up questions. (Select all that apply.) A. "How many packs of cigarettes do you smoke in a day?" B. "How many years have you smoked?" C. "Are you ready to consider quitting?" D. "You know those things will kill you, right?" E. "You don't smoke indoors, do you?" F. "It's a good thing you don't inhale."

How many packs of cigarettes do you smoke in a day How many years have you smoked Are you ready to consider quitting

A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment?

Inspect the pattern of hair distribution

44. During an admission assessment, a nurse has noted a stage I skin ulcer. Which of the following is characteristic of this skin condition? A. Intact skin, non-blanchable discoloration or bruising B. Erosion through the dermis, exposing fat C. Erosion through the muscle, exposing bone D. Erythema, induration, heat, with purulent drainage

Intact skin, non-blanchable discoloration or bruising

17. A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

Irregular

A nurse is inspecting the genitalia of an older adult female client. For which of the following findings should the nurse notify the provider?

Labial ulceration

40. A nurse assessing a client's back notes several skin lesions. Which of the following findings requires a more focused assessment? A. Lesion larger than a pencil eraser B. Lesion with uniform color C. Lesion that has not changed in shape or size over time D. Lesion with sharply defined borders

Lesion larger than a pencil eraser

The client says, "the cut is on the back of my head." Which of the 8 critical variables does this statement represent?

Location

A nurse is teaching a client about performing a breast self-examination at home. In which order should the nurse instruct the client to p the steps of breast self-examination? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Look at the breasts in front of a mirror with hands placed on hips Inspect the breasts for changes in shape, color, or contour. Inspect the nipples for a rash or drainage. Lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers. Palpate each breast from the outer edge, moving from top to bottom across the breast.

Temperature: 99.2 BP: 87/60, left arm Respirations: 18/minute, regular Pulse oximetry: 98%, room air Heart rate: 120/min, regular Click to highlight the assessment findings that are consistent with poor distal perfusion. Click again to deselect an item.

Low blood pressure Delayed capillary refill Weakness or pre-syncope

A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client? (Select all that apply.)

Lung sounds Bowel sounds Pedal pulses Mental status

A nurse is caring for a male client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause oninis condition?

Medication adverse effects

A nurse is teaching a group of female clients about breast self-awareness. Which of the following instructions should the nurse include?

Menstruating females should examine their breasts about 5 days after their menstrual cycle begins

5. A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins Which of the foliowing actions is the nurses priority?

Move any clients in the immediate vicinity

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?

Move any clients in the immediate vicinity

A nurse is completing a client's history and physical /examination. Which of the following information should the nurse consider subiective data?

Nausea

A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should be nurse inspect when performing a general survey of the client? (Select all that apply.)

Nutritional status Hygiene Posture

12. A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should th nurse take to check cranial nerve VIl? A. Check the client's visual acuity using a Snellen chart. B. Observe for facial symmetry while the client smiles. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

Observe for facial symmetry while the client smiles

13. A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI

Observe for the ability of the client to turn their head side to side

A nurse is ¡assessing a client's posterior and lateral chest. Which of the following actions should the nurse take?

Observe for the use of accessory muscles during inspiration.

4. A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? A. Observe for the presence of Kernig's sign. B. Perform a Romberg's test. C. Check the function of cranial nerve V. D. Inspect for the presence of clubbing.

Perform a Romberg test

A nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The nurse chooses to confront this client. which of the following approaches should the nurse use when using confrontation?

Point out inconsistencies in the client's behavior

21.A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bradycardia C. Hypotension D. Pale yellow urine

Poor skin turgor Hypotension

A nurse is preparing to assist the provider with an assessment of a female client's genitourinary system. Which of the following actions should the nurse plan to take

Position the client supine with the head of the bed elevated.

Tertiary prevention

Prevention and treatment of complications Eg: medications, surgical treatment and occupational therapy

A nurse is conducting a he diencreports coulo indictee. the presence of declining kidney function? Select all that apply.

Recent weight gain Shortness of breath Swelling in the ankles

A nurse is inspecting a client's rectal area and notes the presence of bulging red tissue that encompasses the entire anal opening. Which of the following should the nurse suspect?

Rectal prolapse

A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action? (Select all that apply.)

Regularity if the pulse Strength of the pulse

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the

Sitting straight up with arms relaxed and close to the body

A nurse is inspecting a client's axillae. Which of the following should the nurse identify as an expected finding?

Skin has a uniform consistency

21.A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 mm Hg

Skin tenting present

49. A nurse is measuring a client's pulse and notes a regular rhythm with a rate of 110 beats per minute. The nurse should identify this as which of the following unexpected findings? A. Tachycardia B. Bradycardia C. Atrial fibrillation D. Pulse deficit

Tachycardia

35. A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? A. The fourth heart sound (S4) B. A friction rub C. The third heart sound (S3) D. A split second heart sound $2

The third heart sound s3

34. A client has been diagnosed with thrush - a fungal infection of the mouth or throat. What findings should the nur expect during HEENT assessment? A. Thick white patches on the tongue that do not scrape off B. Red, erythematous gums and missing teeth C. Enlarged tonsils with exudate D. Post-nasal drainage and congested nasal airways

Thick white patches on the tongue that do not scrape off

13. The nurse is interviewing a client with limited English proficiency (LEP). Which of the following is an effective communication technique? A. Ask few questions and then proceed directly to the physical exam. B. Use simple yes/no questions, nodding often to set a good example. C. Use a telephone interpretive service. D. Use hand gestures and drawing for communication.

Use a telephone interpretative service

The nurse is interviewing a client with limited English proficiency (LEP). Which of the following is an effective communication technique?

Use a telephone interpretive service

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take

Use attentive listening with the client

A nurse is planning to complete a physical assessment on a client. Which of the following actions should the nurse plan to include?

Use quotation marks when documenting client statements.

23. When auscultating breath sounds, what is an appropriate term for softly coarse, blowing breaths sounds typically heard throughout most of the chest? A. Tracheal B. Vesicular C. Crackles D. Wheezes

Vesicular

33. While assessing the tonsils of an 8-year-old client, a nurse identifies enlarged tonsils, +4. What additional assessment finding can indicate potential obstruction of the upper airway? A. Voice changes or stridor B. Congested nasal passageways C. Sinus congestion and tenderness D. Poor dentition

Voice changes or stridor

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple?

a client's nipple has remained inverted since childhood

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

arterial insufficiency

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

assessment

A nurse is assessing a client's vital signs. While counting the number of respirations, which of the following information should the nurse collect?

characteristics of respirations

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client

conjunctivae

17.A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

rigid abdomen

A nurse is providing education to a young adult client about the human papillomavirus (HPV) vaccine. Which of the following information should the nurse include in the teaching?

• An HPV infection can lead to the development of cancer.

A nurse is measuring the radial pulse of a 19-year-old client. The pulse rate is 55/min, regular. Which of the following actions should the nurse take?

• Document this as an expected finding.

A nurse is preparing to assist with a prostate examination. Which of the following actions should the nurse plan to take

• Position the client standing, facing the examination table

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the client's past health history? (Select all that apply.)

"Have you ever had breast disease?" "Have you experienced breast "Do you perform breast self-examinations?"trauma" Have you had breast surgery?"?"

A nurse is collecting a health history from a client. Which of the following client statements requires further investigation?

"I have noticed that it burns when I urinate."

A nurse intercepts a messenger at the nurses station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?* Which of the following responses should the nurse provide?

"It's my responsibility to remind you that we have to respect our clients' privacy."

8. While conducting a HEENT assessment, a nurse shines a light into a client's pupils, noting a brisk reflexive constriction. In describing the meaning of this assessment to the client, which of the following is the correct statement by the nurse? A. "This tests the pupil muscles themselves, as well as the cranial nerves that control them." B. "This tests the retina and cornea, to ensure you have good visual acuity." C. "This tests for concussions and other major head injuries." D. "This tests for glaucoma, cataracts, and other chronic eye disorders."

"This tests the pupil muscles themselves, as well as the cranial nerves that control them."

32. A nurse is assessing a client for pitting edema and notes a minimal indentation of 2 mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? A. 4+ B. 3+ C. 2+ D. 1+

1+

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow.

1. inspection 2. auscultation 3. superficial palpation 4. deep palpation

1. A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings B. behavioral indicators and effect C. scheduled treatments and client illness D. a self-report pain rating scale

A self reported pain rating scale

34. While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? A. A systolic murmur B. A third heart sound (S3) C. An expected heart sound D. A fourth heart sound (S4)

A systolic murmur

8. A nurse is having trouble obtaining a reliable pulse oximetry measurement. Which of the following can potentially interfere with a pulse oximetry reading? (Select all that apply.) A. Dark skin or dark nailbeds B. Excessive movement C. Cold extremities D. High heart rate E. High blood pressure

A. Dark skin or dark nailbeds B. Excessive movement C. Cold extremities

6. A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III? A. Instruct the client to look up and down without moving his head. B. Observe the client's ability to smile and frown. C. Have the client stand with eyes his closed and touch his nose. D. Ask the client to shrug his shoulders against passive resistance.

A. Instruct the client to look up and down without moving his head.

43. Which of the following skin findings require further assessment by the nurse? (Select all that apply.) A. Yellow discoloration of the palms B. Pale nail beds C. Pinpoint purple spots on the abdomen D. Acne on the face and back E. Wrinkled skin around the eyes

A. Yellow discoloration of the palms B. Pale nail beds C. Pinpoint purple spots on the abdomen

47.A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? A. Wait 30 min and return to measure the oral temperature B. Provide the client a sip of warm water, wait 5 min, and measure the temperature. C. Document that the nurse was unable to measure the client's temperature. D. Proceed to measure temperature by feeling the client's forehead and guessing.

A. wait 30 minutes and return to measure the oral temperature

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health? (Select all that apply).

Ask the client to describe the process for breast self-examination at the end of the teaching. Document instructions provided in the client's medical record. Review recommendations for mammography based on risk with the client.

10. A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve lI? A. Ask the client to read a Snellen chart. B. Listen to the client's speech. C. Ask the client to identify scented aromas. D. Ask the client to clench his teeth.

Ask the client to read a snellen chart

24. A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? A. Assess the apical pulse for a full minute. B. Assess the apical pulse with a Doppler device. C. Assess the pedal pulses for a full minute. D. Assess the pedal pulses with a Doppler device.

Assess the apical pulse for a full minute

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A client has come to the clinic for evaluation of fever and sore throat. During the interview they state "Yesterday I also got sick to my stomach and broke out in a sweat." This represents what type of information?

Associated factors

9. A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerve IX and X. Which of the following assessment findings should the nurse expect? A. Asymmetrical rise of the uvula and tongue weakness. B. Asymmetrical extra ocular movements (EOMS). C. Weakness of the masseter muscle and asymmetrical facial sensation. D. Weakness in head turning or shoulder shrugs.

Asymmetrical rise of the uvula and tongue weakness

A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take?

Auscultate bowel sounds prior to palpating

Anxious about his daughter's volleyball game.

Blood pressure and heart rate

51.A nurse is interviewing an older adult who is being admitted to an assistive living facility, and conducting a gene survey of the client's emotional state. What is a subjective unexpected finding? A. Client reports he feels sad and lonely most of the time B. Client reports anxiety at a new living situation C. Client appears restless and anxious D. Client's heart rate is measured at 105 beats per minute

Client reports he feels sad and lonely most of the time

16. A client involved in a car accident has sustained a serious injury to their left forearm. They are noted to be sweating profusely, holding and protecting the left forearm (guarding). Heart rate is 125 min, and bicod pressure is 160/90. They are moaning and crying. During a pain assessment, they describe the pain as 5 on a 0-10 scale Which of the following is the most reliable indicator of the intensity of the client's pain? A. Client's reported pain rafing of 5 on a 0-10 scale B. Profuse sweating, crying and guarding of the injured limo C. Elevated heart rate and blood pressure

Clients reported pain rating of 5 on a 0-10 scale

12. A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? A. Restlessness B. Retractions C. Dependent edema D. Clubbing of the fingers

Clubbing of the fingers

37.A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN antihypertensive medication. C. Increase the client's fluid intake. D. Hold the client's evening dose of digoxin.

Complete a neurological check

20. A nurse is caring for a client who has hypovolemic shock and associated poor distal tissue perfusion. Which of 1 following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Confusion or other mental status change D. Bradypnea

Confusion or other mental status change

30. A nurse is caring for a client who has hypovolemic shock and associated poor distal tissue perfusion. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Confusion or other mental status change D. Bradypnea

Confusion or other mental status change

6. A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? A. Pinnae of the ears B. Dorsal surface of the hand C. Conjunctivae D. Dorsal surface of the foot

Conjunctivae

Temperature: 90.6 F, oral BP: 118/80, left arm Respirations: 22/minute, regular Pulse oximetry: 100% on room air Heart rate: 265/minute, regular What must the nurse do in response to the unexpected vital signs? (Select all that apply)

Consider if the vitals are measured correctly Proceed to electrical cardiovascular and warming protocols

A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider?

Distended veins in one breast

18. A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following act should the nurse take? A. Ask another nurse to verify the heart rate. B. Document this as an expected finding. C. Call the provider to further assess the newborn. D. Prepare the newborn for transport to the NICU.

Document this as an expected finding

25. A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take

Document this as an expected finding

54. A nurse is measuring the radial pulse of a 19-year-old client. The pulse rate is 56/min, regular. Which of the following actions should the nurse take? A. Verify the heart rate with an ECG B. Document this as an expected finding C. Call the provider to assess the client D. Document vital sign as unobtainable

Document this as an expected finding

39. A nurse is observing a newly licensed nurse who is performing a focused skin assessment on a client who reports a skin condition. Which of the following questions by the newly licensed nurse requires intervention? A. "Does vour skin condition keep you awake at night?" B. "Have you had any changes in your diet?" C. "That rash is pretty rough-looking. Is it always like that?" D. "How does your skin condition make you feel?"

Does your skin condition keep you awake at night

15. A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.) A. Dyspnea B. Bradycardia C. Barrel chest D. Clubbing of the fingers E. Deep respirations

Dyspnea Barrel chest Clubbing of the fingers

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.)

Education Gender Perception

3. A nurse is admitting an older adult client who has a suspected head injury. Which of the following scales shou used as part of the neurological assessment? A. Glasgow Coma Scale (GCS) B. Brief Patient Health Questionnaire (Brief PHQ) C. Abnormal Involuntary Movements Scale (AIMS) D. Scale for Assessment of Negative Symptoms (SANS)

Glasgow coma scale

A nurse is caring for a male client who reports the presence of yellow discharge from the meatus and burning with urination. Which of the followinz infections should the nurse suspect?

Gonorrhea

A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be an appropriate response by the nurse to the woman's statement?

How would you say the pain affects your ability to do your daily activities?

37.A nurse is caring for a client who has urinary incontinence. In what way does this increase the client's risk for skin breakdown, or interruption in skin integrity? A. Incontinence can leave skin wet for long periods of time, leading to breakdown B. Incontinence can lead to dehydration and delayed skin turgor C. Urinary incontinence can lead to urinary track infections D. Request a prescription for the insertion of an indwelling urinary catheter.

Incontinence can leave skin wet for long periods of time, leading to breakdown

22. A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

Increased anteroposterior diameter of the chest

11.A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased heart rate B. Increased lower extremity edema C. Increased respiratory rate D. Crackles, or wet congested breath sounds E. Increased temperature

Increased lower extremity edema Increased respiratory rate Crackles or wet congested breath sounds

19. A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm? A. A bounding distal pulse B. Acute pain C. Ecchymosis of the surrounding skin D. Increasing edema

Increasing edema

27.A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm? A. A bounding distal pulse B. Acute pain C. Ecchymosis of the surrounding skin D. Increasing edema

Increasing edema

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse can see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the client's lymph node enlargement?

Infection

14. A nurse is conducting a HEENT assessment. As part of this assessment, the nurse gently tugs at the tragus, noting any indications of pain or tenderness. This assessment can indicate which of the following? A. Inflammation or infection in the outer ear canal B. Inflammation or infection behind the tympanic membrane C. Inflammation or infection of the inner lining of the eyelids D. Serious deep tissue infection of the ear and surrounding bony structures

Inflammation or infection in the outer ear canal

10. A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. "Information about a client can be disclosed to family members at any time." B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." C. "A client's address would be an example of personally identifiable information." D. "HIPAA is a federal law, not a state law."

Information about a client can be disclosed to family members at any time."

19. A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

A nurse is caring for an older adult client who has an enlarged prostate and reports difficulty voiding. Which of the following actions should the nurse take? (Select all that apply.)

Inspect the client's suprapubic area for distention. Notify the provider if the bladder scan residual volume is greater than 100 mL. Ask the client if they are experiencing pain or a burning sensation when voiding.

A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take? (Select all that apply)

Inspect the condition of each fingernail Compare the amplitude of the radial pulses bilaterally Palpate the shoulder elbow and finger joints

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? (Select all that apply)

Instruct the client to swallow. Apply downward pressure and ask the client to shrug their shoulders. Request the client move their head forward and backward and then side to side.

26. A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's distal perfusion, or neurovascular status of the affected leg? A. Measure the circumference of the thigh. B. Palpate the femoral pulse. C. Monitor the client's calf for edema. D. Instruct the client to wiggle his toes.

Instruct the client to wiggle his toes

7. An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Tonic clonic movements of the arms and legs. B. Tremors of the hands and feet C. Inward and upward flexion of the hands and arms. D. Downward and outward flexion of the hands and arms.

Inward and upward flexion of the hands and arms

28. A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? A. Slow B. Not palpable C. Irregular D. Bounding

Irregular

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles

Justice

41. While assessing a client with darker skin, where should the nurse inspect for pallor? A. Mucous membranes B. Back of the neck C. Palms of the hands D. Bilateral ears

Mucous membranes

42. A nurse is interviewing a client who is experiencing intense epigastric abdominal pain. From the list below, identity the priority symptoms that should be asked about during a review of systems for this client. (Select all that apply.) A. Nausea B. Vomiting C. Diarrhea D. Coughing E. Rashes

Nausea Vomiting Diarrhea

35. During an assessment interview, a client tells the nurse that she is experiencing difficulty swallowing. In addition to a detailed HEENT exam, what other system assessment should the nurse anticipate performing? A. Neurological B. Cardiovascular C. Skin D. Abdominal

Neurological

44. During an assessment interview, a client tells the nurse that she is experiencing difficulty swallowing. In addition to a detailed HEENT exam, what other system assessment should the nurse anticipate performing?

Neurological

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?

Nonmaleficence

50. A nurse is caring for a middle-aged adult with painful sores in their mouth. The client cannot tolerate an oral thermometer probe. What is an appropriate alternative technique to measure a core body temperature? A. Obtain a rectal temperature B. Measure an axillary temperature and add 2 degrees Fahrenheit (1 degree Celsius) C. Apply pain medication to the mouth and take an oral temperature D. Insert a specialized urinary catheter to measure the temperature of the bladder

Obtain a rectal temperature

A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent

Offering false reassurance

A nurse is performing an assessment on a client who reports ear pain. Which of the following actions should the nurse take?

Palpate the mastoid area for pain

36. A nurse in a clinic is caring for an older adult client who reports thirst, a dry mouth, and flaky skin on her upper back. Which of the following is the appropriate next step? A. Document dry, flaky skin as an expected finding. B. Perform examination of the back before the general inspection of the skin. C. Pinch up a fold of skin to check for turgor. D. Use a penlight to examine the back in greater detail.

Pinch up a fold of skin to check for turgor

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Places the client's arm above the level of the client's heart

45. A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? A. Wraps the blood pressure cuff snugly around the client's arm B. Places the client's arm above the level of the client's head. C. Checks the instrument gauge to ensure the reading starts at zero D. Centers the cuff bladder over the client's brachial artery

Places the clients arm above the level of the clients head

7.A nurse asks a client how he is feeling, The client states, "I'm fooling a bit nervous today." Which of the following responses should the nurse make? A. "Please explain what you mean by the word 'nervous." B, "They're serving Jello in the cafeteria." C, "Would a backrub ease your nervousness?" D. "You shouldn't feel nervous."

Please explain what you mean by the word 'nervous."

26. A nurse is assessing breath sounds on a client who has been diagnosed with pleuritis. Breath sounds demonstrate a coarse grating tone on inspiration and expiration. What is the most likely term for this unexpected assessment finding?

Pleural friction rub

16. A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? A. After palpating the abdomen B. Prior to percussing the abdomen C. After assessing for kidney tenderness D. Prior to inspecting the abdomen

Prior to percussing the abdomen

52. A client is being discharged after a brief hospitalization for uncontrolled hypertension. The nurse is teaching a caregiver how to measure blood pressures at home. Teaching should include which of the following that can influence reliability of blood pressure measurement? (Select all that apply.) A. Proper cuff sizing B. Excessive movement during measurement C. Which finger the blood pressure is measured on D. Client's heart rate

Proper cuff sizing Excessive movement during measurement

Primary prevention

Protection from a disease while still in a healthy state Eg: weight loss, exercise, smoking cessation, flu shot

31. As part of a HEENT assessment, a nurse documents "PERRL." What does this common abbreviation indicate? A. Pupils are symmetrical in size and shape, and react briskly to light B. Ears are symmetrical, auricle-shaped, with patent ear canals C. Maxillary and frontal sinuses are nontender D. Nasal airways are patent bilaterally

Pupils are symmetrical in size and shape and react briskly to light

A nurse is performine a breast examination on a client and notices that the client's right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition?

Recent surgery on the right side

Temperature: 103.2 F, oral BP: 118/80, left arm Respirations: 22/minute, regular Pulse oximetry: 92% on room air Heart rate: 110/ minute, regular Click to highlight the documentation that is an unexpected finding and may require further action by the nurse. To deselect a finding, click on it again.

Respirations Pulse oximetry Heart rate Temperature

25. When auscultating breath sounds, a nurse encounters low-pitched gurgles caused by air passing through sputum in the lower respiratory track. What is an appropriate term for these unexpected breath sounds?

Rhonchi

3. During auscultation, a nurse encounters a high-pitched tone, barking or whistling in nature, caused by narrowing the trachea or upper airway. What is the appropriate term for this unexpected finding?

Rhonchi

33. A nurse is teaching a newly licensed nurse about heart sounds. Which of the following sounds is heard when the aortic and pulmonic valves close

S2

A nurse is performing a breast inspection during a client's routine physical examination. Which of the following findings should the nurse report

Scaley skin at the border of one areola

29. A nurse is assessing a client with dark skin and has jaundice. Which of the following areas is the most reliable for the nurse to inspect the client for jaundice? A. Outer elbows B. Sclera C. Palms of the hands D. Back of the neck

Sclera

38. A nurse is assessing a client who has a new skin lesion that has a wavy, S-shaped border. The nurse should document the lesion using which of the following descriptions? A. Annular B. Serpiginous C. Circinate D. Coalesced

Serpiginous

4. The client says, "this only happens when I get too little sleep." Which of the 8 critical variables does this statement represent

Setting

The client says, this only happens if I get too little sleep." Which of the 8 critical variables does this statement represent?

Setting

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

Sharing computer passwords with coworkers

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated

Skin tenting present

A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather? (Select all that apply)

Stethoscope Sphygmomanometer Penlight

57. During auscultation, a nurse encounters a high-pitched tone, barking or whistling in nature, caused by narrowing o the trachea or upper airway. What is the appropriate term for this unexpected finding?

Stridor

5. A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score? A. The client needs total nursing care B. The client is alert and oriented. C. The client is disoriented to time but not place D. Indicates stable neurologic status

The client needs total nursing care

32. While conducting a HEENT assessment, a nurse shines a light into a client's pupils, noting a brisk reflexive constriction. In describing the meaning of this assessment to the client, which of the following is the correct statement by the nurse? A. "This tests the pupil muscles themselves, as well as the cranial nerves that control them." B. "This tests the retina and cornea, to ensure you have good visual acuity." C. "This tests for concussions and other major head injuries."

This tests the pupil muscles themselves as well as the cranial nerves that control them

42. During the assessment of an older adult, a nurse notices smooth, velvety skin. This can be indicative of which health concern? A. Thyroid disorders B. Skin cancers C. Vitamin D deficiency D. Anemia or hemorrhage

Thyroid disorders

28.A nurse encounters a client who is breathing fast, using accessory muscles, and pursed-lip breathing. He is leaning forward, bracing his hands on knees. What is the term for this body position? A. Respiratory distress B. Tripod position C. Semi-Fowlers position

Tripod position

A nurse is preparing to assess a client's genitalia. Which of the following actions should the nurse plan to take

Use a firm, deliberate touch when palpating.

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact

31. A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following assessment findings are consistent with fluid overload? A. Poor skin turgor and tenting B. Wheezing breath sounds in all fields C. Velcro-like popping or crackling breath sounds D. Severe thirst and increased urination

Velcro like popping or crackling breath sounds

is inspecting the genitals of an adult male client. Which of the following should the nurse identify as exoected findines? (Select all that apply.)

Visible dorsal vein on the underside of the penile shaft Absence of pubic hair on the penile shaft Testes that are easily movable during palpation

24. When auscultating breath sounds, a nurse encounters a high-pitched tone heard mostly on expiration that is caused by narrowed lower respiratory track airways. What is the appropriate term for this unexpected finding? A. Wheeze B. Stridor C. Crackles D. Pleural friction rub

Wheeze

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following

When asking if the client took his medications this morning

A nurse is providine education to a female client who has expressed a desire to use a natural method of contraception. Which of the following methods should the nurse recommend? (Select all that apply.)

Withdrawal Fertility tracking with periodic abstinence

You are constructing a health history genogram with a client. When discussing their mother's family, the client says "but mom was adopted and doesn't know her birth family." You know that:

environmental health influences are still relevant here and the adopted family health history should be included.

11.A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? A. Check the client's visual acuity using a Snellen chart. B. Observe for facial symmetry while the client smiles. C. Have the client identify specific smells. D. Whisper in one of the client's ears while occluding the other.

have the client identify specific smells

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

increased heart rate

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

self-report of pain

A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?

the family's religious practices

A nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"A 55-year-old client should receive mammography screenings at least every 2 years."

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

"Are you thinking of harming yourself?"

A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client?

"Can you tell me what month it is?"

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team."

A nurse is providing teaching about the prevention of sexually transmitted infections (STIs) to a 19-year-old client who is sexually active and reports having multiple partners. Which of the following client responses demonstrates an understanding of the teaching?

"I should plan on getting tested each year for sexually transmitted infections.

A nurse is reviewing breast self-examination techniques with a client. Which of the following client statements indicates an understanding of the techniques

"I will use circular motions to feel the texture of my breast tissue."