Nursing Health Assessment: chapter 1-13 exam

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

:A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care?

Validation of data

A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?

hypothyroidism

A nurse recognizes the need to assess a client's spirituality after the client has been admitted from the emergency department to the medical unit. How should the nurse best initiate this assessment?

"Would you describe yourself as being a religious or spiritual type of person?"

A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse?

"A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions"

An emergency department nurse is assessing a client's complaint of upper abdominal pain. To assess the character of the pain, the nurse would begin with what assessment question?

"Can you describe to me how your pain feels?"

The nurse is concerned that a client is experiencing spiritual distress. Which client statement caused the nurse to have this concern?

"I want to just go home to die."

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'."

A client asks, "What does SPF 15 mean when considering a sunscreen?" What information should the nurse use to base the response to this client's question?

"SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

The nurse is performing an initial mental status examination on a client with depression. To obtain subjective data, what is the best question made by the nurse?

"Tell me how you are feeling right now?"

An older client is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this client?

"What is today's date?"

The nurse is preparing to assess a client's remote memory. Which question would be most appropriate for the nurse to use?

"When did you get your first job?"

A 90-year-old client is crying and states to the nurse, "I've had such a wasted life." The most appropriate response from the nurse will be

"You are feeling like you have had a wasted life...?"

Which questions asked by the nurse demonstrate an understanding of the various coexisting conditions that contribute to the mental status of a client? Select all that apply

-"Are you using any substances to help manage your panic attacks?" -"Could your anxiety be a result of the verbal abuse you are experiencing?" -"Would you say that your diabetes has contributed to making you depressed?" -"You seem very angry today; are you particularly anxious about something?"

;A client will require an extended period of intense physical therapy after having a compound fracture of the femur surgically repaired. What question should the nurse ask when assessing the client's perception of the injury and recovery plan? (Select all that apply.)

-"How does experiencing such a trauma make you feel?" -"How do you plan to support yourself financially while you recover?" -"What frustrations are you experiencing since your accident?" -"What do you expect from the physical therapy you will have?"

The Healthy People 2020 objectives where distributed during a staff meeting. Which objectives relate to the prevention of violence? Select all that apply.

-Bullying -Homicides -Firearm injuries -Fatal and nonfatal assaults

Which clients are most at risk for depressive symptoms? (Select all that apply.)

-Divorced clients -Females -Chronically ill clients

Examples of subjective data the nurse would collect on a community include which of the following? (Select all that apply.)

-Expressed concern about insufficient number of long-term beds -Expressed concern about lack of a school nurse -Expressed concern that no one is available to care for injuries or illnesses during school hours

A nursing assessment of a client with dementia is most likely to reveal what findings? (Select all that apply.)

-Global impairment of intellect -Attention preserved -Thoughts impoverished

Which of the following findings from a nutritional history most likely indicate the client is showing signs of an eating disorder? (Select all that apply.)

-Has body mass index of 16 -Discusses feeling fat in clothes

The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. (Select all that apply.)

-Impending death -Family conferences -A client expressing a cultural concern

What are some basic rules for nurses to follow when assessing for violence? Select all that apply.

-Perform assessment and screening only when the client is alone in a safe, private environment -Be very patient when the client talks -Demonstrate compassion, not judgment

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?

"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

The nurse is assessing a middle-aged female client who is new to the clinic. The nurse observes the presence of significant facial hair that is uncharacteristic of the client's ethnicity. What assessment question should the nurse ask?

"Do you take steroid medications on a regular basis?"

The nurse begins an assessment of a client's religion and spirituality. Which statement indicates that the client is spiritual?

"I am at peace when I spend time out of doors."

What are the primary frameworks used in conducting a health assessment? Select all that apply.

-Head to toe -Body systems -Functional systems

Which of the following are stages in Jean Piaget's model of cognitive development? Select all that apply.

-Sensorimotor -Preoperational -Concrete operational -Formal operations

While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?

3 circles and 3 squares with lines through 2 circles

Which of the following assessment findings suggests a problem with the client's cranial nerves?

A client's extraocular movements are asymmetrical and she complains of diplopia.

Recommended protective measures to avoid skin cancer include which of the following?

Avoiding sun exposure

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?

C7

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

A nurse, conducting a functional assessment on an adult client, assesses overall psychosocial well-being by assessing what?

Coping/stress tolerance

The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate?

Explaining the purpose of the interview

When preparing to examine a client's skin, which of the following would be most important for the nurse to do?

Expose only the body part that is being examined

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?

Hyperresonant

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?

Mask-like expression

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?

Previous injuries to the head and neck

In language development, what is the individual's use of spoken or written words referred to as?

Productive language

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?

Recognize the need to reevaluate the client's plan of care.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this client's vision?

Snellen E

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

The nurse has begun a client's assessment and is applying the blood pressure cuff on a client's arm. Which action would be most appropriate?

The cuff is placed about 1 inch above the antecubital area.

A nurse performs the Snellen test on a client and obtains these results: OD 20/40, OS 20/30. What conclusion can the nurse make in regards to the client's vision based on these results?

The larger the bottom number, the worse the visual acuity.

A nurse is assessing an 82-year-old client in terms of his psychosocial development, following Piaget's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client?

The need for assistance in correctly taking daily medication

What is the primary purpose of the health history in relation to the eyes?

To identify changes

The functional reflex that allows the eyes to focus on near objects is termed

accommodation.

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and the lens.

The nurse notes that the pupil of a client's left eye constricts when a light is shined into the right eye. How should the nurse document this finding?

consensual light response present in left eye

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

corneal damage.

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

document the findings in the client's records

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

esotropia.

;While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules

While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a

papule

Q;A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's

vesicles.

Active processing of information while it is held in short-term memory is referred to as?

Working memory

;While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by usinG

percussion

The nurse desires data about a community's religious beliefs and values. Where should the nurse seek this information? Select all that apply.

-Surveys -Personal interviews -Community directory -Chamber of Commerce

The client is having a thyroid crisis. What symptoms would the nurse assess for? Select all that apply.

-Tachypnea -Nausea -Anxiety

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. Which of the following should the nurse mention to the client as potential risk factors?

-Ultraviolet light exposure. -Obesity.

The nurse learns that a client routinely engages in spiritual practices. Which activities should the nurse document as being spiritual in nature? Select all that apply.

-Yoga -Prayer -Attending church

The nurse identifies which of the following as risk factors for spiritual distress? (Select all that apply.)

-negative life changes -natural disasters -chronic illnesses

When reviewing the causes of infant mortality in a community, the nurse knows that they include which of the following? (Select all that apply.)

-sudden infant death syndrome (SIDS) -congenital malformations -unintentional injuries -maternal complications of pregnancy

A nurse weighs a client today and finds that the client's weight has increased 2.2 lbs from the previous day. The nurse interprets this finding as suggesting a fluid gain of which amount?

1.0 liters

A client had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route?

102.4°F

A nurse should anticipate the normal respiratory rate of an elderly client to be how many breaths per minute?

18 breaths/min

;Which vision acuity reading indicates blindness?

20/200

A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

Which child would the nurse expect to learn approximately 22 new words per day?

6-year-old Annabelle

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

A left temporal hemianopsia

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

Which of the following principles would guide the nurse's assessment when caring for a client with suspected physical abuse?

Abuse may start at any time during a relationship.

The nurse prepares to update the care plan of a client recovering from abdominal surgery. Which diagnosis should the nurse select that most appropriately addresses the client's pain?

Acute pain related to abdominal wound

A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?

Alcoholism

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

Alopecia areata

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?

Arcus senilis

;A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

Arthritic changes of the cervical spine

Which technique by the nurse demonstrates proper use of the ophthalmoscope?

Asks the client to fix the gaze upon an object and look straight ahead

;When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and the woman's ability to follow directions. Which of the following would the nurse do first?

Assess the client's vision and hearing.

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation

A client is admitted with pneumonia to the pediatric ward. The child's mother has been staying at the bedside since his admission. When the mother leaves for a few hours to go home and change clothes, the toddler begins to scream and cry loudly. Every time a healthcare worker approaches, he begins to kick. This toddler is experiencing which stage of Erikson's?

Autonomy vs. shame and doubt

In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers?

Body language

Abnormal assessment findings are clearly outlined in which documentation format?

Charting by exception

A 6-year-old client asks the nurse to take him to the playroom located on the pediatric floor. Once there, the client immediately begins to play with the creative toys. Doing this and by using his imagination, the child is primarily developing which of the following?

Cognitive domain

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

Comprehensive.

The student nurse walks into her 8-year-old client's room and finds him looking at a collection of baseball cards. He has spread the cards out all over the bed and arranged them into different piles of teams and positions. This young client is showing signs of being in which of the following stages of Piaget?

Concrete operational

;A nurse is talking to an 8-year-old boy who is proud of himself for washing his hands before every meal this past week. The nurse recognizes that this client is eager to please the nurse and his own parents. The nurse realizes that this boy is most likely in which level of moral development, according to Kohlberg?

Conventional

A nurse is talking to an 8-year-old boy who is proud of himself for washing his hands before every meal this past week. The nurse recognizes that this client is eager to please the nurse and his own parents. The nurse realizes that this boy is most likely in which level of moral development, according to Kohlberg?

Conventional

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII

The nurse knows that she will be caring for a client from Southern Korea who has been visiting with a family member. The nurse obtains some information about the Korean culture so that she will be able to meet the clients needs. What is the nurse demonstrating?

Cultural knowledge

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations

A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client?

Defers to family members to answer questions directed to the client

An emergency department nurse has utilized the Confusion Assessment Method (CAM) in the assessment of a 79-year-old client with a new onset of urinary incontinence. This assessment tool will allow the nurse to confirm the presence of what health problem?

Delirium

A nurse is working with a 13-year-old boy who complains that he has begun to sweat a lot more than he used to. He asks the nurse where sweat comes from. The nurse knows that sweat glands are located in which layer of skin?

Dermis

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

;The nurse is working with a predominately Native American population in a clinic located in New Mexico. The nurse is developing a plan to meet the medical needs of the client population. Which program would benefit this population?

Diabetic screenings and education.

The nurse is preparing client teaching for an adult admitted to the hospital with bilateral pneumonia. What should the nurse know to include in this client teaching?

Dispose of tissues directly into trash cans

;A nurse is assessing a client for possible fluid overload. Which assessment finding is most consistent with this diagnosis?

Distended neck veins with head elevated at 45 degrees

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

A male Hispanic client describes the fact that he mixed hot and cold foods, causing them to lump together and "get stuck in his intestines," causing diarrhea and abdominal pain. The nurse would document this as which of the following?

Empacho

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

A client requests to be cared for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care?

Ethnocentrism

A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what?

Ethnocentrism

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for quality assurance purposes?

Evaluate nursing care provided

While giving client care, a practicing nurse relies on past experiences, uses automatic processing of information and efficient analysis, and is creative and flexible. The nurse is exhibiting which of the following aspects of intelligence?

Expertise

A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. What would the nurse consider when assessing the client's facial expression and eye contact?

Eye contact is strongly influenced by cultural norms.

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?

Eye-openers

;A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client?

Ghost sickness

A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?

Goniometer

What action on the part of a middle-aged client would best exemplify Erikson's concept of generativity?

Guiding and mentoring individuals who are younger

The client states, "I don't know why God as abandoned me; I am a good person." Which tool would be most appropriate for the nurse to administer?

HOPE

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold the Jaeger card 14 inches from the face and read with one eye at a time

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?

Hearing acuity

A nurse is working with a client who confides in the nurse that her boyfriend will not let her get a job and insists on controlling all of their money. He gives her only a small allowance each month to buy food and a few necessities. When the nurse offers information on how to seek help for economic abuse, the client just shakes her head and says, "It's no use. Nothing can be done." Which of the following nursing diagnoses would be most appropriate in this situation?

Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships

A nurse is studying U.S. Census Bureau trends, specifically the nature and size of households in the last 50 years. Which of the following is an example of such a change?

Household size has decreased.

The nurse notes that a client's capillary refill is 5 seconds. What should this finding indicate to the nurse?

Hypoxia

The nurse is deciding if an older client's moral behavior is normal or abnormal. What should the nurse consider before making this decision?

If the client is harming self or others

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

What does the nurse understand has a direct relationship to the health of the residents of the community?

Income

A client has a nursing diagnosis of impaired social interaction. What is a common characteristic of this diagnosis?

Insufficient quantity or quality of social exchange

A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what?

Internal quality improvement

A nurse is presenting a class to a local community about vision and eye health. As part of the presentation the nurse explains how visual perception occurs. Which of the following would the nurse include in the explanation?

Involves light rays striking the retina

A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting?

Isolation

A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?

It provides a chronologic source of client assessment data.

A nurse is caring for a terminally ill client. The client's family has requested that at the time of death, the client's arms not be crossed and any clothing or bandages with the client's blood be prepared for burial with the person. The nurse recognizes that this family follows the rituals of which religion?

Judaism

A client on hospice care tells his nurse that he is not afraid of death. He explains that this is because he believes he has lived a very good life and therefore his next life should be even better than this one, as all of his life actions will be carried into the next. The nurse recognizes this belief as which of the following?

Karma

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

Melasma generally resolves postpartum

;A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

A client's risk for pressure sore development according to the Braden Scale is as follows: Sensory perception: 4 Moisture: 4 Activity: 2 Mobility: 2 Nutrition: 1 Friction and Shear: 3 From this assessment, the nurse determines that the client's risk for pressure sore development is:

Mild risk

In Erik Erikson's stage of generativity vs. stagnation, the mature adult needs to be what?

Needed

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the healthcare provider immediately.

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

Nursing diagnosis

When performing an assessment of a client, the nurse observes that the client begins to cry when asked if she has a religious preference. What part of the care plan would the nurse document this assessment finding?

Objective data

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

Oral mucosa

;A client is concerned about chronic overeating leading to weight gain. What does this indicate according to Freud's theory?

Orally fixated

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

A client has a lesion as shown on the sacrum. For which health problem should the nurse expect this client to be assessed?

Osteomyelitis

The nurse documents data immediately after assessing the client. This is an example of:

Point-of-care documentation

The nurse is teaching parents of children, and states that children in this stage believe inanimate objects have life-like qualities. Which stage of Piaget's theory of cognitive development is the nurse describing?

Preoperational

:During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Presbyopia

the nurse recognizes that a child is most likely in Piaget's preoperational stage of development when observing which activity?

Pretend play

A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions?

Psoriasis, fungal infections, trauma

;The nurse is conducting a health history of a client at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the client?

SAD PERSONAS

When evaluating a community's education, what would the nurse use to identify the effectiveness of the community's school system?

Scores on standardized tests

A nurse is discussing memory with students. What type of memory would the nurse be explaining if he was talking about retrieval of facts, vocabulary, and general knowledge?

Semantic long-term memory

A nurse is assessing a 24-year-old client in terms of her psychosocial development, following Erikson's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client?

Sexual promiscuity

When the nurse asks the client for the reason for coming to the health clinic, the client responds by saying, "bad blood." The nurse recognizes that the client is most likely referring to which of the following?

Sexually transmitted infection

For which assessment would the nurse plan to use direct percussion?

Sinuses

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to the touch

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability?

Speak to the client clearly from a close distance.

Long-term care facilities in a community would be deemed adequate if which situation exists?

Sufficiently specialized care is available for local residents who cannot live independently.

A client explains that she has been feeling stress at work lately because her boss has been asking her to perform accounting measures that went against her conscience. According to Freud, which component of the personality is associated with the conscience?

Superego

An infant was removed from her home by social services because of the dangerous and neglectful conditions that existed. According to Erikson, failure of the infant to resolve the central crisis of infancy may lead to what personality characteristics later in life?

Suspicion and fear

In addition to providing privacy, which of the following would be most appropriate initially in situations involving suspected abuse?

Tell the client, "Injuries like these don't usually happen by accident."

The eudaimonistic model of health emphasizes:

The biopsychosocial and spiritual wellness of the person.

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time.

Suzie is a 16-year-old daughter in the Hanes family. She is the youngest of five children. She has had a series of illnesses and does not seem to be regaining her strength. She likes school but is falling behind a bit. Her mother is very attentive to her needs but does not seem overly concerned with the continuing pattern of illness. Which of the following is most likely a Hanes family belief?

The family values taking sick roles and caregiver roles.

;The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?

The notch on its superior edge

A nurse suspects abuse on a client with a fractured forearm, who does not want to discuss how the fracture happened. What is something the nurse could do to let the client know the client is not alone?

The nurse can educate the client about the high prevalence of human violence

The nurse is assessing the cognitive functioning of an older adult. Which action by the client demonstrates intact episodic long-term memory?

The older adult accurately describes the first date with his spouse of 50 years.

The nursing student asks the nurse what the purpose of the National Standards for Culturally and Linguistically Appropriate Services in Health Care is. What is the best response by the nurse?

The standards require the provision of health care that considers the specific cultural and language background of the client.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer?

There is a non-blanching reddened area on the client's coccyx region.

What is the primary function of the health care team?

To decide the best overall care

Which of the following statements is true regarding Piaget's concept of transductive thinking?

Transductive thinking can be used by formal operational thinkers.

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?

Trigeminal neuralgia

TRUE OR FALSE A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.

True

The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain?

Tuning fork

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

A nurse is interviewing a child who is suspected of being abused. What nursing action would be most appropriate?

Use direct, nonleading questions

;The nurse reviews Kohlberg's theory prior to preparing an in-service on moral development. Which phrase most accurately describes the last stage of this theory?

Willing to live for beliefs

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

Which nursing intervention does a client who is in the obtunded level of consciousness require most?

frequent reorientation

The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for

hyperthyroidism

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism.

A nurse has just learned that a community recreation league for youth has just been eliminated due to lack of funding. Which of the following results should the nurse suspect?

increased gang activity

A nurse has just completed a community assessment for a small rural town. Some data collected include the following: 11.8% unemployment, lack of medical care services, median income below the national average. Based on the limited data given, which of the following is the best nursing diagnosis?

ineffective community coping related to unemployment

The nurse measures the height and body weight of a female client with high muscle mass. The client weighs 175 pounds (79.4 kg) and is 68 inches (173 cm) tall. In which of these categories does the client's body mass index (BMI) fit best

normal

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

tension headaches.

True or False A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.

true

;While conducting a cultural assessment the nurse would like to include the client's spirituality. What needs to be established before this part of the assessment can be successfully completed?

trust

:The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology.