Prep U- Assessment
A patient comes to the clinic at 8 a.m. for a scheduled visit. The nurse obtains the patient's temperature orally. Which finding would the nurse interpret as a potential indicator of a problem? 97.2 degrees F 98.0 degrees F 98.4 degrees F 99.6 degrees F TAKE ANOTHER QUIZ
99.6 degrees F Explanation: A diurnal variation of 1 or 2 degrees in body temperature is normal throughout the day. Temperature is usually lowest in the morning and increases during the day to between 99 to 99.5 degrees F and then decreases during the night. Therefore, an early morning temperature of 99.6 degrees would suggest a potential problem, because this temperature would then increase as the day goes on. Early morning temperatures of 97.2 degrees, 98.0 degrees, and 98.4 degrees would not be a cause for concern.
A client who's a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. Cervical examination is likely to reveal the client is 2 cm dilated; 100% effaced at 0 station. 4 to 5 cm dilated; 80% effaced at -1 station. 2 cm dilated; 50% effaced at +1 station. 3 cm dilated; 50% effaced at 0 station. TAKE ANOTHER QUIZ
Correct response: 2 cm dilated; 100% effaced at 0 station. Explanation: Because the client is a gravida, cervical examination is likely to reveal that she's 2 cm dilated, 100% effaced, and at 0 station. Multigravidas efface and dilate at the same time, whereas primigravidas will efface and then dilate.
The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason? The number of family members that have a certain health problem will help the nurse know if the child will have the same problem. Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. The nurse needs to know everything about a family to take care of the child. By establishing family behavior, the nurse forces the parents to alter their care of their child and make them healthier. TAKE ANOTHER QUIZ
Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. Explanation: Collection a complete family health history helps the nurse learn if there certain behaviors or risk factors for the family and, hopefully, educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.
Early labor
Onset of rhythmic contraction and relaxation of the uterine muscle occurs; contractions become more frequent, closer together, and stronger over time. Contractions start in the back and move toward the front. Contractions are generalized. They usually begin in the low back and wrap around to the front of the uterus. Contractions come regularly, usually 4 to 6 minutes apart, and become closer together, typically lasting 30 to 70 seconds. Contractions become stronger with time; the patient may also feel vaginal or rectal pressure. Progressive dilation occurs. Contractions continue no matter what position the patient assumes; activity, such as walking, may intensify the contractions.
When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?
Palpation Explanation: Physical assessment skills of the nurse include auscultation, percussion, inspection, and palpation. Palpation is the use of touch to assess a client. It would be appropriate for assessing the firmness of the client's abdomen. None of the other assessment skills would allow the nurse to assess the firmness of the client's abdomen. Inspection is the use of visual observation to assess a client. Percussion is the use of striking with the fingers against the client's body to assess a client. Auscultation is the use of a stethoscope to assess body sounds within the client, such as heart and lung sounds.
A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? Hypoactive bowel sounds Severe lower back pain Sensory deficits in one arm Weakness and atrophy of the arm muscles TAKE ANOTHER QUIZ
Severe lower back pain Explanation: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.
False labor
Spontaneous tightening (contractions) in the abdomen occurs that comes and goes; contractions don't get closer together and they have an irregular rhythm. The patient can feel contractions only in the front of the abdomen. Contractions are localized, usually in the front of the abdomen. The patient can usually point to the contraction's location. Contractions are typically irregular. They don't become more frequent or last longer; no pattern is evident. Contractions are usually weak and don't get stronger with time. They can alternate (a strong contraction followed by weaker contractions). Cervical dilation doesn't progress. Contraction may stop or slow down with activity, position change, or hydration.
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? White blood cell (WBC) count of 9,000 cells/mm3 Stage 3 pressure ulcer on the left heel Temperature of 98.3° F (36.8° C) Ate 75% of all meals during the day TAKE ANOTHER QUIZ
Stage 3 pressure ulcer on the left heel Explanation: A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. The WBC count and temperature are within normal limits. Eating 75% of meals is normal and doesn't increase the client's risk for infection. A client who is malnourished is at a greater risk for infection.
Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse? BMI 24; "My family never gives me my favorite foods." Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." Diabetic with fasting blood sugar 92; "It is difficult to afford food with all of these medication costs." Obvious deformity to right arm; "I tripped on the rug and fell on my arm." TAKE ANOTHER QUIZ
Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." Explanation: Neglect is the most common form of elder abuse. The inability of an older adult to obtain basic care is considered neglect. If a client is not being turned or repositioned to prevent skin breakdown, then neglect is happening. A BMI of 24 is within the normal range, and the inability of the client to have his or her favorite foods would not be abuse. The client with diabetes has blood sugar within normal ranges, and the client is only expressing concern over the cost of medications; social services may need to be notified to provide help through community resources. The story provided by the older adult with the deformed arm is consistent with the injury.
A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? Give the feedings at room temperature. Stop the feedings and check for residual volume. Place the client in semi-Fowler's position while feeding. Change the feeding container daily. TAKE ANOTHER QUIZ
Stop the feedings and check for residual volume. Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?
The Hemovac drain isn't compressed; instead it's fully expanded. Explanation: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client?
"When was your last bowel movement?" Explanation: Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.
A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.
36 Explanation: The anterior and posterior portion of one leg is 18%. If both legs are burned, the total is 36%.
The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? An absence seizure A myoclonic seizure A partial seizure A tonic-clonic seizure TAKE ANOTHER QUIZ
An absence seizure Explanation: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?
Assess the client's level of pain and administer prescribed analgesics. Explanation: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and family members should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.
The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea? By collecting the client's urine output By observing the client's diet during the day By measuring the client's abdominal girth By questioning how many pillows the client normally uses for sleep TAKE ANOTHER QUIZ
By questioning how many pillows the client normally uses for sleep Explanation: The nurse should ask the client about nocturnal dyspnea by questioning how many pillows the client normally uses for sleep. This is because being awakened by breathlessness may prompt the client to use several pillows in bed. Collecting the client's urine output, observing the client's diet, or measuring the client's abdominal girth does not help assess for nocturnal dyspnea.
A nurse is caring for a client in the cardiovascular intensive care unit following a coronary artery bypass graft. Which clinical finding requires immediate intervention by the nurse? Central venous pressure reading of 1 Pain score 5/10 Blood pressure 110/68 mm Hg Heart rate 66 bpm TAKE ANOTHER QUIZ
Central venous pressure reading of 1 Explanation: The central venous pressure (CVP) reading of 1 is low (2-6 mm Hg) and indicates reduced right ventricular preload, commonly caused by hypovolemia. Hypovolemia is the most common cause of decreased cardiac output after cardiac surgery. Replacement fluids such as colloids, packed red blood cells, or crystalloid solutions may be prescribed. The other findings require follow-up by the nurse; however, addressing the CVP reading is the nurse's priority.
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?
Cheeseburger, french fries, coleslaw, and ice cream Explanation: Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "I'm so glad that I will be unconscious during the surgery." "I won't feel it, but I'll have a tube to help me breathe." "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions."
Correct response: "I'll be sleepy but able to respond to your questions." Explanation: With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.
Which finding is an early indicator of bladder cancer?
Correct response: painless hematuria Explanation: Initially, as cancer cells destroy normal bladder tissue, bleeding occurs and causes painless hematuria. (Pain is a late symptom of bladder cancer.) Occasional polyuria may occur with diabetes mellitus or increased alcohol or caffeine intake. Nocturia commonly accompanies benign prostatic hypertrophy. Dysuria may indicate a urinary tract infection.
A client with lung cancer develops pleural effusion. During chest auscultation, which breath sound should the nurse expect to hear? Crackles Rhonchi Decreased breath sounds Wheezes
Decreased breath sounds Explanation: In pleural effusion, fluid accumulates in the pleural space, impairing transmission of normal breath sounds. Because of the acoustic mismatch, breath sounds are diminished. Crackles commonly accompany atelectasis, interstitial fibrosis, and left-sided heart failure. Rhonchi suggest secretions in the large airways. Wheezes result from narrowed airways, such as in asthma, chronic obstructive pulmonary disease, and bronchitis.
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure? Dehydration Hyperkalemia Crackles Hypertension
Dehydration Explanation: The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? Nonproductive cough and normal temperature Sore throat and abdominal pain Hemoptysis and dysuria Dyspnea and wheezing TAKE ANOTHER QUIZ
Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:
Fat embolism syndrome Explanation: The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.
After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output? It's a normal finding caused by blood loss during surgery. It's a normal finding associated with the client's nothing-by-mouth status. It's an abnormal finding that requires further assessment. It's an abnormal finding that will correct itself when the client ambulates. TAKE ANOTHER QUIZ
It's an abnormal finding that requires further assessment. Explanation: The drop in urine output to less than 30 ml/hour is abnormal and requires further assessment. The reduction in urine output may be caused by an obstruction in the urinary catheter tubing or deficient fluid volume from blood loss. The client's nothing-by-mouth status isn't the cause of the low urine output because the client is receiving I.V. fluid to compensate for the lack of oral intake. Ambulation promotes urination; however, the client should produce at least 30 ml of urine/hour.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling TAKE ANOTHER QUIZ
Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? Increased ability to sleep Relief from constipation Relief from pain Reduced muscle spasticity TAKE ANOTHER QUIZ
Reduced muscle spasticity Explanation: Dantrolene reduces muscle spasticity. It doesn't increase the ability to sleep or relieve constipation or pain.
A woman is reporting bladder urgency. It is most important to assess: exercise. weight. caffeine intake. vitamin supplements. TAKE ANOTHER QUIZ
caffeine intake. Explanation: Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.
A fourth heart sound (S4) indicates a
failure of the ventricle to eject all blood during systole. An S4 occurs as a result of increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased ventricular compliance. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. A nurse hears decreased myocardial contractility as a third heart sound. A nurse doesn't hear an S4 in a normally functioning heart.
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? rashes on the palms of the hands and soles of the feet cauliflower-like warts on the penis painful red papules on the shaft of the penis foul-smelling discharge from the penis TAKE ANOTHER QUIZ
foul-smelling discharge from the penis Explanation: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.
A nurse is assessing a client with heart failure. When assessing hepatojugular reflux, what is the appropriate action for the nurse to take?
press the right upper abdomen. Explanation: As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.
A nurse is assessing a client who has just been admitted to the emergency department. Which signs suggest an overdose of an antianxiety agent? combativeness, sweating, and confusion agitation, hyperactivity, and grandiose ideation slurred speech, dyspnea, and impaired coordination suspiciousness, dilated pupils, and increased blood pressure TAKE ANOTHER QUIZ
slurred speech, dyspnea, and impaired coordination Explanation: Signs of antianxiety agent overdose include slurred speech, dyspnea, and impaired circulation. Phencyclidine (PCP) overdose can cause combativeness, sweating, and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure. Remediation:
