TEST 1 Study Material
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A. Crepitus B. Inflammation C. Fremitus D. Arthritis
A
Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply. A. The client bites her fingernails. B. The client says that the food makes her nauseous. C. The client sleeps a lot. D. The client eats 25% of her meals. E. The client states that she has been depressed for a long time. F. The client answers questions in a barely audible voice.
A, C, & F
The nurse is assessing a patient using the glascow coma scale. which of the following are components of that scale? (select all that apply) A. verbal responses B. respirations C. brainstem reflexes D. eye opening E. Motor response
A, D, E
Which components are included in the integumentary system? Select all that apply. A. Hair B. Muscles C. Arteries D. Skin E. Nails F. Sweat Glands
A, D, E, F
Mr. Russell has an order for vital signs and neruo checks every 4 hours. Which assessment findings made by the nurse would indicate potential neurological compromise? Select all that apply A. unequal pupils B. difficulty swallowing C. Left sided weakness D. unsteady gait E. decreasing level of consciousness
A, E
When performing hand hygiene, when is it necessary to use soap and water instead of alcohol based hand rub?
After using the bathroom
A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? A. Coarse brown hair B. Pink labia lesions C. Whitish vaginal discharge D. Dark pink vulva
B
A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action? A. Increase the frequency of the client's weight assessments. B. Ensure that the scale is correctly calibrated and repeat the assessment. C. Encourage the client to increase food and fluid intake. D. Report this finding promptly to the client's primary care provider.
B
A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? A. Assist the client to a sitting position. B. Palpate the abdomen before auscultating. C. Warm the diaphragm of the stethoscope. D. Uncover the client to expose the chest and abdomen.
C
A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response? A. "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?" B. "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." C. "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." D. "Your physician will decide when it is best for you to begin having mammograms based on your family history."
C
Mr. Russell is being discharged from the hospital following a mild stroke. What instruction would the nurse include in the discharge information? A. you only need to take your medication when symptoms are present B. Low protein diet is a necessity to maintain your health. C. It is important to begin you on a smoking cessation program d. Be sure to weigh yourself at the same time everyday.
C
Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? A. Fingertips B. Knuckles C. Dorsum D. Palm
C
The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? A. Impaired kidney function B. Inflammation of a vein C. Decreased cardiac output D. Hypertension and circulatory overload
C
The nurse is caring for a patient who has experienced a sudden change in level of consciousness and has been difficulty speaking. What is the priority action of the nurse. A. wait 15 minutes to see if the problem resolves B. document the findings C. assess the patient D. notify the charge nurse
C
A client has been reporting persistent headaches. Which is an example of subjective data? A. The client appears lethargic. B.The client is alert and oriented to person, place, and time. C.Temperature is 104.1°F (40.05°C) D. Pain is 4 out of 10 on a pain scale.
D
A nurse is using the assistance of an interpreter. When interviewing a patient who does not speak English, the nurse should:
Observe the clients body language.
The nurse is palpating a clients pericardium. Which result is an expected clinical finding?
Palpable percussion over the mitral area.
When considering hand hygiene, which action will best remove a possible microorganism reservoir?
Removing any rings
Which statement best explains the importance of theoretic frameworks?
Theoretic frameworks advance nursing knowledge and practice.
When evaluating a patients neurological status. What should the nurse include when assessing a patients level of awareness?
Time (What is todays date? What day of the week is it) Place (Where are you now? What is the name of the city?) Person (What is your name? How old are you?)
The nurse is assessing Mr. Russell's papillary response. List the steps of procedure in the order they should be performed. - darken the room - repeat procedure with the same eye, but this time, observe the other eye. - observe pupil reaction - ask the patient to look straight ahead - repeat the procedure with other eye - bring the penlight in from the side of the patients face and briefly shine the light on the pupil.
1. darken the room 2. ask the patient to look straight ahead 3. bring the penlight in from the side of the patients face and briefly shine the light on the pupil 4. observe pupils reaction 5. repeat procedure with the same eye, but this time, observe the other eye. 6. repeat the procedure with the other eye
A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first? A. Inspect the area of itchy skin. B. Check her chart for allergy information. C. Review her medical history. D. Review her medication record.
A
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? A. "What brings you here today?" B. "What medications do you normally use?" C. "Do you have any allergies?" D. "Are you having any pain?"
A
The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? A. Ask the client to empty her bladder. B. Warm the equipment. C. Place the client in a semi-Fowler's position. D. Measure height and weight
A
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? A. The client is dehydrated. B. The skin has normal turgor. C. The client is overhydrated. D. The skin is less elastic with aging.
A
Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A. wheezes B. fine crackles C. pleural friction rub D. stertorous breathing
A
Which statement best defines human infection?
A disease state that is a result of pathogens in or on the body.
Mr. Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe? (check all that apply) A. instruct patient to call for assistance when getting out of bed B. maintain bed in low position at all times C. place call bell within reach D. Provide non-skid socks for ambulation E. keep side rails x4 up at all times
A, B, C, D
The nurse is caring for a stroke patient with mild dyspagia. What would be an appropriate nursing intervention for this patient in order to minimize risk for injury? select all that apply. A. position patient up right in a wheel chair if not contraindicated B. Providing a 30 minute rest period prior to meals C. Placing food in a easily assailable position. D. providing mouth care before meals E. educate the patient about the importance of altering liquids and solids
A, B, E
The nurse is conducting a neurovascular assessment on a post op knee replacement patient. Which assessment date would indicate a neurological impairment? A. Patient reports "pins & needles" sensation below the incision site. B. Skin directly surrounding the incisional area is taut & firm to the touch. C. Patient rates pain as an 8 out 10 on pain scale. D. Skin temperature on infected leg is cooler distal to incision.
ANSWER: A
The nurse is conducting a neurovascular assessment on a post op patient who had experienced a total knee arthroplasty. What's the nurses initial intervention when it appears there is an absence of pulse in the affected foot? A. Asses the capillary refill in both longer extremities. B. Notify the patient health care provider of the initial finding. C. Assess for paranesthesia in the affected extremity. D. Elevate the affected extremity
ANSWER: A
What type of research study would a hospital conduct to explore clients' and families' perceptions of receiving care? A. Qualitative B. Nonscientific C. Quantitative D. Ordinal
ANSWER: A
Which interventions will help minimize the risk of post op infection? (Select all that apply) A. Check temperature regularly B. Implementing standard precautions C. Maintain hydration D. Following aseptic technique when changing incision dressings E. Managing pain effectively
ANSWER: A,B,C,D
Which factors increase a post operatives patients risk for infection? A. Weight B. Age C. Presence of incision D. Presence of pain E. Immunosuppression
ANSWER: A,B,C,E
Which statement is true about transient bacteria? (Select all that apply) A. Can be removed easily through frequent & effective handwashing. B. Occurs commonly on hands C. Relatively few are found on clean areas of skin D. Requires friction with a brush to assure removal E. Found in greatest number under fingernails
ANSWER: A,B,C,E
The nurse has an order to complete neurological checks every 4 hours. Which assessments would the nurse include in a neurological assessment? (select all that apply) A. Memory B. Cranial Nerves C. Range of motion D. Sensory perception E. Level of consciousness
ANSWER: A,B,D,E
Which interventions will the nurse implement when maintaining medical asepsis? (Select all that apply) A. Clean least soiled areas first B. Do not place soiled bed linen on the floor C. Allow only sterile items to touch sterile items D. Practice good hand hygiene E. Keep personal fingernails short
ANSWER: A,B,D,E
Mr. Griffin is receiving sodium therapy. Which assessment data would the nurse report to the patients health provider to ensure his post operative safety? A. Platelet reading of 260,000 per mcL B. Moderate amount of gum bleeding after oral hygiene C. A hemoglobin reading of 15g/dL D. Reports no bowel movement for 2 days
ANSWER: B
When considering a 40 year old postoperative patient, which factor is most likely to present the greatest risk of the development of infection? A. Integrity & number of the patients white blood cells. B. Invasive or indwelling medical procedures or devices. C. The PH levels of the bodys gastrointestinal and GI tracts. D. Patients age, gender, and race.
ANSWER: B
When taking a patients health HX, which of the following does the nurse identify as risk factors for having a stroke? (Select all that apply) A. Recent weight loss B. Hypertension C. Smoking D. Diabetes Mellitus E. Asthma
ANSWER: B,C,D
Which nursing inventions will have the greatest impact on minimizing the spread of MRSA among patients on a surgical unit? (Select all that apply) A. Obtaining wound cultures are ordered B. Using appropriate PPE C. Administered prescribed anti biotics D. Implementing standard precautions E. Instituting meticulous hang washing
ANSWER: B,D,E
The nurse is caring for a patient suspected of having a stroke. What should be the nurses first action to ensure patient safety when it appears the patient is having difficulty swallowing prescribed oral meA. Notify the provider of suspected problem. B. Hold the meds & make patient NPO C. Educate the patient about substantial risk aspiration associated with stroke D. Schedule an immediate speed therapist swallow study.dication?
ANSWER: B.
Which type of quantitative research will examine cause-and-effect relationships between selected variables? A. Descriptive B. Correlational C. Quasi Experimental D. Experimental
ANSWER: C
Which observation supports the possibility that a patient who has experienced a stroke has aspirated? (select all that apply) A. Reports of nausea B. Vomiting C. Hoarseness D. Coughing E. Regurgitation into the mouth
ANSWER: C,D,E
The nurse should use the bell of the stethoscope during auscultation of: A. a client's breath sounds B. a client's bowel sounds C. A client's apical heart rate D. A clients heart murmur
ANSWER: D
The nurse is caring for a medical surgical patient. Which patient should be assessed using the Glascow Coma scale? A. A 32 year old para pelagic patient who has pneumonia B. An 85 year old patient with dementia & increasing confusion C. A 51 year old cancer patient who is experiencing episodes of anxiety & depression. D. A 47 year old patient who has suffered a brain injury and loss of consciousness in MVA.
ANSWER: D. The glasgow coma scale is always to measure consciousness.
A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale? A. 4 B. 12 C. 15 D. 8
ANSWER:C
A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? A. Auscultation B. Palpation C. Percussion D. Inspection
B
A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? A. whether they have home maintenance skills B. whether they have a program of regular physical activity C. whether they have anemia D. whether they have proper dietary habits
B
A patient has been admitted with a dx of stroke, and the nurse has received orders to hold Warfrin until labs are complete. What lab result would the nurse anticipate reviewing prior to administering medication? A. d dimer B. PT/INR C. Platelets D. H & H
B
The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider? A. Auscultation of gurgles and clicks B. Auscultation of a bruit C. Umbilicus centrally located D. Auscultation of bowel sounds every 30 seconds
B
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: A. clear. B. blurred. c. 20/20. D. clouded.
B
Mr. Russell has experienced dysphagia and mild left sided weakness following a stroke. For which additional symptoms of stroke should the nurse assess? (select all that apply) A. decreased peristalsis B. sensory deficits C. Urinary incontinence D. hearing loss E. communication difficulties
B, C, E
To assess subjective data related to a client's elimination pattern, the nurse: A. palpates the abdomen for pain or distention. B. reviews the latest laboratory report of the urine. C.asks the client about changes in elimination patterns. D. notes the frequency, amount, and time the client voids.
C
When percussing the liver, the sound should be: A. Flat B. Resonant C. Dull D. Hypersonant
C
A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply: A. Single color B. Symmetrical shape C. Larger than 1/4 inch in diameter D. Irregular edges E. Change in the mole
C, D, E
A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of: A.comprehensive data. B. subjective data. C. baseline data. D. objective data.
D
A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A. Assess for asthma. B. Recommend testing for pneumonia. C. Suspect an inflamed pleura rubbing against the chest wall. D. Document normal breath sounds.
D
A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease? A. Inspect and palpate the left and then the right carotid arteries. B. Palpate the thyroid gland. C. Inspect the client's ability to move his neck. D. Inspect and palpate the supraclavicular area.
D
The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis? A. Chronic Confusion B. Disturbed Thought Processes C. Acute Confusion D. Risk for Falls
D
The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? A. The tympanic membrane is reddish. B. The ear canal is smooth and white. C. The ear canal is rough and pinkish. D. The tympanic membrane is translucent, shiny, and gray.
D
The nurse is calling in a report to the provider using SBAR format. Which statement by the nurse would be the "S" when reporting this technique? A. i recommend the patient be sent for a swallow study B. The patients lungs are clear to ausculation C. The patient was admitted with a stroke and mild dysplagia D. The patient began coughing when eating breakfast this morning.
D
Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's: A. objective assessment. B. review of systems. C. symptoms. D. chief concern.
D
Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: A. ectropion. B. miosis. C. entropion. D. ptosis.
D
What percentage of weight change in 6 months is considered abnormal? A. 1% B. 2% C. 5% D. 10%
D
Mr. Griffin surgical care includes anticoagulation therapy. Which diagnostic blood count indicates spontaneous bleeding and should be reported to the health care provider immediately?
Platelet count <50,000
In which stage of the development of an infection does the patient present a greater risk to others?
Prodromal
