230- HEALTH AND PHYSICAL ASSESSMENT
A nurse teaches a client about various measures to protect against food-borne illness. Which statement by the client indicates a need for further teaching?
"I won't eat any leftovers in my refrigerator after they've been there for 5 days."
The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply.
- "My first child was born when I was 32." - "I noticed a slight discharge from a nipple." - "I consume two to four glasses of alcohol a day."
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply.
- Assessment of skin turgor - Administration of antiemetic drugs - Replacement of fluid and electrolytes
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply.
- The client reports pain with movement. - The client has pain over the surgical area. - The client rates the pain as 8 on a scale of 0 to 10.
A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?
Be consistent about established rules.
The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III?
Client C - crossed eyes
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what?
Full
The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate?
Magicoreligious belief
A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client?
Oral cavity
A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food borne disease would be suspected in this client?
Salmonellosis
A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching?
"The client's first exposure to latex will cause a type IV allergic reaction."
While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? Select all that apply.
-Poor fitting of the cuff -Deflating the cuff too quickly
