Chapter 12 Fund

A client who thinks he has an infection has come to the clinic. During the assessment, which question would the nurse most likely ask first?

"How long have you had the infection?"

The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate?

"If my pulse is higher than 100 beats/min at rest, that is considered abnormal."

A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?

"Put away the salt shaker and eat low-salt foods."

What is the most appropriate nursing response when a client with a BMI of 29 expresses concerns of developing hypertension?

"Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management."

A nurse is obtaining an oral temperature on a client, using an electronic thermometer. The client notes having an electronic thermometer at home and asks how to care for it. Which response is appropriate?

"When not in use, keep the probe in the storage place within the unit."

The home care nurse notices that the client only has a glass thermometer. What is the best response by the nurse?

"Would you consider using a digital thermometer?"

The mother of a newborn asks the nurse about her newborn's risk for infection. Which statement by the nurse would be most appropriate?

"Your baby's resistance comes from the antibodies you passed on to him before birth and now with breast feeding."

The nurse has requested the unlicensed assistive personnel (UAP) check the temperature of a 19-month-old client who has been admitted for pneumonia. Which reading should the nurse question if noted in the record?

102.4°F/39.1°C (T)

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

A client is being screened for a parasitic infection and the physician orders stool specimens. When explaining to the client about collecting the specimens, the nurse would inform the client that the specimens will be collected daily for:

3 days

The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% of the circumference of the limb to be used

Which term describes foreign particles that enter a host and stimulate the body's immune response?

Antigen

A nursing instructor is preparing a class to discuss the different types of white blood cells. What would the instructor most likely include as granulocytes? Select all that apply.

Basophils Neutrophils Eosinophils

Which guideline should the nurse follow when assessing a client's blood pressure using a Doppler ultrasound?

Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery.

The nurse is taking a client's vital signs and finds the blood pressure is 99/60 mm Hg. The client states, "That is strange, I have hypertension and my blood pressure has never been lower than 130/90 mm Hg." The nurse confirms the client's report in the recent vital signs trend. What is the nurse's next action?

Determine if the cuff size is appropriate for the client's arm circumference.

Which statement describes diastolic blood pressure?

During ventricular relaxation, blood pressure is due to elastic recoil of the vessels.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

Give the client a bath in tepid water.

Assessment of a client's temperature reveals hyperpyrexia. The nurse interprets this as indicating that the client's temperature is most likely:

Greater than 40.5°C

An older adult hospitalized client develops severe diarrhea from gram-negative rods that compromised the normal flora of the bowel. What is the cause of the infection?

Healthcare-associated infection (HAI)

The nurse is caring for an adult postoperative client. Which physiologic response is related to pain?

Heart rate of 110 beats/min

A group of nursing students is reviewing the various white blood cells and how they function in infection. The students demonstrate understanding of the information when they identify which cell as important in synthesizing immunoglobulins?

T Lymphocytes

The student nurse observes another nurse wash her hands in the client's bathroom before exiting the room. This client's stool came back positive (+) for Clostridium Difficile (C diff). Why is this behavior incorrect?

The bathroom is highly contaminated with the Clostridium difficile bacteria.

When assessing a client's vital signs, a nursing student has explained to the client each of their next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce their intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?

The client may alter the rate of respirations if the client is aware that his breaths are being counted.

The nurse teaches a client diagnosed with hypertension to self-measure blood pressure with an automated device. Which client behavior indicates the need for additional teaching?

The client sits in the chair with feet flat on the floor and arm below the level of the heart.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client?

Wait for 30 minutes before measuring the oral temperature

A nursing unit uses a tympanic thermometer as the thermometer of choice on the nursing unit. For which client would the nurse select another style of thermometer?

a client who has a middle ear infection with pain

A nurse instructs a new mother on immunizations. An immunization produces:

active immunity

When an 86-year-old client reports an inability to concentrate, uneasiness, lightheadedness, weakness, muscle and joint discomfort, and demonstrates normal temperature, the clinic nurse recalls that:

an older adult can have an infection without a fever.

The nurse walks into the client's room to pick up the dinner tray and notes the client has not eaten. Which action should the nurse prioritize after noting the client appears sleepy, has perspiration on the forehead, and the face appears flushed?

assess temperature

An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment?

auscultate the client's apical pulse

The laboratory calls the nurse to report the client has a shift of the differential count to the left. The nurse knows this indicates the client most likely suffers from:

bacterial infection.

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess?

clear mucus

After educating students about changes in the immune system and risk for infection as people age, the instructor determines that the education was successful when the students identify:

decreased cellular immunity.

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

A nurse is caring for a middle-age client who looks worried and flares his nostrils when breathing. The client reports difficulty in breathing, even when he walks to the bathroom. Which breathing disorder is most appropriate to describe the client's condition?

dyspnea

Before assessing a client's respiratory rate, the nurse should remind the client to breathe normally.

false

A physician performs lumbar puncture and advises the nurse to send the obtained cerebrospinal fluid for Gram stains. The nurse understands that this type of testing is beneficial for which reason?

helps to determine prescribed antibiotic therapy

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature.

A nurse is preparing an education plan for a client being discharged home after successful treatment for a wound infection. What would the nurse be least likely to include in the education plan?

intravenous antibiotic administration

Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?

oral

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?

postural hypotension

A client is experiencing generalized weakness and body aches. In the progress of infection, the client is in the:

prodromal period

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, +3, and equal in radial, popliteal, and dorsalis pedis. What does the number +3 represent?

pulse amplitude

Which term indicates a potentially serious client condition?

pyrexia

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

rectal

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure?

the ability of the arteries to stretch