Chapter 8 PrepU
a
A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding? a- "have you been siting for a long time?" b- "what vitamin supplements are you currently taking?" c- "are you feeling feverish today?" d- "how is your stress level today?"
a
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. which of the following is the best rationale for this action? a- to see the client before the client assumes a social face or behavior b- to determine whether you recognize the client from a previous visit c- to check the client for skin lesions the client may not be aware of d- to overhear the clients conversation with a family member
d
a 55- year old bookkeeper comes to the office for a routine visit. the nurse notes that on a previous visit for treatment of contact dermatitis, the clients blood pressure was elevated. she does not have prior elevated readings, and her family history is negative for hypertension. the nurse measures her blood pressure in the office today. which of the following factors can result in a false high reading: a- blood pressure is measured on a bare arm b- clients arm is resting, supported by the nurses arm at the clients mid chest level c- client is seated quietly for 10 minutes prior to measurement d- blood pressure cuff is tightly fitted
c
a client has arrived to the clinic for a routine physical examination. prior to assessing the clients blood pressure, what should the nurse do? a- palpate the radial artery to confirm a pulse is present b- make sure the arm selected is covered with clothing c- ask the client to sit quietly in a chair for 5 mnutes d- position the arm so that it is below waist level
c
a client rates the current pain level as being a 5 on the numeric rating scale. how should the nurse document this pain assessment a- patient experiencing a moderate amount of pain b- patient experiencing mild pain c- patient rated pain level as being a 5 using the rating scale d- patient stated "pain level not that bad"
b
a client recovering from a stroke complains of pain. the nurse suspects this client is most likely experiencing which type of pain? a- idiopathic b- neuropathic c- nocieptive d- somatic
b
a client recovering from abdominal surgery is complaining of pain. the nurse realizes that the client is most likely experiencing which type of pain a- idiopathic b- somatic c- psychogenic d- neuropathic
a
a clients blood pressure is affected by a- cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity b- cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity c- cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness d- cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness
a
a nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. the sitting blood pressure is 140/75 mmHg. which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension? a- 120/55 mmHg b- 130/65 mmHg c- 160/85 mmHg d- 140/55 mmHg
a
a nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mmHg. what is the clients pulse pressure a- 50 mmHg b- 103 mmHg c- 78 mmHg d- 128 mmHg
b
a nurse is assessing the blood pressure on an obese woman. what error might occur if the cuff used is too narrow a- it will be difficult to pump up the bladder b- reading is erroneously high c- pressure on the cuff would be painful d- reading is erroneously low
d
a nurse is assessing the pulse volume of a client with influenza. the nurse notes that the client has thready pulse. which of the following is a description of a thready pulse a- pulse is strong and remains despite moderate pressure b- pulse is strong and light pressure causes it to disappear c- pulse is felt easily and moderate pressure causes it to disappear d- pulse is felt with difficulty and disappears with slight pressure
c
a nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. which of the following health problems should the nurse consider when client falls occur? a- dyspnea b- secondary hypertension c- orthostatic hypotension d- primary hypertension
c
a nurse observes that a young mans arm span appears to be greater than his height. which condition should the nurse suspect in this client a- gignatism b- anorexia c- marfan syndrome d- cushing's syndrome
a
a nurse obtains a pulse rate on an adult client of 56 beats per minute. what is the correct term that the nurse should use to document this finding? a- bradycardia b- tachycardia c- hypocardia d- normal
a
an 86 year old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. the nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow direction to close his mouth and secure the thermometer sublingually. as well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. how should the nurse proceed with assessment a- assess the clients temperature by axilla b- take the clients temperature rectally c- assess the clients skin tone and presence or absence of sweating to determine whether the client is febrile d- use a disposable mercury thermometer to take the clients temperature
d
an elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. the nurse suspects that the clients cold intolerance is a result of: a- neurologic deficits b- recent durgery c- pancreatic descrease d- decreased body metabolism
b
as adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure a- the blood pressure is erratic b- the blood pressure increases c- the blood pressure decreases d- the blood pressure does not change
a
before completing the physical examination, the nurse determines that the client is awake, alert, and oriented. this information would be important for which part of the general survey? a- level of consciousness b- facial expression c- apparent state of health d- posture, gait, motor activity, and speech
c
during the first assessment of the client, the nurse assess the blood pressure in both arms. which of the following findings is an acceptable variation? a- 140/90 mmHg in the right arm and 150/96 mm Hg in the left arm b- 118/78 mmHg in the right arm and 130/84 mmHg in the left arm c- 118/78 mmHG in the right arm and 122/80 in the left arm d- 140/95 mmHg in the right arm and 130/85 mmHg in the left arm
c
since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average sized cuff. what blood pressure reading will the nurse most likely obtain for this client a- correct reading b- reading cannot be obtained c- reading will be high d- reading will be low
b
the current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. the last two readings were 130/75 and 125/70 while resting in bed. the nurse should be alert for signs of: a- postural hypertension b- orthostatic hypotension c- hypertensive crisis d- supine hypotension
a,c,e
the nurse explains to the client that smoking has what effect on the body? a- hypertension b- vasodilation c- hypotension d- peripheral vascular disease
a
the nurse is admitting an elderly client with a diagnosis of congestive heart failure. admission vital signs are respirations 38; pulse 172; blood pressure 86/72. how should the nurse best respond? a- notify the rapid response team b- administer diuretics c- infuse IV fluids d- reassess client in one hour
d
the nurse is caring for a client who is having northing by mouth on the first postoperative day. the clients blood pressure was 120/80 mmHg approximately 4 hours ago, but it is now 140/88 mmHg. the nurse should ask the client which of the following questions a- "what is your typical blood pressure reading?" b- "do you have enough blankets to stay warm?" c- "are you taking any medications for hypertension?" d- "Are you having pain from your surgery?"
c
the nurse is caring for a newly admitted adult client. when performing the general survey of this client, the nurse knows that accurate measurements provide critical information about what? a- safety b- growth pattern c- state of health d- past surgeries
c
the nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The clients pulse is 52 bpm. the nurse retakes the pulse; the finding is the same. the client tells the nurse that he has been training for 6 months for this mini-marathon. what should the nurse do in regard to this reading? a- give oxygen at 2 liters per nasal cannula b- notify the physician immediately c- document the finding d- lower the head of the bed
b
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? a- measure the clients blood pressure and heart rate while she is standing then after 10 minutes of lying supine b- measure the clients heart rate and blood pressure while supine then within 3 minutes of standing c- alternate the scheduled blood pressure measurements between the standing and lying positions d- estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing
c
the nurse is taking routine vital signs toward the end of shift. a clients BP reads 2-4/148. The clients baseline BP has been in the 130s systolic. what should the nurse do first? a- give PRN blood pressure medications b- document the findings c- retake the blood pressure d- notify the physician immediately
d
when assessing a clients pulse, the nurse should be alert to which of the following characteristics? a- tenderness, moistness, contour, elasticity, pressure b- pain, temperature, amplitude and contour, and elasticity c- rate rhythm, temperature, rigidity, color, and elasticity d- rate, rhythm, amplitude and contour, and elasticity
a
when assessing a clients respirations, what is most important to include in the documentations a- presence of dyspnea b- position of the client c- numerical pain rating d- assessment of pedal pulses
a
when can the general inspection be started? a- as soon as the examiner first sees the client b- after height and weight have been taken c- during the examiners preparation to meet the client d- when the client is completely exposed.
c
which abnormal skin color should a nurse anticipate assessing on a dark-skinned client a- yellowish b- reddish c- ashen gray d- beige-pink
