EAQ 1

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

Clear breath sounds

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation?

1+

While assessing a client who experienced an accident, the nurse found that the client is unable to move eyeballs laterally. Which nerve damage led to this condition in the client?

Abducens nerve

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?

Assessment Dx Planning Implementation Evaluation

The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action

Cranial nerve XI

Which clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Distended jugular veins

Which Korotkoff sound represents systolic blood pressure in children?

First

A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?

"I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year."

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition?

Autoimmune disease

Which client is suspected to have an increased risk of hyperlipidemia? SAP

Client with corneal arcus Client with yellow lipid lesions on eyelids

The nurse is assessing a young client who presents with recurrent GI disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client?

Educate the client on managing stress.

While assessing the eyes of a client, a healthcare provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding might be noted to support a diagnosis of glaucoma?

Elevated intraocular pressure

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?

Fluid and electrolyte balance

The nurse recognizes that a common conflict experienced by older adults is the conflict between what?

Independence and dependence

A nurse is caring for a client who underwent cardiac catheterization. The client's skin was found to be blanched, and there was formation of edema of 15.2 cm (1-6 inches) at the site of catheterization. Upon further assessment, the skin was found to be cool, and the client complains of tenderness. Which condition does the nurse expect?

Infiltration

Sequence of techniques used during an examination of the abdomen.

Inspection Auscultation Percussion Palpation

A client has a fever spike that is combined with normal temperature levels. The client's body temperature returns to a normal body temperature at least once a day. Which type of fever can be assessed in the client?

Intermittent

After performing an optical assessment on a client, a HCP notices impaired near vision. Which other finding in this client confirms the dx as presbyopia?

Loss of elasticity of the lens

Which finding is inferred from a grade 4 intensity of heart murmurs?

Loud murmur associated with thrill

The nurse is caring for a African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural belief does the client communicate?

Magicoreligious belief

The RN is instructed to asses the body temp of a neonate. Which site for placing the thermo is contradicted in these clients?

Oral

A RN must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contradicted in this client?

Oral cavity

Arrange the steps of the bimanual deep palpation technique in a sequence.

Relax sensing hand Place the sensing hand on the skin Place the active hand on the sensing hand Apply pressure to the sensing hand Depress the area to be examined to 2 inches

A client is admitted with metabolic acidosis the nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assessed for compensatory changes?

Respiratory and urinary

How does the nurse identify an illness as chronic? SAP

The illness persists for longer than 6 months The client may develop life threatening relapse The illness affects the functioning of one or more systems

A RN is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education?

"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

A older adult is found to have a thin white ring around the margin of the iris. What condition does this denote?

Arcus senilis

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

Arrange the sequence of steps in which the assessment of a lesion would be performed?

Collecting information about its color/size/shape/type/grouping/distribution Observing for any exudate/odor/amount/consistency Measuring the size in CMs Measuring each lesion for height/width/depth

A client who experienced extensive burns is receiving IV fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?

Crackles in the lungs

While assessing the client skins a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client?

Erythema

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which conditions may result in this condition?

Endocrine disease

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment?

Fingerprints

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice?

Family practices

After an eye assessment, the nurse finds that both of the client's eyes are not focusing on an object simultaneously and appear crossed. What could be the cause for this condition?

Impairment of the extraocular muscles

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

Which error will result in false high diastolic readings while measuring a client's BP during a physical exam?

Inflating the cuff too slowly

Which landmark is correct for a nurse to use when auscultating the mitral value?

Left fifth intercostal space, midclavicular line

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic exam to the client. Which position is most suitable for assessing the client in this condition?

Lithotomy position

The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change?

Maintenance

A client complain of rapid, involuntary movement of the eyes after a minor eye injury. A nurse assesses the client and finds that it is a disorder of the cranial nerves. Which condition does the nurse suspect?

Nystagmus

Which clients suffer from impaired near vision? SAP

Presbyopia Hyperopia

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature?

Rectal

What is the correct order of phases a client experiences in the event of a change in body image following an illness?

Shock Withdrawal Acknowledgement Acceptance Rehabilitation

A client suspected to have a prostate disorder is encouraged to have a rectal examination. What position of the client will facilitate a rectal exam by the RN?

Sims position

The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction made by the client leads the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image?

The client recognizes reality and becomes anxious

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor

While assessing a client, the nurse finds inflammation of the skin at the bases of the client's nails. What might be the reason behind this condition?

Trauma