EAQ 2

While assessing a client with dehydration, the nurse notices diminished skin elasticity. Which portion of the hand is used to perform this assessment? 1 Fingertips 2 Pads of fingertips 3 Ulnar surface of hand 4 Palmer surface of finger pads

1 Fingertips The fingertips are used to palpate the skin for elasticity. The pads of the fingertips are used to palpate pulse amplitude. The ulnar surface of the hand is used to detect fremitus. The palmer surface of the fingertips is used to examine the thorax.

The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care? 1 Safety 2 Self-esteem 3 Self-actualization 4 Love and belonging

1 Safety An elderly client with dementia has impaired cognition. Therefore the nurse should make arrangements such as applying bed side rails to ensure that the client's safety needs are met first. At this stage, self-esteem or factors that enhance confidence and self-worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. 1 Heart 2 Vagina 3 Rectum 4 Female genitalia 5 Musculoskeletal system

2 Vagina 3 Rectum Sims' position is indicated to examine vagina and rectum. Lithotomy to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound? 1 Inflammation of the pleura 2 Muscular spasms in the larger airways 3 Sudden reinflation of groups of alveoli 4 High velocity airflow through an obstructed airway

4 High velocity airflow through an obstructed airway Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.

Which client is expected to be diagnosed with macular degeneration?

Client with loss of central vision Client B's loss of central vision is caused by macular degeneration. Impaired near vision in client A is due to presbyopia or hyperopia. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously; this results in the cross appearance of eyes, as seen in client C. Client D's inability to see distant objects is caused by myopia. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response.

Which client body temperatures are indicative of moderate hypothermia? Select all that apply. 1 80° F (26.7° C) 2 84° F (28.9° C) 3 88° F (31.1° C) 4 92° F (33.3° C) 5 96° F (35.6° C)

3 88° F (31.1° C) 4 92° F (33.3° C) Moderate hypothermia is a body temperature between 86°F and 93.2°F (30° C to 34° C). Therefore clients with body temperatures between 88°F and 92°F (31.1° C to 33.3° C) have moderate hypothermia. Mild hypothermia is a body temperature between 93.2°F and 96.8°F (34° C to 36° C). Therefore clients with body temperatures of 96°F (35.6° C) have mild hypothermia. Body temperature below 86°F (30° C) indicates severe hypothermia.

While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? 1 Aging 2 Poor nutrition 3 Endocrine disease 4 Arterial insufficiency

3 Endocrine disease Endocrine diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. Aging and poor nutrition will result in decreased hair growth. Arterial insufficiency will result in decreased hair growth due to compromised blood supply.

A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings might have led the nurse to this suspicion? 1 Sunken eyes and loss of weight 2 Uncommunicative and uninteractive with others 3 Foreign bodies in the rectum, urethra, or vagina 4 Strangulation marks on neck from rope burns or bruises

3 Foreign bodies in the rectum, urethra, or vagina One of the physical findings that may be required to confirm child abuse is the presence of foreign bodies in the rectum, urethra, or vagina. Weight loss and sunken eyes may be a physical finding for older adult abuse. When the abuse is related to an intimate partner, the nurse may observe strangulation marks on the neck from rope burns or bruises. Staying isolated and not communicating with others are behavioral findings that may be related to older adult abuse.

A client complains 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? 1 Cataract 2 Glaucoma 3 Nystagmus 4 Strabismus

3 Nystagmus Nystagmus is a condition defined by rapid, involuntary, rhythmical oscillation of the eyes. This condition is caused by local injury to the eye muscles and supporting structures. A cataract is a condition in which the opacity of the lens will be increased; this disorder is commonly related to age. Glaucoma is intraocular structural damage resulting from elevated intraocular pressure. Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously. In this condition, the eyes appear crossed.

A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition? 1 Sims position 2 Supine position 3 Lithotomy position 4 Dorsal recumbent position

4 Dorsal recumbent position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when? 1 First 2 Second 3 Third 4 Last

4. Last The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.

A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have? 1 Ascites 2 Cyanosis 3 Accidental injury 4 Bleeding disorder

1 Ascites Symptoms of ascites include a shiny and taut appearance of the abdominal skin. Cyanosis occurs when there is a bluish discoloration of the skin. Accidental injury and different types of bleeding disorders are characterized by bruises or needle marks on the skin.

A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? Select all that apply. 1 Fainting 2 Headache 3 Weakness 4 Light headedness 5 Shortness of breath

1 Fainting 3 Weakness 5 Light headedness Head trauma may cause blood loss. Clients with recent blood loss are at risk of orthostatic hypotension. While obtaining the orthostatic measurements, the nurse should check for fainting, light-headedness, and weakness. Headaches and shortness of breath are the symptoms of hypertension. Topics

Which Korotkoff sound represents the diastolic pressure in children? 1 First 2 Second 3 Fourth 4 Fifth

3 Fourth The fourth Korotkoff sound represents the diastolic pressure in children. The first Korotkoff sound represents the systolic pressure. The fifth Korotkoff sound represents the diastolic pressure in adults and adolescents. A blowing or swishing sound occurs in the second Korotkoff sound.

A registered nurse is teaching a nursing student about skin assessment. Which statement made by the nursing student indicates the need for further teaching? 1 "Skin assessments are best performed in daylight." 2 "Skin assessments performed at cool room temperatures can result in cyanosis." 3 "Skin assessment performed at warm room temperatures can result in vasodilatation." 4 "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."

4 "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light." Though skin assessments are best conducted in daylight, in the absence of sunlight, they are best performed in fluorescent lighting. Skin exposure during skin assessments in cool room temperature can result in cyanosis. Skin exposure during skin assessments made in warm room temperature can result in vasodilatation.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique? 1 "Effectiveness depends on the child's age." 2 "Spanking is strongly suggestive of negative role behavior." 3 "Spanking may be the only option when no other technique works." 4 "Research studies have shown it to be an effective disciplinary technique."

2 "Spanking is strongly suggestive of negative role behavior." Research suggests that children who are spanked tend to use aggressive behavior; as they grow older they learn their own behavior through their parents' behavior. Age is not significant in terms of the effectiveness of spanking. Research studies contradict the assertion that spanking is an effective disciplinary technique.

The nurse is performing a skin assessment of a client. Which findings in the client may indicate a risk of skin cancer? Select all that apply. 1 Lesion 2 Lumps 3 Rashes 4 Bruising 5 Dryness

1 Lesion 2 Lumps 3 Rashes Lesions on the skin that take a long time to heal may indicate skin cancer. Lumps and rashes on the skin are characteristics of skin cancer. Bruising may indicate a bleeding disorder or injury. Dryness of the skin may be due to excessive bathing and use of harsh soaps.

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. 1 Nursing diagnoses involve the client when possible. 2 Nursing diagnoses are based on results of diagnostic tests and procedures. 3 Nursing diagnoses are the identification of a disease condition in the client. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems

1 Nursing diagnoses involve the client when possible. 4 Nursing diagnoses involve the sorting of health problems within the nursing domain. 5 Nursing diagnoses involve clinical judgment about the client's response to health problems Establishing a nursing diagnosis is the second step in the nursing process. It is unique and involves the client's participation in the process. Nursing diagnoses classify health problems to be treated primarily by nurses. The nurse reviews the client assessment, sees cues and patterns in the data, and identifies the client's specific health care problems. The nursing diagnosis is a clinical judgment about the client's actual or potential health problems that the nurse is licensed to treat. A medical diagnosis is based on results of diagnostic tests and procedures, whereas a nursing diagnosis is based on the results of the nursing assessment. A medical diagnosis identifies a disease condition in the client.

Which infant does the nurse anticipate to be of abnormal weight? 1. Age 4 months weight at birth 2.9 kg, current weight 6.1kg 2. Age 5 months, weight at birth 3.3 kg, current weight 8.5kg 3. Age 12 months, weight at birth 3.35kg, current weight 10kg 4. Age 11 months, weight at birth 3.4 kg current weight 10.3 kg

2 The average birth weight of a newborn is 3.2 to 3.4 kg. An infant usually doubles his or her birth weight at 4 to 5 months of age. Therefore, infant 2's weight of 8.5 kg at 5 months is abnormal. Infant 1, weighing 6.1 kg, is of a normal weight. An infant has usually tripled his or her birth weight by around 1 year. Therefore, infants 3 and 4 are experiencing normal weight gain.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Select all that apply. 1 Reassess the client. 2 Reject all diagnoses. 3 Gather more information. 4 Identify related factors. 5 Review all defining characteristics.

3 Gather more information. 4 Identify related factors. 5 Review all defining characteristics.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? 1 Assess the client's lungs. 2 Assess the client for pain. 3 Obtain details of smoking habits. 4 Ask about the onset of breathlessness.

1 Assess the client's lungs. The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. 1 Client with corneal arcus 2 Client with periorbital edema 3 Client with decreased skin turgor 4 Client with paleness of conjunctivae 5 Client with yellow lipid lesions on eyelids

1 Client with corneal arcus 5 Client with yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. 1 Lips 2 Sclera 3 Mouth 4 Sacrum 5 Nail beds 6 Shoulders

1 Lips 3 Mouth 5 Nail beds Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, while shoulders are assessed to confirm the condition of erythema.

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply. 1 Use of hard soap 2 Frequent bathing 3 Use of tanning pills 4 Presence of an allergy 5 Use of petroleum products

1 Use of hard soap 2 Frequent bathing The use of hard soap and frequent bathing may result in dry skin. A skin allergy may result in skin rashes, but not dry skin. Using tanning pills and petroleum products may result in skin cancer.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply. 1 Impaired near vision 2 Crossed appearance of eyes 3 Elevated intraocular pressure 4 Impaired extraocular muscles 5 Degeneration of central retina

2 Crossed appearance of eyes 4 Impaired extraocular muscles Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. This condition is caused by impaired extraocular muscles. Impaired near vision is associated with hyperopia or presbyopia. Elevated intraocular pressure results in glaucoma. Macular degeneration is caused by degeneration of the central retina.

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply. 1 Instruct the client to apply bed side rails. 2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 4 Ask the client to install hand rails in the bathroom. 5 Help the client rearrange furniture in the house.

2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 5 Help the client rearrange furniture in the house. The nurse should encourage the client to wear nonskid shoes that will provide a firm grip while walking and help reduce the chance of falls. The nurse should suggest that the client use an assistive device such as a cane or walker for support while walking. The nurse should make environmental changes by helping the client rearrange the furniture in the house. This will help reduce the incidence of falls within the house. These interventions reduce the fear of falling and encourage the client to participate in physical activity indoors and outdoors. The bed side rails protect the client from falling from the bed. The hand rails in the bathroom assist provide support while using the bathroom.

Which landmark is correct for a nurse to use when auscultating the mitral valve? 1 Left fifth intercostal space, midaxillary line 2 Left fifth intercostal space, midclavicular line 3 Left second intercostal space, sternal border 4 Left fifth intercostal space, sternal border

2 Left fifth intercostal space, midclavicular line The correct landmark for auscultating the mitral valve (apical pulse) is found at the left fifth intercostal space (ICS) in the midclavicular line. Auscultation at the fifth ICS in the midaxillary line would yield breath sounds of the lateral lung field. Auscultation at the left second ICS at the sternal border is best to hear the pulmonic valve, and at the left fifth ICS at the sternal border for the tricuspid valve.

Which nursing intervention is employed to encourage the client to fully reveal the nature of their health problem? 1 The nurse takes down notes while the client is talking. 2 The nurse leans forward attentively during the discussion. 3 The nurse refrains from pausing enough after each question. 4 The nurse asks questions that can be answered as "yes" or "no."

2 The nurse leans forward attentively during the discussion. The nurse leans forward attentively to show awareness, attention, and immediacy during discussion with the client. This encourages the client to fully reveal the nature of his or her health problem. The client may feel that the nurse is too busy to pay attention if the nurse takes down notes during the discussion. If the nurse hurries with the assessment, the client is likely to understand that the nurse is busy or not interested. The nurse should ask open-ended questions that encourage the client to give detailed information about his or her health. Closed-ended questions that can be answered with "yes" or "no" often bring the conversation to a close.

Which finding is inferred from a grade 4 intensity of heart murmurs? 1 Thrill is easily palpable 2 Quiet and clearly audible thrill 3 Loud murmur associated with thrill 4 Moderately loud murmur without thrill

3 Loud murmur associated with thrill Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

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? 1 Cranial nerve II 2 Cranial nerve XI 3 Cranial nerve VI 4 Cranial nerve VII

2 Cranial nerve XI Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor nerve that coordinates the lateral movement of eyeballs. Cranial nerve VII or (auditory nerve) is a sensory nerve which coordinates the hearing sense.

The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? 1 Skin 2 Oral 3 Axilla 4 Rectal

4 Rectal Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.

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, eye finding 1. drooping eye 2. nearsightedness 3. cross-eye 4. protruding eyes

1. Drooping eyes Injury to the third cranial nerve may result in edema or impairment of the third cranial nerve. This results in the abnormal drooping of the eyelids, a condition called ptosis. Myopia is nearsightedness, a refractive error in which rays of light enter the eye and focus in front of the retina. Cross-eyes result from strabismus, which results from neuromuscular injury or congenital anomaly. Protruding eyes (exophthalmoses) is indicative of hyperthyroidism.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39ºC. What is this temperature in Fahrenheit? Record your answer using one decimal place. _____ºF

102.2 Celsius is converted to Fahrenheit by multiplying the Celsius reading by 9/5 and adding the product to 32. In this case, the calculation is: (9/5)(39) + 32 = 102.2.

The nurse is performing a skin assessment. Which illustration may represent a tumor?

A solid mass that extends deep through the subcutaneous tissue may indicate a skin tumor called an epithelioma (as seen in the first figure). A palpable, circumscribed, solid elevation in the skin indicates the formation of a papule (as seen in the second figure). An elevated solid mass that is deeper and firmer than a papule indicates the formation of a nodule (as seen in the third figure). A circumscribed elevation of the skin that is similar to a vesicle but filled with pus indicates a pustule (as seen in the fourth figure).

Which client is suspected of having hypertension based on the given data? Client, cardiac output, peripheral resistance, hematocrit 1. A, decreased, normal, decreased 2. B, increased, increased, increased 3. C, decreased, normal, normal 4. D, normal, increased, normal

B The blood pressure (BP) in a client rises when the client's cardiac output, peripheral resistance, and hematocrit are increased. Because all of these parameters are increased in client B, then that client is suspected to have hypertension. The BP falls when cardiac output is decreased. So, clients A and C may be at risk of hypotension. Client D's cardiac output may not be at risk of hypertension.

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? 1 "I will ask the client to move his or her arm towards the body." 2 "I will ask the client to bend his or her limb by decreasing the angle." 3 "I will ask the client to move his or her hand so that the ventral surface faces downward." 4 "I will ask the client to move his or her head beyond its normal resting extended position."

1 "I will ask the client to move his or her arm towards the body." Adduction is moving the arm towards the body. Assessing the range of motion by bending the limb and decreasing the angle indicates flexion. Moving the hand by facing the ventral surface downwards indicates pronation. The movement of the head beyond the normal resting extended position indicates hyperextension.

Which statement made by the nurse indicates that the client interview is coming to a close? 1 "I have just one more question for you." 2 "I hope you are comfortable and not in pain." 3 "I would like to spend some time to understand your concerns." 4 "I assure you that information I gather now will be confidential."

1 "I have just one more question for you." The nurse should give the client a clue that the interview is drawing to a close. The nurse can do this by letting the client know that after one more question the interview will be over. The nurse sets the stage for the interview by ensuring that the client is comfortable and not in pain. The nurse begins the interview by stating that he or she would like to spend some time to understand the client's health concerns. The nurse informs the client at the beginning of the interview that the information shared by the client is confidential. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply. 1 Client has lordosis. 2 Client is an older adult. 3 Client has osteoporosis. 4 Client has a history of smoking. 5 Client has chronic lung disease.

2 Client is an older adult. 4 Client has a history of smoking. 5 Client has chronic lung disease. The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

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? 1 "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." 2 "I will advise a client with a blood pressure of 110/70 mm Hg to follow up in a year." 3 "I will advise a client with a blood pressure of 150/90 mm Hg to follow up in a month." 4 "I will advise a client with a blood pressure of 185/115 mm Hg to follow up in a month."

1 "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year." A client with prehypertension tends to have a blood pressure (BP) between 120/80 and 139/89 mm Hg. These clients should be rechecked in a year. Clients with BP less than 120/80 mm Hg are considered normal. These clients should be rechecked in two years. Clients with stage 1 hypertension have a BP between 140/90 and 159/99 mm Hg. These clients should be rechecked in two months to confirm stage 1 hypertension. Clients with stage 2 hypertension have a BP greater than 160/100 mm Hg. These clients should be rechecked in one month. If a client's BP is greater than 180/110 mm Hg, then he or she should be treated immediately or within 1 week.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

A nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results? 1. Site - Ulnar - Location - Ulnar side of the forearm at the wrist - Assessment criteria - cardiac arrest when other sites are not palpable 2. Carotid - Along the medial edge of the sternocleidomastoid muscle in the neck. 3. Dorsalis pedis - along the top of the foot - status of the circulation to the foot 4. Posterior Tibial - Above the medial malleolus - status of circulation to the foot

3 The dorsalis pedis is located along the top of the foot. This site is used to assess the status of circulation in the foot. The ulnar site, found on the ulnar side of the forearm at the wrist, is used to assess the status of circulation to the hand and to perform the Allen test. The carotid site is found along the medial edge of the sternocleidomastoid muscle of the neck. It is easily accessible in times of physiological shock or cardiac arrest when other sites are not palpable. The posterior tibial site is found below (not above) the medial malleolus. It is used to assess the status of circulation in the foot.

A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number. _____mL/min

5040 The volume of blood pumped by the heart in 1 minute is the cardiac output. Cardiac output is the product of the heart rate and the stroke volume of the ventricle. Therefore cardiac output in the client with a heart rate of 72 beats/min and stroke volume of 70 mL is 5040 mL/min: 72 × 70 = 5040.

Where is the location of the popliteal pulse

The palpation of the popliteal pulse is done on the popliteal artery, which is present in the posterior surface of the knee, as depicted in the first figure. The palpation of the femoral pulse is in the femoral artery, which is present in the right groin as seen in the second figure. The third figure depicts the palpation of the brachial pulse. The fourth figure shows the palpation of the ulnar pulse.

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis

1 Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4 A long-lasting passive immunity is produced

2 A high titer of antibodies is generated. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.

A nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would most likely describe the nurse's finding? 1 Lordosis 2 Kyphosis 3 Presbycusis 4 Osteoporosis

2 Kyphosis Kyphosis is an increase in the curvature of the thoracic spine and may result from a congenital abnormality. Lordosis, also known as swayback, is an increased lumbar curvature and may not be a congenital abnormality. Presbycusis is the loss of acuity for high-frequency tones and is not related to the spine. Osteoporosis is a condition in which the bones become brittle and fragile from the loss of tissue and bone mass.

A nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? age, family history of breast cancer, children, age of menopause 1. 60, yes, 2, 45 2.60, yes, none, 50 3.60, no, none, 50 4. 60, no, 2, 45

2. Women over 40 years of age with a personal or family history of breast cancer, late-age menopause (after age 50), who have not had children or who conceived after the age of 30 years, or women with excessive oral contraceptives use are at risk of developing breast cancer. Client B has all the criteria that increase the risk of developing breast cancer, such as age over 60 years, positive family history, no children, and menopause at a later age. Therefore she is at the highest risk of developing breast cancer compared to clients A, C, and D. Client A has children and therefore has a relatively lower risk of developing breast cancer. Client C has negative family history and therefore has a relatively lower risk of developing breast cancer. Client D has children and also has a negative family history, and therefore has a relatively lower risk of developing breast cancer.

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? 1 Blurred central vision 2 Increased opacity of the lens 3 Elevated intraocular pressure 4 Changes in retinal blood vessels

3 Elevated intraocular pressure In glaucoma, there is an obstruction of the outflow of aqueous humor due to an intraocular structural damage, which may result from elevated intraocular pressure. Blurred central vision is seen in macular degeneration. Increased opacity of the lens may be seen in cataracts. Retinopathy may result from the changes in retinal blood vessels.

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? 1 Syphilis 2 Iron deficiency anemia 3 Subacute bacterial endocarditis 4 Chronic obstructive pulmonary disease

3 Subacute bacterial endocarditis Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia cause concavely curved nails, called koilonychia. Heart and lung abnormalities such as chronic obstructive pulmonary disease cause clubbing of the nail beds.

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? 1 "Type I immune response to latex has an immediate onset." 2 "Type I immune reaction to latex leads to release of IgE antibodies." 3 "The client's first exposure to latex will cause a type IV allergic reaction." 4 "Type IV immune response to latex occurs after 12 to 48 hours after exposure."

3 "The client's first exposure to latex will cause a type IV allergic reaction." Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

While caring for different clients with respiratory problems, the nurse assesses the different alterations in the breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration? Client, breathing pattern, beats per min 1. regular and abnormally snow, 11 2. regular but abnormally rapid, 25 3. Irregular, alternating apnea and hyperventilation, 12 4. Abnormally shallow for two breaths followed by apnea, 30

3. Irregular, alternating apnea and hyperventilation, 12 In Cheyne-Stokes respiration, a client's breathing pattern is characterized by progressively deeper and faster breathing, that is, hyperventilation followed by apnea. Client 3 exhibits this type of respiration. Client 1's breathing pattern indicates bradypnea, while client 2 exhibits tachypnea. Client 4 is exhibiting Biot's respirations. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

A nurse is assessing several clients. Which client will require parenteral nutrition? 1 A client with brain neoplasm 2 A client with anorexia nervosa 3 A client with inflammatory bowel disease 4 A client with severe malabsorption disorder

4 A client with severe malabsorption disorder A client with severe malabsorption disorder requires parenteral nutrition. Clients with a brain neoplasm, anorexia nervosa, or inflammatory bowel disease will require enteral nutrition.

While assessing the client's skin, 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? 1 Pallor 2 Vitiligo 3 Cyanosis 4 Erythema

4 Erythema Erythema occurs due to an increased visibility of oxyhemoglobin, which is caused by increased blood flow. Pallor is caused by a reduced amount of oxyhemoglobin or a reduced visibility of oxyhemoglobin. Vitiligo is a pigmentation disorder caused by autoimmune diseases. Cyanosis is a bluish discoloration of the skin around the lips; this occurs due to an increased amount of deoxygenated hemoglobin in the blood.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. 1 Back of the neck 2 Back of the hand 3 Palm of the hand 4 On the sternal area 5 Back of the fore arm

4 On the sternal area 5 Back of the fore arm Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? Select all that apply. 1 Slowed neurologic responses 2 Lowered intelligence quotient 3 Long-term memory impairment 4 Forgetfulness about recent events 5 Reduced ability to maintain an erection

1 Slowed neurologic responses 4 Forgetfulness about recent events 5 Reduced ability to maintain an erection Slowing of neurologic responses is part of the aging process. Memory for short-term situations and events is reduced. The ability of the male to attain and sustain an erection is reduced. There should not be a loss of intellectual ability. Memory of long-term experiences and events should not be impaired.

The nurse is caring for a client whose forehead feels warm to the touch. The nurse uses a thermometer and obtains the client's temperature. What is the nurse doing? 1 Validation 2 Assessment 3 Interpretation 4 Documentation

1. Validation The nurse is validating the presence of fever in the client. Validation is the process of gathering more assessment data. It involves clarifying vague or unclear data. Assessment is the first step of the nursing process. It involves collecting information from the client and secondary sources. During interpretation, the nurse recognizes that further observations are needed to clarify information. Data documentation is the last part of a complete assessment. The nurse must document facts in a timely, thorough, and accurate manner to prevent information from getting lost.

A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child? 1 Avoid answering questions. 2 Give the child a list of expectations. 3 Be consistent about established rules. 4 Allow the child to plan the day's activities.

3 Be consistent about established rules. Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions should be answered, but the answers should not be judgmental. A list of expectations may be overwhelming at this age. Parents need to assist children with routine tasks; children this age may not be concerned with time frames. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? 1 "Edema results in the separation of skin from pigmented and vascular tissue." 2 "Pitting edema leaves an indentation on the site of application of pressure." 3 "Trauma or impaired venous return should be suspected in clients with edema." 4 "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

4 "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given." The depth of indentation left after applying pressure to an edematous site determines the degree of edema. A 1+ score is given if the depth of indentation is 2 mm. A 2+ is the score given if the depth of edema indentation is 4 mm. An accumulation of edematous fluid will result in the separation of skin and underlying vasculature. Edema is classified as pitting if the application of pressure on the edematous site will leave an indentation for some time. Edema results from a direct trauma to the tissue or by impaired venous return.

The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight? 1 Do you follow a strict calorie intake? 2 Have you notices any changes in the social aspects of eating? 3 Are you taking diuretics or insulin? 4 Have you noticed any unintentional weight loss in the past six months?

4 Have you noticed any unintentional weight loss in the past six months? Unintentional or undesired weight loss during a certain period of time may indicate a weight change due to a disease, such as gastrointestinal problems. A strict calorie intake in a permitted limit is not related to any disease. Assessing the social aspects of a client's eating habits determines any lifestyle changes that may cause a weight change. Diuretics and insulin may cause weight loss or weight gain; this change is not disease-related.

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? 1 Yin/Yang balance 2 Biomedical belief 3 Determinism belief 4 Magicoreligious belief

4 Magicoreligious belief An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected? 1 Facial nerve 2 Trochlear nerve 3 Abducens nerve 4 Trigeminal nerve

4 Trigeminal nerve The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and motor innervations for facial expressions. The trochlear nerve is involved in downward and inward eye movements. The abducens nerve helps in the eyeball's lateral movement.

The nurse is assessing a young client who presents with recurrent gastrointestinal 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? 1 Educate the client on managing stress. 2 Teach the client to maintain a balanced diet. 3 Instruct the client to have regular health checkups. 4 Ask the client to use sunscreen when working outdoors.

1 Educate the client on managing stress. The client is experiencing job-related pressure, so the nurse should educate the client about managing stress as it is a lifestyle risk factor. Stress threatens both mental health and physical well-being. Stress is associated with illnesses such as heart disease, cancer, and gastrointestinal disorders. The nurse teaches the client to maintain a balanced diet as a primary preventive care to promote health. The nurse should instruct the client to have regular health checkups as a primary preventive measure. The nurse should ask the client to use sunscreen when working outdoors to avoid excess sun exposure and prevent skin cancer.

A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "I should examine the client in noise-free areas." 2 "I should use latex gloves during the physical examination." 3 "I should perform a physical examination in a cool room." 4 "I should leave a combative client alone during a physical examination." 5 "I should wear eye shields while examining a client with excessive drainage."

1 "I should examine the client in noise-free areas." 5 "I should wear eye shields while examining a client with excessive drainage." Clients should be examined in noise-free areas to prevent interruptions. Wearing eye shields while examining a client with excessive drainage helps to reduce contamination. Latex gloves should be used with caution because they may cause allergy in clients who are allergic to latex. A physical examination should be performed in a warm room to minimize discomfort. Combative clients should never be left alone during physical examinations. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Arrange the steps of the bimanual deep palpation technique in a sequence. 1. Relax the sensing hand 2. Place the sensing hand on the skin 3. Apply pressure on the sensing hand 4. Depress the area to be examined to 2 inches 5. Place the active hand on the sensing hand

I don't know the correct order. Explanation was During a deep palpation, the area under the examination is depressed to 2 inches using one or both hands. When both the hands are used for palpation, the sensing hand is relaxed and placed over the client's skin. Then the active hand is placed over the sensing hand and pressure is applied on the sensing hand.

A nurse is preparing to assess the heart of a client during a routine health checkup. Which positioning of the client would be appropriate to assess the murmurs of the heart effectively?

The client should lie in the lateral recumbent position so that the nurse can effectively detect heart murmurs (as shown in figure 2). The supine position provides easy access to the pulse sites (shown in figure 1). The client should be placed in the dorsal recumbent position (figure 3) for abdominal assessment. Sims' position (figure 4) is used so the nurse can assess the rectum and vagina.

Which position is used to assess the extension of the hip joint and buttocks?

To assess the extension of hip joint and buttocks, the client should be positioned in prone position (as seen in the second figure). The dorsal recumbent position (as seen in the first figure) is used for an abdominal assessment. The lateral recumbent position (as seen in the third figure) is used to assess murmurs. The supine position (as seen in the fourth figure) is used to assess the heart, abdomen, extremities, and pulses.

A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse? 1 95 2 85 3 75 4 65

1 95 A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse reassesses the client and notices a pulse deficit of 15. What is the client's apical pulse?

A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed? 1 Lung cancer 2 Cerebrovascular disease 3 Cardiopulmonary alterations 4 Human immunodeficiency virus (HIV) infection

4 Human immunodeficiency virus (HIV) infection A client with a history of persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, or fever may have a human immunodeficiency virus (HIV) infection or tuberculosis. Lung cancer and cerebrovascular disease are risks to be assessed in the client with a history of tobacco or marijuana use. Cardiopulmonary alterations may be present in a client with a persistent cough (productive or nonproductive), sputum streaked with blood, or voice changes.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? 1 Alkalosis 2 Renal failure 3 Hypervolemia 4 Pulmonary edema

4 Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

Which positioning of the hand would be appropriate for assessing turgor in a client?

Using fingers to pinch at sternum. While measuring position, consistency, and turgor, the client's body parts should be grasped lightly with the fingertips as depicted in figure 4. The palmar surface of the hand and finger pads as shown in figure 1 is more sensitive than the fingertips. These should be used to determine position, texture, size, consistency, masses, fluid, and crepitus. While assessing body temperature, the dorsal surface (or back) of the hand should be used as shown in figure 2. In figure 3, the palmar surface of the hand and fingers is used because it is more sensitive to vibrations.

A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients? 1 Axilla 2 Oral cavity 3 Temporal artery 4 Tympanic membrane

2 Oral cavity The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The temporal artery is indicated for rapid temperature measurement. This site is indicated for premature infants, newborns, and children. The tympanic membrane is indicated in newborns to reduce infant handling and heat loss.

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview? 1 Asking about the client's current concerns 2 Ensuring the interview follows a strict agenda 3 Asking questions that promote short responses by the client 4 Telling the client what he or she should expect from the visit

1 Asking about the client's current concerns The nurse should begin the interview by gathering information about the client's current concerns to encourage the client to express his or her chief problems. The nurse then sets an agenda for the interview. However, the nurse must remember that the best interview focuses on the client and not the nurse's agenda. The nurse must ask open-ended questions that allow the client to describe his or her concerns more clearly. The nurse should ask the client to describe his or her healthcare expectations to help the client understand that the nurse is genuinely interested in the client's health. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which clients should be considered for assessing the carotid pulse? Select all that apply. 1 Client with cardiac arrest 2 Client indicated for Allen test 3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand

1 Client with cardiac arrest 3 Client under physiologic shock Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which actions by the nurse help set the stage for a patient-centered interview during the first visit after admission to the healthcare facility? Select all that apply. 1 Close the door after entering the room. 2 Greet the client using his or her last name. 3 Open the curtains to allow plenty of light in the room. 4 Introduce oneself with a smile and explain the reason for the visit. 5 Obtain an authorization from the client after the interview.

1 Close the door after entering the room. 2 Greet the client using his or her last name. 4 Introduce oneself with a smile and explain the reason for the visit. The nurse should maintain the client's privacy by closing the door after entering the room. The nurse should maintain the dignity of the client by greeting the client using his or her last name. Smiling is a positive sign of warmth and immediacy when first establishing the nurse-client relationship. The nurse should explain his or her role in the providing care for the client. The nurse should ensure the room is adequately lit, comfortable, and soothing for the client. The nurse need not open the curtains to allow plenty of light in the room. The Health Insurance Portability and Accountability Act (HIPAA) requires the nurse to obtain an authorization from the client before collecting personal health data.

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? 1 Inflating the cuff too slowly 2 Wrapping the cuff too loosely 3 Applying the stethoscope too firmly 4 Repeating the assessment too quickly

1 Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.

After performing an optical assessment on a client, a primary healthcare provider notices impaired near vision. Which other finding in this client confirms the diagnosis as presbyopia? 1 Loss of elasticity of the lens 2 Increased opacity of the lens 3 Elevated intraocular pressure 4 Noninflammatory changes in eyes

1 Loss of elasticity of the lens Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Increased opacity of the lens is seen in cataracts. Elevated intraocular pressure is associated with glaucoma. Retinopathy causes noninflammatory eye changes. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse is assessing a client with a history of marijuana use. Which long-term effects are associated with marijuana? Select all that apply. 1 Lung cancer 2 Emphysema 3 Heart disease 4 Laryngeal disorder 5 Stroke 6 Chronic nasal irritation

1 Lung cancer 2 Emphysema 3 Heart disease Lung cancer, emphysema, and heart disease are outcomes that may occur due to marijuana use. Laryngeal disorders, stroke, and chronic nasal irritation are associated with the abuse of cocaine but are not associated with marijuana use.

While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit? 1 Radial and apical pulse 2 Apical and carotid pulse 3 Radial and brachial pulse 4 Apical and temporal pulse

1 Radial and apical pulse Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used to measure blood pressure. The temporal pulse is used to assess the pulse in children.

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)? 1 Pregnancy 2 Inactivity 3 Aerobic exercise 4 Tight clothing

2 Inactivity A DVT, or thrombus, may form as a result of venous stasis. It may lodge in a vein and can cause venous occlusion. Inactivity is a major cause of venous stasis leading to DVT. Pregnancy and tight clothing are also risk factors for DVT secondary to inactivity. Aerobic exercise is not a risk factor for DVT. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment? 1 "Does walking for long periods of time increase your pain?" 2 "Does standing without moving decrease your pain?" 3 "Have you had your potassium level checked recently?" 4 "Have you had any broken bones in your lower extremities?"

1. "Does walking for long periods of time increase your pain?" Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose veins often develop vascular-related complications. The nurse should recognize that the relationship of symptoms to exercise will clarify whether the presenting problem is vascular or musculoskeletal. Pain caused by a vascular condition tends to increase with activity. Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause cramping in the lower extremities; however, given the client's health history, vascular insufficiency should be suspected. Previously healed broken bones do not cause cramping and pain. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular

2 Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

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? 1 "I'll clean the inside of my refrigerator and microwave regularly." 2 "I'll wash my cooking utensils and cutting boards with tap water." 3 "I'll wash my hands with warm, soapy water before touching or eating food." 4 "I won't eat any leftovers in my refrigerator after they've been there for 5 days."

2 "I'll wash my cooking utensils and cutting boards with tap water." Eating leftovers that have been kept in a refrigerator for more than 2 days may result in a food-borne illness caused by microbial growth in the food. Cleaning the inside of the refrigerator and microwave regularly will help prevent microbial growth. Cooking utensils and cutting boards should be washed with hot, soapy tap water as a means of preventing food-borne illness. Washing the hands with warm, soapy water before touching or eating food is one technique for preventing food borne illness.

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning? 1 "The client claims to feel fat despite being underweight." 2 "The client experiences recurrent episodes of binge eating." 3 "The client exhibits intense fear of gaining weight although underweight." 4 "The client refuses to maintain body weight over a minimal ideal body weight."

2 "The client experiences recurrent episodes of binge eating." Bulimia nervosa is an eating disorder in which the client has an obsessive desire to lose weight. In this condition, bouts of extreme overeating are followed by fasting or self-induced vomiting. A recurrent episode of binge eating is an indicator of bulimia nervosa. A client claims to feel fat despite being underweight may have anorexia nervosa. Other assessment findings of anorexia nervosa include an intense fear of gaining weight despite being underweight and a refusal to maintain a body weight over a minimal ideal body weight.

A registered nurse is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition requires correction? 1 "The client may have deterioration of the cochlea." 2 "The client may have thinning of the tympanic membrane." 3 "The client may have an inability to hear high-frequency sounds." 4 "The client may have an inability to differentiate between consonants."

2 "The client may have thinning of the tympanic membrane." An older adult who is on aminoglycoside antibiotic therapy is at a high risk of developing ototoxicity. The client with ototoxicity may have thickening of the tympanic membrane, but not thinning of the tympanic membrane. Deterioration of the cochlea may cause older adults to gradually lose hearing. They may experience an inability to hear high-frequency sounds and differentiate between consonants. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

An older adult is found to have a thin white ring around the margin of the iris. What condition does this denote? 1 Cataract 2 Arcus senilis 3 Conjunctivitis 4 Macular degeneration

2 Arcus senilis In older adults, the iris becomes faded and a thin white ring (known as arcus senilis) appears around the margin of the iris. A cataract is a condition involving increased opacity of the lens that blocks light rays from entering the eye. The presence of redness indicates allergic or infectious conjunctivitis. Macular degeneration is marked by a blurring of central vision caused by progressive degeneration of the center of the retina.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially? 1 Encourage the client to exercise during the day. 2 Arrange a referral for a thorough medical evaluation. 3 Explain that this behavior is an attempt to avoid facing daily responsibilities. 4 Identify that the client is describing clinical findings associated with narcolepsy.

2 Arrange a referral for a thorough medical evaluation. This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature? 1 Oral 2 Axilla 3 Temporal artery 4 Tympanic membrane

2 Axilla The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Therefore, obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition should be suspected in this client? 1 Insomnia 2 Cataplexy 3 Narcolepsy 4 Sleep apnea

2 Cataplexy Cataplexy is a condition in which muscle weakness occurs suddenly during times of intense emotion, such as anger, sadness, or laughter. A cataplexic attack may occur at any time during the day. Insomnia is a condition in which a person has chronic difficulty falling asleep. A person with narcolepsy also experiences frequent awakenings from sleep, short periods of sleep or nonrestorative sleep, or some combination thereof. Narcolepsy is a dysfunction of the mechanisms that regulate sleeping and waking states. Sleep apnea is a disorder characterized by a lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, what should the nurse teach the client to do? 1 Limit fluids at bedtime. 2 Change positions slowly. 3 Take the medication between meals. 4 Assess the skin for breakdown daily.

2 Change positions slowly. With aging there is a decreased vasomotor response and diminished elasticity of blood vessels, which therefore do not respond quickly to changes from horizontal to vertical; orthostatic hypotension may occur. Changing positions slowly allows the body to adjust, which prevents dizziness and loss of balance. Usual fluid intake patterns can be maintained. Furosemide should be taken with meals to prevent gastric irritation. It is best to take it in the morning rather than at night so that sleep is not interrupted with the need to void. There is no link between furosemide and skin breakdown.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high frequency sounds 5 Increased ability to tolerate environmental heat

2 Diminished sensation of pain 4 Impaired hearing of high frequency sounds Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

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? 1 Loss of elasticity of the lens 2 Impairment of the extraocular muscles 3 Obstruction of the aqueous humor outflow 4 Progressive degeneration of the center of the retina

2 Impairment of the extraocular muscles Strabismus is a condition where the eyes appear crossed; this condition is caused by the impairment of the extraocular muscles. A loss of lens elasticity may lead to presbyopia, which causes impaired near vision. An obstruction of the aqueous humor outflow may lead to glaucoma. The progressive degeneration of the center of the retina indicates macular degeneration and leads to blurred central vision.

How does the nurse identify an illness as chronic? Select all that apply. 1 The illness is reversible and often severe. 2 The illness persists for longer than six months. 3 The client may develop life threatening relapse. 4 The symptoms are intense and appear abruptly. 5 The illness affects the functioning of one or more systems.

2 The illness persists for longer than six months. 3 The client may develop life threatening relapse. 5 The illness affects the functioning of one or more systems. A chronic illness usually lasts longer than six months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply. 1 Cortisol 2 Thyroid 3 Estrogen 4 Testosterone 5 Progesterone

2 Thyroid 4 Testosterone Body temperature is assessed during physical assessment. An increased basal metabolism rate increases the body temperature. Hormonal imbalances may alter the basal metabolic rate (BMR). Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1 Eggs 2 Yogurt 3 Potatoes 4 Applesauce

2 Yogurt Yogurt, which contains calcium, is digested more easily than milk because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8 oz (237 mL) container depending on how it is prepared. Eggs contain approximately 22 mg of calcium. One potato contains approximately 7 to 20 mg of calcium depending on how it is prepared. Eight ounces of applesauce contain approximately 3 mg of calcium.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1 Sunken eyes 2 Dry, flaky skin 3 Change in mental status 4 Decreased bowel sounds

3 Change in mental status Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.

While assessing a 7-month-old infant, the nurse advises the mother to avoid regular cow's milk. Which of these are valid reasons for the suggestion? Select all that apply. 1 Cow's milk is not tolerated by infants. 2 Cow's milk is a potential source of botulism toxin. 3 Cow's milk increases the risk of milk product allergies. 4 Cow's milk is a poor source of iron and vitamins C and E. 5 Cow's milk is too concentrated for an infant's kidneys to manage.

3 Cow's milk increases the risk of milk product allergies. 4 Cow's milk is a poor source of iron and vitamins C and E. 5 Cow's milk is too concentrated for an infant's kidneys to manage. Regular cow's milk is avoided in infants during the first year of life because it is too concentrated for an infant's kidneys to manage. It also increases the risk of milk product allergies and is also a poor source of iron and vitamins C and E. Honey and corn syrup are potential sources of botulism toxin. Most infants are not allergic to or intolerant of cow's milk. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options are likely related to the situation, but only some of the options may be related directly to the situation.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? 1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization

3 Expectoration of blood After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

The nurse is performing an assessment of the client's reproductive system. Which finding of the past medical history indicates the client is at risk of cervical cancer? 1 Vaginal discharge 2 Ovarian dysfunction 3 Human papilloma virus infection 4 Hematuria and urinary incontinence

3 Human papilloma virus infection A human papilloma virus (HPV) infection increases the risk of cervical cancer. The presence of vaginal discharge may indicate a sexually transmitted disease. A history of ovarian dysfunction may increase the risk of ovarian cancer. The presence of hematuria and urinary incontinence may indicate urinary problems associated with gynecological disorders. Test-Taking Tip: Cervical cancer is the cancer arising from the cervix. Recall the risk factors of cervical cancer and choose the correct answer.

The nurse recognizes that a common conflict experienced by older adults is the conflict between what? 1 Youth and old age 2 Retirement and work 3 Independence and dependence 4 Wishing to die and wishing to live

3 Independence and dependence A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retirement and working may occur but is not common. The conflict between wishing to die and wishing to live may occur but is not common.

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? 1 Phlebitis 2 Infection 3 Infiltration 4 Circulatory overload

3 Infiltration The client with blanched skin, edema of 15.2 cm, cool temperature, and pain at the site of catheterization has symptoms of grade 2 infiltration. Phlebitis is an inflammation of the inner layer of the vein. The findings for this include redness, tenderness, pain, and warmth along the course of the vein starting at the access site. If there is infection, there will be findings that include redness, heat, swelling at catheter-skin entry point, and possible purulent drainage. Circulatory overload can occur if intravenous solutions are infused too rapidly or in great amounts.

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? 1 Action 2 Preparation 3 Maintenance 4 Contemplation

3 Maintenance The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes in to the lifestyle. This stage begins six months after the action has started and continues indefinitely. The action stage lasts for six months from the time the client has incorporated the changes in to the lifestyle. During the preparation stage, the client begins to realize that the advantages of the change outweigh the disadvantages. The client starts making small changes in preparation for major changes the following month. During the contemplation stage, the client is still considering whether to incorporate changes in the next six months.

While auscultating the heart, a healthcare provider notices S3 heart sounds in four clients. Which client is at more risk for heart failure? 1 Child client 2 Pregnant client 3 Older adult client 4 Young adult client

3 Older adult client The S3 is the third heart sound heard after the normal "lub-dub." It is indicative of congestive heart failure in adults over 30 years old. In young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 3 Papules 4 Vesicles

3 Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules, but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care? 1 Meet the clients' family. 2 Read the clients' medical reports. 3 Participate in the bedside rounds. 4 Visit the clients and introduce self.

3 Participate in the bedside rounds. The nurse should participate in bedside rounds with the healthcare team from the previous shift. The nurse who is completing care for one shift prepares the change-of-shift report to communicate client details to the nurse in the next shift. These bedside rounds provide patient-centered care as the nurse shares information about the client's condition, status of problems, and treatment plan for the next shift. The nurse can meet the client's family after obtaining firsthand information from the nurse completing the shift. The nurses review the client's medical reports and discuss treatment plans for the next shift after completing the bedside rounds. The nurse may meet the client during bedside rounds or after obtaining the handover report.

The nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers? 1 Record subjective information in own words. 2 Form judgments through written communication. 3 Record objective information using accurate terminology. 4 Compare data from the physical examination with client behavior.

3 Record objective information using accurate terminology. The nurse should document all objective information using accurate terminology. The nurse should pay attention to the facts and report findings exactly as seen, felt, or smelled. If the information is not specific, another healthcare provider reading the data gets only general impressions. The nurse should record subjective information in quotations, exactly as described by the client. The nurse should refrain from generalizing or forming judgments during documentation. This information is used to form nursing diagnoses, which must be factual and accurate. During validation, the nurse compares data from the physical examination with client behavior.

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? 1 Listeriosis 2 Shigellosis 3 Salmonellosis 4 Staphylococcus

3 Salmonellosis A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paratyphi. The causative organism is usually present in such foods as eggs, salad dressings, and sandwich fillings. A client with listeriosis will experience severe diarrhea, fever, headache, pneumonia, meningitis, and endocarditis 3 to 21 days after infection. The symptoms of shigellosis range from cramps and diarrhea to a fatal dysentery that lasts for 3 to 14 days. Pain, vomiting, diarrhea, perspiration, headache, fever, and prostration lasting for 1 or 2 days are the symptoms of a Staphylococcus infection. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify an incorrect answer.

When nurses are conducting health assessment interviews with older clients, what step should be included? 1 Leave a written questionnaire for clients to complete at their leisure. 2 Ask family members rather than the client to supply the necessary information. 3 Spend time in several short sessions to elicit more complete information from the clients. 4 Keep referring to previous questions to ascertain that the information given by clients is correct.

3 Spend time in several short sessions to elicit more complete information from the clients. Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at their leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

Which assessment should the nurse exclude when dealing with a client with receptive and expressive aphasia? 1 Ask the client to read simple sentences aloud 2 Point to a familiar object and ask the client to name it 3 Test the mental status by asking for feedback from the client 4 Ask the client to respond to simple verbal commands such as "Stand up"

3 Test the mental status by asking for feedback from the client Receptive and expressive aphasia are the two types of aphasia. A client with receptive is unable to understand written or verbal speech. A client with expressive aphasia understands written and verbal speech but cannot write or speak appropriately. A client with aphasia may not have the mental ability to give feedback; asking for feedback is ineffective. Asking the client to read simple sentences aloud is an effective way of dealing with this client. Pointing to a familiar object and asking the client to name it is also effective. A client with aphasia can understand simple verbal commands.

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds? 1 Parietal pleura rubbing against visceral pleura 2 Random, sudden reinflation of groups of alveoli 3 Turbulence due to muscular spasm and fluid or mucus in the larger airways 4 High-velocity airflow through severely narrowed or an obstructed airway

3 Turbulence due to muscular spasm and fluid or mucus in the larger airways Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways. Pleural rub produces a dry or grating quality sound, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.

A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student indicates ineffective learning? 1 "I'll compare the two sides of the body for symmetry." 2 "I'll record quick notes during the examination to avoid delays." 3 "I'll perform painful procedures at the beginning of the examination." 4 "I'll record assessments in specific terms in the electronic or paper record."

3"I'll perform painful procedures at the beginning of the examination." Any painful procedures should be performed at the end of the examination. The two sides of the body should be compared for symmetry, because some asymmetries are abnormal. Recording quick notes during the examination will help prevent delays during the examination. More extensive notes may be completed at the end of the examination. Assessments should be recorded in specific terms in the electronic or paper record. This standard form allows information to be recorded in the same sequence in which it is gathered.

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? 1 Anemia 2 Pregnancy 3 Lung disease 4 Autoimmune disease

4 Autoimmune disease Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

4 Contracture Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints caused by wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles because of a lack of physical activity or a neurologic or musculoskeletal disorder.

An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record? 1 Confirm the client's relationship first. 2 Ask the client's primary healthcare provider. 3 Inform the nurse manager and show the records. 4 Explain that medical health records are confidential.

4 Explain that medical health records are confidential. The Health Insurance Portability and Accountability Act (HIPAA) sets the standards for the protection of the client's health information. The nurse must explain that medical health records are confidential. The healthcare team must be aware of the organization's policies for reviewing a client's medical record for assessment. The nurse need not confirm the client's relationship because the client's medical records are confidential and cannot be shared with anyone unless authorized by the client. The primary healthcare provider cannot authorize the nurse to show the medical records. The nurse cannot inform the nurse manager and show the medical record to persons not involved in direct client care. Healthcare providers share information with reasonable safeguards within the healthcare team for the purpose of providing client care. Test-Taking Tip: The nurse must follow the standards set by The Health Insurance Portability and Accountability Act.

A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate? 1 Ulnar 2 Radial 3 Brachial 4 Femoral

4 Femoral A client with chest pain, shortness of breath, weakness, and vomiting may be experiencing cardiac arrest. In a client with cardiac arrest, the most appropriate place to check the pulse rate is the femoral site, because other pulses may not be palpable at this time. The ulnar site is used to assess the status of circulation to the hand and also used to perform the Allen test. The radial site is commonly used to assess the character of the pulse peripherally and to assess the status of the circulation to the hand. The brachial site is used to assess the status of the circulation to the client's lower arm or the blood pressure is being auscultated. Test-Taking Tip: Assessing the condition of the client will help you determine which site is the appropriate place to check the client's pulse rate.

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? 1 Sustained 2 Relapsing 3 Remittent 4 Intermittent

4 Intermittent An intermittent fever is characterized by fever spikes interspersed with normal temperatures. In this type of fever, the body temperature returns to normal at least once in 24 hours. In the case of sustained fever, there is a constant body temperature greater than 38ºC. In relapsing fever, there is an occurrence of periods of febrile episodes with acceptable temperature values. In remittent fever, the body temperature increases and decreases without returning to normal body temperature levels.

A nurse is discussing weight loss with an obese individual with Ménière disease. Which suggestion by the nurse is most important? 1 Limit intake to 900 calories per day. 2 Enroll in an exercise class. 3 Get involved in diversionary activities when there is an urge to eat. 4 Keep a diary of all foods eaten each day.

4 Keep a diary of all foods eaten each day. Keeping a record of what one eats helps to limit nonconscious and nervous eating by making the individual aware of intake. Limiting calories to 900 per day is a severe restriction that requires a primary healthcare provider's prescription. Exercise causes rapid head movements, which may precipitate a Ménière attack. Although diversionary activities are a therapeutic intervention, the nurse first should make suggestions that help increase the client's awareness of personal eating habits.

What would cause a client to have concavely curved nails?

Conditions such as iron deficiency anemia and syphilis cause concave curvature of the nails, which is called koilonychia (spoon nails). Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis. They are called splinter hemorrhages. Softening of the nail bed and enlargement of the finger tips with flattened nails are signs of clubbing of nails, which is seen in conditions of oxygen deficiency such as in heart or pulmonary diseases, cyanotic heart disease, and chronic obstructive pulmonary disease. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and assistant/patient interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

Which client is at the highest medical risk of coronary heart disease and hypertension? 1. Client A - height (cm) 180 weight (kg) 70 2. Client B - height (cm) 185 weight (kg) 95 3. Client C - height (cm) 152 weight (kg) 56 4 Client D - height (cm) 145 weight (kg) 67

D A body mass index (BMI) higher than 30 is considered obesity and puts the client at a higher medical risk of coronary heart disease, some cancers, and hypertension. Client D (who is 145 cm tall and weighs 67 kg) has a BMI of 31.9, which indicates obesity. This can lead to coronary heart disease and hypertension. Client A has a BMI of 21.6, which indicates a normal weight. Client B has a BMI of 27.77, which indicates that the client is overweight but not obese. Client C, with a BMI of 24.24, is considered as having a normal weight.