EAQ: Mastery achievement
A client reports sleeping until noon every day and taking frequent naps during the rest of the day. Initially, which action would the nurse take?
Arrange a referral for a thorough medical evaulation.
Which step would the nurse take FIRST when preparing a concept map for as assigned client?
Arrange cues into clusters that form patterns
While preforming a physical assessment of a client, the nurse notices patchy areas with pigmentation loss on the skin, hands, and arms. With which probable cause would the nurse associate this findings?
Autoimmune disease
Which skin condition would the nurse associate with a client whose skin pathophysiology involves increased visibility of oxyhemoglobin caused by an increase blood flow due to capillary dilation?
Erythema
Which condition would the nurse suspect when an older adult is unable to see nearby objects?SATA.
Hyperopia. Presbyopia.
A client in the second trimester of pregnancy arrives at the clinic for a general health checkup,including a pelvic examination. For which position would the nurse prepare the client?
Lithotomy position
After performing an optical assessment on a client, a primary health care provider notices impaired near vision. Which other finding would confirm the clients diagnosis as presbyopia?
Loss of elasticity of the lens.
When an African American client with renal failure reports the illness is a punishment for sins, which cultural health beliefs is the client communicating?
Magicoreligious belief
Which action would the nurse take when a client is receiving total parenteral nutrition (TPN)?
Monitor for hydration. Monitor weight daily. Monitor vital signs every 4 hours. Discard any solution after 24 hours. Check the expiration date of the solution before administration.
While assessing a client, the nurse identifies adventitious breath sounds. Upon further evaluation, the nurse finds loud, low pitched, rumbling coarse sounds during inspiration. This sound is clearly heard while the client is coughing. Which condition would the nurse associate with these sounds?
Muscular spasms in the larger airways.
Which feature distinguishes nursing diagnoses from medical diagnoses? SATA
Nursing diagnoses involve the client when possible. Nursing diagnoses involve the sorting of health problem within the nursing domain. Nursing diagnosis involve clinical judgement about the clients response to health problems.
Which nurses action is important for establishing good communication with the client who has impaired hearing?
Obtaining the clients attention before speaking
While auscultating the heart, a health care provider notices S3 heart sounds in four clients.Which client has the HIGHEST risk for heart failure?
older adult clients
Which client would experience impaired near vision? SATA.
A client with presbyopia. A client with hyperopia.
The nurse administers an older adult client's medications via gastrostomy tube in the long-term care setting. Which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? SATA.
A. absence of bowel sounds B. presence of abdominal distention C. residual capacity exceeding 300 mL D. positive guaiac test of abdominal contents E. seepage of feeding around tracheostomy ALL OF THESE
While assessing a client who experienced an accident, the nurse found the client was unable to move her eyes laterally. Damage to which nerve led to this condition in the client?
Abducen nerve
Which condition would the nurse suspect when an older adult has a thin white ring around the margin of her iris?
Arcus senilis
When assessing risk factors, which questions would the nurse ask a client who has developed pneumonia?
Are you diabetic
A client reports difficulty breathing and the nurse auscultates bilateral wheezing in the anterior upper lobes. Which potential rationale would explain this sound?
High velocity airflow through an obstructed airway.
When providing care for a client with diarrhea, in which clinical indicatory would the nurse anticipate a decrease?
Tissue turgor
While assessing a client, the nurse finds inflammation of the skin at the bases of the clients nails. Which even or disorder would the nurse associate with the reason behind this conditions?
Trauma
The nurse documents auscultation of coarse rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which condition would the nurse associate with these sounds?
Turbulence due to muscular spasm and fluid or mucus in the larger airways
Which Korotkoff sound represents the diastolic pressure for children?
fourth
While providing postoperative care for a client, who had surgery to repair a deviated septum, the nurse would monitor for which complication associated with this type of surgery?
Expectoration of blood
Which site would the nurse prefer to assess for determing the turgor of an older adult? SATA.
On the sternal area. Back of the forearm.
Which nurses statement indicates the clients interview is coming to a close?
" I have just one more question for you."
For a client who arrived at the health care facility for an appointment, which nurses actions would be beneficial during the assessment interview?
Ask about the clients current concers
During a fall risk assessment, which action would the nurse take after learning the client experienced a recent fall?
Assess the circumstances of the fall, including feelings and settings
While preparing to teach a client about self injection of insulin, which nurses action would increase the effectiveness of the teaching session?
Assess the clients barriers to learning self-injection techniques.
Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration?
Change in mental status
Which client would the nurse suspect as having an increased risk of hyperlipidemia?
Client with corneal arcus. Client with yellow lipid lesions on eyelids
Which nurses action would help set the stage for a client centered interview?
Close the door after entering the room. Greet the client using his or her last name. Introduce oneself with a smile and explain the reason for the visit.
A client reports right ear hearing loss. When preforming a Weber test with a tuning fork, the client hears the sounds better with the right ear. Which condition would the nurse suspect from these results?
Conduction hearing loss
For the client with a closed chest tube drainage system connected to suction, which assessment finding required additional evaluation by the nurse?
Constant bubbling in the water-seal chamber
Of which cranial nerve does the nurse assess the function when asking the client to shrug their shoulders and to turn their head against passive resistance?
Cranial nerve XI
When the nurse completes a thorough assessment to identify the reason for a clients anxiety, which critical thinking attitude is involved in this situation?
Discipline
While assessing the eyes of a client, health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?
Elevated intraocular pressure
For an older adult client, admitted to the health care facility following a stroke, which action would the nurse take when the clients cousins asks to see the clients health record?
Explain medical health records are confidential.
A client, admitted to the hospital with chest pain, reports shortness of breath, weakness, and vomiting. The nurse suspects acute coronary syndrome (ACS). At which site would the nurse check the clients pulse rate?
Femoral
Upon entering the examination room of a client and their spouse, which action would the nurse take when the client is withdrawn and appears fearful of the spouse?
Find a way to interview the client in private
Which condition would the nurse suspect upon finding a bluish coloration of the skin during an assessment?
Heart disease
After an eye assessment, the nurse finds that the clients eyes are not focusing on an object simultaneously and appear crossed. Which potential cause would the nurse associae with this condition?
Impairment of the extraocular muscles
When teaching a health awareness class, which situation would the nurse teach as being the HIGHEST risk factor for the development of a deep vein thrombosis (DVT)?
Inactivity
For which clinical indicator would the nurse question a prescription for gastric lavage?
Increased serum bicarbonate level
The nurse, providing care for a client who underwent cardiac catheterization, found the clients skin was cool, tender to touch, with edema of 15.2 cm (1-6 inches) at the site of catherterization. Which condition would the nurse suspect?
Infiltration
When measuring a clients blood pressure during a physical examination, which error will result in false high diastolic reading?
Inflating the cuff too slowly
Which type of fever does a client have when experiencing fever spikes combined with a normal body temperature occurring at least once day?
Intermittent
An assessment of an 89 year old client yields a history of sever congenital spinal deformity. Which condition would describe the nursing findings?
Kyphosis
A client with a family history of diabetes mellitus has been following a diet regimen recommended by the dietitian and walking for 45 minutes daily for the past 8 months. Based on the transtheoretical model of health behavior change, which stage would the nurse document for this clients?
Maintenance
The nurse just arrived on the unit for his shift. Which action would the nurse take FIRST to collect an initial set of data about the clients assigned to the nurses car?
Participate in the bedside rounds.
The nurse documents data that was gathered during an assessment in a clients medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?
Record objective information using accurate terminology.
For a client admitted with metabolic acidosis, which two body systems would the nurse assess for compensatory change?
Respiratory and Urinary
During orientation, a registered nurse review content about the third heart sounds (S3) with recently employed nurses. Which participants statement indicates ineffective learning?
S3 is normal in pregnant women.
A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting for 5 days. Upon further assessment, the primary health care provider finds the symptoms occurred after the borne disease would the provider suspect in this client?
Salmonellosis
Based on current research, when asked about spanking as a disciplinary technique, which response would the nurse utilize?
Spanking is strongly suggestive of negative role behavior.
Which factor would cause the nurse to identify an illness as chronic?
The illness persists for longer than 6 months. The client may develop a life threatening relapse. The illness affects the functioning or one of one or more systems.
A client developed an allergic reaction during a physical assessment. Which nurses statement indicates a lack of understanding?
Type IV immune reaction to latex occurs with first exposure.
While collecting a clients urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia?
Urinary tract infection
Which nurses action would prevent aspiration when administering medications through a nasogastric tube?
Verify placement of the nasogastric tube