EAQ Set # 5
The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? 1 Strong 2 Bounding 3 Expected 4 Diminished
A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.
Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order. Correct 1. Immune system response is triggered Incorrect 2. Body temperature is increased Incorrect 3. The set point of the hypothalamus is raised Incorrect 4. Heat loss responses are initiated Incorrect 5. Pyrogens are destroyed
A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. 1 Axilla 2 Fingers 3 Ear lobes 4 Forehead 5 Upper thorax
Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.
An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 1 Industry versus inferiority 2 Identity versus role confusion Correct3 Generativity versus stagnation 4 Autonomy versus shame/doubt
The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.
What is the sequence of techniques used while assessing the abdomen? Correct 1. Inspection Correct 2. Auscultation Incorrect 3. Palpation Incorrect 4. Percussion
The order of an abdominal assessment begins with inspection of the contour, symmetry, and surface motion of the abdomen. The nurse will note any masses, bulging, or distention. The second step is auscultation, which is done before palpation to reduce the chance of altering the frequency and character of bowel sounds. The third step is percussion, which is used to assess kidney inflammation. The fourth step is palpation, which detects areas of abdominal tenderness, distention, or masses.
A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved? 1 Mastoid 2 Occipital 3 Submental Correct4 Pre-auricular
The pre-auricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.
The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? 1 Frostbite 2 Heatstroke 3 Hypothermia 4 Hyperthermia
Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.
A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings? Correct1 False high reading 2 False low diastolic reading 3 False high systolic reading 4 False high diastolic reading
If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.
The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent
In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.
What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? 1 Age and sex 2 Physical and physiological status 3 Intelligence and economic status 4 Previous experience and cultural values
Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.
While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate? 1 Relapsing 2 Sustained 3 Remittent 4 Intermittent
Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.
What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. Correct 1 Ptosis and blurred vision Incorrect 2 Agitation and hyperactivity Incorrect 3 Confusion and disorientation 4 Increased sensitivity to pain Correct 5 Decreased auditory alertness
Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.
A client seeking advice regarding contraception asks a nurse to explain how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? 1 "It covers the entrance to the cervical os." 2 "The openings to the fallopian tubes are blocked." 3 "The sperm are kept from reaching the vagina." Correct4 "It produces a spermicidal intrauterine environment."
Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD inflames the endometrium, damaging or killing sperm and preventing fertilization and/or implantation. A levonorgestrel-releasing IUD damages sperm and causes the endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical os. The IUD does not act by blocking the openings to the fallopian tubes. Preventing sperm from reaching the vagina is the function of a condom.
Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow. Incorrect 1. Self-esteem Incorrect 2. Self-actualization Incorrect 3. Safety and security Incorrect 4. Physiological needs Incorrect 5. Love and belonging needs
Maslow's hierarchy of needs helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person's level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one's individual potential and allows for continual discovery of self.
A nurse advises the father of a toddler to encourage pretend play in the child. What are the reasons behind this advice? Select all that apply. 1 To help improve sleeping habits 2 To help develop fine muscle skills Correct 3 To help the child become more creative Correct 4 To help the child develop social problem-solving skills Correct 5 To help the child learn to understand other points of view
Pretend play helps children become more creative, develop skills in solving social problems, and to learn to understand other points of view. Parents should help their children slow down before bedtime to develop better sleeping habits. Scribbling and drawing help a child develop fine muscle skills.
After assessing a 2-year-old child, the nurse concludes that the child lacks physical readiness for toilet training. Which assessment finding supports the nurse's conclusion? Incorrect1 The child wets two diapers per day. Correct2 The child stays dry for 1 hour during the day. 3 The child behaves impatiently with soiled diapers. 4 The child sits on the toilet for 6 minutes without fussing.
The child develops voluntary control of the anal and urethral sphincters by the age of 22 to 30 months, allowing the child to remain dry for at least 2 hours. If the child is unable to remain dry for 2 hours, it indicates a lack of physical readiness for toilet training. The number of wet diapers decreases as the child attains physical readiness for toilet training. Therefore, if a 2-year-old child wets two diapers per day, it is a normal finding. If the child becomes impatient with soiled diapers and has the desire to change the diapers immediately, it indicates psychological readiness for toilet training. Sitting on the toilet for 5 to 8 minutes without fussing or getting off also indicates psychological readiness for toilet training.
A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? 1 Pons 2 Medulla 3 Thalamus 4 Hypothalamus
The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.
What is the correct order of phases a client experiences in the event of a change in body image following an illness? Correct 1. Shock Correct 2. Withdrawal Correct 3. Acknowledgement Incorrect 4. Rehabilitation Incorrect 5. Acceptance
When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgement phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use prosthesis, or change lifestyles or goals.
Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order. Incorrect 1. The set point of the hypothalamus is raised Incorrect 2. Immune system response is triggered Correct 3. Body temperature is increased Correct 4. Pyrogens are destroyed Correct 5. Heat loss responses are initiated
A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.
The nurse is gathering a client's health history. Which information does should the nurse classify as biographical information? Select all that apply. 1 Symptoms Correct 2 Client's age Incorrect 3 Family structure Correct 4 Type of insurance Correct 5 Occupation status
Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client's age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.
An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client's developmental level?: 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia
Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.
How does the World Health Organization (WHO) define "health"? 1 A condition when people are free of disease 2 A condition of life rather than pathological state 3 An actualization of inherent and acquired human potential Correct4 A state of complete physical, mental, and social well-being
The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.
While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? 1 Heroin 2 Atropine 3 Morphine 4 Pilocarpine
The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.
What would be the respiratory rate in two-year-old child? 1. 20 2. 30 3. 40 4. 50
The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.
Which sites would be safe and inexpensive for temperature measurement? Select all that apply. 1. Skin 2. Oral 3. Axilla 4. Rectal 5. Tympanic membrane
The skin and axilla are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? 1 Increased skin elasticity and a decrease in libido Incorrect2 Impaired fat digestion and increased salivary secretions Correct3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties
With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.
A client in labor states that she feels the urge to push. After a vaginal examination, the nurse determines that the cervix is 10 cm dilated. Which breathing pattern does the nurse encourage the client to use? 1 Expulsion breathing 2 Rhythmic chest breathing 3 Continuous blowing-breathing 4 Accelerated-decelerated breathing
Expulsion breathing (pushing) should be encouraged when the cervix is fully dilated; doing it before 10 cm of dilation may cause cervical trauma and fatigue. Rhythmic chest breathing is used in the early active phase of labor for relief of discomfort; it is not used to overcome the desire to push. A breathing pattern consisting of continuous blowing can assist in overcoming the urge to push when a client is in transition. Accelerated-decelerated breathing is not effective in overcoming the urge to push.
What is the appropriate blood pressure of a 12-year-old client? 1 95/65 mm Hg 2 105/65 mm Hg Correct3 110/65 mm Hg Incorrect4 119/75 mm Hg
A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.
The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter? Correct1 "I'm not exactly sure how an epidural works." 2 "I understand that the epidural might or might not take my pain away." 3 "I signed the consent form for an epidural at my last clinic appointment." 4 "I'm aware that the epidural could cause my contractions to slow down."
A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman received information about analgesia and anesthesia earlier in her pregnancy. Nurses play a significant role in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary healthcare provider for further explanation. There are three essential components of an informed consent. First, the procedure and its advantages and disadvantages must be thoroughly explained. Second, the woman must agree with the plan of labor pain management as explained to her. Third, her consent must be given freely without coercion or manipulation from the healthcare provider.
Which statement best describes a diagnostic label? 1 It is a condition that responds to nursing interventions. 2 It describes the essence of the client's response to health conditions. 3 It describes the characteristics of the client's response to health conditions. 4 It is identified from the client's assessment data and associated with the diagnosis.
A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client's response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client's response to health conditions. The related factor of a nursing diagnosis is identified from the client's assessment data and associated with the diagnosis.
Which of the following is a description of the percussion technique? 1 Listening to sounds that the body makes 2 Using the sense of touch to assess and collect data 3 Carefully looking for abnormal findings 4 Tapping the skin with the fingertips to vibrate underlying tissues
Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.
Which type of breathing pattern alteration is manifested with hypercarbia? 1 Eupnea 2 Tachypnea 3 Hypoventilation 4 Kussmaul's respiration
Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul's respirations.
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. Correct3 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.
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.
The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? Correct1 Data collection Incorrect2 Data validation 3 Data clustering 4 Data interpretation
The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? 1 The nurse notes nonverbal signs of discomfort. 2 The nurse observes the client's position in bed. 3 The nurse asks the client to explain the surgery. 4 The nurse asks the client to rate the severity of pain.
The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client's positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.
The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process? 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation
The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client's health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client's response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client's care. The nurse selects interventions (nursing and collaborative) individualized to each of the client's nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client's response and whether the interventions were effective. The nursing process is dynamic and continuous.
