Exam 1 Week 1-3
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
"Can you tell me about your sleep problem from when it started until now?"
When documenting assessment data, the nurse should avoid which phrases because of their lack of description? Select all that apply.
"Client presented as well developed." "Client is of average height and well nourished." "Client appears to be in no apparent physical distress."
A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?
"Do you perform any sustained or continually repetitive motions with that arm?"
During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
"How do you manage your stress?"
An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient?
"What is today's date?"
Which of the following questions is most useful in the assessment of a client's diabetes management?
"What is your routine for checking your blood sugar these days?"
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
"What other symptoms occurred during the spell?"
Which question asked by the nurse assesses judgment of the patient?
"What will you do if you feel the need to use cocaine again?"
Which clients are most at risk for depressive symptoms?
-Divorced patients -Females -Chronically ill patients
The nurse is preparing to conduct a mental status examination with a patient. Which areas will the nurse include when assessing the patient's appearance and behavior?
-Posture-Level of consciousness-Facial expression
The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?
1630
Which Glasgow Coma Score indicates the client is in a deep coma?
3
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply.
A description of a large bruise on the client's thigh The client's weight The presence of a lump in the client's breast discovered on palpation
Which of the following clients is most likely to be diagnosed with migraine headaches?
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
Where is the temporal artery palpated?
Above the cheekbone near the scalp line
A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?
Active listening
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Ashen gray
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?
Ask the client to repeat the statement or question.
After assessing a patient's radial pulse, the nurse determines that an apical pulse needs to be assessed. What will the nurse do when assessing the apical rate?
Assess the rate for 1 minute. Place the stethoscope at the apex of the heart.
The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain?
Blood pressure 180/75.Heart rate 115 beats/minute.
A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?
Explaining the reason for taking down notes
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?
Hair Color
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
You should use the bell of the stethoscope when auscultating what type of sounds?
Low-frequency sounds
A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?
Palmar surface
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
A client states, "I feel worse since the nurse gave me that medication." What is the nurse's best action?
Record the information as subjective data.
When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?
Repeat the command louder and in a lower tone of voice
While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?
Speech and language
What is used to gauge central and peripheral nervous system disorders?
Strength of a reflex
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?
Tension pneumothorax
For which client should the nurse wear gloves to provide care?
The client with Clostridium difficile The client with vancomycin-resistant enterococci The client requiring oropharyngeal suctioning
Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the client's breath.
A patient reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?
The release of endorphins
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?
acute
A client presents to the emergency department after falling off a ladder and reports pain in the right shoulder. He says that he has not taken anything for the pain yet. The nurse recognizes this as what type of pain?
acute
A client is experiencing periodic abdominal pain. Which technique should the nurse plan to use immediately after inspecting the area?
auscultation
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's
bone
A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called:
charting by exception
A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?
health maintenance
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
hyperresonance
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
hypothyroidism
Light palpation is most appropriate to assess the
inflamed areas of skin
For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have
knowledge of his or her own thoughts and feelings about these issues.
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
last surgery date validated by adult daughter
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?
malignancy
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Ask the client to:
open the mouth
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?
red cheeks
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?
relieving factors
The nurse is having difficulty auscultating Korotkoff sounds. The nurse should
reposition the stethoscope consider shock be certain there is full skin contact with the bell
Short, pale, and fine hair that is present over much of the body is termed
vellus.
When assessing the client's ability to make sound judgments, what question should the nurse ask?
"How do you plan to pay rent if you lose your job?"
The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?
"It means I need to make sure that all the information I gathered today is reliable and accurate."
Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?
"Let me stress the importance of being medication adherent."
Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
A patient who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return?
"That is called phantom pain, and it is not unusual."
A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure?
50 mm Hg Systolic-diastolic The pulse pressure is the difference between the SBP and the DBP and reflects the stroke volume. Normal pulse pressure is approximately 40 mm Hg. The mean arterial pressure is calculated by adding one third of the SBP and two thirds of the DBP. A mean pressure of 60 mm Hg is needed to perfuse the vital organs.
The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client
A patient who has had a recent stroke
After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make
A referral to the primary health care provider for further evaluation.
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following?
Abstract reasoning
Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?
Acute infection
A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?
Adequate lighting
The nurse is caring for a patient who is experiencing visceral pain. What is this patient's most likely diagnosis?
Appendicitis
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
Arthritis
A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first?
Ask the patient to sip and swallow water.
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?
Atelectasis
The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?
Balance
Universal precautions are primarily designed to protect the health care worker from what?
Blood-borne pathogens
The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion?
CAGE questionnaire
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?
Cardiovascular
A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?
Check the client's vital signs and connect her to a cardiac monitor.
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Client safety increases
While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?
Confabulation
On which health problem should the nurse focus when assessing this client?
Cushing's syndrome
The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?
Cyanotic left lower extremity
During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?
Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.
A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?
Details are often missing
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client
The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?
Do you have any thoughts of wanting to harm or kill yourself?
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
Which of the following is a general procedural rule when performing a complete physical examination?
Examine the right then the left side of the body.
A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?
Explain the importance of the examination and the risks of breast cancer
The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?
Eye opening, and appropriateness of verbal and motor responses.
Primary headaches are more worrisome than secondary headaches.
F
A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?
Faces Pain Scale
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue
A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?
Flight of ideas
A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?
Focused
A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?
Give the prn morphine
Learning about the effects of the illness does what for the nurse and the client?
Gives them the opportunity to create a complete and congruent picture of the problem
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out?
Graves' disease
A nurse rA nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?
Have the patient read a few sentences out loud.
The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants.
At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?
Immediate
The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?
In coma
Which of the following techniques are used in a physical assessment? Select all that apply.
Inspection Palpation Auscultation
How does the client's medical record affect financial reimbursement?
Insurance companies audit client records to ensure that billing is accurate
Prior to inflating the cuff to measure the client's blood pressure, the nurse has palpated the radial artery, inflated the cuff, and noted the point at which the radial pulse disappears. What is the rationale for the nurse's action?
It prevents client discomfort and an auscultatory gap. Estimating systolic pressure by palpation allows the nurse to gauge how high to inflate the cuff, thus preventing over inflation and consequent discomfort, as well as avoiding errors related to an auscultatory gap.
Examples of objective data include all the following except:
Itchy skin
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?
Laboratory tests
The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?
Leave the room to obtain another armband for the client.
A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?
Lie on the back with legs together on the examination table.
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
Light palpation
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?
Limit position changes as much as possible
The nurse understands the importance of performing an accurate pain assessment. In addition to having the patient rate the pain on a pain scale, other things to assess are the following
Location and duration Alleviating and aggravating factors Quality and description
Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients?
Make sure that dress and appearance are professional Do not use facial expressions such as rolling the eyes or looking bored or disgusted Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally
A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?
Marfan's syndrome
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?
Neuropahtic pain
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately.
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?
Ophthalmoscope
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients?
Pain assessment may require multiple methods in order to ensure accurate pain data.
Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture?-Pain is honorable and should be endured.-Pain must be endured to perform gender role duties, but response to it is very expressive.-Pain is part of the preparation for the next life in the cycle of reincarnation.-Pain may be caused by past transgressions and helps to atone and achieve higher spirituality.
Pain must be endured to perform gender role duties, but response to it is very expressive.
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?
Parotid enlargement
The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?
Patient Advocate
The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this patient?
Patient demonstrates flight of ideas
A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?
Progress notes
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
Reduce all environmental noise.
The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?
Retake the blood pressure
The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?
Rigid The older clients artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults.
A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique?
Risk for injury
The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first
ask the client if touching the head is permissible.
The nurse is preparing to document assessment findings in a client's record. The nurse should
avoid slang terms or labels unless they are direct quotes.
A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?
Snellen chart
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases. The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.
Which describes the nurse using the technique of auscultation?
The nurse detects gurgling throughout the abdomen.
Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?
The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg.
Which describes the nurse using the technique of palpation?
The nurse notes increased warmth surrounding an abdominal incision.
Which describes the nurse using the technique of percussion?
The nurse notes resonance over the individual's thorax.
While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?
To clarify
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?
Upon meeting the client and family members
Which action by a nurse demonstrates the correct application of the principles of standard precautions?
Wearing gloves when palpating the tongue, lips, & gums
A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?
Wood's light
During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?
Working
A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?
characteristic symptoms
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?
coping-stress-tolerance
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing
deep palpation.
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing.
The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should
explain the role and purpose of the nurse.
The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by
expressing interest in a neutral manner.
The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?
family violence
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed
focused
A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?
health maintenance
The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?
inspection
While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting
normal changes that occur with the aging process. In the older adult, temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.
Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?
open-ended questions to encourage the client to tell his or her story
The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of
orthostatic hypotension
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?
palpation
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an
parotid gland enlargement.
The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?
percussion
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
percussion
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?
preauricular
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form
prevents missed questions during data collection.
One disadvantage of the open-ended assessment form is that it
requires a lot of time to complete.
While assessing an older adult client's respirations, the nurse can anticipate that the respiratory pattern may exhibit a
shorter inspiratory phase. In the older adult, the respiratory rate may range from 15 to 22. The rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease with aging.
The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as
stage II.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a
tumor-related headache.
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?
use as a drape
The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to
use very basic lay terminology.
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed
working.
A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?
Somatic pain Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments, bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or subcutaneous tissues. Visceral pain is poorly localized and originates in body organs. Phantom pain occurs in an amputated leg for which receptors and nerves are clearly absent, but the pain is a real experience for the patient.
The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action?
Speak to the client face to face.
A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty area assessment form
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
Sternocleidomastoid
When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?
Suicide Ideation
Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?
Systolic pressure
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?
The ability of the arteries to stretch Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood.
A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?
The blood pressure is elevated Many variables affect vital signs, including pain, stress, anxiety, and activity. Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale.
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?
The client
A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.
The client's occupation The client's family history of cancer The client's weight-lifting routine
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?
The notch on its superior edge
The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?
"Has this been having an effect on your ability to carry out your routines and get around your home?"
The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?
"Have you ever had a problem with mental or emotional illness?"
A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record?
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse?
"The electronic medical record is one of the tools we use to keep you safe."
Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?
"There's a very minimal risk of addiction, and controlling his pain is our first concern."
A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?
"They make sure that any microorganisms on my hands do not touch your skin."
Which question is appropriate for a nurse to ask a client to assess the client's recent memory?
"What did you eat for breakfast today?"
Identify the steps in nociception.
1. Noxious stimuli cause a nerve impulse perceived by free nerve endings. 2. The neuronal signal moves from the periphery to the spinal cord and up to the brain. 3. The impulses being transmitted to the higher areas of the brain are identified as pain. 4. Inhibitory and facilitating input from the brain influences the sensory transmission at the level of the spinal cord.
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
45 to 60 The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?
A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.
A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?
Acute pain related to sore throat
A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?
Administer migraine medication
A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?
Age
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?
Anxiety The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact.
After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?
Application of an alcohol-based hand rub
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?
Arthritic changes of the cervical spine
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background?
Ask permission before palpating the head and neck
A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess characteristics
An 86-year-old male patient with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the patient is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?
Assess the patient's temperature by axilla The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac patients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the patient is febrile.
The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?
Assists in friction protection& assists the skin with moisture retention
The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?
At the beginning of the interview
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiological cause for this finding is related to what disease process?
Atelectasis
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?
Attempting to roll the structure up and down and side to side
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
Auscultate with the bell over the lateral lobes
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
Auscultation
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?
Auscultation
How may a nurse demonstrate cultural competence when responding to patients in pain?
Avoid stereotyping responses to pain by patients.
The nurse is reviewing the client's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)
Bowel sounds are hyperactive in all 4 quadrants. Coarse rhonchi noted throughout lung fields Left dorsalis pedis pulse weaker than right.
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination.
Breasts Chest and thorax Cardiovascular Groin, hips, and knees, Shins and ankles
Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?
Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed.
A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?
Broca's aphasia
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data?
Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today.
A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?
Compare objective findings with subjective findings.
Which assessment is most likely performed when a client is admitted to the hospital?
Comprehensive
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?
Cushing's syndrome
A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client?
Date and location of the clients last blood pressure check Onset and character of the clients chest pain A list of all of the client's current medications On the other hand;Objective findings, which are obtained by the nurses direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.
A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding
The nurse would use what part of the hand when assessing temperature during palpation?
Dorsal surface
The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply.
Elimination of redundant data collection by other health care team members Increased likelihood that clients will receive life-saving treatment Potential lowered risk of hospital-acquired infections Ability to link the client's health record to other documents
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?
Ensuring that contact with the skin is maintained
When observing a patient diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following?
Euphoric
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?
Evaluation of insight and judgement
A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:
FACES scale
A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.
Face shield Gown Gloves
The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?
Focused
Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview?
Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan.
A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?
Hallucination
The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?
Have a nurse who is the same sex as the client examine him Clients from conservative religious groups (e.g., Orthodox Jews or Muslims) may require that the nurse be the same sex as the client. The client must still undress and put on an examination gown. It is not likely that the client will want to pray before the examination, and it is not necessary to avoid asking questions regarding his lifestyle.
A nurse receives lab results on a client that show that the client is pregnant. The client says that this is impossible, however, because she is still breastfeeding her 1-year-old son. Which of the following would be appropriate ways for the nurse to validate the positive finding for pregnancy? Select all that apply.
Have the client take a different pregnancy test
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
Heart murmur
A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?
How does the pain influence your overall mood?
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?
Hyperresonant
The nurse explains to the client that smoking has what effect on the body?
Hypertension Vasoconstriction Peripheral vascular disease
A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?
Hypothyroidism
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?
I must take thyroid hormone replacement medication for the rest of my life.
A 27-year-old woman comes to the office with her mother, who tells the nurse that her daughter has had schizophrenia for the last 8 years and is starting to decompensate despite medication. The client states that she has been taking her antipsychotic and is doing fine. Her mother retorts that her daughter has become quite paranoid and gives an example. She says that her daughter goes and gets the mail every day and then microwaves the letters. The client agrees that she does this but only because she sees the mailman flipping through the envelopes. She says that she knows he's putting anthrax on the letters. Her mother turns to her and says, "He's only sorting the mail!" Which best describes the client's abnormality of perception?
Illusion
A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?
Isolated systolic hypertension The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant.
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?
It provides quick access to abnormal findings.
A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?
Kicking
A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?
Knee-chest
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
Limiting abbreviations to those approved for use by the institution.
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?
Lithotomy
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?
Maintain a professional distance during assessment.
A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumours about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have?
Manic episode
A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight.
During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?
Memory and attention
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation
A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
Minimum data set
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Narrative notes
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?
Neuropathic Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.
Which of the following should the nurse do before conducting a physical examination of a client?
Obtain and check needed equipment. Wash hands. Identify ways to ensure client privacy.
Where should a nurse place the hands to palpate the submandibular lymph nodes
On the medial border of the mandible
A nurse is collecting data on a client's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "When did this pain start?" Which component of symptom analysis does this question represent?
Onset
A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates the client will respond to stimulation in what manner?
Opens eyes to a loud voice and answers with confusion
Which of the following is an average normal temperature in centigrade for a healthy adult?
Oral: 96.6 - 99.5
The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.
Orientation, memory, and cognitive function
A nurse is caring for a patient who is ambulating for the first time after surgery. Upon standing, the patient complains of dizziness and faintness. The patient's blood pressure is 90/50. What is the name for this condition?
Orthostatic hypotension Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.
The nurse places the following device on a client's finger. What information is this device providing to the nurse?
Oxygen saturation Oxygen saturation is the percentage to which hemoglobin is filled with oxygen. Pulse oximetry is a noninvasive technique to measure oxygen saturation of arterial blood. This device is not used to measure pulse, temperature, or respiratory rate.
During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?
Palpation
Which would the nurse recognize as an example of visceral pain?
Pancreatic pain Gallbladder pain Liver pain
What is the nurse's best defense if a client alleges nursing negligence?
Patient's record
A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?
Previous injuries to the head and neck
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart?
Psoriasis
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?
Range of motion of the neck
An approximate reading of core body temperature can be taken at various anatomic sites. Which of the following would not be a correct place to take a core body temperature?
Rectum. For the body to function on a cellular level, a core body temperature between 36.5°C and 37.7°C (96.0°F and 99.9°F orally) must be maintained.
The patient comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?
Referred pain Referred pain originates from a specific site, but the person feels the pain at another site site along the innervated spinal nerve. An example is cardiac pain that the person experiences as arm pain and indigeston. Visceral pain originates from abdominal organs. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. Somatic pain originates from skin, muscles, bones, and joints.
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope
A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
Resonance
What would be the expected tone elicited by percussion of a normal lung?
Resonance
After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?
Risk for suicide
You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?
Routine recalibration of the device Follow the guidelines listed, and advise your patients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.
The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?
SBAR
client comes to the cardiovascular intensive care unit (CVICU) directly after a three-vessel coronary artery bypass graft (CABG). The client's orders state "maintain systolic blood pressure >90 but <120." How does this order affect the monitoring of the client's blood pressure?
The nurse will assess blood pressure more frequently to ensure that it does not go beyond the ordered limits Vital signs reflect health status, cardiopulmonary function, and overall body function. They are called vital signs because of their importance as indicators of physiological state and response to physical, environmental, and psychological stressors. Changes in vital signs often indicate changes in health. Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. It would not be appropriate to monitor this client's BP every hour or every 4 hours or to delegate the taking of this client's BP to a patient care assistant.
A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?
Time
To make a legal entry into the medical record, the nurse must document what?
Time of the assessment
While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?
To determine whether a structure is filled with air or fluid or is a solid structure
A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?
To have up-to-date information on which to base clinical decisions
Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?
To see the client before the client assumes a social face or behavior If possible, try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to see the client before the client assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain before the client, knowingly or unknowingly, may mask it.
A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?
Transduction
How should the nurse place the ear of an adult when using the otoscope?
Up and back
An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Verify the data by having another nurse come in to perform the percussion.
A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?
Visceral pain
Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?
Visceral pain
A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?
Vision and hearing
A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?
Wash hands before examination in the examination room.
The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data?
When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed?
The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?
assists the nurse in formulating appropriate subjective questioning The General Survey chapter provides an overview of the nurse's initial client assessment prior to exploring each system in detail. The objective observation of the client begins with the first moments of the encounter and continues throughout the history and physical examination. The nonverbal cues collected during the general survey enable the nurse to select appropriate subjective questions for the individual client to garner more information. While the remaining options are true statements concerning a general survey, none demonstrate the primary purpose for the collection of objective information.
When assessing the client for pain, the nurse should-doubt the client when he or she describes the pain.-assess for the presence of physiologic indicators (such as diaphoresis, tachycardia, etc.), then believe the client.-assess for underlying causes of pain, then believe the client. -believe the client when he or she claims to be in pain.
believe the client when he or she claims to be in pain.
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram
An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of
decreased body metabolism Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.
A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behaviour has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighbourhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings?
Schizophrenia
The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care as a consequence of what disorder?
Schizophrenia
A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
Skinfold calipers