Final Exam Health Assessment
Which question asked by the nurse is assessing problems with tinnitus?
"Do you experience buzzing in your ears?"
A client recently recovering from shingles states that he suffers from pain and burning along his back and sides where the lesions are dried and crusted and requests pain medication. What is the nurse's best response?
"Rate your pain on a 0-10 scale; 0 being no pain and 10 the worst."
A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement?
-Use sunlight, if possible, to inspect the skin • Have the client remove his toupee • Wear gloves when palpating lesions • Keep the room door closed
Documentation
-needed to communicate- what did we assess, what did we find -reassess/provide good continuity of care
The client is experiencing severe sepsis. What assessment finding would the nurse expect?
1+ pulses
What visual acuity indicates blindness?
20/200
The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?
A Glasgow Coma Score of 15 would indicate no impairments. All other scores indicate some degree of impairment up to and including deep coma.
Which of the following assessment findings suggests a problem with the client's cranial nerves?
A client's extraocular movements are asymmetrical and she complains of diplopia. Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia.
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?
A hard nodule composed of uric acid crystals
Medical Diagnosis
A medical diagnosis is treated by the physician and is usually stated as a disease process.
The peritoneum is a serous membrane that contains which of the following?
A parietal layer.
An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls?
A patient with vertigo
What is the most important physical sign of acute pericarditis?
A pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. The pericardial friction rub is heard most frequently during expiration and increases when the patient is upright and leaning forward.
Risk Diagnosis
A risk diagnosis indicates that the patient does not currently have the problem, but is at high risk for developing it.
A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:
A wellness diagnosis indicates that the patient has the opportunity for enhancement of a health state.
Which is true of women who have had a unilateral mastectomy?
A woman who has had breast cancer remains at high risk for recurrence, especially in the contralateral breast. The mastectomy site should be carefully examined for local recurrence as well.
A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?
Acute pain
The nurse is attempting to assess pain in a nonverbal, very lethargic client. The client just arrived back to his room after an MRI scan and appears restless. There are no visitors in the room with the client. What is the nurse's best action?
Administer a trial dose of analgesia.
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:
After entering the anterior nares, air enters the vestibule and passes through the narrow nasal passage to the nasopharynx.
What do retinal abnormalities include?
Age-related macular degeneration
A nurse notes that a client looks much older than his chronologic age. Which of the following conditions would most likely contribute to this appearance?
Alcoholism
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?
All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination.
The nurse has learned that after completing the assesment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?
Analyze the data
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 can cause the trachea to be pushed to one side from its midline position.
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?
Burning, tingling
What can the nurse use to learn new information and add to their knowledge base?
Clinical experience
While the nurse examines a patient's pupillary response to light in the right eye, the pupil in the left eye is constricted. What does this finding suggest to the nurse?
Consensual reaction (when pupil constricts in opposite eye)
You note that your patient has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes?
Dehydration
Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?
Dermis
The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?
Diagnostic reasoning skills are required to interpret data accurately.
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?
Equalizes the pressure in the middle ear with atmospheric pressure.
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.
When using the PERRLA acronym, the nurse is assessing which body part(s)?
Eyes
A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?
Facial hair on females = Cushing's disease. Hirsutism, or facial hair on females, is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones.
T/F Primary headaches are more worrisome than secondary headaches.
False
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?
Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted patients; no additional follow-up is needed.
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
Funnel chest Pectus excavatum or funnel chest occurs when the sternum and adjacent cartilages are significantly sunken inward or dented.
A client complains of abdominal pain that is worsened when he lies on his back. The nurse should suspect which of the following as the underlying cause?
Gastroesophageal reflux is worsened when supine
The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?
Heart failure
The thoracic cavity contains which of the following organs?
Heart, lungs, most of esophagus
While interviewing a client, the nurse asks her what her typical daily diet consists of. Which of the following is associated with an increased risk for breast cancer?
High-fat diet
While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?
Hyperactive bowel sounds referred to as "borborygmus" are heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling."
A nurse is discussing summer plans with a 16-year-old girl. The client tells the nurse she will be working her first job. The nurse recalls that, according to Erikson, which of the following is the primary task of adolescents?
Identity vs. Role confusion
A middle-aged client reports difficulty in reading. Which action by the nurse is appropriate to test near visual acuity using a Jaeger reading card?
Instruct the client to hold the card 14 inches away from eyes
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?
Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal Apparatus
When examining a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to:
Look up
A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially
Malignant melanoma.
Malnutrition can be too much or too little nutrition. What can malnutrition do in the human body?
Malnutrition interferes with wound healing, increases susceptibility to infection, and contributes to an increased incidence of complications, longer hospital stays, and prolonged confinement of patients to bed.
A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?
Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being
A mother brought a child in to the Emergency Department stating that she thinks her child's appendix has ruptured. Before any diagnostic tests can be done, the father comes in and says, "I don't want anything done, we will take the child to our church where prayer will heal him." What is an appropriate action by the nurse at this time?
Notify the ethics committee
One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?
Nurses perform all these functions for clients. Nevertheless, the best way to provide safe client care is to continually communicate with all members of the health care team.
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
Observe for a decrease in jugular venous pressure
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?
Ongoing or partial assessments help to determine any major changes from the baseline data.
A nurse performs the Allen's test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test?
Opening the hand into exaggerated extension may cause persistent pallor, giving a false-positive test; hence, the nurse should ensure that the client's hand is not opened in exaggerated extension. To perform the test, the nurse is required to have the client rest the hand palm side up and make a fist, use the thumbs to occlude the radial and ulnar arteries, and keep both arteries occluded and have the client release the fist.
As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Orientation to what is lost first and what is lost last?
Orientation to time is usually lost first and orientation to person is usually lost last.
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.
Jewish Orthodox practices
Orthodox or Kosher involves no mixing of meat with dairy; separate cooking and eating utensils are used for food preparation and consumption. Kosher laws include special slaughter and food handling. "Keeping Kosher" is predominantly an Orthodox practice. No pork products or shellfish are allowed in the dietary restrictions. -have healthcare professional of same sex do assessment
When assessing a client's terminal hair distribution, the nurse inspects all the following areas except:
Palmar surfaces. The palms are one of the few areas not covered with hair, while the limbs, vertex, and eyebrows all have terminal hair present.
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
Perform a focused assessment
A client is diagnosed with heart failure. The nurse would most likely assess the sputum color as which of the following?
Pink.
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
Pleurisy Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing.
Which terms refers to the progressive hearing loss associated with aging?
Presbycusis
When Erikson published his theory in 1963, he predicted the end of childhood was what?
Puberty
What action should the nurse implement when assessing the ear of an adult client using an otoscope?
Pull the auricle out, up and back
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?
Red, bulging, with an absent light reflex
A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?
Red, swollen, with purulent discharge
During the physical examination of a client's breast, which finding should the nurse recognize as a possible indication of a malignant tumor?
Retraction of nipples Retracted nipples are indicative of a malignant tumor. A malignant tumor has fibrous strands attached to the breast tissue and the fascia of the muscles. As the muscle contracts, it draws the breast tissue and skin with it, causing dimpling or retraction.
A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
Rinse mouth with antifungal medication as prescribed - oral candiasis
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 patient. The nurse should be aware of what risk when using this assessment technique?
Risk for injury
SOAP Documentation
S= subjective O= objective A= assessment P= plan
What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?
Suggest methods and provide resources to assist with smoking cessation
The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.
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?
The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved.
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
The client record serves as a legal document recording the client's health status and any care the client receives.
What is the primary function of the health care team?
The health care team meets to collaborate on patients and decide the best overall care. This occurs throughout the lifespan, from the inception of life until death
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?
The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees
The sigmoid colon is located in this area of the abdomen: the
The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon.
Where are the heart and great vessels located in the human body?
The mediastinum, between the lungs above the diaphragm
Which action by the nurse is consistent with Weber's test?
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss.
A patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient?
The submental lymph nodes are located near the region of the chin and should be assessed in the patient.
A patient is having their tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response?
The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat.
What are nurses able to detect through the health assessment?
Through the health assessment nurses are able to detect areas in need of health adjustments.
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive
Which of the following statements is true regarding Piaget's concept of transductive thinking?
Transductive thinking can be used by formal operational thinkers. In transductive reasoning, thinking occurs from specific to specific; if two things are alike in one aspect, the child thinks they are alike in all aspects.
T/F Rovsing's sign is a test of referred rebound tenderness in appendicitis.
True Pain in the RLQ during pressure in the LLQ is a positive Rovsing's sign. It suggests acute appendicitis.
An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible
Tuberculosis or pneumonia
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Unequal expansion of chest (lung collapse)
During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue?
Use a square gauze pad to hold the client's tongue to each side
Which patients are most at risk for depressive symptoms?
Watch carefully for depressive symptoms, especially in patients who are young, female, single, divorced or separated, seriously or chronically ill, or bereaved. Those with a prior history or family history of depression are also at risk
A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test?
When performing the Trendelenburg test, the nurse should elevate the client's leg for 15 seconds to empty the veins. The tourniquet should be put on after leg elevation. The client should stand upright with the tourniquet on the leg. The client is not asked to sit with the leg hanging down when performing the Trendelenburg test.
A client presents at the cardiology clinic for a checkup 6 months after a myocardial infarction. The client is known to have a bundle branch block that delays activation of the right ventricle. What would the nurse expect to hear when auscultating heart sounds?
Wide splitting occurs when a bundle branch block delays activation of the right ventricle. It also can happen when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle.
Spirituality can best be described as
a source of inner strength
The clinic nurse is teaching a young female college student about risk factors for developing breast cancer in an attempt to impress upon her the importance of doing breast self-examinations. Included in the teaching should be which of the following (Select all that apply.)
early menarche • late pregnancies • late menopause
Breast cancer
greater risk in caucasian, hawaiian, and african american women
Osteoporosis risk
greater risk in small framed people such as asians
Skin cancer risk
light skinned
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should
position the client 609.6 cm (20 ft) away from the chart. Snellen used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.
Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to
promote harmony between health and spirituality.
Each of Erik Erikson's central developmental tasks is composed of opposing viewpoints. Erikson thus theorized that
the person must accomplish a healthy balance between these opposing viewpoints in order to progress to the next psychosocial stage.
A nurse inspects the gums and teeth of a client and notices a brownish tint to the teeth. What questions should the nurse ask the client to determine the cause of this finding? Select all that apply.
• "How many cigarettes do you smoke daily?" • "Do you drink a lot of coffee or tea?"
A family member of a patient recovering from a traumatic brain injury asks the nurse what can be done to prevent future head injuries. What should the nurse instruct this family member?
• Wear helmets when playing all contact sports. • Never drive under the influence of alcohol. • Avoid the use of throw rugs.
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 hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply. a) Use past clinical experience to build knowledge. b) Use rationale to support opinions and decisions. c) Avoid considering the client's cultural background when analyzing data. d) Hypothesize one diagnosis before diagnosing the client. e) Reflect on thoughts before reaching a conclusion.
* Use rationale to support opinions and decisions. • Reflect on thoughts before reaching a conclusion. • Use past clinical experience to build knowledge.
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area the nodes drain.
A nurse is talking to an 8-year-old boy who is proud of himself for washing his hands before every meal this past week. The nurse recognizes that this client is eager to please the nurse and his own parents. The nurse realizes that this boy is most likely in which level of moral development, according to Kohlberg?
This boy appears to be in the conventional level of moral development according to Kohlberg, in which one maintains external expectations of others.
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?
This represents flight of ideas, because the ideas are connected in some logical way.
A nurse is working with an elderly Jewish man who is experiencing excruciating pain from a severe burn that he suffered earlier in the day. Given his cultural background, which expression of pain should the nurse most expect to find in this client?
Those of a Jewish background tend to believe that pain should be expressed openly, with much complaining.
A patient just died, and the nurse is preparing the body for the funeral home. The patient practiced Judaism and a rabbi was present at the time of death. The nurse is careful to do which of the following to honor the patient's religious beliefs concerning death?
Those who follow Judaism upon death recite psalms and the last prayer of confession at the bedside. At death, arms are not crossed; any clothing or bandages with the patient's blood should be prepared for burial with the person. It is important that the whole person be buried together.
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?
120/55 mmHg A drop in both the systolic and diastolic readings of 20 mmHg and more indicates orthostatic hypotension. A drop of less than 20 mmHg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.
Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?
2 × 2 gauze pads are used during tongue examination.
At what percent of weight over ideal weight is a person considered obese?
20% above ideal weight
A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?
40. A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation
The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?
5-8 L/min
A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?
A goniometer is a device used for measuring the degree of flexion and extension available at a joint.
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?
A grey-white line along the gum line is seen in cases of lead poisoning.
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
A large amount of exudate in the sinuses. Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses.
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?
A left temporal hemianopsia When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
Which of the following wounds is most likely attributable to neuropathy?
A painless wound on the sole of the client's foot, which is surrounded by calloused skin Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain.
How many steps can you climb before you get short of breath?" is an example of what kind of question?
A question that elicits a graded response
A nursing student is caring for an older Hispanic adult. The nurse's preceptor asks the student what would be an important assessment to make to provide quality nursing care for this client. What would be the student's most appropriate response?
A specific example of a comprehensive nursing assessment that attends to both social and cultural dimensions is the transcultural assessment
A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?
A very loud murmur that can be heard with the stethoscope partly off the chest is graded as Grade 5. A Grade 1 is very faint and a Grade 6 can be heard with the stethoscope entirely off the chest. A Grade 2 is quiet but heard immediately on placing the stethoscope on the chest.
The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?
A weak pulse can indicate hypovolemia, shock or decreased cardiac output
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
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 resasoning
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 is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours.
Actual Diagnosis
An actual diagnosis indicates that the patient is currently experiencing the stated problem or has a dysfunctional pattern
While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?
Anteroposterior to lateral diameter An important component of chest inspection is assessment of the anteroposterior diameter versus the transverse diameter. This is achieved by viewing the client from the back and side.
A patient comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The patient appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this patient?
Anxiety related to lesions on body
When palpating the female breast for masses, the nurse distinguishes which of the following characteristics as a potentially cancerous mass
Any mass that is firm, fixed, poorly circumscribed, and qualitatively different from surrounding tissue strongly suggests cancer.
A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?
Are you taking any meds on a daily basis? A persistent cough without any other respiratory symptoms could be related to new medications, especially beta blockers or angiotensin converting enzyme (ACE) inhibitors, which are prescribed for hypertension.
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 in cervical spine. Arthritic changes in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities.
As a nurse becomes more proficient and comfortable in his or her role, what increases?
As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence.
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 head and neck
A mother of a small child calls the clinica and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?
Ask the mother how long the tubes have been in place Ear tubes generally fall out spontaneously in 2-5 years after placement, and the membrane most often closes. The client does not need manual removal in the office or operating room unless the child is experiencing problems.
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
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?
Assist the client to walk as soon and as often as possible. Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation.
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?
Asthma This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke.
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 is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12 or niacin
A client who is an active outdoor swimmer recently received a diagnosis of discoid systemic lupus erythematosus. The client visits the clinic for a routine examination and tells the nurse that she continues to swim in the sunlight three times per week. She has accepted her patchy hair loss and wears a wig on occasion. A priority nursing diagnosis for the client is
Because the client has the diagnosis of discoid systemic lupus erythematosus and continues to swim in the sunlight three times per week she is at risk for a health problem. The diagnosis risk for ineffective health maintenance related to deficient knowledge of effects of sunlight on skin lesions is the most accurate for this client.
Universal precautions are primarily designed to protect the health care worker from what?
Blood borne pathogens
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
COPD An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention.
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?
Chronic hypoxia. Clubbing of the nails indicates chronic hypoxia. Clubbing is identified when the angle of the nail to the finger is more than 160 degrees.
Circumstantiality
Circumstantiality is characterized by the client speaking "around" the subject and using excessive detail, though thoughts are meaningfully connected
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? a) Blood pressure was 130/85 3 months ago but 120/80 today. b) Client's weight was 200 lb 3 months ago but 125 lb today. c) Resting heart rate was 65 bpm 3 months ago but 70 bpm today. d) Client's temperature was 98.6°F 3 months ago but is 99.2°F today.
Client's weight was 200 lb 3 months ago but 125 lb today.
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action?
Closure of the semilunar valves (aortic and pulmonic valves), causes sound S2, signals end of systole
A nurse is assigned to care for a client who practices Orthodox Judaism. After reading the client's medical record, the nurse takes time to talk with the client about how to make his hospital stay more comfortable. The nurse admits to the client that she is not familiar with Orthodox Judaism but would like to learn more. The nurse is in which stage of cultural awareness?
Conscious incompetence
The components of a nail examination include
Contour, consistency and color
Which of the following assessment findings is most congruent with chronic arterial insufficiency?
Cool foot temperature and ulceration on the client's great toe, thin shiny atrophic skin
DAR Notes
D= Data (patient admited for hypoglycemia = shaky, glucose = 65 mg/dL) A= Action = patient given 120 mL orange juice R= response = after 15 min, blood glucose measured 120 mg/dL, shakiness resolved
Derailment
Derailment, or loosening of associations, has more disconnection within clauses.
A nurse is assessing a client from India who complains of panic, sexual dysfunction, fatigue, weakness, and loss of appetite. Which culture-bound syndrome should the nurse suspect in this client?
Dhat is a culture-bound syndrome of India and includes symptoms of panic, sexual complaints, fatigue, weakness, loss of appetite, guilt, and sexual dysfunction with no physical findings.
During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?
Diabetes
While palpating a client's nipples, the nurse notes a clear discharge from one breast. This unilateral discharge could best be explained by which of the following?
Discharge from one breast may indicate benign intraductal papilloma, fibrocystic disease, or cancer of the breast. Discharge may be seen in endocrine disorders and with certain medications (i.e., antihypertensives, tricyclic antidepressants, and estrogen), but it would tend to be bilateral in these cases.
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 is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant?
Dullness
In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices?
Erik Erikson's eighth and last stage applies to late adulthood. The task for the older adult is ego integrity vs. despair. The older adult with ego integrity has come to terms with his or her life choices. He or she comes to recognize that the life that has been lived was the only possible one and that it had dignity, which the person is ready to defend against physical or economic threats.
The nurse completes her interview of a 39-year-old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor. The nurse would be able to conclude that this client is in which of the following psychosocial developmental stages?
Generativity
The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the patient's pain, what is the most appropriate pain assessment tool for the nurse to use?
FACES pain scale
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
The size and shape of the breasts in females are related to the amount of
Fatty tissue
The nurse finds the client's abdomen to be distended. The nurse recognize distention may be caused by what? Select all that apply.
Feces, fluid, fetus, fat, gas
Which technique is appropriate for the nurse to use to palpate a client's breast?
Flat pads of three fingers
A patient comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the patient asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse's best response?
Fluid overload from elevation of legs, which shifts the fluid present there to the body's core. The excess fluid cannot be pumped through the heart and suddenly accumulates in the lungs, causing dyspnea.
A nurse assesses the parallel alignment of a client's eyes by testing the corneal light reflex. Where should the nurse shine the penlight to obtain an accurate result?
Focused on the bridge of the nose When testing the corneal light reflex, the nurse should shine the light toward the bridge of the nose. At the same time, the client is instructed to stare straight ahead. This facilitates a parallel image on the cornea. The eye response upon shining the light toward the eye may interfere with the assessment.
A patient with a body mass index of 28 wants to lose weight. What can the nurse recommend to this patient?
General recommendations for the control of obesity in adults include setting a weight loss goal of ½ to 1 pound per week. A more rapid weight loss does not lead to better results, which could be the case if the patient consumes no more than 500 calories each day. This restricted level of caloric intake could also lead to nutritional deficiencies. A 10% weight reduction over 6 months is recommended.
The functional part of the breast that allows for milk production consists of tissue termed
Glandular
While examining a client's breasts, a nurse notices milky discharge from the nipple. The client explains that she recently had a baby and is currently breastfeeding. The nurse understands that which type of tissue in the breast is responsible for allowing milk production?
Glandular tissue constitutes the functional part of the breast, allowing for milk production.
What is the most common type of hyperthyroidism?
Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic.
The nurse is assessing a 15 year old male and finds soft, fatty enlargement of breast tissue. The nurse would document this as what?
Gynecomastia is breast enlargment
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
Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema. Emphysema: a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness.
A 43-year-old Asian female 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. intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism.
A nurse assesses the spirituality of a client who is terminally ill with pancreatic cancer. Which of the following is the best rationale for this action, from the nurse's perspective?
Identifying possible coping mechanisms. Religion and spirituality have been related to a client's well-being in the face or illness and disease. They can be powerful coping mechanisms when a client is facing end-of-life issues.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
If a nurse palpates an enlargement of the thyroid, auscultation should be performed over the lateral lobes with the bell of the stethoscope to assess for the presence of a bruit.
The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should
If you are interviewing a client who smokes, avoid lecturing condescendingly about the dangers of smoking. Also, avoid telling the client that he or she is foolish and avoid projecting an attitude of disgust. This will only harm the nurse-client relationship and will do nothing to improve the client's health. The client is, no doubt, already aware of the dangers of smoking. Forcing guilt on him is unhelpful. Accept the client, be understanding of the habit, and work together to improve the client's health. This does not mean you should not encourage the client to quit; it means that how you approach the situation makes a difference. Let the client know you understand that it is hard to quit smoking, support efforts to quit, and offer suggestions on the latest methods available to help kick the smoking habit.
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?
Imbalanced Nutrition.
The nurse is planning care for a patient recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development?
Immobility. Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis.
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?
Impending stroke
When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
In addition to avoiding abbreviations that are prohibited by the Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided.
Cutaneous Pain
In cutaneous pain, the discomfort originates at the skin level.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed?
In the midline of the client's skull or in the center of the forehead.
A hospitalized patient is found on the floor of the room, kneeling on a small rug praying. The nurse understands that this ritualistic behavior is common in which religious practice?
In the religion of Islam, prayer occurs five times a day. Prayers are done facing east toward the sacred place of Mecca and often occur on a prayer rug with ritual washing of hands, face, and feet prior to prayer
A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?
Inspect nostrils with otoscope. Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose.
A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs. He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?
Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem
The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflect these guidelines?
Joint Commission Standards for Pain Management.
To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment?
Jugular venous pulse
An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?
Kiesselbach plexus is the most common site of epistaxis.
A client reports severe pain in the left lower quadrant of 3 days' duration. How should the nurse conduct palpation of the abdomen due to this history?
LLQ is palpated last . The nurse should avoid touching tender or painful areas until last and reassure the client. The area needs to be assessed for the presence of abnormal findings and should not be avoided
Learning about the effects of the illness does what for the nurse and the patient?
Learning about the effects of the illness gives the nurse and the patient the opportunity to create a complete and congruent picture of the problem.
The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?
Lymphedema
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of
Macules
A nurse cares for a client with a distended abdomen due to peritonitis. Which parameter should the nurse measure to assess improvement?
Measure abdominal girth
A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?
Measure calves is what you should do first. The nurse should complete the inspection process before going on to the other physical assessment techniques. After inspecting asymmetry of the legs, the nurse should measure the calves to determine the exact difference in diameter. Then the nurse can palpate for edema and temperature and notify the health care provider with the information once it is all gathered.
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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation is a likely cause of this condition which manifests as sudden headache, neck pain with stiffness, and fever.
A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur?
Mitral
A nurse is assessing a Hispanic woman. Which of the following diseases is this client most at risk for due to her cultural group?
National Cancer Institute data for 2004 to 2008 show that the highest incidence of cervical cancer in the United States is among Hispanics and African Americans, and the lowest is among Asian/Pacific Islanders, Native Americans, and Alaskans. Hispanics are not at greater risk, as a group, for osteoporosis (greater risk in small-framed people such as Asians), skin cancer (greater risk in light-skinned people), or breast cancer (greater risk in Caucasian, Hawaiian, and African American women)
A nurse begins an interview with a client who is a Native American. The nurse should recognize that this client will display what type of behavior when responding to questions or engaging in conversation with the nurse?
Native Americans and people from Eastern countries tend to look down to show respect to the person talking. Some African Americans look away when being talked to but give a very high level of eye contact when speaking. Hispanic Americans males, and peoples of some other cultures, tend to stand with the face slightly away from the other speaker.
An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?
Nodes are delimited on palpation. If a node is palpable, it is important to describe the following characteristics: location—which lymphatic chain and where along that chain is the node; size—in mm or cm; consistency—how hard or soft is the node; mobility—delimitation—there should not be any matting together of lymph nodes.
Nodules
Nodules are 0.5-2 cm and circumscribed; tumors are greater than 1-2 cm and do not always have sharp borders. Examples of nodules include a keloid. Extend deeper into dermis than papule
A nurse is filling out an incident report after an older adult patient fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when patient falls occur?
Orthostatic Hypotension
A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?
Otitis externa
During a breast assessment the nurse finds scaly lesions at the nipple with a lump behind the nipple. The nurse suspects what?
Paget disease
During the breast examination of a client, the nurse notes red, scaly, and crusty areas over the areola. The nurse understands that this appearance of the skin is due to what type of breast condition?
Paget's disease
Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric patients? a) The developing neurological system children transmits less pain than in older patients. b) A numeric scale should be used to assess pain if the child is older than 5 years of age. c) Pharmacologic pain relief should be used only as an intervention of last resort. d) Pain assessment may require multiple methods in order to ensure accurate pain data.
Pain assessment may require multiple methods in order to ensure accurate pain data.
The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?
Patient may have been abused. Multiple ecchymoses may be from repeated trauma (falls), clotting disorder, or physical abuse.
The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to
Perform Weber's test if the client reports diminished or lost hearing in one ear. The test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead
How does the nurse differentiate a pleural friction rub from a pericardial friction rub?
Pericardial friction rubs can be differentiated from pleural friction rubs by having the client hold the breath. If present without breathing, the rub is pericardial. Turning the client to the right side and auscultating either the base of the heart or the upper back do not differentiate between pericardial and pleural friction rubs.
A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client?
Peripheral arterial disease. Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD)
The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition?
Place bell over apex on left side. This mid-diastolic murmur is associated with an opening snap and has a low-pitched, rumbling quality. Heard best with the bell over the apex with the patient turned to the left
The nurse recognizes that a child is most likely in Piaget's preoperational stage of development when observing which activity?
Pretend play
Photoreceptors of the eye are located in the eye's
Retina. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. Client states he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
Risk for injury
Scotomas
Scotomas are specks in the vision or areas where the client cannot see; therefore, this is a common and concerning symptom of the eye.
Jacob, a 33-year-old construction worker, complains of a "lump on his back" over his scapula. It has been there for about 1 year and is getting larger. He says his wife has been able to squeeze out a cheesy textured substance on occasion. He worries this may be cancer. When gently pinched from the side, a prominent dimple forms in the middle of the mass. What is most likely?
Sebaceous cyst. This is a classic description of an epidermal inclusion cyst resulting from a blocked sebaceous gland.
The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner.
Small bowel obstruction.
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
A nursing student is caring for his first patient who is of Latin American descent. Before entering the room, the student reviews how this patient perceives space. The student realizes that when he speaks to the patient, he needs to do which of the following?
Stay close together when talking
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
The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised
The nurse is caring for a 4-week-old postoperative patient. The most appropriate pain assessment tool would be the:
The Face, Legs, Activity, Cry, Consolability Scale is the appropriate pain assessment tool for a 4-week-old postoperative patient. This tool measures pain using observable behaviors as pain indicators.
A nurse uses the Glasgow Coma Scale to assess a client's response to stimuli. The client receives a score of 10. Which of the following is the client's status?
The Glasgow Coma Scale is useful for rating one's response to stimuli. The client who scores 10 or lower needs emergency attention. The client with a score of 7 or lower is generally considered to be in a coma.
The nurse is caring for Hindu client. What should the nurse include in the assessment phase?
The Hindu culture often have shrines that represent their beliefs. These shrines may be in the home or evening in the hospital. Accommodations should be made for the client to pray in a private setting.
The results of a client's Rinne test are as follows: bone condcution > air conduction. How should the nurse explain these findings to the client?
The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds.
The nurse is using the Visual Analog Scale to assess pain of an adult patient. The nurse instructs the patient to:
The Visual Analog Scale is a 100-mm line with "no pain" at one end and "worst possible pain" at the other.
As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?
The client and the examiner see the examiner's finger at the same time.
How should the nurse perform blunt percussion over the liver?
The correct way of performing blunt percussion is to place left hand on right lower rib cage, strike it with ulnar side of right fist. Placing the hand on the mid of rib cage would not enable the nurse to assess the liver.
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 patient'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?
The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope.
A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?
The nurse assesses a decrease in the carotid pulses (1+ is considered weak) and a weak radial pulse is present. The client also has a murmur. These findings allow the nurse to confirm the diagnosis of Ineffective Tissue Perfusion.
Why is the nurse always reassessing the patient for changes?
The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession.
A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?
The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner.
A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?
The nurse should document the tonsillar grading as 1+ because the tonsils are just visible. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+
A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?
The nurse should firmly compress the lower portion of the varicose vein with one hand. The nurse should ask the client to stand, not sit, on a chair for the examination. The second hand should be placed 6 to 8 inches, not 3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the fingers in the upper hand
A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?
The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner.
The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?
The nurse should review the client's current orders to confirm which IV solution should be infused. Hanging the IV bag that was left on the pole is assuming that the assigned nurse hung the correct IV solution. Nurses should always verify orders themselves. Obtaining a bag of the current IV solution to hang is assuming, rather than verifying, as well. Discontinuing the solution is not necessary while verifying the orders.
A 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
An elderly client presents to the health care clinic for a routine physical examination. The client tells the nurse that is has become difficult to cut his toenails because the nails have become hard and brittle. The client also states that his feet are always cold and he must wear socks to bed. Which nursing diagnosis can be confirmed from this data?
The nursing diagnosis of Risk for Impaired Skin Integrity can be confirmed because of the presence of thickened toenails that may cause damage to the epidermis of the skin on the lower extremities.
A patient of Islamic faith is being educated on a new diagnosis of diabetes mellitus. The patient asks no questions during or after the session. What does the nurse understand may be the reason for the patient not asking questions?
The patient considers asking questions of the nurse a sign of mistrust in her abilities.
The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following?
The second set of identified pitfalls occurs during the analysis phase. Cues may be clustered yet unrelated to each other. For example the patient may be quiet and withdrawn, and the nurse may assume that the patient is grieving because her husband recently died.
A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound?
The stomach is air filled, and the normal sound heard over an area that is air filled is tympany. This is a very loud, high-pitched, drumlike sound.
A client explains that she has been feeling stress at work lately because her boss has been asking her to perform accounting measures that went against her conscience. According to Freud, which component of the personality is associated with the conscience?
The superego, often referred to as the moral component of personality (or in lay terms, one's "conscience"), provides feedback to the person regarding how closely the person's behavior conforms to the external value system.
A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?
The vestibular portion of the inner ear
During the health interview of the head and neck, the patient tells the nurse about having a lump in the neck. Which question would the nurse ask to assess manifestations associated with this lump?
To assess manifestations associated with the lump in the neck, the nurse would ask if the patient has difficulty swallowing.
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
The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following?
Too many or too few data. Pitfalls decrease the reliability of cues and decrease diagnostic accuracy. One set of pitfalls inculdes too many or too few data, unreliable data, or invalid data and an insufficient number of cues available to support the diagnosis.
T/F The nurse tests the six cardinal directions to test extraocular movement of the eye.
True
T/F When the spleen enlarges, the nurse would not be surprised to percuss dullness over the stomach.
True
The nurse is explaining to the patient that the physician wrote an order to administer a blood transfusion for severe anemia. The patients emphatically refuses the blood transfusion. What religious practice should the nurse inquire about?
Use of blood products and blood transfusions is accepted by most religions except for Jehovah's Witness.
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data.
When planning care for a patient with an inner ear infection, the nurse will include interventions to address which potential problem?
Vertigo The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's
Vesicles are circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn
When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient?
Vitamin B
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
a foreign body obstruction
During the interview of an adult client, the nurse should a) provide the client with information as questions arise. b) complete the interview as quickly as possible. c) read each question carefully from the history form. d) use leading questions for valid responses.
a) provide the client with information as questions arise.
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for
acromegaly
The meibomian glands secrete
an oily substance to lubricate the eyes
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's
bone- dense tissue
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
Ataxia is best described as
impaired ability to coordinate movement
A 50-year-old patient tells the nurse that she enjoys babysitting her grandchildren while their parents are attending night classes at the local college. She also shares that on many days she volunteers at a neighborhood food bank. Erikson would most likely place this patient as
positively resolving a sense of generativity versus stagnation. The central task of generativity vs. stagnation is focused on the younger generation—often children (whether one's own or those of others), family, community, mentoring others, helping to care for others, discovering new abilities/talents, continuing to create, and "giving back."
To assess an adult client for possible appendicitis and a positive psoas sign, the nurse should
raise the client's right leg from the hip.
The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.
seeing things as only right or wrong
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to
sit in an upright position
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision?
snellen E
