HA Exam 1 PrepU

When a client reports a sudden but painless loss of vision in the right eye, which question should the nurse ask?

"Do you have a history of diabetes?"

The nurse is explaining the pathophysiology of pain to a nursing student. The nurse determines understanding of the main concepts when the student nurse makes which of the following statements?

"Nociceptors at the peripheral nerve endings transmit pain."

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature."

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 nurse reviews a 70-year-old client's labs: sodium (Na+) 134 mEq/L (135-145 mEq/L), potassium (K+) 5.8 mEq/L (3.5-5 mEq/L), BUN 40 mg/dL (10-20mg/dL), creatinine 2.5 mg/dL ( 0.5-1.5 mg/dL), hematocrit 33% (35%-45%), hemoglobin 10 g/dL (12-15 g/dL). The nurse is concerned about renal function. What action should the nurse take? Select all that apply.

Assess urine output. Assess client's weight. Determine client's 24-hour intake.

During an interview, how can the nurse best assist the client as the client tells their story?

Avoid interrupting the client.

A nurse is caring for a client who has been intubated and is on a mechanical ventilator. Which of the following pain assessment tools should the nurse use to assess the client's pain?

Behavioral Pain Scale (BPS)

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

Blue

A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?

Chewing betel nuts

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

Chief complaint

The middle layer of the eye is known as the

Choroid layer

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

The nurse notes that a client's gums are swollen and overgrown. What should the nurse include when assessing this client?

Current medications

One technique of therapeutic communication is silence. What does silence allow the client to do?

Decide how much information to disclose

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis

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

Which of the following is not released during the stress response?

Dopamine

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?

Empathy

A client is diagnosed with glaucoma. When performing the ophthalmic exam, what changes should the nurse anticipate finding?

Enlarged physiologic cup that occupies more than half of disc's diameter

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

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.

Gloves Gown Faceshield

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?

External otitis

How would the nursing instructor explain the goal of guided questioning to his or her students?

Facilitating the client's fullest communication

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

When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations?

Gamma-aminobutyric acid

What is the most commonly accepted theory of pain?

Gate control theory

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

Heart rate 115 beats/minute. Blood pressure 180/75.

A registered nurse is working with a nurse practitioner at a local walk-in clinic. The nurse practitioner needs to perform an objective assessment of a client's left ear. What equipment would the RN make sure is in the room? Select all that apply.

High pitched tuning fork Otoscope

A client has anisocoria on examination. Pathological causes of this include which of the following?

Horner's syndrome

When providing client teaching about the ears, what should the nurse be sure to include?

How the client cleans the ears

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

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

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

Kyphosis

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

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

Laryngeal cancer

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?

Near the center

When providing information to a client concerning the client's osteoarthritic, nociceptive pain, the nurse should include which statements about this type of pain? Select all that apply.

Neurotransmitters like endorphins and histamines regulate this pain. The pain is associated with the inflammatory process. This form of pain can be either chronic or acute in nature.

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

On the medial border of the mandible

A nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition?

Otitis externa

A client with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the client hears the tuning fork better on the left. Which of the following is most likely?

Otosclerosis of the left ear

The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies:

Pain is a natural part of aging

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document?

Papilledema

On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?

Paralysis of cranial nerve X (vagus)

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

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply.

Perspiration Increased heartrate Sleeplessness

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data

A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

Pinch a fold of skin on the client's forearm.

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

Spooning

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff Neck

The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?

Signs and symptoms of melanoma

A client reports burning in the perineal area. Which position should the nurse place the client to assess the rectum and vagina?

Sims

When assessing a client with Graves disease, how would you expect the thyroid gland to be?

Soft

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

Connecting the skin to underlying structures is/are the

Subcutaneous tissue

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

Superficial

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 who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want the sister to know their private information

A client 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

Which of the following findings from the health history of a 70-year-old woman with tinnitus is likely most significant to her diagnosis?

The woman takes aspirin 4 times daily to treat her rheumatoid arthritis.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis

What is the primary function of the health care team?

To decide the best overall care

What is the primary purpose of the health history in relation to the eyes?

To identify changes

The nurse understands that malocclusion may be related to what?

Tooth loss

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing?

Tympanic

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the tongue?

Use a square gauze pad to hold the client's tongue to each side.

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with

Vitamin A deficiency

A client tells the nurse that it is difficult to hear normal conversation when in a room with a lot of noise. Which test should the nurse perform to assess the hearing ability of the client?

Weber

The three salivary glands also contain drainage ducts. Which drainage ducts are associated with the submandibular gland?

Wharton's ducts

A nurse cares for a client with optic atrophy. The nurse recognizes that an ophthalmoscopic examination of the eye should reveal which characteristic finding in the optic disc?

White-colored

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible

increased intracranial pressure.

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa.

What information concerning a client's respirations should the nurse record after completing a general physical assessment?

rate, rhythm, and depth of respirations taken for a full minute

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?

tic douloureux