HA - LIPPINCOTT Q's

Gestational hypertension

A 35-year-old bus driver comes to the office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She mentions having heartburn but no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. Her blood pressure is 142/92; urine shows no glucose, protein, or leukocytes. Weight gain is appropriate, with no large recent increases. Fetal tones are 140, and her uterus measures 32 centimetres from the pubic bone. Looking back through her chart, the nurse sees that the client's prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80. What type of blood pressure is this?

Eye drops and sucking on hard candy may used to relieve dryness. (dry eyes, dry mouth)

A client diagnosed with Sjogren syndrome should be given which instructions?

"The area of cramping is close to the area of arterial occlusion."

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?

Parathyroid gland

A client has a dysfunction in one of his glands that is causing a decrease in the level of calcium in the blood. What gland should be evaluated for dysfunction?

systematic desensitization

A client has become increasingly afraid to ride in elevators. While in an elevator one morning, the client experiences shortness of breath, palpitations, dizziness, and trembling. A physician can find no physiological basis for these symptoms and refers the client to a psychiatric clinical nurse specialist for outpatient counseling sessions. Which type of therapy is most likely to reduce the client's anxiety level?

flexion

A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?

Dyspnea

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Incompetent cervix

A client in the sixth week of pregnancy informs the nurse that two of her previous pregnancies ended in spontaneous abortions in the first trimester. The nurse should evaluate the client for the presence of what condition to determine the cause for the previous miscarriages?

Hypertension causes the heart's chambers to enlarge and weaken.

A client is already being treated for hypertension. The doctor is concerned about the potential for heart failure, and has the client return for regular check-ups. What does hypertension have to do with heart failure?

Having his home checked for radon

A client is concerned about developing lung cancer, as he smoked for years. He tells the nurse that he quit smoking last year but wonders if there is anything else he can do to reduce his risk for developing this disease. Which of the following should the nurse recommend?

leukopenia and cardiac toxicity.

A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for

Cervical strain

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

"What does the pain feel like?"

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

Ask the client to raise the leg to the point of pain and then dorsiflex the foot

A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test?

Opiates, which may cause hypoventilation

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

This is called nystagmus to the left.

A client with a history of seizure disorder and taking several seizure medications reports that a friend noted "jumping eye movements." The client describes a sensation of movement at rest since his medications were adjusted upward following a breakthrough seizure several weeks ago. Examination shows that both eyes slowly move to the right then quickly jump to the left. Based on these signs, which of the following is true?

osteomyelitis

A client with insulin-dependent diabetes visits the clinic and complains of painful hip joints. The nurse should assess the client carefully for signs and symptoms of

"You may not be able to use desmopressin nasally if you have nasal discharge or blockage."

A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?

Inform the spouse that the client will be going to the recovery room after the operation, and that someone will notify the unit when the client is ready to come back.

A client's spouse has arrived prior to surgery. When the client is transferred to the operating room, what would be appropriate for the nurse to tell the spouse?

Dorsiflexion and plantar flexion

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

"It is not 100% that you will get breast cancer."

A female client discovers that she has the BRCA1 breast cancer gene. The client asks the nurse if she will get breast cancer. What is the nurse's best response?

Notify the healthcare provider.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Instruct the client to cough forcefully

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Average weakness

A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding?

"It will get better and worse again."

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

Economic abuse

A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse?

Compare this finding to the range of motion to the right side

A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding?

Bradypnea

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Grading

A nursing student who is studying cancer correctly identifies which of the following as a method for classifying cancers?

regular exercise for at least 30 minutes a day

A patient with prehypertension is in the clinic for counseling. All lifestyle modifications are important in preventing or managing hypertension. Which modification would be the best to implement first for this patient?

Knock kneed

A school age client has been diagnosed with genu valgum. What is the other name for this disease?

Is normally smaller than the male heart

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

Asked the client to open and close the mouth Asked the client to jut the jaw forward Asked the client to rock the jaw laterally

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.)

brachial pulse.

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's

Delirium usually lasts only a short time.

An 84-year-old client has returned from the PACU. The client is orientated to name only. The client's family is very upset because before having surgery the client knew the family. The client is diagnosed with delirium. What should the nurse explain to the client's family?

touching each other.

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

herniated intervertebral disc.

An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of

Narrowing or partial obstruction of an airway passage

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

toxoplasmosis

During the assessment of a pregnant client, the nurse learns that the client is passionate about animals. Her home is a shelter for several stray dogs and cats, which she attends to herself, until she can find suitable homes for them. The nurse should inform the client that she is at risk for which complication of pregnancy due to the cats?

5/5

How would the nurse document normal muscle strength?

left midclavicular line at the fifth intercostal space

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers?

Acromioclavicular joint involvement

Phil comes to the office with left "shoulder pain" that is markedly worse when his left arm is drawn across his chest (adduction). Which of the following is suspected?

Educating them about not drinking and driving

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?

some impairment.

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

Difficulty swallowing

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

In the midline of the client's skull or in the center of the forehead.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

"I have to call my doctor so I can get antibiotics before seeing the dentist."

The nurse determines that a client recently diagnosed with subacute bacterial endocarditis understands discharge teaching upon which client statement?

Swaying

The nurse documents "Romberg test positive" on a client's medical record. What did the nurse most likely assess in this client?

previous rib cartilages

The nurse is assessing a client's thorax. Which structures should the nurse identify as articulating anteriorly with the 10th rib?

The pressures that exist within the client's right atrium

The nurse is assessing the jugular venous pressure (JVP) of a 72-year-old client with recent complaints of fatigue, shortness of breath, and swollen ankles. What cardiac phenomena are represented by the oscillations that the nurse observes in the client's internal jugular veins?

The nurse must allow the elderly mother to decide if she wants to leave the situation or not.

The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family?

"If you start to get well and feel better, the skin will return to its normal color."

The nurse is caring for a young adult with hepatitis A. The client is crying and saying that they hate the way they look with yellow skin. Which response is most appropriate?

"I have not seen my parents in 6 months; they live only 30 minutes away."

The nurse is conducting the initial prenatal visit with a patient who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the patient describes isolation?

Encourage the use of safety equipment

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Arterials lines provide continuous beat-to-beat monitoring of arterial pressure Arterial lines provide real-time blood pressure monitoring

The nurse is explaining to a client's spouse why an arterial line is needed to monitor the blood pressure for the hemodynamically unstable client. The nurse determines that the client's spouse understands the information when the spouse makes which statement? Select all that apply.

Renal failure Drug overdose Increased intracranial pressure Severe congestive heart failure

The nurse notes that client's breathing pattern is regular but has periods of deep, rapid breathing followed by periods of apnea. What should the nurse consider as causing this client's breathing patterns? Select all that apply.

Elbow extension

The nurse performs the maneuver shown with the client. What is the nurse assessing?

Abdominal bruit

The nurse suspects an abdominal aortic aneurysm when what is assessed?

Drooping of the left eye

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Perform assessment and screening only when the client is alone in a safe, private environment Be very patient when the client talks Demonstrate compassion, not judgment

What are some basic rules for nurses to follow when assessing for violence? Select all that apply.

Criticizing Ridiculing Threatening a victim's dog

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply.

Have the client cough and then listen again.

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?

Coarse crackles

When auscultating a client's lungs, the nurse hears a sound like Velcro being pulled apart over the client's right middle lobe. How should the nurse document this finding?

Accentuated

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2?

Tension-building

When describing an episode, the victim reports that she attempted to calm her partner down to keep things from escalating. This behavior reflects which phase of the cycle of violence?

Resonance

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

neurological system

When providing teaching to clients in the community, a nurse is accurate in stating that the musculoskeletal system is most closely aligned with which other body system?

Furosemide

Which medication is categorized as a loop diuretic?

Calcium

Which nutrient deficiency should a nurse recognize as placing a client at risk for osteoporosis?

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.

Which of the following is not a true statement about intimate partner violence?

Some experts purport that cultural attitudes influence violence.

Which of the following is true about violence against women?

Bronchitis is characterized by excess mucus production and chronic cough.

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

"Do you experience buzzing in your ears?"

Which question asked by the nurse is assessing problems with tinnitus?

"Are clients allowed to keep drugstore medications at their bedside?"

Which question by a depressed, inpatient, psychiatric-mental health client should the nurse interpret as a potential suicide clue?