Individ Health Assess. Midterm Questions
What does demarcated mean?
Separated
How do you calculate pack years?
# of packs per day x # of years smoked
What does patency mean?
Being open, expanded or unobstructed
A client brought to the emergency department after a diving accident tells the nurse, "I think I hit a rock, and now I can't feel my arms or legs." A rapid physical assessment shows no other apparent injuries. What initial nursing intervention is essential to the safety of this client? A. Send for a CT scan immediately. B. Draw a basic metabolic panel to check for infection. C. Maintain immobilization of the spine until it is cleared of injury. D. Log roll the client to remove backboard, reducing pressure on the spine.
C
A client has been prescribed tetracycline for acne. What is the most important point the nurse should make in client teaching about this medication? A. The client may experience phototoxicity B. The medication may interfere with the menstrual cycle C. The client may experience photosensitivity D. The medication may be inactivated by antacids
C
A client presents with a diagnosed C. albicans infection. What assessment should the nurse ask initially to determine the possible cause of the infection? A. "Are you allergic to nystatin?" B. "When did the symptoms begin?" C. "Are you currently prescribed an antibiotic?" D. "Have you experienced these symptoms before?"
C
A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response? A. "Take the newborn to the emergency room to be evaluated." B. "Bring your newborn to the clinic immediately." C. "This may be normal in newborns." D. "This is a sign of a nutritional deficiency. What are you feeding your newborn?"
C
A person who is pregnant is being screened for adequate intake of calcium and vitamin D. Which of the following tools is most appropriate for the nurse to administer? A. 24-hour recall B. 3-day diet history C. Food frequency questionnaire D. Comprehensive nutrition assessment
C
A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne. What would be the nurse's best response? A. Acne is caused by the apocrine glands B. Acne is caused by decreased activity of the sebaceous glands C. Acne is caused by the impedance of sebum secretion onto the skin's surface D. Acne is caused by enlarged apocrine glands
C
What does delimited mean?
Connected
A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound? A. Hyper-resonance B. Dullness C. Resonance D. Tympany
A
A female teenager comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the client also reports that hair is growing on her upper inner thighs. What would the nurse suspect? A. Endocrine disorder B. Ovarian dysfunction C. Hepatic dysfunction D. Chronic nephrosis
A
Amber and Manuel Carr need to be taught that 2-month-old Emily A. needs auditory, visual, tactile, vestibular, and gustatory stimuli each day in short periods when she is awake. B. will benefit from as much attention as possible. C. needs to have stimuli limited to basic needs when she is seeking to get attention. D. will benefit from long periods of rest and sleep to allow the brain to develop.
A
The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client? A. The client exhibits no signs or symptoms of infection B. The client changes position every 2 hours C. The client keeps the area clean and dry D. The client knows prevention measures for pressure ulcers
A
The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client? A. Hirsutism B. Rapid heart rate C. Sensitivity to cold D. Muscle cramps
A
The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as: A. Vitiligo. B. erythema. C. pallor. D. tinea corporis.
A
The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized? A. A neuropathic ulcer can develop without feeling it. B. Skin collagen decreases with age. C. Wound healing becomes prolonged with age. D. Hydration alters skin turgor.
A
The nurse's response to Emily's length, which is 66 cm (26 in.) now at age 12 months and was 51 cm (20 in.) at birth, is to be A. concerned because Emily should have grown 25 to 30 em (10 to 12 in.) by now. B. unconcerned because Emily should have grown 15 cm (6 in.) by now. C. concerned because Emily should have doubled her birth length by now. D. unconcerned because Emily should have grown 7.6 to 10 cm (3 to 4 in.) by now.
A
What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis? A. Friction rub B. Decreased breath sounds C. Sibilant wheeze D. Stridor
A
When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following? A. Softly repeat the words "one-two-three" B. Say "ninety-nine" C. Cough each time the stethoscope is moved D. Say the letter "e"
A
Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? A. There is loss of involuntary respiratory control. B. The client will respond negatively to increased stimuli. C. There is an increased level of carbon dioxide in the blood. D. The client's oxygen levels in the blood will be increased.
A
Select all actions that are acceptable under the HIPAA Privacy Rule. (Select all that apply.) A. Communicate report with the next nurse during change of shift. B. Communicate with the primary care provider about a patient's change in assessment. C. Consult in the hall with the instructor about the patient's abnormal findings. D. Describe patient assessment findings to a colleague in the cafeteria.
A, B
Which of the following are nutritional cardiac risk factors? Select all that apply. A. Waist circumference of >40 in. in males B. Waist circumference of >35 in. in females C. A waist-to-hip ratio ≤1.0 D. Significant unintentional weight loss of 10% or more in 180 days
A, B
What physical characteristics should the nurse describe when discussing the characteristics of fetal alcohol syndrome? (Select all that apply.) A. Microcephaly B. Small eyes C. Flattened upper lip D. Prominent cheekbones E. Macrocephaly
A, B, C
Which of the following findings during the general survey may indicate a change in mental status? Select all that apply. A. Disheveled appearance B. Rapid speech C. Lethargy D. Asymmetrical movements
A, B, C
Earl is healthy and vigorous at 68 years. Which of the following is a concern as he ages? Select all that apply. A. Nutritional changes B. Mobility impairments affecting ADLs C. Fall risk D. Polypharmacy
A, B, C, D
Symptoms and assessment for alcohol withdrawal are measured by which of the following assessments? Select all that apply. A. Observing for tremors with arms extended and fingers spread apart B. Observing for paroxysmal sweats C. Observing for agitation D. Asking, "Are you hearing things you know are not there?" E. Asking, "Are you seeing anything that is disturbing to You?" F. Assessing orientation to person, place, and time G. Assessing developmental stage
A, B, C, D, E, F (ALL)
Select all of the documentation errors that are potentially high risk. (Select all that apply.) A. Failure to document completely B. Inadequate admission assessment C. Charting in advance D. Bunch charting at the end of shift
A, B, C, D.
When inspecting the hair, what would the nurse note? (Select all that apply.) A. Color B. Condition of hair shaft C. Length of hair D. Hair breakage of more than 6 hairs E. Hair shafts that are shiny
A, B, E
Which actions will result in an inaccurate BP reading? Select all that apply. A. Obtaining a BP immediately after the patient has entered the room. B. Using a BP cuff with a bladder length that is 80% of the arm circumference. C. Asking the patient to hold out their arm above heart level. D. Pumping the cuff 10 mm Hg above the palpated SBP.
A, C, D
To assess self-perception, the nurse asks A. "How would you describe yourself?" B. "Are you having difficulty handling any family problems?" C. "What gives you hope when times are troubled?" D. "How do you usually deal with stress? Is it effective?"
A. "How would you describe yourself?" Rationale: Assessment of self-perception focuses on how the patient thinks about himself or herself. Role addresses the daily duties or tasks. Values address important big concepts of life and death. Coping is in response to a stressor.
When assessing a child, the nurse makes the following adaptation to the usual techniques: A. A pediatric stethoscope is used for better contact. B. The child is seated away from the parent. C. The room is full of toys for play. D. The child is undressed, including the diaper.
A. A pediatric stethoscope is used for better contact
The nurse conducts the health history based on the patient's responses to the medical diagnosis. This type of framework is based on the A. functional framework. B. objective framework. C. coordinator framework. D. collaborative framework.
A. Functional framework. Rationale: It is based on the functional framework. In the medical model, the provider evaluates the medical diagnosis, such as myocardial infarction. The provider may order some diagnostic tests to evaluate the extent of damage. The nurse assesses the patient's response to the myocardial infarction, such as fluid retention or arrhythmias. Additionally, the nurse assesses functional abilities, such as coping, role performance, and activity tolerance.
The nurse provides teaching about smoking cessation to a 20-year-old patient. The nurse assesses that the patient is concerned because their father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient? A. Health belief model B. Diagnostic reasoning model C. Cultural competence model D. Body systems model
A. Health belief model. Rationale: The nurse will use the health belief model to assess the patient's perspective about the relationship between smoking and lung disease. The nurse must assess the patient's family experience. They may have some personal beliefs that influence their motivation to stop smoking.
Which organs or body areas does the nurse auscultate as part of the admitting assessment? A. Heart, lungs, and abdomen B. Kidneys, bladder, and ureters C. Abdomen, flank, and groin D. Neck, jaw, and clavicle
A. Heart, lungs, and abdomen. Rationale: The nurse auscultates heart, breath, and abdominal sounds as part of the complete assessment. All these involve movement, which generates sounds.
Which of the following are advantages of the electronic medical record? (Select all that apply.) A. Nurses can enter data by checking boxes and adding free full text. B. It is economical and easy to learn and implement. C. It allows primary care providers to directly order into the computer. D. It cannot be used as a legal document in case of a lawsuit.
A. Nurses can enter data by checking boxes and adding free full text
A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion? A. Patch B. Plaque C. Papule D. Macule
A. Patch. Rationale: Patches are nonpalpable, defined lesions larger than 1.0 cm. Macules have the same characteristics of patches but are less than 1.0 cm. Papules are solid, raised, palpable lesions less than 1.0 cm. Plaques are papules larger than 1.0 cm.
A 24-year-old patient reports an itchy red rash under their breasts/chest. Examination reveals large, reddened, moist patches under both breasts/chest in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions? A. Satellite B. Discrete C. Confluent D. Zosteriform
A. Satellite. Rationale: Single lesions in close proximity to a larger lesion are termed satellite lesions. Discrete distribution identifies lesions that are totally separate from one another. Confluent lesions are several lesions that have merged together, and zosteriform distribution identifies lesions, which follow a dermatomal pathway.
A patient says that they are having throbbing pain that they rate as 6 on a 10-point scale. This is referred to as A. subjective primary data. B. subjective secondary data. C. objective primary data. D. objective secondary data.
A. Subjective primary data. Rationale: Subjective data are open to interpretation; only the patient knows what they are. Objective data are measurable and visible signs, such as a facial grimace. Patients report primary data; nurses collect secondary data from other sources such as the family, chart, or staff. Pain is what the patient says it is.
The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking A. uses subjective data to analyze findings and intervene. B. documents and communicates data using appropriate medical terminologies. C. individualizes health assessment considering the age, gender, and culture of the patient. D. uses assessment findings to identify medical and nursing diagnoses.
A. Uses subjective data to analyze findings and intervene. Rationale: The nurse is using data from the assessment to analyze that nutrition is a risk for illness and intervenes with patient teaching.
Standard precautions A. are used on every patient because it is not always known whether a patient is infected. B. state that hand gel is used for infection with Clostridium difficile. C. include the use of gowns, gloves, and masks with all patients. D. recognize that transmission-based precautions are common.
A. are used on every patient because it is not always known whether a patient is infected
The purpose of health assessment is to A. obtain subjective and objective data. B. intervene to correct difficulties. C. outline appropriate care. D. determine whether interventions are effective.
A. obtain subjective and objective data Rationale: Health assessment is the method by which nurses gather subjective and objective data
Nurses belong to the ANA as part of their A. ongoing professional responsibility B. role as manager of care C. wellness promotion for patients D. cultural education activities
A. ongoing professional responsibility Rationale: nurses continually learn and promote health as part of their ongoing professional responsibility
All formats of progress notes A. use the nursing process in some form to show nursing thinking. B. identify the patient outcomes or goals to evaluate. C. include head-to-toe assessment data for completeness. D. have a section for evaluation of care so that nurses may revise interventions.
A. use the nursing process in some form to show nursing thinking
Then nurse is most likely to assess pain using the McGill Pain Questionnaire to collect which data? A. Verbal description B. Alleviating factors C. Functional status goal D. Pain goal
A. verbal description
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? A. Ask the doctor for an order for an MRI B. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment
B
An obese adult client is undergoing a preoperative examination prior to having bariatric surgery. The client tells the nurse that he has a red sore in the groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect? A. Roseola B. Candida C. Pityriasis rosea D. Herpes simplex
B
Jasmyn, who has just had her second birthday, comes to the well-child clinic for an assessment. The nurse reviews her records and discovers that Jasmyn weighed 3.1 kg (7 lb) at birth. Today, the nurse expects that Jasmyn's weight should be A. 9.5 kg (21 lb). B. 12.7 kg (28 lb). C. 15.9 kg (35 lb). D. 19 kg (42 lb).
B
Nell, 50 years old, is worried about whether her intelligence will change as she continues to advance through middle age. What can the nurse tell Nell about what might happen to her cognitive skills in middle age? A. Nell can expect her vocabulary to gradually decrease over time. B. Nell can expect to be slightly slower as she does cognitive tasks. C. Nell will have great difficulty learning new skills. D. Nell will find that her life experience is unhelpful in problem-solving.
B
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? A. Skin self-examination B. Signs and symptoms of melanoma C. Recognizing different types of lesions D. Protection from sun damage
B
The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students? A. Assists in keeping the skin intact B. Assists in friction protection C. Assists in protection from infection D. Assists in keeping skin dry
B
What transfers the signals into electrical impulses for the auditory nerve? A. Cochlea В. Organ of Corti C. Labyrinth D. Oval window
B
When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? A. Myxedema B. Cushing's syndrome C. Scleroderma D. Bell's palsy
B
Which of the following is the healthiest eating plan? Select all that apply. A. Excludes lean meats, poultry, and fish B. Allows for moderate intake of salt and sugars C. With nonfat or low-fat milk and dairy products D. Emphasizes fruits, vegetables, and whole grains
B, C, D
A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.) A. Scheduling a magnetic resonance imaging (MRI) scan B. Physical examination for neurologic changes C. Scheduling a computerized tomography (CT) scan D. Conducting a focused history interview E. Scheduling an electroencephalography (EEG)
B, D
An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Mark all that apply.) A. Depth B. Location C. Other lesions on body D. Size E. Texture
B, D, E
An auscultatory gap is defined as A. a drop in the SBP of 15 mm Hg or more with position change. B. a period of silence heard between Korotkoff sounds. C. the difference between the apical and radial pulse. D. SBP minus the DBP.
B. A period of silence heard between Korotkoff sounds
A patient is having adverse effects resulting from a medication. The nurse calls the primary care provider to request a change in the medication order. The nurse is functioning as a(n) A. educator. B. advocate. C. organizer. D. counselor.
B. Advocate
A patient reports pain, depression, and insomnia. The nurse observes a masklike facial expression and frequent position changes. Which of the following is the nurse most likely to use to describe the patient's findings? A. Acute pain B. Chronic pain C. Neuropathic pain D. Chronic regional pain syndrome
B. Chronic pain
What structure is found midline in the tracheal area just beneath the mandible? A. Cricoid cartilage B. Hyoid bone C. Thyroid cartilage D. Adam's apple
B. Hyoid bone
The patient is complaining of abdominal pain. What technique is used to form an overall impression? A. Auscultation B. Light palpation C. Direct percussion D. Deep palpation
B. Light palpation
In the SBAR reporting format, which of the following would be an example of data found in the assessment? A. Mrs. Kelly's diagnosis is Stage II breast cancer. B. Mr. Imami's lung sounds are decreased. C. Ms. Choi needs to have a social work consult. D. Mr. Jones was admitted at 10:30 this morning.
B. Mr. Imami's lung sounds are decreased.
Which of the following interventions is most important to prevent nosocomial infections? A. Proper glove use B. Hand hygiene C. Appropriate draping D. Quiet environment
B. hand hygiene Rationale: hand hygiene is the single most important intervention to prevent the spread of infection. either hand washing or using hand gel between patients is acceptable
Caitlyn was about 50 cm (20 in.) tall at birth and weighed 3 kg (7 lb, 8 oz). At her 1-year well-child checkup, the nurse determines that Caitlyn is 66 cm (26 in.) tall and weighs 7 kg (16 lb). The nurse's reaction to these assessment findings is to be A. concerned; Caitlyn should have quadrupled her birth weight by now. B. unconcerned; Caitlyn is growing in height and weight at an expected pace. C. concerned because Caitlyn should have tripled her birth weight by now. D. unconcerned because Caitlyn has slightly more than doubled her birth weight.
C
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus? A. Just above the thyroid cartilage B. Between the thyroid and the cricoid cartilages C. Just below the cricoid cartilage D. In front of the sternocleidomastoid muscle
C
Oscar, 6 years old, has come to the well-child clinic for a visit. He is 1.16 m (46 in.) tall today. Assuming that he grows at an expected pace, how tall would the nurse expect Oscar to be at 10 years? A. 1.27 m (50 in.) B. 1.32 m (52 in.) C. 1.37 m (54 in.) D. 1.57 m (62 in.)
C
The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger." How would the nurse note these findings in the client's medical record? A. The client has abnormal thinning of skin B. The client's integumentary system is within normal limits C. The client states that wounds are taking longer to heal D. The client has an abnormal inability to maintain temperature
C
The patient's radial pulse is weak and thready. The next action of the nurse is to A. transfer the patient to a critical care unit. B. notify the primary care provider. C. compare findings with previous findings and opposite extremity. D. assess vital signs every 15 minutes
C
Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? A. Diabetes mellitus B. Heart failure C. Chronic obstructive pulmonary disease D. System lupus erythematous
C
What color of sputum would support the diagnosis of heart failure? A. White B. Yellow C. Pink D. Rust
C
When considering the head and neck, what screening should be included as a component of a pregnant woman's regular examinations? A. B12 B. folic acid C. Thyroid D. amniocentesis
C
Which of the following patients is at highest risk for complications related to folate deficiency? A. A 3-year-old boy who is developmentally delayed B. A 15-year-old girl who just started her menses C. A 24-year-old person who is attempting pregnancy D. An 82-year-old male living in a nursing home
C
The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing A. whether the patient is a reliable historian. B. functional health patterns. C. ADLs. D. review of systems.
C. ADLs
Tympany is a percussion sound commonly located in the A. thorax. B. upper arm. C. abdomen. D. lower leg.
C. Abdomen
A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission? A. Emergency B. Focused C. Comprehensive D. Illness
C. Comprehensive
Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of A. perseveration. B. auditory hallucinations. C. divergent tactics. D. altered mood.
C. Divergent tactics. Rationale: The patient is attending to the nurse in this situation but is using distracting tactics, so the nurse does not get answers to the questions asked. The patient who perseverates repeats content. Those with auditory hallucinations may respond to voices rather than to the nurse. Patients with an altered mood will be more focused on their mood than on the nurse.
Which of the following is an appropriate use of gloves? A. Gloves are worn during anticipated contact with intact skin. B. Gloves are removed when going from clean to contaminated areas. C. Gloves are worn during anticipated contact with body secretions. D. Gloves are removed when assessing the back of an incontinent patient.
C. Gloves are worn during anticipated contact with body secretions.
When gathering the family history, the nurse draws a genogram A. using circles for males and squares for females. B. putting the patient on the left to show birth order. C. inserting lines between parents to show marriage. D. listing health problems above the symbol for the patient.
C. Inserting lines between parents to show marriage
Nurses advocate for underserved populations to reduce health disparities. This promotes A. autonomy. B. altruism. C. respect. D. human dignity.
C. Respect
When inspecting the bulbar conjunctiva, what would you expect to find? A. A pink to light red color B. Small areas of rough tissue C. Small blood vessels D. An opaque membrane
C. Small blood vessels Bulbar conjunctiva is normally transparent with small blood vessels visible.
What technique facilitates accurate auscultation? A. Earpieces of the stethoscope are positioned to point toward the back. B. The tubing of the stethoscope is long and dark in color. C. The chestpiece of the stethoscope is sealed against the skin. D. The diaphragm of the stethoscope is used for low-frequency sounds.
C. The chestpiece of the stethoscope is sealed against the skin.
The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the A. preinteraction phase. B. beginning phase. C. working phase. D. closing phase.
C. Working phase
Strategies for effective handoffs during change-of-shift report are to A. tape-record the report for efficiency. B. vary the format to individualize to the patient. C. allow an opportunity to ask and answer questions. D. put report in writing so that the next shift care provider can get right to work.
C. allow an opportunity to ask and answer questions
The purpose of auditing charting is to A. enhance nurses' learning and understanding of complex clinical situations. B. identify staff members who document completely and counsel those who do not. C. determine whether staff members are providing and documenting standards of care. D. locate data in the chart the evening before a morning clinical visit.
C. determine whether staff members are providing and documenting standards of care
The nurse assessing an older adult focuses the health history on A. previous pregnancies, obstetric history, and psychosocial factors. B. birth history, immunizations, and growth and development. C. sensory deficits, illness history, and lifestyle factors. D. religion, spirituality, culture, and values.
C. sensory deficits, illness history, and lifestyle factors
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Work with medical team to evaluate possible surgery. B. Discuss pharmacologic interventions. C. Educate the client regarding cervical spine pain. D. Assess the client regarding characteristics of the pain.
D
A newborn has a hemangioma on the face. What would be important for the nurse to include in client teaching? A. Will need surgery to remove B. Will become smaller over the first year of life C. Is made of epithelial cells that form caverns and fill with blood D. Will usually resolve by age 9 years
D
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? A. Pinch a fold of skin on the client's abdomen. B. Pinch a fold of skin on the client's cheek. C. Pinch a fold of skin on the client's upper thigh. D. Pinch a fold of skin on the client's forearm.
D
During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on? A. Pneumonia-related dyspnea B. Tuberculosis-related cough C. Bronchitis D. Heart failure induced orthopnea
D
Mallory, 16 years old, is having difficulty in school and with her friends. She has not decided what she wants to do with the rest of her life after high school. Erik Erikson would say that Mallory is at risk for A. industry. B. inferiority. C. identity. D. role confusion.
D
Tamika is often in a hurry with her toddler daughter Samantha and usually does things for her that Samantha could do herself if given more time. Erikson would say that Tamika's daughter A. will develop a healthy sense of autonomy because of her mother's help. B. will not develop shame and doubt because of these interactions with her mother. C. will develop a sense of autonomy no matter what her mother does. D. is at risk for developing a sense of shame and doubt because of her mother's behavior.
D
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? A. Rush B. Gurgle C. Murmur D. bruit
D
What might the nurse suggest to Manuel, age 35, to improve memory now that he has entered into early adulthood? A. Reflective thinking B. Use only logical analysis to systematically consider all the pros and cons C. Be more practical, considering the complexities of the situation D. Use organization and imagery to remember things
D
What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs? A. Refer the client for further medical evaluation. B. Auscultate for egophony. C. Perform bronchophony. D Have the client cough and then listen again.
D
When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck? A. Signs of a strain B. Indications of a vertebral injury C. Lymph node enlargement D. Limitations in movement
D
Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. Their hand is pale, cool, and swollen. The pain medication is ineffective, and they are at risk for impaired circulation. What action will the nurse take first? A. Reassess the pain in 30 minutes and contact the provider if unresolved. B. Give additional pain medication and reassess the pain in 30 minutes. C. Document the abnormal findings and give an extra dose of pain medication now. D. Contact the primary care provider and document the findings now.
D
Is the following statement true or false? The nurse should include teaching the patient how to correctly clean the external ear canal with a cotton-tipped swab.
False
A 90-year-old patient has a drooped body position, appears sad, and says that they have seasonal affective disorder. What tool would the nurse use to assess them? A. MMSE B. CAGE C. SAD PERSONAS assessment D. Geriatric Depression Scale
D. Rationale: The Geriatric Depression Scale would be used because the patient is a 90-year-old with a type of depression. Mini-Mental State Examination (MMSE) is used to test cognition, CAGE is the alcohol assessment tool, and SAD PERSONAS assessment is used to assess suicide risk.
The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is A. "Don't cry. It will be OK." B. "My mother has the same thing." C. "I think that you should have surgery." D. "I'll stay with you" (gets a tissue).
D. "I'll stay with you" (gets a tissue)
The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is A. "You must be extremely worried." B. "I'd be in worse shape than you are if it were my baby." C. "Is there anyone here that you can talk to?" D. "You seem worried, but I need to ask a few questions."
D. "You seem worried, but I need to ask a few questions."
In the clinic within an adult assisted-living complex, a 68-year-old retired detective reports his mouth is continually dry. This is problematic for him. What are the functions of saliva? A. Provides lubrication B. Protects oral mucosa C. Rinses oral cavity D. All of the above
D. All of the above Rationale: Saliva begins the digestive process by releasing enzymes upon contact with food. Saliva protects the oral mucosa from heat, chemicals, and irritants. Saliva also transmits taste information, rinses the oral cavity to maintain pH, and provides lubrication for the movement of food.
The proper technique for correcting written documentation is to A. use correction fluid and write over the error. B. completely black out the error with a black marker. C. write over the error in darker ink. D. draw a line through the error and write the date, time, reason for error, and your initials.
D. Draw a line through the error and write the date, time, reason for error, and your initials.
Which of the following are the components of a comprehensive health assessment? A. Nursing diagnoses B. Goals and outcomes C. Collaborative problems D. Examination of body systems
D. Examination of body systems
The nurse documents the following information in a patient's chart: "Cough and deep breathe every hour while awake." This is an example of A. evidence-based nursing. B. priority setting. C. comprehensive assessment. D. nursing interventions.
D. Nursing interventions. Rationale: Nursing interventions are actions taken by the nurse to promote health. They usually begin with a verb and have a time frame.
Which of the following is an example of inspection? A. Heart rate and rhythm regular B. Lungs clear C. Abdomen tympanic D. Skin pink
D. Skin pink
Which of the following processes is the most important when providing nursing care to a patient who is ill? A. Writing outcomes B. Performing a focused assessment C. Collecting objective data D. Using clinical judgment.
D. Using clinical judgment. Rationale: Assessment provides a solid foundation for care, but it is only one step in the nursing process. Clinical judgment is used in all phases of the nursing process.
Latex allergies A. always result in anaphylactic reactions and shock. B. can be reduced by moisturizing the hands after washing. C. cannot be caused by equipment such as a stethoscope. D. are more common in nurses and in frequently hospitalized patients.
D. are more common in nurses and in frequently hospitalized patients
Adult patients may have variations in pulse rates with A. respirations. B. food intake. C. heat. D. exercise.
D. exercise. Rationale: Exercise will increase heart rate due to increased metabolic demands. Sinus arrhythmia, a variation in pulse with respiration, is common among children. The pulse rate varies with respiration, speeding up during inspiration and slowing down during expiration.
The patient has serum values that are abnormal for sodium and potassium. The nurse recognizes that these values are important to maintain in normal range for proper A. tissue oxygenation. B. tensile strength in the hair. C. oil production in the skin. D. fluid and electrolyte function.
D. fluid and electrolyte function
The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to A. role. B. self-perception. C. coping. D. values.
D. values Rationale: values address important big concepts of life and death. Role addresses the daily duties or tasks. Assessment of self-perception focuses on how the patient thinks about himself or herself. Coping is in response to a stressor.
What does papular mean?
bumpy/ raised rash
Which of the following tools would a nurse use to perform a multidimensional pain assessment? A. Visual analogue scale B. Brief Pain Inventory C. Numeric pain intensity D. Verbal descriptor
b. brief pain inventory
Normal speech is audible. This is a normal finding describing which quality of speech? A. Fluency B. Quality C. Loudness D. Articulation
c. loudness
Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on A. an admission assessment. B. a POC C. a progress note. D. a focused assessment flow sheet.
d. a focused assessment flow sheet
A patient is admitted to the hospital with multiple trauma from an automobile accident 5 days ago. Which of the following is the best indicator of current nutritional status? A. Transferrin B. Total protein C. Albumin D. Prealbumin
d. prealbumin
What is medication reconciliation?
the process of comparing a patient's medication orders to all of the medications that the patient has been taking (over the counter as well)