NURS 198 Exam 1

The nursing instructor is discussing the importance of spiritually assessing a client in order to be able to provide holistic care. What suggestion can she give to the student who is not sure of the correct questions to ask?

" You may use the FICA spiritual assessment tool."

A new nurse asks the charge nurse what the Mini-Mental Status Examination tests. What is the appropriate response by the charge nurse?

"A quick tool that is useful to examine the orientation, memory, speech, and cognitive functions"

After assessment and documentation of the information obtained from the client, the nurse needs to analyze the data collected. Which nursing actions depend on accurate analysis of data during this phase of the nursing process?

- Identification of collaborative problems - Identification of the need for referrals - Formulation of nursing diagnosis/es

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

As a nurse is adjusting a client's hospital bed, the nurse accidentally pinches a finger between the bed and the wall. What components of the PNS is involved in the transduction of the pain the nurse feels?

A-delta and C fibers

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

Allen test

A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is:

Diaphoresis (excessive sweating or perspiration)

The nurse in a prenatal clinic is performing an assessment on a pregnant client. When the nurse notes that the client has bruises in various stages of healing on the abdomen, the nurse will ask what assessment question?

Do you feel safe in your home setting?

The nurse auscultates the base of the lungs to assess for what reason?

It is where fluid occurs with pulmonary edema.

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropathic

If palpable, superficial inguinal nodes are expected to be:

Nontender, mobile, and 1 cm in diameter

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

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

A new nurse on the vascular unit is caring for a client with an embolus in the deep part of the peripheral vascular system. In what vessel might the embolus be?

Peroneal tibial vessel

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

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?

Provide simple and organized information.

A nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following:

Release of epinephrine, cortisol, and norepinephrine

The term "base of the heart" refers to what areas of the heart?

Right and left 2nd intercostal spaces, close to the sternum

Pathway of heart conduction

SA node, AV node, Bundle of His, Bundle branches, Purkinje fibers

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which style of documentation is the nursing implementing?

SOAP charting

The nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy (inflammation of membrane that seperates the lungs from chest wall) . The nurse interprets this finding as...

The pattern is expected with this condition

What is the principle of percussion?

To create vibration in a body wall

The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment?

Use the client's family as a source of information

When do we have patient's say 99?

When he nurse is palpating for fremitus and when the nurse plans to auscultate for voice sounds (bronchophony)

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII

Where is the apex of the lungs?

above clavicle

The clavicles extend from the _______ of the scapula to the part of the sternum termed the _______.

acromion manubrium

What are the 11 domains of mental status?

appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment.

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds, and . What would the nurse suspect?

arterial insufficiency

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

ashen gray

A nurse reviews the vital signs of a 77-year-old client: temperature 99.2 F° (37.33° C), heart rate 90 beats/min, blood pressure 130/50 mm Hg, respiratory rate 22 breaths/min and shallow, and oxygen saturation rate 93% on room air. Which action should the nurse take next?

assess for infection

The nurse will complete a physical examination on a newly admitted client to the rehabilitation unit of a long-term care facility. After gathering equipment, what technique of examination will the nurse use first?

assess temperature with a thermometer

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

What is halitosis? Anosmia? epistaxis?

bad breath loss of smell nosebleeds

What is the normal temperature range?

between 97 F (36.1 C) and 99 F (37.2 C) or more

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

collect subjective data

What is dyspnea? Bradypnea? Tachypnea? Hyperpnea? Orthopnea?

difficulty breathing slow breathing fast breathing taking in more air (exercise) breathlessness when laying flat

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment?

evaluation

The nurse is preparing to assess a client's apical impulse. The nurse should palpate at which location?

fourth or fifth intercostal space at the left midclavicular line.

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

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?

ineffective tissue perfusion

When is a stethoscope bell used? Diaphragm?

low pitched sounds high pitched sounds

A client is noted to have a bifid uvula. The nurse understands that this finding is most common in which ethnic group?

native americans

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?

nerve damage from several eye injuries

A client's blood pressure amplitude is low during inspiration and higher during expiration. What should this finding suggest to the nurse?

paradoxical pulse

A client is diagnosed with pulmonary edema. The nurse would most likely assess the sputum color as which of the following?

pink

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

pneumonia

When assessing for human violence in clients, it is important for the nurse to...

reexamine assumptions and stereotypes.

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following?

resonance

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

stage 2 hypertension

The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.

subjective

The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize what implication of this statement?

symptoms of heart failure

The nurse plans to administer the CAGE Self-Assessment tool on a client. The nurse explains to the client how and when the tool is used by stating which of the following?

"It is a short tool used to identify people at risk for substance use disorder. It consists of four questions."

A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse?

Ask the client if they are experiencing any other symptoms

What does the COLDSPA mnemonic stand for?

Character Onset Location Duration Severity Pattern Associated factors

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. What question should the nurse ask for this assessment?

How does the pain influence your overall mood?

vThe nurse caring for a patient diagnosed with a 2nd rib fracture should know the location of the sternal angle is also called as what?

angle of louis

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following statements would the nurse include in the teaching?

avoid things that will irritate the mouth

A nurse administers the Elder Abuse Suspicion Index (EASI) on a 73-year-old client suspected of neglect. The client responds "yes" to three of the items. Which action should the nurse take next?

further investigate suspicions of abuse or neglect

A nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race?

larger thorax and lung capacity

Variations in the presentation of S1 are due to alterations in which heart valve

mitral

When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely:

neuropathic

What is responsible for transmitting the sensations to the central nervous system?

nocioceptors

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

over client's thigh

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?

skinfold calipers

The nurse is assessing a client's ability to employ coping mechanisms when given a diagnosis of cancer. What type of assessment would be beneficial for the nurse to use?

spiritual assessment

The path one pursues in the search for life's meaning and purpose.

spirituality

A nursing instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first?

time

4 steps of nociception

transduction, transmission, perception, modulation

How many lobes does the left lung have? Right lung?

2 (superior and inferior) 3 (upper, middle, lower)

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale

The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment?

Listen at each site for at least one complete respiratory cycle.

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. What would the nurse implement in response to a collaborative problem?

Measure the client's blood glucose four times daily.

The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?

Perform further assessments addressing various aspects of the client's pain.

In which order should a nurse assess a client's vital signs?

Temperature, pulse, respiration, and blood pressure

How will you assess a client's sinuses who is experiencing frontal headache?

To palpate the sinuses, the nurse will sit facing the client and press up on the frontal sinuses under the brow bone. Then, the nurse will palpate over the cheek bones to assess the maxillary sinuses. Afterward, the nurse will tap lightly over the sinus areas to assess for tenderness

During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using?

active listening

An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action?

administer O2

What are various measurements of the human body, including height and weight, called?

anthropometric measurements

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first?

any chest pian?

When crackles, sonorous wheezes, or rhonchi clear with a cough, what of the following is a likely etiology?

bronchitis

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

bruits

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

A parent brings her 5-year-old child to the clinic, reporting that she has noticed the child does not seem to be hearing well. There also has been a noticeable speech delay. What does the nurse understand can be a predisposing factor to possible hearing loss?

chronic middle ear infection

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility? -Collect subjective data related to overall function -Perform a musculoskeletal examination -Take anthropometric measurements -Obtain a 24-hour diet recall

collect subjective data related to overall function

The nurse is caring for a married female client who defers to her husband to answer all assessment questions. The nurse understands that it is common in some cultures for the male to hold a dominant role in the relationship. What stage of cultural awareness does the nurse display?

conscious competence

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

A nurse is participating in an educational exercise in which she is conducting a self-examination of her own biases. This activity addresses what construct of cultural competence?

cultural awareness

A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?

cyanotic

A nurse is performing a health history on a new client. What biographical data should the nurse obtain?

date of birth religion occupation

When obtaining an oral temperature on a client, the nurse inserts the thermometer:

deep in the posterior sublingual pocket

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing....

deep palpation

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis

When planning a community program related to Healthy People 2030, the critical first step involves

defining the community

The nurse performs an assessment on a newly admitted client. Data analysis reveals temperature 100.9 F (38.3 C), BP 82/58 mm Hg, 02 Saturation 91% RA, productive cough, lethargy, diaphoresis, WBC 15,000 mm3, Hemoglobin 9 g/dL, Hematocrit 29%. What action should the nurse take next?

develop diagnosis

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. What should the nurse do next?

document finding as normal

What is lugwig's angina?

edema pushing tongue up and back à airway obstruction from infection of the mouth floor

A nurse suspects abuse on a client with a fractured forearm, who does not want to discuss how the fracture happened. What is something the nurse could do to let the client know the client is not alone?

educate the client of the high prevalence of human violence

Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

either side of the frenulum on the floor of the mouth

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?

endorphins

The spouse of a client believed to be a victim of intimate partner violence refuses to leave the room for the nurse to complete an assessment. What should the nurse do first?

ensure for personal safety

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

erb point

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, what action should the nurse prioritize?

establishing a trusting relationship

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

explain the purpose of the interview

A nurse is assessing a client admitted with anorexia nervosa. The nurse expects what signs and symptoms?

fear of obesity, restricted food intake

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

focused

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?

focused assessment form

While auscultating a client's lungs, the nurse notes the presence of adventitious sounds. What action would the nurse do first?

have client cough and listen again

The nurse is assessing a client for varicose veins. Which action, by the nurse is appropriate?

have client stand and firmly compress the lower portion of the varicose vein

Within the 65-year-old and older age group, a nurse knows that the most common cause of mortality is from what source?

heart disease

advantages of using EHRs (Electronic Health Records)

improvement in risk management prevention of provider liability improvement in public health and client outcomes reduction in errors

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium?

inflammation of the pericardial sac

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 an otoscope

During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential?

introductory

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication?

lymphedema

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

marfan syndrome

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following?

murmur

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?

perform emergency assessment

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following?

personal and social history

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?

right cervical node

The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?

rigid

While discussing health patterns, a client says, "I hate my job." In which category should the nurse document and further assess this information?

role-relationship

What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months?

screen for depression

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?

sexual history

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

thin, shiny, atrophic skin

Patients with PAD need to understand why it is important to monitor

triglyceride levels

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?

tympanic

The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique?

vagal nerve function

The nurse performs a comprehensive assessment on a new client. What is the next action of the nurse?

validate problems and determine client's goals

A client has a brownish discoloration of the skin of both lower legs. What should the nurse suspect is occurring with this client?

venous insufficiency

The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?

verbal handoff

6 types of pains

visceral- abdominal organs somatic- tissues, bones, joints cutaneous- skin referred- feeling pain somewhere other than affected body part phantom- pain felt in missing limb neuropathic- constant stimulus

Interventions for nose, throat, sinus, and mouth infections

ØProvide oral hygiene every 8 hours. ØConsult with speech pathologist to evaluate swallowing. ØEncourage fluid increase to 2 L daily to liquefy secretions.