Nurs 212 exam 2

you are providing health promotion education for a client which client statement requires further education

I use an indoor tanning bed to improve my skin color

a nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus which of the following actions should the nurse take

ask the client for additional information regarding the management of their diabetes

which of the following factors are included in health history

basic reading skills competency using numbers ability to follow verbal instructions

a nurse is assessing the mouth of a client who has a vitamin B12 insufficiency which of the following findings should the nurse expect

beefy red tongue

a nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash the nurse should identify that which of the following findings indicated the client might have a skull fracture

bloody drainage

cyanosis

bluish color of skin

a nurse is an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature which of the following should the nurse recognize as the most reliable indicator of fluid loss

body weight

a nurse is collecting data during a review of systems and asks the client how many pillows are required to sleep comfortably at night. the question involves assessment of which of the following systems

cardiovascular

a nurse is performing a focused assessment on a client who reports having difficulty swallowing and a continuous headache the nurse should identify that these findings can indicate which of the following conditions

central nervous system disorder

a nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea the nurse should identify this as which of the following types of breathing

cheyne-stokes breathing

a nurse is assessing a clients behavior during the initial survey which of the following does the nurse include in this assessment

clients clothing clients speech

which of the following factors could present a barrier to the nurse effectively communicating with the client?

clients hearing deficit volume of the clients television numerous visitors in the clients room using earphones while listening to music

a nurse is assessing a client who has chronic respiratory insufficiency which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation?

clubbing of the fingers

a charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client which of the following statements by the newly licensed nurse indicates an understanding of the teaching

clubbing of the fingers indicates a chronic state of impaired perfusion

a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub which of the following descriptions should the nurse use to describe a pleural friction rub

coarse grating tone heard on inspiration and expiration pain with breathing

a nurse is assesing for cyanosis in a client who has dark skin which of the following sites should the nurse examine to identify cyanosis in this client?

conjunctivae

which of the following are characteristics of the dermis layer of the skin

contains blood vessels hair follicles and nerve endings composed of thick fibrous connective tissue

a nurse is assessing a client who has a left forearm fracture which of the following findings indicates impaired arterial blood flow below the area of injury?

cool hand and fingers

a nurse is assessing an older client's mouth the nurse should identify that which of the following is an expected variation for this client

darkening of the mucosa

a nurse is assessing the eye of a client who experienced a subconjuctival hemorrhage as a result of vomiting which of the following findings should the nurse expect

defined reddened area of the sclera

a nurse is completing an initial assessment checklist on an older client the client is accompanied by their caregiver for which of the following indicators should the nurse observe when assessing for potential maltreatment of the client.

dirty clothing unexplained physical injuries malnourished appearance.

a nurse is caring for a newborn and auscultates an apical hear rate of 130/min which of the following actions should the nurse take first

document this as an expected finding

a nurse is collecting information about a client's spirituality using FICA spirituality history tool

does the client identify spiritual or religious beliefs that are of importance of them what impact does the client's spiritual or religious beliefs have on their health care decision making are there any spiritual or religious practices that should be included when planning the client's care is there a spiritual or religious group that the client identifies as having an importance in their life.

a nurse is caring for a client who has emphysema this chronic lung disease is a component of COPD and can involve chronic over inflation of the lungs and decreased oxygen levels which of the following findings should the nurse expect to assess in this client

dyspnea barrel chest clubbing of the fingers

a nurse is caring for a client who is having difficulty breathing which action should the nurse take first

elevate the head of the client's bed

a nurse is performing a head and neck assessment on a client the client reports a high pitched ringing in their ears in which of the following sections of the client's electronic health record (EHR) should the nurse document this finding

encounter

a nurse is preparing to conduct an initial survey and assessment on a newly admitted client which of the following actions should the nurse plan to take

engage in active listening with the client and allow the client to express concerns early in the assessment process

a nurse is preparing to obtain a client's height during a general survey which of the following actions should the nurse take

ensure the client's feet are in contact with the wall or measuring pole

you are constructing a health history genogram with a client when disussing their maternal mother's family the client says "but she was adopted and doesn't know her birth family you know that:

enviornmental health influences are still relevant here and the adopted family health history should be included

you are performing as assessment on a client and observe a shallow wound on the client's leg the wound only penetrates the epidermis and there is no bleeding present which of the following terms correctly describes this wound

erosion

place the following actions to check capillary refill in the order of performance

explain to the client that you are going to evaluate their circulation press on a fingernail pad until it blanches release pressure on the finger pad note the amount of time it takes for nail-bed to return baseline color document capillary refill as brisk or sluggish

a nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the clients left arm which of the following terms should the nurse use to describe this involuntary movement

fasciculation

a nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities using a pulse oximeter where does the nurse place the sensor probe

forehead bridge of nose earlobe

a nurse is planning to conduct a health history interview with a client which of the following actions should the nurse plan to take

gather supplies to take notes select a position that is 2 to 3 feet from the client during the interview ensure face to face is at eye level

a nurse is conducting a health history interview which of the following questions should the nurse ask when gathering information about a clients cardiac and peripheral vascular systems

have you experinced any chest pain tightness or discomfort have you noticed any swelling in your hands feet or ankles do you feel short of breath during the day or while sleeping

a nurse is obtaining a client's history which of the following questions should the nurse ask the client to obtain a focused history of the ears

have you had trouble hearing do you ever lose your balance have you ever used hearing aids do you have ringing in your ears

select the 3 findings that require immediate follow up

heart rate (48/min) respiratory rate (28/min) skin is cool pale weak peripheral pulses

consumed energy drinks and cigarettes at breakfast and lunch effects which vital signs

heart rate and blood pressure

urticaria

hives skin rash with red raised and itchy bumps

a nurse is observing a newly licensed nurse who is performing a focused skin assessment of a client who reports a skin condition which of the following questions by the newly licensed nurse requires intervention

how do you handle stress?

a nurse is preparing to collect a health history from a client which of the following should the nurse plan to assess as a component of functional assessment

if the client is experiencing abuse or human trafficking the environment in which the client resides the client's use of substances client's ability to perform activities associated with daily living

a nurse on a medical surgical unit is perfoming an admission assessment of a client who has COPD with emphysema the client reports that he has a frequent productive cough and is short of breath the nurse should anticipate which of the following findings for this client?

increased anteroposterior diameter of the chest

a nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration in which of the following locations should the nurse perform the assessment

inferior to the collar bone

erythema

inflammation of skin color

a nurse is reviewing information about the health insurance portability and accountability act (HIPAA) with a newly licensed nurse. which of the following statements by the newly licensed nurse indicated a need for further teaching?

information about a client can be disclosed to family members at any time

a nurse is preparing education material for a client to maintain a healthy respiratory status which of the following information should the nurse include in the materials

instruct and encourage the client to obtain the influenza vaccine counsel the client about smoking cessation educate the client that hand hygiene is the first line of defense to prevent illness

a nurse is caring for a client who has atrial fibrillation and reports feeling a new onset of palpations and shortness of breath which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation

irregular hear rhythm with a difference between apical and radial pulse rates

a nurse is planning care for a client who has a stage 1 pressure injury on their coccyx which of the following interventions should the nurse plan to include

limit elevation of the head of the bed 30 or less

a nurse has collected biographic data from a client which of the following findings in the clients community is considered a social determinant of health that can negatively impact the client's health

limited access to pharmacy

a nurse is caring for a client who has a stage 1 pressure injury which of the following information should the nurse include when documenting the characteristics of the wound

location of the pressure injury size of the injury in centimeters integrity of the skin surrounding the wound

a nurse is measuring vital signs of a 32 year old male who has been diagnosed with heat stroke and dehydration. which of the following vital signs are consistant with poor distal perfusion?

low blood pressure delayed capillary refill weakness or pre-syncope

a nurse is taking a rectal temperature on a client which of the following actions does the nurse perform

lubricates the probe cover inserts the probe into the rectum 1 to 1.5 in

a nurse is caring for a client who has a suspected stroke which of the following actions should the nurse take

make the client NPO assess the client's orientation obtain the client's vital signs

shock is characterized by poor tissue perfusion resulting in tissue ischemia a nurse is caring for a client who has hypovolemic shock which of the following should the nurse recognize as an expected finding?

mental status change, or confusion

a nurse is conducting a health history interview and asks the client to describe the pain that they are experiencing this is an example of what type of question

open-ended question

a nurse is assessing a client's head which of the following should the nurse identify as an unexpected finding

oval white patches in the client's hair a lesion on the clients scalp protrusion of the client's head edema around the client's eye

a nurse is documenting a clients vital sings in the medical record following a general survey which of the following entries should the nurse place in the record

oxygen saturation 96% on oxygen 2L min via nasal cannula

a nurse is caring for a client who is hyperventilating the nurse should identify which of the following circumstances can contribute to hyperventilation

pain anxiety fear

a nurse is inspecting the sinuses of a client who has allergies which of the following findings should the nurse epect

pale mucosa

a nurse is collecting information about a client's family history the nurse should plan to collect information about the health of which of the following client relatives

parents siblings grandparents

a nurse in a clinic is interviewing a client who will undergo diagnostic testing the nurse should ask about a clients potential allergies during which phase of the nursing process?

assessment

a client has come to the clinic for evaluation of fever and sore throat during the interview they state yesterday I also got sick to my stomach and broke out in a sweat this represents what type of information

associated factors

a nurse is assessing a client's skin color which of the following findings should the nurse report to the provider

pinpoint areas of purplish red coloration across the abdomen pale-colored nailbeds

a nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope in what order should the nurse take the following steps

place the client in a supine position and allow them to rest is the first step take the clients blood pressure in the supine position is the second step keep the cuff in place and assist the client to a seated position take the clients blood pressure in a seated position assist the client to stand and obtain their blood pressure

a nurse asks a client how he is feeling the client states " im feeling a bit nervous today" which of the following responses should the nurse make?

please explain what you mean by the word "nervous"

a nurse is assessing a client and notes minimal air movement with the clients inspirations which of the following should the nurse recognize as a contributing factor

pneumonia chest trauma prolonged fever

a nurse is inspecting the fingernails of an older adult client which of the following findings should the nurse report to the provider

spongy nail base

ecchymosis

spot or blotch larger than petechiae bruises

which of the following is considered an unexpected finding for a 40-year-old clients pulse

stronger radial pulse on left compared to right

edema

swelling presence of excess interstitial fluid

a nurse is assessing a client who has hypoxia which of the following findings should the nurse expect

tachycardia

a nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min the nurse should identify this as which of the following unexpected findings

tachycardia

a nurse is teaching a young adult about risk factors for developing melanoma which of the following client statements indicates an understanding of the teaching

the blistering sunburns I had as a child increase my risk for melanoma as an adult

a nurse is palpating a clients extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms how should the nurse interpret this finding

the client might have a blood clot

a nurse is evaluating assessment findings of a client's skin, the nurse should identify that which of the following findings is associated with a possible infection

vesicles

which normal breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees

vesicular

a nurse is discussing a client's tobacco usage during a health history interview which of the following questions should the nurse ask to maintain nurse client rapport

would you like any information on smoking cessation

a nurse is performing a skin assessment on a client which of the following findings should the nurse report to the provider

yellow discoloration of the palms

jaudice

yellowish color of skin

a nurse is providing teaching to a client who reports acne on their face and chest which of the following client statements indicates an understanding of the teaching

I should wash the areas frequently with warm water and soap

a charge nurse is reviewing the documentation of a newly licensed nurse which of the following entries made by the newly licensed nurse is an example of correct documentation

inspiratory wheeze auscultated at left lateral chest

pruitus

intense itching causing the desire or reflect to scratch

a nurse is admitting a client who has had a stoke which of the following actions should the nurse take

keep the client's bed in the lowest position

a client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket which begins to smolder which of the following actions is the nurses priority?

move any clients in the immediate vicinity

a nurse is assessing a client's skin color which of the following areas should the nurse check to determine the presence of pallor

mucous membranes

a nurse is assessing a client who is dark skinned in which of the following areas of the client's body should the nurse assess the client for adequate oxygenation

nail beds oral mucosa lips

a nurse is completing a clients history and physical examination which of the following information should the nurse consider subjunctive data.

nausea

A nurse is providing care for a surgeon on a medical-surgical unit A nurse from another unit asks the nurse about the surgeon's medical diagnosis the nurse responds that he is unable to provide the information requested the nurse is displaying which of the following ethical principles

nonmaleficence

place the steps in the correct order to record information when using the GTPAL format

number of pregnancies number of term deliveries number of preterm deliveries number of voluntary or involuntary abortions current number of living children

a nurse is caring for a client who is experiencing episodes of hyperventilation which of the following manifestations should the nurse expect during hyperventilation

numbness and tingling of extremities lightheadedness chest pain

a nurse is assessing a clients behavior during the initial survey on a client and calculates a BMI of 31 kg/m the nurse classifies the client in which of the following weight ranges

obese

seborrhea

oily skin

you are collecting subjective data prior to performing a skin assessment on a client which of the following responses requires additional investigation

one of my moles now has several colors on it

a nurse is performing a head to toe assessment of a client which of the following findings indicate the client might be experiencing respiratory difficulty

the client Is sitting in a tripod position the client is using pursed lipped breathing the client appears confused

a nurse in the ED is assessing a client who has experienced thoracic trauma from a motor vehicle crash which of the following findings is an indication of a pneumothorax

the client is experiencing unequal movement of the posterior chest

which of the following is a closed-ended question

what time do you usually get up in the morning

pallor

pale or lighter color than usual

a nurse is preparing to perform a skin assessment on a client which of the following tools should the nurse plan to use

penlight

which aspect of life is assessed using the FICA approach

spirituality

how many generations should you collect medical history about

3 generations

a nurse is completing a respiratory assessment of a client place the following steps in order when auscultating the posterior chest of the client

3 inches to the side of the spine at c7 3 inches to the side of the spine at t4 midaxillary line at T4 3 inches to the side of the spine at the intercostal space of the 8th rib

a nurse is measuring the respiratory rate of a client who has an irregular breathing pattern for how many seconds should the nurse count the clients respirations

60 seconds

wearing boots and hardhat effects which vital signs

BMI and Oral temperature

wearing leather vest and pants effects which vital signs

BMI and Oral temperature

hypopigmentation

decrease in skin color

diaphoresis

profuse perspiration

place the steps in the correct order to conduct a review of symptoms

head eyes ears nose mouth neck

anxious about his daughter's volleyball game effects which vital signs

Heart rate and Blood pressure

xerosis

dry skin

hyperpigmentation

increase in skin color

nevus

mole

petechiae

reddish/purple spots

a nurse is performing an initial assessment on a clients skin which of the following observations will require further assessment of the clients circulation

cyanosis is noted on fingers

a nurse is conducting a review of systems with a client during a health history interview which of the following responses by the client requires additional investigation

I have a cough

a nurse is collecting data from a client about their skin and nails which of the following statements by the client should the nurse identify as needing further assessment

I noticed that my fingernails have changed recently

hematoma

blood clot in organ space or tissue

pigmentation

skin color

a nurse is preparing to assess the eyes of a client who has liver disease which of the following findings should the nurse expect

yellow sclera

a nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine which of the following statements should the nurse make

you should make every effort to receive a flu vaccine every year

when checking a clients capillary refill the nurse finds that the color returns in 10 seconds the nurse should understand that this finding indicates which of the following

arterial insufficiency

a nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA) which os the following parameters should the nurse use first in order to assess the clients pain level

a self report pain rating scale

a nurse is providing teaching to client who reports extremely dry skin which of the following interventions should the nurse recommend

apply an alcohol free lotion

a nurse is preparing to assess a client's conjunctiva identify the sequence the nurse should follow when taking the following actions

apply examination gloves instruct the client to look up place the thumbs below each of the clients lower eyelids gently pull the client's skin down to the top edge of the bony orbital rim inspect the color and condition of the conjunctivia and sclera noting any color change swelling drainage or lesions

a nurse is assessing a client who has a lump on their neck which of the following questions should the nurse ask the client

are you experiencing difficulty breathing? how long has the lump been on your neck? is the lump causing you discomfort? are you having difficulty swallowing?

a client who has major depressive disorder statees to the nurse that he and his family would be better off if he were gone which of the following is the nurses priority response

are you thinking of harming yourself

a nurse is perparing to palpate a clients sinuses identify the sequence the nurse should follow when taking the following actions

position the thumbs on teh supra orbital ridge just below the clients eyebrows to assess the clients frontal sinuses firmly press upward on the ridge and make sure not to apply pressure to the clients eyes ask the client if they detect tenderness or pain position the thumbs below the clients cheeckhones with fingers alongside the client's head to assess the client's maxillary sinuses apply firm upward pressure and ask the client if they detect tenderness or pain

place the steps for assessing a client's skin turgor and mobility in the order of performance

position your hand with fingers just below the clients collar bone pinch a large fold of skin between your thumb and forefinger note the ease with which you were able to move the client's skin open the pinch and release the skin note how quickly the skin returns to a flat position on the chest

a nurse is gathering information about a client's personal lifestyle choices. which of the following information should the nurse seek to gather while investigating substance use

prescription medications taken for recreational purposes determination of when the client last has an alcoholic drink

the client is at greatest risk for developing

pressure injury due to urinary incontience

a nurse is preparing to conduct a health history interview which of the following actions should the nurse plan to perform during the closing stage of the interview

provide an opportunity for the client to ask questions

a nurse is having difficulty obtaining a pulse oximetry reading from a client the nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading

recent scan with contrast dye

a nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client.

rectal

a nurse is admitting a client who has a new diagnosis of COPD which of the following information documented by the nurse is subjective data

report from the client says they sleep while propped on two pillows at night client says they quit smoking 2 years ago client states being short of breath all of the time Is making me depressed

a nurse is performing a head and neck assessment on a client after checking the client's vision the nurse notes the client has difficulty reading fine print in which of the following sections of the client's electronic heath record should the nurse document this finding

review of symptoms

the client says, this only happens if I get too little sleep which of the 8 critical variables does this statement represent?

setting

which of the following findings are associated with a possible malignant lesion

several colors within a single mole a mole that is larger than a pencil eraser a report of a mole being itchy occasional bloody drainage from a mole a mole that becomes elevated

for which of the following disease should you obtain family history

sickle-cell anemia

a nurse is examining a lesion on a clients back which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion

size of a pencil eraser

vitilgo

skin areas without usual brown pigmentation

a nurse is performing an admission assessment on a client which of the following findings should the nurse identify as an indication that the client is dehydrates

skin tenting is present

a nurse is providing teaching to a client who has a new diagnosis of asthma and reports smoking history of 20 years which of the following statements should the nurse make when counseling the client about their tobacco use

smoking is linked to various forms of cancer it might take several attempts to finally stop smoking there are pharmacologic therapies that can help a person stop smoking

you are assessing the texture of a clients skin which of the following findings require additional investigation

smooth velvety skin

a nurse is collecting a health history from a client who is accompanied by an interpreter which of the following actions should the nurse take

speak directly to the client throughout the interview

you are assesing a client and note a pressure injury on the clients sacrum the lesion is a deep depression below the level of the skin and subcutaneous fat is visible what stage of pressure injury would you document for this wound

stage III

a nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min the nurse should identify this as which of the following unexpected findings

tachypnea

a nurse is reviewing the vital signs for a client who was admitted with shortness of breath the nurse notes the client's respiratory rate is 24/min the nurse should use which of the following terms when documenting this finding

tachypnea

a nurse is caring for a client who is reporting pain as 4 on a scale of 0-10 upon further assessment which of the following findings should the nurse identify as manifestations of chronic pain

the client report that the pain has been present for approximately 4 years the client reports never feeling total relief from pain the client reports that the pain is recurring and does not always originate in the same location

a nurse is conducting a general survey on a client who is being admitted to a long term care facility the nurse is assessing the client's emotional state which of the following findings should the nurse record as a subjective unexpected finding

the client reports they feel sad and lonely most of the time

a nurse assess a clients respiratory rate and notes that it is below the expected reference range the nurse should identify that which of the following findings can cause a decreased respiratory rate

the client take a narcotic pain medication for chronic pain

a nurse is caring for a client who is postoperative the nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pain?

the clients self report of pain severity

a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client for which of the following actions should the charge nurse intervene

the nurse is auscultating through the gown

a nurse is inspecting a client and documents that the spine is straight and the movement upon inspiration is symmetrical which of the following describes the location that the nurse is documenting

the posterior chest

the nurse is inspecting a client's anterior chest which of the following findings should the nurse expect

the ribs are sloping downward at an angle

a nurse is conducting a health history interview with a client which of the following is accurate about a directive interview technique

this technique consists of mostly closed-ended questions

a nurse is performing a head to toe assessment on a client and notes a lump on the anterior portion of their neck the nurse should identify that this finding can indicate which of the following conditions

thyroid disorder

a nurse is providing teaching to a client who asks what are things that can affect my blood pressure

time of day obesity diuretic medication smoking

which of the following is a purpose of obtaining a health history

to establish a baseline of the client's health status

which of the following are research validated reasons to conduct a health history using an interpreter

to increase the accuracy on the communication to increase the client's satisfaction with care.

a nurse is caring for a child with an outer ear infection which of the following assessment findings should the nurse expect?

tragal tenderness

a nurse is performing an eye assessment on a client which of the following should the nurse identify as the cornea of the eyes

transparent layer that covers the iris and pupil

a nurse is caring for a client who is experiencing respiratory distress which of the following positions should the nurse assist the client into

tripod position

the nurse is interviewing a client with limited english proficiency which of the following is an effective communication technique

use a telephone interpretive service

a nurse is documenting information in a clients medical record during an initital assessment which of the following information should the nurse include in the documentation

use of assistive devices height and weight behavior and mood

a nurse is examining the texture of an older adult client's skin. which of the following findings should the nurse report to the provider

velvety skin

a nurse is assessing a client who is admitted with abdominal pain the client reports that the pain is in the stomach and is crampy dull ache which type of pain should the nurse identify this client is experiencing

visceral

a nurse is teaching an older adult client about health promotion the nurse should instruct the client to have which of the following examinations performed on a regular basis

vision screening every year dental examination every 6 months

a nurse is collecting biographic data from a client who reports they are seeking health care due to a persistent cough the client states they identify as transgender which of the following questions should the nurse ask

what pronouns do you use

a nurse is assessing the mouth of a client who has candidiasis an oral fungal infection which of the following findings should the nurse expect

white patches on the tongue