Nursing Fundamental FINAL
The nurse observes the client as he walks into the room. What information will this provide the nurse?
information regarding the client's gait
Which guideline should a nursing instructor provide to nursing students who are now responsible for assessing their clients?
"Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." Data about the client are collected continuously because the client's health status can change quickly.
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond?
"Do you take anything to help your constipation?" A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement such as asking about chest pain, ask why questions such as asking about taking a laxative every day, or make assumptions that everyone has bowel problems.
A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?
"How many pillows do you sleep on at night to breathe better?" People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.
Which entry would be an example of appropriate documentation?
"I am so down today, and I just don't have any energy." Subjective data should be recorded in the client's own words, and quotation marks should be used. Avoid using nonspecific terms such as good, average, large, and small. Do not make judgments or inferences
The nurse is teaching a client how to take a daily blood pressure reading at home. The nurse includes instructions about obtaining an accurate blood pressure measurement. What additional information would the nurse include? Select all that apply. Hint: 4 correct answers
"Keep both feet flat on the ground; do not cross your legs." "Rest 3 to 5 minutes before taking your blood pressure." "Place your arm on a table that is level with your heart." "Take your blood pressure every day prior to eating breakfast." To obtain an accurate blood pressure measurement, the client should follow recommended practice. These recommendations include take the blood pressure prior to eating a meal, rest 3 to 5 minutes before taking the blood pressure, keep both feet on the ground during the measurement, and place the arm on a table that is level with the client's heart. Coffee, if ingested, should be at least 30 minutes prior to taking the measurement. It is recommended to take three blood pressure measurements at one sitting with each one at least 1 minute apart and record the average.
The primary care provider is yelling at the nurse in the client's room because the client has not received an intravenous antibiotic. Which statement by the nurse demonstrates assertiveness?
"Let's go to the nurses' station, and I will explain." The assertive response is to remove the conversation from the client's room and show respect for each other. The other responses are aggressive in being defensive or blaming.
A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement by the nurse would recognize the client's value as an individual?
"Mr. Koeppe, tell me what you do to take care of yourself." Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client sends a message that the nurse does not have time or has doubts in the client's ability to communicate.
A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension?
"Put away the salt shaker and eat low-salt foods." High salt intake is a high risk factor for the development of hypertension.
Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. Hint: 3 correct answers
Need for nursing Diet and exercise program Ability to pay for services Developmental stage Standing in the community
An adolescent comes to a community health clinic reporting vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which response should the nurse use during the health history to elicit information?
"Tell me about the sexual activity with your boyfriend." The health history is used to collect subjective data about the client's health status. Nurses use therapeutic communication skills, including open-ended statements and questions that are not threatening or negative, to establish an effective nurse/client relationship that facilitates communication. Asking a question such as Why did you ever have sex with someone you don't know? does not allow for open communication and is threatening to the client. Age of the child does not govern use of condoms; therefore the nurse should teach information regarding condoms if assessed that this is important for the client to understand. Telling the client that they are careless is judgmental.
A nurse is conducting a health history for a client with a skin problem. What question or statement would be most useful in eliciting information about personal hygiene?
"Tell me about what you do to take care of your skin." When skin problems are present, the nurse asks the client about usual personal hygiene practices and documents the client's responses. The questions should be open-ended and nonthreatening. Why do you only take a bath once a week? asks a question. Perhaps you don't recognize your body odor and you eat a lot of greasy foods both impose an assumption about the client and can be threatening to the client/nurse relationship.
Which questions asked by the nurse when taking a client's health history would collect data about infection control?
"When did you complete your immunizations?" The nurse's role in infection control includes early detection and surveillance. When taking a health history, the nurse asks about immunization status and previous/recurring infections. The other questions are appropriate in a health history, but are not specific to infections.
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?
A reservoir Humans may act as reservoirs for an infectious agent and not exhibit any manifestations of the disease. They are considered carriers and can transmit the disease. In this case, the woman is the reservoir for HIV.
As a component of a head to toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?
Ask the client to follow her finger as she slowly moves it towards the client's nose. Eye convergence is assessed by holding your finger 6 to 8 in (15 to 20 cm) from the patient's nose and asking the patient to follow it as it moves closer. A pen light is used to assess pupillary reaction. Visual acuity is assessed with the use of a Snellen chart. Following a pencil from side to side is a test for extraocular movements
A male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment?
Assess the client's temperature by axilla. The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.
All of the following are factors to consider when caring for clients with limited income. Which one is the most important?
Basic human needs may go unmet Poverty prevents many people from consistently meeting their basic human needs. Limited means of transportation, decreased access to health care services, and an increased incidence of disease are also influenced by limited income, but meeting one's basic human needs is the most important factor.
While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?
Bronchovesicular Bronchovesicular sounds are moderate "blowing" sounds with equal inspiration and expiration. Bronchial breath sounds are high pitched, with expiration longer than inspiration. Vesicular sounds are soft and low-pitched, with longer inspiration than expiration. Adventitious sounds are not normally heard in the lungs.
In providing nursing care, it is most important to perform which action?
Coordination of care with the health care team Nurses have moved from simply observing and giving prescribed medications to coordinating clinical information for the entire health care team.
Which of the following is a tenet of Maslow's basic human needs hierarchy?
Certain needs are more basic than others and must be met first. Maslow arranged the hierarchy to show that certain needs are more basic than others. Although all people have all the needs all the time, people generally strive to meet priority needs (at least to a minimal level) before attending to other needs.The hierarchy is also based on the theory that something is a basic need if it has the following characteristics: (1) its absence results in illness, (2) its presence helps prevent illness or signals health, (3) meeting the need restores health, (4) it is preferred over other satisfactions when unmet, (5) one feels something is missing when the need is not met, and (6) one feels satisfaction when the need is met.
A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?
Client's wife In this case, the primary source of information is the client's wife, as she can provide a detailed description of the incident as well as provide the medical history of the client. The medical files, test results, and assessment data are secondary sources of information.
What step in the nursing process is most closely associated with cognitively skilled nurses?
Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes.
A nurse explains the informed consent form to a client who is scheduled for heart bypass surgery. Which of the following are elements of this consent form? Select all that apply. Hint: 3 correct answers
Competence Comprehension Disclosure Every person is granted freedom from bodily contact by another person, unless consent is granted. In all health care agencies, informed and voluntary consent is needed for admission (for routine treatment), for each specialized diagnostic procedure or medical or surgical treatment, and for any experimental treatments or procedures. Elements of informed consent include disclosure, comprehension, competence, and voluntariness.
A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which mechanism of heat transfer?
Convection Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.
A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client about the harmful effects of alcohol and educates the family on how to cope with the client and his alcohol addiction. Which type of skill is the nurse using?
Counseling The nurse is using counseling skills to educate the client about the harmful effects of alcohol. The nurse can also suggest rehabilitative care for the client. The nurse uses therapeutic communication techniques to encourage verbal expression and to understand the client's perspective. Caring, comforting, and assessment may require active listening, but counseling is based upon the active listening and interaction between the client and the counselor.
During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is being tested by this action?
Cranial nerve VII Cranial nerve VII is the facial nerve tested by smiling, frowning, wrinkling the forehead, and puffing out the cheeks. Cranial nerve I is the olfactory nerve, cranial nerves II and III are the optic and oculomotor nerves, and cranial nerve VIII is the acoustic nerve.
When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition would the nurse document?
Cyanosis Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Jaundice is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis. Erythema is redness of the skin associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is paleness of the skin, which often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.
What is one method by which a nurse can be a role model to promote health in the community?
Demonstrating a healthy lifestyle Nurses promote health in the community by providing health care services in a variety of settings, by serving as volunteers in health-related activities, and by being role models for health practices and lifestyles.
A client has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?
Dorsalis pedis artery The nurse would assess circulation in the lower extremities by palpating the dorsalis pedis artery. The other arteries listed would not be used to assess circulation to the legs.
The beginning nurse is managing a team alone for the first time. Several ethical situations have occurred throughout the day that have caused the nurse to question his career choice. What actions can the nurse take to improve his ability to be resilient? Select all that apply. Hint: 2 correct answers
Ensure he takes entitled breaks and lunch during his shift Cultivate relationships with other people who are supportive Events occur throughout the day that will cause the nurse to be stressed. Resilience is the ability to adapt to challenging events. Ways for the nurse to build resilience include cultivating good relationships and taking care of oneself—such as ensuring breaks throughout the day. Ways that will inhibit the nurse to build resilience include adhering to a strict schedule that does not allow for change, believing each crisis is out of her control, and questioning each decision she made.
A client who has difficulty sleeping expresses to the nurse that watching television may help him relax and get sleep. The nurse disregards the client's concern and suggests drinking warm milk before going to bed. Which cultural characteristic is the nurse demonstrating? Stereotype
Ethnocentrism The nurse disregarding the client's concern is an example of ethnocentrism. Ethnocentric people view one's own culture as the only correct standard by which to view people of other cultures. Stereotypes are preconceived and untested beliefs about people. Racism uses skin color as the primary indicator of social value. Understanding that cultures relate differently to the same given situation is called relativity.
A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process?
Extraocular movements The nurse tests for extraocular movements by assessing the cardinal fields of vision for coordination and alignment. Normally both eyes move together, are coordinated, and are parallel. Visual acuity is assessed with the Snellen chart. Tests for peripheral vision (or visual fields) are used to assess retinal function and optic nerve function. Full peripheral vision is normal. Cataracts are noted by inspection (cloudiness of the lens).
A nurse uses proper body mechanics to move a client up in bed. Which action is a guideline for using these techniques properly?
Face the direction of movement. When using body mechanics, the nurse should face the direction of movement and avoid twisting the body. Maintaining balance involves keeping the spine in vertical alignment, body weight close to the center of gravity, and feet spread for a broad base of support.
Who was the first nurse to develop a nursing theory?
Florence Nightingale developed and published a philosophy and a theory of health and nursing that has served as a solid foundation for the nursing profession. The other nurses listed are also important to nursing, but none of them was the first to develop a nursing theory.
A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform?
Focused assessment A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.
During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this?
Focused assessment Often, nurses must select the most important interviewing questions or assessment techniques to use, and perform a focused health assessment based on the client's problem.
What are the concepts that are common to all theories of nursing? Select all that apply. Hint: 4 correct answers
Health The environment Illness Nursing
Nurse researchers have predicted that a newly created mentorship program will result in decreased absenteeism, increased retention, and decreased attrition among a hospital's nursing staff. What does this predicted relationship represent?
Hypothesis A hypothesis is an expected statement of the relationship between variables in a study. In this study, the dependent variables are absenteeism, retention, and attrition while the independent variable is the mentorship program. The methodology of a study is the logistical framework that guides the planning and execution of the study. An abstract is a summary of a research study published in a journal.
The family of a client in a burn unit asks the nurse for information. The nurse sits with the family and discusses their concerns. What type of communication is this?
Interpersonal Interpersonal communication occurs among two or more people with a goal to exchange messages. Nurses spend most of their day communicating with clients, family members, and health care team members.
While giving a client a bath, a student nurse observes the color of the client's skin as having a yellowish tinge. What term would be used to document this assessment?
Jaundice Jaundice is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis (breakdown of red blood cells). It usually develops first in the sclera of the eyes and then in the skin and mucous membranes. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate circulation. Cyanosis is assessed as a blue tinge in clients with white skin and as dullness in people with dark skin. Other skin colors include pallor (paleness) and erythema (redness).
The client who has an immobilizer on the arm reports shortness of breath following ambulation to the bathroom. The nurse notes the client's pulse increased from 82 to 124 beats per minute, respirations increased from 16 to 24 breaths per minute, and blood pressure is 90/50 mm Hg. The nurse makes the nursing diagnosis of Activity Intolerance. What are the client's defining characteristics for this diagnosis? Select all that apply. Hint: 4 correct answers
Limited range of motion Client reports of shortness of breath Decrease in blood pressure Increase in respiratory rate Increase in pulse rate
Which client would be most at risk for alterations in oral health?
Man with a nasogastric tube A variety of illnesses and habits may increase the risk for oral health problems such as those with nasogastric tube or oral airways. This is due to the drying of the secretions in the mouth which allows for the growth of bacteria leading to infection. Other risks of oral health problems include poor nutrition, treatment with chemotherapy, and those who are NPO.
Which of the following health care insurance programs is most suitable for a client 68 years of age?
Medicare Medicare is a federal program that finances health care costs of persons 65 years and older, permanently disabled workers of any age and their dependents, and those with end-stage renal disease. The system is funded primarily through withholdings from an employed person's income. Capitation is a reimbursement strategy in managed care organizations. AmeriCare is a type of private insurance. Capitation and AmeriCare are not the preferred providers for the client, considering the client's old age. Medicaid is a federal program that is operated by the states, and each state decides who is eligible and the scope of health services offered. In Medicaid, eligibility may be decided by the state, which is not the case in Medicare.
A nurse is educating an older woman on how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's education plan?
Minimize stress on the wife's joints. Older adults often have osteoarthritis, a noninflammatory progressive disorder of the moveable joints, particularly weight-bearing joints. Teaching clients to minimize stress on the joints to prevent possible injury and reduce pain is important. A physical therapist could recommend physical exercise for the husband and not the nurse. The nurse's priority is not to maintain the self-esteem of the wife or increase socialization with neighbors but to minimize additional strain and movement problems with the osteoarthritis.
A mother always thanks clerks at the grocery store. Her daughter, age 6 years, echoes her thank you. The child is demonstrating what mode of value transmission?
Modeling Through modeling, children learn of high or low value by observing parents, peers, and significant others. Modeling can thus lead to socially acceptable or unacceptable behaviors. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Through rewarding and punishing, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Caregivers who follow the responsible-choice mode of value transmission encourage children to explore competing values and to weigh their consequences.
A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate?
Normal body temperature A person with normal body temperature is referred to as afebrile.
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 difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.
The nurse cares for a newly admitted client who will soon need to be taken to the radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52. Which of the following strategies to transport the client is most appropriate?
Obtain a mechanical lateral transfer device to move the client onto a stretcher. The combined weight of the bed and client will be difficult to move safely. Additionally, this strategy does not address the need to transfer the client onto, and off of, equipment in the radiology department.
Which site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious?
Oral Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults, as well as in infants and young children. This is due to the danger of breaking the thermometer in the mouth.
When assessing the abdomen, which assessment technique is used last?
Palpation The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.
A baby is born with Down syndrome, which influences his health-illness status. This is an example of which of the following human dimensions?
Physical The physical dimension includes genetic inheritance, age, developmental level, race, and gender. These components strongly influence the person's health status and health practices.
Upon review of the client's orders, the nurse notes that the client was recently started on an anticoagulant agents. What is an appropriate consideration when assisting the client with morning hygiene?
Provide the client with an electric shaver. Electric shavers are recommended when a client is receiving anticoagulant therapy. In addition, the nurse should not provide a firm-bristled toothbrush because the client is more prone to bleeding, and the firm bristles may lead to bleeding. The client should be allowed to shower, unless there are other contraindications. A back massage will provide an ideal time to perform a skin assessment for bruising or breakdown.
What is the purpose of the affective and coping function of the family?
Providing emotional comfort and identity The affective and coping function of the family is necessary to provide emotional comfort to family members and to help members establish an identity to be maintained in times of stress. The physical function provides a safe environment for growth and development, the economic function ensures financial assistance, and the socialization function transmits values, attitudes, and beliefs.
A nurse walks into a client's room and finds the client having difficulty breathing and complaining of chest pain. The client has bradycardia and hypotension. What should the nurse do next?
Report findings to the physician immediately. The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.
A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make?
Safety of the immediate environment The nurse should also observe the safety of the immediate environment as it is can be a source of concern for a client. Observation is the conscious and deliberate use of the five senses to gather data. Each time a client is observed, the nurse observes the client's current responses, ability to provide self-care, the immediate environment, and the larger environment. The number of rooms in a house is an observation but not a safety concern. The number of home visits are dependent on the progress of the client. By observing the friendliness of the client and family determines appropriate health care attitudes toward the nurse and other providers.
What statements describe how risk factors may increase a person's chances for illness or injury? Select all that apply. Hint: 3 correct answers
School-aged children are at high risk for communicable diseases. An increase in risk factors increases the possibility of illness. A family history of breast cancer is a nonmodifiable risk factor. A risk factor is something that increases a person's chances for illness or injury. Like other components of health and illness, risk factors are often interrelated. Risk factors may be further defined as modifiable (able to be changed, such as quitting smoking) or nonmodifiable (unable to be changed, such as a family history of cancer). As the number of risk factors increases, so does the possibility of illness. School-aged children are at high risk for communicable diseases. Multiple sexual relationships increase the risk for sexually transmitted diseases (e.g., gonorrhea or acquired immunodeficiency syndrome AIDS).
Which source of knowledge is based on objective data?
Scientific Both traditional and authoritative knowledge are practical to implement but are often based on subjective data, limiting their usefulness in a wide variety of practice settings. For this reason, nurses increasingly focus on scientific knowledge or objective knowledge to provide care, commonly called evidence-based practice.
The nurse is assessing the functions of a family. Which items are functions of the family? Select all that apply. Hint: 4 correct answers
Secure adequate income to meet the needs of the family. Provide emotional support to family members. Communicate cultural values and beliefs to family members. Provide a safe, comfortable home in which to reside. Family functions include: (1) providing a safe, comfortable home; (2) securing adequate income; (3) providing emotional support; and (4) communicating cultural values and beliefs. Nurses make referrals to community-based health care agencies to secure resources for families in need.
An woman 80 years of age states, "I have successfully raised my family and had a good life." This statement illustrates meeting which basic human need?
Self-actualization The highest level on the hierarchy of basic human needs is for self-actualization, which includes acceptance of self and others, reaching one's full potential, and feelings of happiness and affection for others.
An older adult asks the nurse about the appearance of flat brown age spots on the hands. After examining the client's hands, the nurse recognizes these skin characteristics as a common skin variation in the older adult and documents the variations as which of the following?
Senile lentigines Senile lentigines are flat, brown age spots, senile keratosis are raised, dark areas, and cherry angiomas are small, round red spots. All are common skin variations in the older adult. Lanugo is a fine downy hair that appears on the newborn for the first two weeks of life.
A nurse is using inspection as an assessment technique. What does the nurse use during inspection?
Senses of vision, hearing, smell Inspection is the process of performing deliberate, purposeful observations. The nurse observes visually but also uses hearing and smell to gather data throughout the assessment. A stethoscope is used for auscultation, and the hands are used to percuss and palpate.
The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which symptom would the nurse identify as a subjective cue?
Sharp pain in the knee Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F (38.9 degrees C), and a pulse rate of 90 beats per minute are examples of objective cues.
A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision?
Snellen chart A Snellen chart is used as a screening test for distant vision. It consists of characters in 11 lines of different-sized type, with the largest characters at the top of the chart and the smallest characters at the bottom. Vision is recorded as a score; for example, 20/20 is normal vision. A stethoscope is used to auscultate body sounds. An ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.
The mother of a toddler with asthma seeks support from the parents of other children with asthma. The nurse recognizes that seeking and utilizing support systems is an example of which human dimension?
Sociocultural dimension Communicating with others and the use of support systems relate to the sociocultural dimension. An individual's relationship with others, being connected to a community, and feeling accepted and loved by others are also related to the sociocultural dimension.
When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?
Symmetry (comparison of bilateral body parts) When conducting a physical assessment, the nurse assesses and compares all bilateral body parts. The symmetry of parts of the body (such as the skull) and the extremities (arms and legs) is an important assessment to document.
The nurse is providing primary prevention education to a group of clients. What actions by the nurse would indicate primary prevention activities? Select all that apply. Hint: 2 correct answers
Teaching clients about a healthy nutritional plan Counseling a client about smoking cessation and making a plan . There are three levels of health promotion and illness prevention. The levels are primary, secondary, and tertiary preventions. Primary level prevention is directed at preventing health problems. Examples of primary level prevention are the nurse counseling the teenager about smoking cessation and teaching middle school children about a healthy diet. The nurse conducting a health fair for high blood pressure screening and providing information for a client diagnosed with lung cancer are secondary level preventions. Arranging rehabilitation services for a client is a tertiary level prevention.
Which of the following can a nurse assess by palpation?
Temperature, turgor, moisture Palpation is an assessment technique that uses the sense of touch. The hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.
Which data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. Hint: 2 correct answers
The client has been experiencing fatigue in recent weeks. The client's chemotherapy causes him nausea and loss of appetite. Reports of nausea, anorexia, and fatigue are subjective data that depend on the client's self-report. Weeping, ostomy output, and an inability to perform a kinesthetic task are observable assessment findings that would be characterized as objective.
When assessing a client's vital signs, a nursing student has explained to the client each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nursing student did not announce her intention to assess the client's respiratory rate prior to measuring it. What is the rationale for the nursing student's decision to withhold this information?
The client may alter the rate of respirations if the client is aware that his breaths are being counted. Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.
A client in a physician's office has a blood pressure (BP) reading of 150/92 mm Hg. What must be considered prior to this client being diagnosed as having hypertension?
The client must have at least two blood pressure readings that are elevated for the diagnosis. The American Heart Association recommends that blood pressure readings be measured on two or more subsequent occasions before diagnosing hypertension. The client's blood pressure fluctuates throughout the day with afternoon readings usually being higher. Women tend to have lower blood pressure readings when compared to men of the same age until menopause.
The nurse uses the nursing process to provide care to clients. What are the benefits for the clients? Select all that apply. Hint: 3 correct answers
The client receives care that is evidence based. Care is individualized for the client. The nurse provides care that is consistent for the client. The client benefits from the nurse's use of the nursing process. Benefits for the client include nursing care that is researched, based on evidence, and individualized. Nursing care is planned and consistent. When using the nursing process, the client will collaborate with the nurse about his or her care and care will be holistic and not focused solely on one main problem.
The nurse works on a pediatric unit and is beginning assessments for clients. Which client would the nurse assess first, based on recent vital sign readings?
The client who is 2 years old and whose respiratory rate is 16 breaths/minute Normal respiratory rate for a child 1 to 3 years of age is 20 to 30 breaths/minute. Therefore, the nurse should assess the 2-year-old who has a respiratory rate of 16 breaths/minute first. The other clients' vital signs are within normal limits for their age.
What would describe clients as health care consumers today? Select all that apply. Hint: 4 correct answers
The clients often have health information obtained from the Internet. The clients express concern regarding access to care and the quality of service. The clients have helped develop clients' rights and cost-containment measures. The clients prefer to control the decisions made about their own health care. Health care consumers are increasingly more knowledgeable about health, and prefer to control the decisions about their care. They express concern about access to services, and the cost and quality of care. They question duplication of services, and are actively engaged. They have helped to develop client rights and cost-containment measures as protections for clients in health care settings. Today clients are surveyed regarding their experiences with doctors and nurses in hospitals.
A child age 4 years has leukemia but is now in remission. What does it mean to be in remission when one has a chronic illness?
The disease is present, but symptoms are not experienced. Many chronic illnesses have periods of remission and exacerbation. During remission, the disease is present but the person does not experience symptoms. During exacerbation, the symptoms of the illness reappear.
Hospice nurses provide care in a variety of settings, including clients' homes, long-term-care facilities, and hospice residences. After the client dies, what happens next?
The hospice nurse continues to care for the client's family for up to one year. After the death of the patient, the hospice nurse continues to care for the client's family during the bereavement period for up to one year. Nurses help the family to work through their loss.
Which statements describe the nurse applying critical thinking to clinical reasoning and judgment in nursing practice? Select all that apply. Hint: 3 correct answers
The nurse is guided by standards, policies and procedures, ethics codes, and the state nurse practice act. The nurse demonstrates use of nursing process, problem solving, and the scientific method. The nurse identifies key problems, issues, and risks involved. The nurse who applies critical thinking to clinical reasoning and judgement is guided by standards, policies and procedures, ethics codes, and laws (states' nurse practice acts). The nurse uses nursing process, problem solving, and the scientific method when making decisions. The nurse also identifies the key problems, issues, and risks involved. Clients, families, and major care providers are involved in decision making. The nurse is constantly re-evaluating, self-correcting, and striving to improve. The nurse keeps his or her mind open to other options.
A nurse exemplifies the professional value of altruism. What behaviors recognized by others demonstrates this concept? Select all that apply. Hint: 2 correct answers
The nurse notifies the health care provider that a client reports pain medication is ineffective. The nurse arranges for an interpreter for a client that doesn't speak English. The altruistic nurse demonstrates understanding of cultures, beliefs, and perspectives of others; advocates for clients; and takes risks on behalf of clients and colleagues. The nurse who is demonstrating the professional value of altruism is the nurse who arranges for an interpreter and the nurse who notifies the physician about ineffective pain relief. The professional practice reflects autonomy when the nurse respects clients' rights to make decisions about their health care. This is the nurse who provides information to the client. Human dignity is reflected when the nurse values and respects all clients and colleagues by preserving their confidentiality. This is the nurse who determines who may be informed of the patient's condition. Integrity is reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. The is the nurse who documents accurately and honestly.
Which of the following are examples nurses following the Institute of Medicine's (IOM) recommendations for transforming the nursing profession? Select all that apply. Hint: 3 correct answers
The nurse participates in a state-wide committee with other health professionals and legislators to address human trafficking. The nurse is a graduate with an associate degree and enrolls in a program to obtain a bachelor's degree in nursing. The nurse notes an increase in hospitalized clients who have heart failure and implements a research study addressing this issue. The IOM's recommendations for transforming the nursing profession include the following: Nurses should practice to the full extent of their education and training. Currently, the nurse practitioner does not have the same scope-of-practice in every state. Scope-of-practice for the nurse practitioner varies according to the laws in each state. The nurse who initiates a research study is an example of practicing to the full extent of education and training. Another recommendation is that nurses should achieve higher levels of education through a seamless academic process. An example of this is the associate degree nurse who is able to enter a bachelor's degree program without taking additional courses. Another recommendation is the nurse should be a full partner in redesigning health care. An example is the nurse on a state-wide committee addressing human trafficking. The chief nursing officer should be a voting member of the hospital board.
A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture?
The shoulder and upper back curves forward. In kyphosis, the shoulder and upper back tend to curve forward. In lordosis, the lumbar region curves inward and the sacral region curves outward. Scoliosis is a curvature of a portion of the spine to the side, laterally.
Which statement describes the concepts of disease and illness?
The terms of disease and illness are often used for each other. The terms of disease and illness are often used interchangeably. A disease is traditionally diagnosed and treated by a physician or an advanced practice nurse. A person may have an illness or injury and still achieves maximum functioning and quality of life. This person may consider oneself to be healthy. Illness is the response of the person to a disease, and levels of functioning will change when compared with a previous level.
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment?
Time-lapse The time-lapse assessment is scheduled to compare a client's current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapse assessments to reassess health status and to make necessary revisions in the plan of care. A comprehensive assessment should be performed upon admission to a health care organization. Focused assessment is completed every 4-8 hours, depending on the health care facility, which centers on the main issue or problem keeping the client in the setting. Emergency assessments are sometimes completed after the client has stabilized for an acute issue or problem. Documentation may not have been the priority of care during this time.
How would a nurse assess a client for pupillary accommodation?
Using an ophthalmoscope, check the red reflex. Ask the client to read the smallest possible line of letters on the Snellen chart. Ask the client to focus on a finger and move the client's eyes through the six cardinal positions of gaze. Ask the client to focus on an object as it is brought closer to the nose. The normal pupillary response is constriction, and convergence when focusing on a near object. Presence of the red reflex indicates that the cornea, anterior chamber, and lens are free of opacity and clouding. A client's focusing on a finger and gazing about evaluates the function of each of the eye muscles and cranial nerves. The Snellen chart tests visual acuity.
A nurse tells a client, "Aren't you going to get out of bed or are you just going to sleep all day and night?" This is an example of which barrier to communication?
Using judgmental or belittling language Using judgmental comments tends to impose the nurse's standards on the client. In this case, the nurse judges the client as being lazy and the nurse's apparent hostility could end effective communication. Leading questions are usually open ended and allow for the client to finish a sentence or to provide direction in the form of oral communication. Probing questions are follow-up questions when a response is not fully understood or when answers are vague or ambiguous to obtain more specific or in-depth information. Comments that give advice provide guidance to the client.
Which description most accurately defines an infection?
a disease resulting from pathogens in or on the body An infection is a disease state that results from the presence of pathogens (disease-producing microorganisms) in or on the body. Infection can develop from a traumatic injury but it is not related to acute or chronic illness. An unclean environment does not lead to an infection in the client. A knowledge deficit in food preparation does not lead to food borne illnesses or infection.
Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/min. The nurse notifies the physician because the client is exhibiting signs of:
a dysrhythmia. An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/min. Bradycardia is a pulse rate below 60 beats/min. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.
Which of the following is a criteria that defines nursing as profession?
a strong service orientation Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge; strong service orientation; recognized authority by a professional group; code of ethics; professional organization that sets standards; ongoing research; and autonomy.
All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned?
an infant 2 months of age A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms.
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which client information as objective data?
auscultation of the lungs Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.
What is one responsibility of nurses who work in physicians' offices?
conducting health assessments Nurses in physicians' offices make health assessments, perform technical procedures, assist the physician, and provide health education. They do not prescribe medications, perform minor surgery, or make independent home visits.
A nurse is caring for an older adult from a far eastern culture. How does the nurse demonstrate awareness of culturally competent care?
establishing effective communication Establishment of an environment of culturally competent care and respect begins with effective communication, which occurs not only through words, but also through body language and other cues, such as voice, tone, and loudness. Maintaining eye contact at all times is inappropriate because not all cultures are comfortable with eye contact. Speaking louder is an incorrect answer because the issue is a communication problem, not a hearing problem. Not all cultures are comfortable with touch so this would block communication.
Of the following information collected during a patient assessment, which are subjective data?
nausea, abdominal pain Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data. Vomiting, vital signs (temp, heart rate, blood pressure, respiratory rate, and SpO2), pale skin, and thick toenails are all objective data that are observed and recorded.
A group of nurses working in a long-term care facility fails to keep the narcotic medications in a secure location. The nurses also fail to count the medications before and after each shift, as indicated by the institution's policies and procedures. These failures may result in disciplinary action against the:
nurses' licenses. In institutions, most controlled substances must be kept secure and monitored closely in accordance with institutional and state regulations. Failure to do so may lead to disciplinary action against the nurse's license.
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position themself?
sitting at a 45-degree angle to the bed If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.
A nursing student assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?
systolic pressure Maximum blood pressure is exerted on the walls of the arteries when the left ventricle pushes blood through the aortic valve into the aorta at the beginning of systole. The higher pressure (here, 140) is the systolic pressure.
A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?
tachycardia The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.
A school nurse is assessing children in the third grade for pediculosis capitis. What assessments should be made?
the head for nits on hair shafts Pediculosis capitis is lice infest of the hair and scalp. Lice lay eggs, called nits, on the hair shafts. Nits are white or light gray and look like dandruff, but cannot be brushed or shaken off the hair. Assessing the public area for growth of hair would be determining the beginning of puberty. Nails for cleanliness is not associated with lice infestations. Physical abuse is identified by bruising in various colors from red to yellow.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
to identify a life-threatening problem When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).
What is the primary purpose of validation as a part of assessment?
to plan appropriate nursing care Validation is the act of confirming or verifying to plan appropriate nursing care. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Validation does not identify data to be validated, nor does it establish effective nurse-client communication or relationships with coworkers.
When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure?
to reduce friction as the client is pulled laterally onto the stretcher The transfer board or other lateral-assist device reduces friction, easing work load to move the client. It is positioned partially under the client, across the space between the bed and stretcher.
When documenting subjective data, the nurse should:
use the client's own words placed in quotation marks. Subjective data should be recorded using the client's own words, whenever possible. Quotation marks should be used around the client's statement. The tendency to use nonspecific terms that are subject to individual definition, paraphrasing or interpretation should be avoided.
