Prep U for Exam 1

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?

50 mm Hg

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Airway

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance

The principle of confidentiality is of paramount importance in the nurse-client relationship. When should you inform the client of with whom his or her information will be shared?

At the beginning of the interview

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

Comprehensive

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what?

Higher than normal

Examples of objective data include all the following except: Foul-smelling discharge Coughing Itchy skin Reddened skin

Itchy skin

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?

Lithotomy

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention

The client has a murmur. This is what type of data?

Objective

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process?

Planning

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high.

What would be the expected tone elicited by percussion of a normal lung?

Resonance

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications.

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is theinstructor describing?

Tympanic

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?

Unable to feel his leg

How should the nurse place the ear of an adult when using the otoscope?

Up and back

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:

orthostatic hypotension

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing?

Ongoing

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing