PREPU CH./9/16. VSIM JERAD GRIFFIN. FHA 1
The nurse is gathering subjective data during a cardiovascular assessment from a patient's spouse. Which question is particularly appropriate for a patient who has reported that, "My heart seems to skip beats"?
"Have you seen periods when your spouse seems to experience uncommon fatigue?" Rationale: Episodes of fatigue are a symptom associated with compromised cardiac output. Irregular cardiac rhythm (skipped beats) can be a factor associated with impaired cardiac output. Edema and an urgent need to urinate at night (nocturia) are associated with congested heart failure (CHF). Tobacco use is a risk factor for heart disease.
The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiological process?
- Air passing through constricted passageways. Wheezes appear when air passes through constricted passages. Wheezes are not the result of diversion of air to the bronchi, increased turbulence, or air entering the pleural space.
A 37-year-old man presents at the emergency department complaining that he is having trouble breathing. What would the nurse prioritize in this client's acute assessment?
- Assessing pulse. If a client has acute shortness of breath, immediately assess respiratory and pulse rates, blood pressure, and oxygen saturation.
A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?
- Bacterial Infection. Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. Lung cancer and sleep apnea are chronic conditions, which would be more likely to result in a gradual onset of dyspnea.
The thoracic cavity contains which of the following organs? Select all that apply.
- Heart. - Lungs. - Most of esophagus. The cavity contains the heart, lungs, thymus, distal part of the trachea, and most of the esophagus. It does not contain the stomach or the pancreas.
The medical record states that the patient's pulse is "small and weak." Which characteristic will the nurse expect to detect when performing a cardiovascular assessment on this patient? (Select all that apply.)
- Slow upstroke. - Diminished pulse pressure. - A prolonged systolic peak. Pulse characteristics of a small, weak pulse would include slow upstroke, diminished pulse pressure, and a prolonged systolic peak. Bounding on palpation and a rapid rise and fall of the systolic peak are associated with large, bounding pulses.
A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?
- Stridor. Stridor, a high-pitched crowing sound from the upper airway, results from tracheal or laryngeal spasm. In severe laryngospasm, the larynx may completely close off. This life-threatening emergency requires immediate medical assistance. Crackles, wheezes, and rales are adventitious breath sounds heard upon auscultation of the lungs.
The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's
- pectus excavatum. Pectus excavatum is a markedly sunken sternum and adjacent cartilages (often referred to as funnel chest). It is a congenital malformation that seldom causes symptoms other than self-consciousness.
While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible
- pneumonia. Crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia.
While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to
- repeat the phrase "ninety-nine." To assess bronchophony ask the client to repeat the phrase "ninety-nine" while you auscultate the chest wall.
An emergency department nurse suspects a young client may be a victim of human trafficking when the nurse observes which of the following? Select all that apply.
- unable to state month or day. - not allowed to speak for themselves. - seems fearful and anxious. - appears malnourished. Signs and symptoms of human trafficking include, but are not limited to, not being free to leave the home (high security measures), being unpaid or paid very little, having no health insurance, owing a large debt that they are unable to pay off, appearing fearful and anxious, lacking health care, having few personal possessions, losing sense of time, being malnourished, and not being allowed to speak on their own behalf.
Which terms are used to identify the lobes of the right lung? Select all that apply.
- upper, middle, and lower lobe. Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes. The left lung has only two lobes, upper and lower. Neither base nor major are terms used to identify the lobes of the lung.
Chapter 16: Thorax and Lungs
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Chapter 9: Mental Health, Violence, and Substance Use.
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Health Assessment Case: Jared Griffin: VSIM
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pectus excavatum (funnel chest)
Depression of the sternum
SAD PERSONAS Suicide Risk Assessment
Sex Age Depression Previous attempt Ethanol abuse Rational thought loss Social supports lacking Organized plan No spouse Access to lethal means Sickness
Pulmonary embolism
clot or other material lodges in vessels of the lung
atelectasis
collapsed lung; incomplete expansion of alveoli
Funnel chest (pectus excavatum)
depression in the lower portion of the sternum; compression of the heart and great vessels may cause murmurs
kyphosis
hunchback
aphasia
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).
pleurisy (pleuritis)
inflammation of the pleura
Hyperresonance
lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax
Cheyne-Stokes respiration
pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea.
Dysarthria
slurred speech
While assessing the health of a client's respiratory system, the nurse is palpating for fremitus. What instruction should the nurse provide to the client during this component of assessment?
- "Please say the number 'ninety-nine' for me." To palpate for fremitus, the nurse uses the ball or ulnar edge of one hand to assess for vibrations of air in the bronchial tubes transmitted to the chest wall. As the nurse moves a hand to each area, the client is asked to say "ninety-nine." None of the other listed actions will allow the nurse to assess for vibration in the chest wall.
Which patient is expected to have the lowest resting pulse rate (RPR)?
- A non-Hispanic Black male. Non-Hispanic Black males have a lower mean RPR than those of non-Hispanic White males or Mexican American males, whereas non-Hispanic Black females and Mexican American females have lower mean RPRs than non-Hispanic White females. Adult females generally have RPRs that are a few beats faster than adult males.
Which point on the heart will the nurse use to auscultate an apical pulse?
- Apex. An apical pulse is best heard at the apex of the heart. The remaining options are locations used to auscultate the sounds related to the heart's valves.
Which of the following would be the most likely example of emotional or psychological abuse?
- Belittling a child in front of others. Belittling children can be as hurtful to them as physical abuse because it prevents them from being able to achieve.
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?
- Chronic obstructive lung disease. The client with COPD may describe the dyspnea as not being able to "breathe or take a deep breath." Although dyspnea is associated with anxiety, pulmonary embolism, and congestive heart failure, the shortness of breath is not described as the inability to take in a deep breath.
A nurse is interviewing a client who has been abused by her partner. Which of the following should the nurse do?
- Convey a concerned and nonjudgmental attitude, When interviewing a client who has been abused by her partner, the nurse should convey a concerned and nonjudgmental attitude. Legal issues should be discussed with the client. The nurse need not screen if there are any safety concerns for the client or the nurse. Issues regarding the clients personal safety should be discussed. The nurse should not allow the partner to be present with the client during the interview.
The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?
- Eye opening, and appropriateness of verbal and motor responses. The Glasgow Coma Scale rates responses to eye opening, verbal, and motor responses.
A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?
- Hyperresonance. Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client's sputum?
- Pink and frothy. Pink sputum is associated with pulmonary edema. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?
- Psychological . Threat to harm and intimidation are examples of psychological abuse. Economic abuse includes forging signatures. Physical abuse includes direct physical violence with harm inflicted. Sexual abuse includes fondling.
Which of the following occurs in respiratory distress?
- Skin between the ribs moves inward with inspiration. This description is consistent with retractions, which occur with respiratory distress. Other features include speaking in short sentences, use of accessory muscles, leaning forward to gain mechanical advantage for the diaphragm, and pursed lip breathing in which the client exhales against the lips, which are pressed together.
When assessing posteriorly, where would the trachea bifurcate into its mainstem bronchi?
- T4 spinous process. The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly.
An older adult client scores a 15 on a Mini-Mental Status Examination (MMSE). What does this score tell the nurse about the client?
- The client's score indicates cognitive impairment. Taking only 5 to 10 minutes to administer makes the MMSE easy to use with elderly clients or clients with poor attention span. A score of 24 to 30 is in the normal range. A score of 23 or lower on the MMSE indicates cognitive impairment.
A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is
- a foreign body obstruction.
The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used?
- dementia. The Mini-Mental State Examination is a brief questionnaire which has been widely used to screen clients for cognitive dysfunction or dementia. The Mini-Mental State Examination is not routinely used to assess depression, schizophrenia, or bipolar disorder.
Spontaneous pneumothorax
A pneumothorax that occurs when a weak area on the lung ruptures in the absence of major injury, allowing air to leak into the pleural space.
The nurse is assessing a client's breath sounds. Where should the nurse expect to hear bronchovesicular sounds?
Bronchovesicular breath sounds are heard between the scapula on the posterior chest.
MMSE (Mini Mental State Examination)-
simplified scored form of the cognitive functions of the mental status exam.
The nurse is assisting a woman who is a victim of intimate partner violence in preparing a plan for leaving the relationship. Which of the following instructions would the nurse include? Select all that apply.
- "Be sure to have some type of identification, like a photo ID or driver's license." - "Take the deed to the house or your apartment lease with you." - "Set up a specific plan for leaving and then practice it." When leaving an abusive relationship, a victim should take with her a driver's license or photo ID, the deed to the house or apartment lease, and a change of clothes for herself and her children. She should develop a game plan for leaving and then rehearse it. The woman should not use phone cards because they can leave a trail the abuser can follow.
A client has presented to the emergency department (ED) with a lower leg laceration that she suffered "while I was on a bender last night." The nurse recognizes the need to screen for alcohol use and will implement the CAGE questionnaire. What question will the nurse ask during this assessment?
- "Have you ever felt guilty about your alcohol use?" In the CAGE questionnaire, the "G" corresponds the question, "Have you ever felt guilt about your use?" The other listed questions are not components of this screening tool.
Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment?
- "How do you plan to meet your responsibilities at work?" Asking the client to explain his or her response to financial, interpersonal, or logistical challenges can yield insight into the client's judgment. Asking the client to explain the cause of mood changes can help the clinician gauge the client's insight but not judgement, while asking about seeing and hearing things addresses perception, specifically hallucinations. Asking about previous successful coping strategies can be useful but does not assess judgment.
The nurse is conducting an assessment of Maggie, a 16-year-old child rape victim. Which statement by Maggie would concern the nurse most?
- "I could just die; I feel so humiliated." The nurse would be concerned by Maggie's comments of humiliation. Humiliation can lead to significant levels of low self-esteem and depression which can place Maggie at risk for suicide. The options suggest effective coping and motivation to recover and move on with life.
The nurse is assessing a client's progress in smoking cessation according to the Stages of Change Model. Which statement indicates that the client is in the Action stage?
- "I just quit smoking today." The statement "I just quit smoking today" indicates that the client is in the Action stage according to the Stages of Change Model. "I am not ready to quit, but I am concerned about my smoking habit" is consistent with the Contemplation stage. "I am ready to quit smoking" is consistent with the Preparation stage. "I stopped smoking a year ago" is consistent with the Maintenance stage.
A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries?
- "Injuries like yours could have been caused by someone hurting you. Did someone hurt you?"
As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?
- "What do you do if you have pain?" To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning.
A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?
- 25. For clients with a high school education a score of 20-27 on the SLUMS exam indicates mild cognitive impairment (MCI) and for clients with less than high school education a score of 14-19 indicates MCI. For clients with a high school education a score of 1-19 indicates dementia and for clients with less than high school education a score of 1-14 indicates dementia.
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
- <90 degrees. The right and left costal margins meeting at the level of the xiphoid process form an angle between them. This angle, commonly referred to as the costal angle, is an important landmark for assessment. It is normally less than 90 degrees but may be increased in instances of long-standing hyperinflation of the lungs, as in emphysema (less).
A nurse is discussing the evaluation of an electrocardiograph recently performed on a patient with a nursing student. Which data will the nurse identify for the student as being within normal limits? (Select all that apply.)
- A P wave is visible before each QRS complex. - Heart rate is between 60 and 100 beats/min (bpm). - The T wave is rounded and smooth. Normal results for an ECG include a heart rate between 60 and 100 beats/min, normal sinus rhythm, a P wave that precedes each QRS complex, a PR interval that lasts 0.12 to 0.20 seconds, a QRS complex that lasts 0.12 seconds, an ST segment less than or equal to 0.1 mV, a T wave that is rounded, smooth, and is positive in leads I, II, V3, V4, V5, and V6. Finally, the QT interval duration varies but usually lasts 0.36 to 0.44 seconds.
During the mental status assessment of a new client, the nurse has asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding?
- A deficit in abstract reasoning. Asking a client to describe similarities and/or differences between two objects that are alike allows the nurse to assess the client's abstract reasoning. This is not synonymous with intelligence and does not providing insight into the client's ability to follow directions. This task is unrelated to spatial orientation.
A nurse is palpating a Caucasian client's chest as part of a routine assessment. Which of the following findings would the nurse expect in this client because of his race?
- A larger thorax and greater lung capacity. The size of the thorax, which affects pulmonary function, differs by race. Compared with African Americans, Asians, and Native Americans, adult Caucasians have a larger thorax and greater lung capacity. A costal angle greater than 90 degrees is an indicator of long-standing hyperinflation of the lungs, as in emphysema. Pectus carinatum is a forward protrusion of the sternum causing the adjacent ribs to slope backward (often referred to as pigeon chest). Barrel-chest configuration results in a more horizontal position of the ribs and costal angle of more than 90 degrees. This often results from long-standing emphysema.
Preparing for an electrocardiogram (ECG) is a priority nursing intervention for which patient? (Select all that apply.)
- A patient is reporting, "I feel like my heart is skipping beats." - A patient experiencing diaphoresis and arm pain. - A patient who just had a pacemaker placed. - A patient newly diagnosed with mild hypokalemia. The ECG is used to identify conduction abnormalities, cardiac arrhythmias (associated with hypokalemia), and myocardial infarctions. It is also used to document pacemaker performance. It is reasonable to expect that the patient recovering from the MI will be prescribed an ECG to monitor ongoing status of heart conduction, but this does not take priority over identifying the acute presence of cardiac dysfunction presented by the correct options.
Which assessment findings suggest an arterial vascular system abnormality? (Select all that apply.)
- Absence of hair over the lower legs. - Thin, shiny skin over calves. Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair, especially over the lower legs, are associated with arterial insufficiency. Warm skin and brown pigmentation around the ankles are associated with venous insufficiency. Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks—but rarely in the feet with activity. These symptoms are quickly relieved by rest. Ulcers associated with arterial disease are usually painful and are often located on the toes, foot, or lateral ankle. Venous ulcers are usually painless and occur on the lower leg or medial ankle.
When providing care to a victim of abuse, which of the following would the nurse do?
- Allow the woman to participate in her care. Active participation in care is critical because it promotes feelings of control. The victim should be allowed to actively participate in her care and decision making. The nurse should offer step-by-step explanations of procedures to alleviate her fears and to demonstrate a caring attitude. The nurse should let the woman set the pace of the nursing interventions.
A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?
- Ask about any medications being used for hypertension. The nurse needs to ask the client about medications being used to treat his hypertension. Side effects of certain antihypertensive medications include persistent cough, which is of no consequence except for its annoying nature. Once this information is obtained then the nurse can gather additional information and complete the assessment to ensure that the findings are related to the medication and not another problem
The nurse is assessing a client's respiratory rate and rhythm during the beginning of a shift. The client's rate is 29 breaths per minute. How should the nurse respond to this assessment finding?
- Ask the client if she has recently exerted herself. Respiratory rate is highly dependent on recent exertion and activity. This variable should be ruled out before making a referral. Palpation is unlikely to ascertain the cause of the increased respiratory rate. Smoking is a possible cause, but activity is more likely.
A nurse hears adventitious lung sounds while auscultating a client's lung fields. What action should the nurse take?
- Ask the client to cough. If adventitious lung sounds are heard on auscultation, the nurse should have the client cough to try and clear the secretions and then auscultate again. Coughing may clear the secretions and improve lung sounds. A STAT x-ray is not required because no other signs and symptoms are discussed. The nurse will need to assess the client further before contacting the health care provider. The nurse will document the findings, but adventitious lung sounds would not be considered normal.
A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?
- Asthma. Asthma causes shortness of breath and a nocturnal cough. It is often associated with a history of allergies and can be exacerbated by exercise or irritants such as smoke in a bar. On auscultation there can be normal to decreased air movement. Wheezing is heard on expiration and sometimes inspiration. The duration of wheezing in expiration usually correlates with the severity of illness, so it is important to document this length (e.g., wheezes heard halfway through exhalation). In severe asthma, wheezes may not be heard because of the lack of air movement. Paradoxically, these clients may have more wheezes after treatment, which actually indicates an improvement in condition. Peak flow measurements help to discern this.
To assess a patient's heart during a physical assessment, which actions will the nurse perform? (Select all that apply.)
- Auscultate over the aortic, pulmonic, tricuspid, and mitral areas, as well as Erb's point. - Assess the apex, left sternal border, and base of the heart for abnormal pulsations. - Ask the patient to lie on the left side to assess sounds from the apex of the heart. - Assess the HR and rhythm use the diaphragm of the stethoscope. Effective technique for the assessment of the heart would include assessing the apex, left sternal border, and base of the heart for abnormal pulsations; auscultating over the aortic, pulmonic, tricuspid, and mitral areas, as well Erb's point; assessing sounds from the apex of the heart while the patient is positioned on the left side; and using the diaphragm of the stethoscope to assess the heart's rate and rhythm. Assessing S1 and S2 heart sounds is done using the diaphragm of the stethoscope, not the bell.
A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score?
- Beating up and severe contusions. An abuse score of 4 corresponds to beating up and severe contusions. Punching and kicking are given a score of 3. Head injury and internal injury are rated a score of 5. Threat of abuse by weapons is given a score of 1.
A nurse cares for a client admitted after falling off a ladder onto a concrete floor. The client is not arousable and pupils are fixed and dilated. When performing a respiratory assessment, the nurse recognizes which breathing pattern as normal for client's with brain damage?
- Biot's. In people with irritation or brain damage, the respiratory pattern will be irregular and characterized by varying depth and rate followed by periods of apnea. Cheyne-Stokes is a regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea. Retractive is not an observable pattern of respirations. Kussmaul is seen in clients with diabetic ketoacidosis and are characterized by deep but rapid respirations similar to hyperventilation.
A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?
- Bradypnea. A respiratory rate of less than 10 breaths per minute is called bradypnea. Tachypnea is a respiratory rate greater than 24 breaths per minute. Hyperventilation is used to describe respirations that are increased in rate and depth. Hypoventilation is a rate that is decreased, with a decrease in depth and with an irregular pattern.
Which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?
- Bronchial. Bronchial sounds are normally heard over the main bronchi. The consolidation of the lung due to right lower lobe pneumonia may carry the bronchial sounds to the peripheral lung area. Vesicular sounds are heard from the bronchioles and lobes. Bronchovesicular lung sounds are normally heard over the main bronchi. Diminished breath sounds occur if the pneumonia has caused severe damage to the lung tissue.
Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
- Bronchial. These characteristics are consistent with bronchial breath sounds. Be alert for these because they may occur elsewhere and indicate pneumonia or other pathology. The current explanation for this phenomenon is that fluid carries the sound from the trachea very well to the chest wall. This same explanation explains 'ee' to & 'aa' changes, whispered pectoriloquy, bronchophony, and others in which high-frequency sounds, normally blocked by air-filled alveoli, could be transmitted to the chest wall.
Which of the following statements relating to assessment of the lungs and thorax is most accurate?
- Bronchitis is characterized by excess mucus production and chronic cough. Bronchitis is marked by a chronic, productive cough that results from excess mucus production. Hemoptysis is uncommon in younger clients. It would be simplistic to differentiate cardiac from respiratory chest pain based on severity alone. Similarly, it is inaccurate to characterize all loud percussion sounds as pathological.
When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?
- Bronchitis. Adventitious sounds that clear with cough are usually consistent with bronchitis or atelectasis. The other conditions would not have findings that cleared with a cough.
Which example of nursing documentation best indicates that the patient has peripheral perfusion that reflects adequate cardiac output?
- Capillary refill noted in less than 2 seconds. A capillary refill time of 2 seconds or less is indication of cardiac output that supports peripheral perfusion. The remaining options are examples of abnormal findings associated with insufficient peripheral perfusion.
The nurse is performing a respiratory assessment of a client who is palliative due to severe, uncompensated heart failure. What type of respiratory pattern should the nurse anticipate?
- Cheyne-Stokes. Cheyne-Stokes respirations, a regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate of less than 10/minute and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.
A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?
- Chronic obstructive pulmonary disease (COPD) This disorder is insidious in onset and generally affects the older population with a smoking history. The diameter of the chest is often enlarged like a barrel. Percussing the chest elicits hyperresonance; during auscultation there is often distant breath sounds. Coarse breath sounds of rhonchi are also often heard. It is important to quantify this client's exercise capacity because it may affect his employment and also allows examiners to follow the progression of his disease. Clinicians must offer smoking cessation as an option.
Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?
- Chronic obstructive pulmonary disease. An increase in the anterior posterior diameter is seen in clients with chronic obstructive pulmonary disease. This occurs be because of air trapping in the airways that causes hyperinflation and over distention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.
Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?
- Chronic obstructive pulmonary disease. An increase in the ratio of anteroposterior to transverse diameter is seen in clients with chronic obstructive pulmonary disease. This occurs because of air trapped in the airways that causes hyperinflation and overdistention. Carcinoma of the lungs, pneumothorax, and tuberculosis do not change the chest diameter.
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of what condition?
- Chronic obstructive pulmonary disease. The client is assuming the tripod position, which is often seen in chronic obstructive pulmonary disease. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with pneumonia or pleural effusion.
While performing an initial assessment on a new 24-year-old female client, the nurse determines the client may be at risk for intimate partner violence when which of the following information is obtained? Select all that apply.
- Client is currently unemployed. - Client describes self as a loner. - Client reports an unplanned pregnancy. Individual risk factors for intimate partner violence include, but are not limited to, low self-esteem, low income, low academic achievement, young age, depression, heavy alcohol and drug use, having few friends or no support system, and unplanned pregnancy. This client is exhibiting several risk factors for domestic violence: unemployment, lack of friends/a support network, and an unplanned pregnancy.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?
- Coarse crackles. Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound that is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low-pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.
During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched bubbling, moist sounds that persists from early inspiration to early expiration. How should the nurse document these sounds?
- Coarse crackles. Low-pitched bubbling, moist sounds that persists from early inspiration to early expiration and sounds like softly separating Velcro should be documented as coarse crackles. These sounds are produced when inhaled air comes into contact with secretions in the large bronchi and trachea. Pleural friction rub is low-pitched, dry, grating sound which is superficial and occurs during both inspiration and expiration. Sonorous wheezes are low pitched snoring or moaning sounds that may be heard primarily during expiration but may be heard throughout the respiratory cycle. Sibilant wheezes are high-pitched musical sounds heard primarily during expiration but may also be heard on inspiration.
Which of the following are cues that a person may have dementia? Select all that apply.
- Disorientation. - Looking to a family member to answer questions directed to the client. - Repeatedly failing to follow instructions. Some cues that the client may have dementia include being disoriented, being a "poor historian," deferring to relatives to answer questions directed to the client, repeatedly and apparently unintentionally failing to follow instructions, having difficulty finding the right words or using inappropriate or incomprehensible words, and having difficulty following conversations.
While examining a client, the nurse observes the client's chest to be barrel shaped. The nurse would interpret this as indicating which of the following?
- Emphysema. A barrel chest is often seen in emphysema because of hyperinflation of the lungs. A change in chest shape would be rare with pneumonia. Pectus excavatum or funnel chest is a congenital malformation.
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
- Evaluate changes in respiratory pattern and rate. Observe quality and pattern of respiration. Note breathing characteristics as well as rate, rhythm, and depth. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?
- Evaluation of insight and judgment. The mental status examination is a central aspect of the psychiatric assessment process that assesses current cognitive and affective functioning through data collection on appearance, behavior, level of consciousness, speech, thought content and processes, cognitive ability, mood and affect, insight, and judgment. This assessment relies almost exclusively on observation rather than inquiry and is expected to change during treatment.
A client has a nursing diagnosis of impaired gas exchange related to alveolar-capillary membrane changes. What interventions are appropriate in this situation? Select all that apply.
- Facilitate deep breathing. - Administer oxygen. - Use an incentive spirometer. Interventions that are appropriate for a client with impaired gas exchange related to alveolar-capillary membrane changes include administering oxygen, teaching deep breathing, and encouraging use of incentive spirometry or an inhaler. Neither increasing fluids nor reducing fever is an appropriate intervention with this nursing diagnosis.
A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply.
- Failure to provide adequate nutrition to an elder. - Having an elder sign financial documents without an understanding of what is being signed. - Shoving an elder into a wheelchair. - Forcing an elder to perform a sexual act. Elder mistreatment, also known as elder abuse, includes neglect (e.g., failure to provide adequate nutrition); physical abuse (e.g., shoving an elder into a wheelchair); sexual abuse (e.g., forcing an elder to perform a sexual act); financial abuse (e.g., having an elder sign financial documents without an understanding of what is being signed); psychological abuse (including humiliation, intimidation and threats; exploitation; and abandonment or prejudicial attitudes that decrease one's quality of life, and are demeaning to those over the age of 65 years. Administering the wrong medication to an elder inadvertently is a medical error but is not elder mistreatment, as it is an accident.
A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?
- Fluid in the alveoli. When fluid fills the alveoli, fine crackles may be audible on auscultation. Excessive fluid in the alveoli may lead to airway collapse and decreased breath sounds. Fine crackles are not indicative of fluid in the bronchioles or bronchus or the absence of fluid in the lungs.
The nurse is assessing a client who has been admitted for the treatment of severe dehydration. What would the nurse expect to hear when auscultating the lungs of this client?
- Friction rub. The pleural space is one of the physiologic third spaces for body fluid storage. Severe dehydration will reduce the volume of pleural fluid, resulting in the increased transmission of lung sounds and a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngeal spasms, such as croup.
A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?
- Funnel chest (pectus excavatum). Funnel chest is caused by a depression in the lower portion of the sternum. If severe enough there can be compression of the heart and great vessels, leading to murmurs on auscultation. This is usually only a cosmetic problem, but corrective surgeries can be performed if necessary.
A nurse has interviewed a client with a mental health disorder who does not speak English. The nurse enlists assistance from an interpreter. What is important for the nurse and interpreter to do after concluding the interview?
- Go into a private conference area and question the interpreter about the communication style and context of the client. The nurse should establish if the client made sense, if sentences were structured properly and completely, if the client had difficulty with self-expression, if the client was oriented to reality, and if the nurse should be aware of any cultural practices or beliefs.
Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?
- Have the client cough, then listen again. If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax.
The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?
- Have the client draw the face of a clock. Having the client draw the face of a clock is one way to assess visual, perceptual, and constructional ability. The SLUMS exam tests cognitive function. Giving directions to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client today's date is an assessment of orientation.
During the health interview, a client tells the nurse that he "can't breathe all that well" at night when he is lying down and that this significantly disrupts his sleep. The nurse should assess this client further for what problem?
- Heart failure. Difficulty breathing when lying supine (orthopnea) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakes a person from sleep) also is associated with heart failure. There is no indication that the client might have pneumonia, tuberculosis, or bronchitis. These conditions would most likely involve a client's complaint of cough with or without mucus production.
A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply.
- History of hospitalization for a mental health problem. - Use of recreational drugs. - History of Alzheimer's disease in a family member. - Onset of memory lapses. Subjective data are those that the client reports to the nurse, such as history of hospitalization for a mental health problem, family history of Alzheimer's disease, use of recreational drugs, and onset of memory lapses. Objective data are those that the nurse directly observes in the client or obtains via direct assessments, such as the Glasgow Coma Scale score and the tone, clarity, and pace of speech.
A nurse is caring for a client diagnosed with cystic fibrosis. The client has a history of repeated hospital admissions for complications of his disease and receives daily treatments to mobilize the secretions. When planning the care of this client, what nursing diagnosis is most appropriate?
- Ineffective Airway Clearance related to respiratory secretions. Increased respiratory secretions create a risk for ineffective airway clearance. The client's breathing rate is likely to be affected, but the increased secretions are the essence of the client's challenge. Mucous membranes are unlikely to be affected. There is no explicit statement that the client possesses readiness for enhanced breathing patterns, although this is likely.
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
- Ineffective Airway Clearance. The nurse observes the client's inability to cough up secretions which is a major defining characteristic for accepting the nursing diagnosis of Ineffective Airway Clearance. There is no indication that this client has or is at risk for an infection. Impaired Gas Exchange can not be confirmed because there is no indication that the client is having poor muscle tone or has damage to lung tissue. For Ineffective Breathing Pattern to be confirmed the client must demonstrate a pattern of hyper or hypoventilation.
The nurse suspects a client has undiagnosed Alzheimer disease but changes the care plan after talking with a family member. What information caused the nurse to alter the client's plan of care?
- Ingests a 6-pack of beer every evening. Drinking in some older adults may cause symptoms of forgetfulness or confusion which could be mistaken for signs of Alzheimer disease. A Mediterranean eating plan, previous spinal surgery, or osteoarthritis would not cause symptoms similar to Alzheimer disease.
Which action taken during a cardiovascular assessment will best assist the nurse in determining the hemodynamics of the right side of a patient's heart?
- Inspection of the jugular venous pulse level. The level of the jugular venous pressure reflects right atrial (central venous) pressure and, usually, right ventricular diastolic ï¬lling pressure. Right-sided heart failure raises pressure and volume, thus raising jugular venous pressure. Auscultation of the carotid artery is associated with the detection of a bruit, indicative of some degree of occlusion. Palpation of the carotid artery is done to detect a loss of elasticity that is associated with arteriosclerosis. Inspection for apical impulse is done to determine the presence of an enlarged ventricle.
A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?
- Instruct the client to cough forcefully. When auscultating crackles in the lung fields, the nurse should instruct the client to cough forcefully in an effort to open the airways. Then the nurse should auscultate again and note any changes. Lung sounds should be listened to with the diaphragm because they are high-pitched sounds. The bell is used for low-pitched sounds such as abnormal heart sounds. Breathing through the mouth lets the air in quicker but will not clear the airways. Use of accessory muscles is seen with respiratory distress.
A nurse is interviewing a client who is a suspected victim of abuse. Which practice should the nurse avoid during this phase of assessment?
- Interjecting often to clarify information. When interviewing a client, the nurse must remember to ask questions and allow the client to answer completely, without interrupting the client. The questions should be specific, such as; has anyone in your home ever hurt you? The nurse should convey a concerned, nonjudgmental attitude and appropriate empathy.
If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts:
- Is important and will not stimulate the thought of suicide. Many clinicians avoid the topic of self-harm or suicide because they worry that broaching it will implant the idea in the client's mind. There is little risk that talking about suicide with someone who is not already thinking about it will prompt him or her to do it. Consequently, the issue should be prioritized and directly addressed with clients who are or may be depressed.
The nurse auscultates the base of the lungs to assess for what reason?
- It is where fluid occurs with pulmonary edema. Auscultation of the bases is important because it is where fluid occurs with pulmonary edema and the location for fluid accumulation with a pleural effusion. It does not indicate infection or health of the lungs.
The nurse is providing care for a patient whose partner says, "We're told that he occasionally has an irregular heartbeat. Is that bad?" Which response should the nurse make to best address the partner's concern?
- It's normal to experience occasional premature beats. Occasional premature beats are normal. Frequent episodes of irregular cardiac rhythm may be a result of a potassium imbalance or hypoxia or triggered by digoxin toxicity.
Which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?
- Knife-like pain that worsens on inspiration. Knife-like pain that worsens on inspiration is a characteristic finding that indicates pleurisy in the client. Pleurisy or a pleural rub is caused when the inflamed pleural surface comes in contact with each other on inspiration. Dyspnea is exaggerated by activity but is not a characteristic feature. Clients with pleurisy do not have throbbing pain. Dyspnea in pleurisy is not exaggerated by lying down.
The nurse observes a client in the day room laughing uncontrollably and within 5 minutes sitting in the corner sobbing. This behavior continues throughout the day. What term would the nurse use in documenting this behavior?
- Lability. Lability is a quick change of expression of mood or feelings. Elation is a high degree of confidence, boastfulness, uncritical optimism, and joy accompanied by increased motor activity. Blunted affect is a severe reduction in emotional expressiveness. Euphoria is an excessive sense of emotional and physical well-being inappropriate to the actual situation or environmental stimuli.
Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?
- Listen at each site for at least one complete respiratory cycle. The client is instructed to breathe deeply though the mouth for each area as the nurse listens through inspiration and expiration. The sequence should be performed in an anterior then posterior sequence to avoid missing any areas. The bell is not used for breath sounds because it detects low pitched sound such as abnormal heart sounds.
The nurse is preparing to auscultate the client's thorax. What action is the priority during this component of assessment?
- Listen at each site for at least one complete respiratory cycle. The client should breathe deeply through the mouth during thoracic auscultation. It is important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The client does not need to cough or hold the breath before the nurse listens at each site.
The nurse and a nursing student are reviewing the electrocardiograph (ECG) of a patient diagnosed with atrial fibrillation (AF). Which characteristics noted will the nurse identify as being associated with this cardiac condition? (Select all that apply.)
- Low-amplitude fibrillation waves. - Absent P waves. - Irregular QRS complexes. The ECG associated with atrial fibrillation is characterized by irregular QRS complexes with low-amplitude fibrillation waves without a P wave. Neither of the other options is associated with AF.
When reviewing Mr. Griffin's medical record, the nurse recognizes what information as being a risk factor for atrial fibrillation? (Select all that apply.)
- Male over the age of 60. - History of hypertension. Mr. Griffin's medical record confirms risk factors including a history of hypertension and being a male over the age of 60. Neither being black nor being a methicillin-resistant Staphylococcus aureus (MRSA) carrier is considered a risk factor for atrial fibrillation, nor is taking enoxaparin.
A nurse is auscultating the bronchi of a client. The nurse understands that the bronchi are located in which of the following locations in the body?
- Mediastinum. The thoracic cavity consists of the mediastinum and the lungs, and is lined by the pleural membranes. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, bronchi, esophagus, heart, and great vessels (less).
The nurse understands that to build rapport and establish a connection with a client who may have encountered an act of violence, what type of approach would best be used?
- Narrative. Nurses can encourage rapport, connection, and client participation by using a narrative approach in their interactions. A client of any age tells his or her story while the nurse collects data and listens for aspects of the story that need clarification.
A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?
- Observe for the use of accessory muscles. The tripod position is often assumed by the client with chronic obstructive pulmonary disease (COPD) in order to help elevate the diaphragm during inspiration. This is often accompanied by the use of accessory muscles of the neck. Crackles are present in pneumonia or fluid in the lungs. Tactile fremitus helps to assess for the presence of a consolidation such as pleural effusion or pneumonia. Diaphragmatic excursion assesses the movement of the diaphragm.
An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?
- Observe the client's respiratory rate and pattern. It is normal for elderly clients to feel short of breath or dyspneic with activities of daily living due to age related changes of loss of elasticity, fewer functional capillaries, and loss of lung resiliency. Observing chest expansion would be appropriate assessment for a client with a pneumothorax. This finding does not need to be reported to the health care provider unless accompanied by other findings of inadequate oxygenation. Asking the client how long they need to rest between activities will not provide the nurse any objective information to differentiate the problem.
The nurse is assessing the lungs of an older adult client. What consideration will the nurse take into account while performing the assessment?
- Offer rest as needed. Deep breathing may be especially difficult for the older adult client; therefore, the nurse will offer rest as needed. The nurse will have the client breathe deeply through the mouth, not the nose. When assessing the apices of the lungs, the nurse will auscultate the breath sounds at C7, not C9. The nurse will listen to each site for at least one complete respiratory cycle, not until inhalation is completed.
Of the medications Mr. Griffin has been prescribed, which one will the nurse discuss with the surgeon regarding its possible association with the patient's irregular heartbeat?
- Oxycodone/acetaminophen. A cardiovascular adverse reaction associated with oxycodone/acetaminophen is arrhythmia. None of the remaining options has this known risk.
While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?
- Palpation. The nurse should use the palpation technique to elicit crepitus. Crepitus is a crackling sensation that occurs when air passes through fluid or exudate. Auscultation, percussion, and inspection cannot elicit crepitus because it is air trapped into the tissue around the lungs.
A patient has been recently diagnosed with atrial fibrillation. Which expected outcome will the nurse include in the care plan to address the resulting anxiety?
- Patient will learn and demonstrate effective coping behaviors. Effective coping will assist the patient in effectively managing the resulting anxiety. Increased energy is associated with the presence of activity intolerance. Mental status is associated with cardiac output, whereas an understanding of treatment regimen is directed toward correcting a knowledge deficiency.
During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse?
- Perform a focused assessment. The nurse should immediately perform a focused assessment on the client to determine the origin of the pain, such as using COLDSPA (characteristic, onset, location, duration, severity, palliative, associated). The nurse should not contact the health care provider until the focused assessment has been completed. The nurse should not continue with the comprehensive assessment but rather perform a focused assessment of the chest pain. There is not enough information for the nurse to call an ambulance.
A client is diagnosed with pulmonary edema. The nurse would most likely assess the sputum color as which of the following?
- Pink. Pink sputum is associated with pulmonary edema. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.
Which action by a nurse demonstrates proper technique for assessment of chest expansion?
- Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath. The correct technique for assessment of chest expansion is for the examiner to place the hands on the posterior chest wall with thumbs at the level of T9 or T110 and pressing together a small skin fold. Ask the client to take a deep breath and observe the movement of the thumbs. Using the ball of the hand to feel vibration tests for tactile fremitus. Percussion of the posterior chest wall assesses for tone. The use of a stethoscope is auscultation and this technique assesses for adventitious sounds within the lungs.
The nurse is preparing to auscultate a client's lungs after completing thoracic inspection, palpation, and percussion. How should the nurse best prepare for this assessment technique?
- Place the diaphragm on the client's posterior chest wall. To auscultate, the nurse places the diaphragm of the stethoscope firmly and directly on the posterior chest wall, at the apex of the lung at C7. Clothing and gowns must be removed to ensure accurate assessment. The client should not be asked to breathe more rapidly than normal.
The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?
- Pleural effusion. When a flat sound is percussed over lung tissue, this is an indication of a pleural effusion. Resonance is the percussion sound of healthy lung tissue. The sound of a gastric air bubble is tympany. Hyperresonance is the percussion sound associated with emphysema.
A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?
- Pleurisy. Pleurisy can follow inflammation of the parietal pleura. Patients usually describe such pain as sharp or stabbing, worsening with deep breathing or coughing. Pneumonia does not always cause pain on respiration nor does asthma. Rales are an adventitious breath sound, not a respiratory condition.
A nurse is at a family reunion playing football when a relative takes a hit to his right lateral thorax and is in pain. He asks the nurse if he has a rib fracture. The family reunion is in a very remote location. What should the nurse's next step be?
- Press on his sternum and spine simultaneously. The area involved in the injury will of course be tender. Pressing in an area remote to the injury, but over the same bone that may be involved, can produce tenderness at the site of injury. This would indicate that there may be a fracture at the lateral ribs.
The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?
- Pulmonary edema. Pink, frothy sputum may indicate pulmonary edema. Tuberculosis sputum may be a rusty color and green sputum may indicate an infection. The client with atelectasis may not be coughing any sputum up.
The nurse is caring for a client who is 48 hours postop from the repair of a fractured hip. She has a sudden onset of dyspnea without pain. What disease process would the nurse suspect?
- Pulmonary embolism. Risk factors for pulmonary embolism include postpartum or postoperative periods, prolonged bed rest, congestive heart failure, chronic lung disease, fractures of hip or leg, and deep venous thrombosis (often not clinically apparent).
When percussing the posterior lung fields, which of the following findings is expected?
- Resonance over all lung fields. All lung tissue is expected to be resonant on percussion. Hyperresonance and tympany suggest a hyperinflated lung or pneumothorax. Dullness is expected in structures below the level of the diaphragm, but dullness in the bases of the lungs themselves would be considered pathological.
When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?
- Resonance. Normal lung tissue elicits a resonance tone when percussed. Hyperresonance is elicited in cases of trapped air such as in emphysema or pneumothorax. Dullness may characterize areas of increased density such as consolidation, pleural effusion, or tumor. Tympany is elicited over air filled spaces such as puffed out check or stomach bubble.
The nurse is conducting a health history of a client at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the client?
- SAD PERSONAS. The nurse uses the SAD PERSONAS to assess the suicide risk for a client. The nurse uses the CAGE Questionnaire to assess substance use. The HOPE Assessment tool assesses spiritual beliefs. The Mini-Mental Status Exam assesses cognitive function.
A client's recent episode of becoming lost near home has prompted the nurse to use an assessment tool to help identify signs of dementia. Which tool should the nurse use?
- SLUMS tool. The nurse should use the SLUMS tool to help identify signs of dementia. The Glasgow Coma Scale is useful for clients who are unresponsive or are not responding to questions. The PHQ-2 may be used for the assessment of anxiety and depression. SBIRT is an assessment tool used for clients concerned about their alcohol intake.
Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be?
- Screening for depression. Although the nurse may consider referrals to help with diagnosis and treatment of this client, screening is a time-efficient way to recognize depression. This will allow her to be treated more expediently. The nurse may tell the client that no answer is clear yet, but also that he or she will not stop investigating until the client has gotten the help she needs. Research has shown that health care providers routinely fail to screen for depression.
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
- Sibilant wheezes heard primarily during expiration but may also be heard on inspiration. Sibilant wheezes are often heard in cases of acute asthma or chronic emphysema. Fine crackles occurring late in inspiration are associated with restrictive diseases such as pneumonia and congestive heart failure. Course crackles that persist from early inspiration to early expiration may indicate pneumonia, pulmonary edema, or pulmonary fibrosis. Sonorous wheezes are often heard in cases of bronchitis or single obstructions and snoring before an episode of sleep apnea.
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?
- Slight kyphosis. Kyphosis (an increased curve of the thoracic spine) is common in older clients. Inaudible lung sounds, wheezing, and asymmetrical expansion are considered pathologic findings in clients of all ages.
When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?
- Softly repeat the words "one-two-three." Softly whispering "one-two-three" while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say "ninety-nine" is used to test bronchophony. Saying the letter "e" is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.
When assessing whispered pectoriloquy, what would the nurse instruct the client to do?
- Softly repeat the words 'one-two-three'. Softly whispering 'one-two-three' while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say 'ninety-nine' is used to test bronchophony. Saying the letter 'e' is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.
An adult daughter of a client with Alzheimer disease asks what can be done to protect brain health. What should the nurse recommend to the daughter? Select all that apply.
- Spend time with other people. - Keep the mind active. - Eat a nutritious diet. - Engage in physical exercise. Ways to prevent or delay the onset of Alzheimer disease includes active participation in four healthy behaviors: physical health and exercise, diet and nutrition, cognitive activity, and social engagement. Alcohol intake is not recommended as an approach to prevent or delay the development of Alzheimer disease.
The school nurse assesses unequal shoulder and scapula height in an adolescent. Which of the following would the nurse assess next?
- Spinal Column Unequal shoulder and scapula heights in an adolescent may represent scoliosis and may be further assessed by inspecting the spinal column for curves. Assessing the lateral aspect of the thorax or lung volumes is not indicated. Hip levels may be assessed later on to gather additional data to support possible scoliosis.
The school nurse assesses unequal shoulder and scapula height in an adolescent. What would the nurse assess next?
- Spinal column. Unequal shoulder and scapula heights in an adolescent may represent scoliosis and may be further assessed by inspecting the spinal column for curves. Assessing the lateral aspect of the thorax or lung volumes is not indicated. Hip levels may be assessed later on to gather additional data to support possible scoliosis.
A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honor student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?
- Spontaneous pneumothorax. Spontaneous pneumothorax occurs suddenly, causing severe dyspnea and chest pain on the affected side. It is more common in thin young males. On auscultation of the affected side there will be no breath sounds; on percussion there is hyperresonance or tympany. There will be an absence of fremitus to palpation. Given this young man's habitus and pneumothorax, you may consider looking for features of Marfan syndrome.
When preparing a patient for an electrocardiograph (ECG) the nurse will include which instructional information? (Select all that apply.)
- Sticky backed electrodes will be attached directly to the skin on the patient's arms, legs, and chest. - It's important that the patient remain as still and relaxed as possible during the test. - The patient will be asked to lie on his or her back for the length of the test, which is 5-10 minutes. - The test is painless. Instructional information regarding an ECG should include the use of sticky electrodes being attached to the skin on the arms, legs, and chest. The importance of remaining physically still and relaxed while lying on the back for approximately 5-10 minutes should also be discussed. It is important that the patient be reassured that the test is painless. The patient is not required to answer questions during the test, and talking is discouraged.
The results of a client's ECG and D-dimer levels suggest a pulmonary embolism. Which of the following history and examination findings would the nurse expect in light of this diagnosis?
- Sudden onset of dyspnea. The arterial occlusion that results in pulmonary embolism normally manifests as a sudden onset of dyspnea, which deep breathing is unlikely to relieve, because part of the pulmonary arterial tree is occluded. A history of heart failure is not a notable risk factor. Absent breath sounds, not crackles, are an expected finding on auscultation
The client states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the client is at risk for:
- Suicide. The client who does not experience a sense of hope for the future may be at risk for suicide. Confabulation refers to making up answer to cover for not knowing. Psychosis occurs when the client has difficulty distinguishing reality from internal perceptions. Delusions are false beliefs the person holds despite lack of supportive evidence.
In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?
- Suprasternal notch. The sternum, or breastbone, lies in the center of the chest anteriorly and is divided into three parts: the manubrium, the body, and the xiphoid process. The manubrium connects laterally with the clavicles (collar bones) and the first two pairs of ribs. The clavicles extend from the manubrium to the acromion of the scapula. A U-shaped indentation located on the superior border of the manubrium is an important landmark known as the suprasternal notch. A few centimeters below the suprasternal notch, a bony ridge can be palpated at the point where the manubrium articulates with the body of the sternum. This landmark, often referred to as the sternal angle (or angle of Louis), is also the location of the second pair of ribs and becomes a reference point for counting ribs and intercostal spaces.
A client has a nursing diagnosis of ineffective airway clearance. What intervention would be most appropriate?
- Teach deep breathing and coughing. For the nursing diagnosis of Ineffective airway clearance the intervention cough and deep breathe is the most appropriate.
The life partner of a patient diagnosed with atrial fibrillation (AF) demonstrates a need for instruction when asking the nurse, "Can you tell me why this is a problem?" What is the nurse's best response?
- The abnormal heartbeat results in poor blood flow to the heart. The result of the irregular, rapid heartbeats is impaired blood flow that can result in a stroke, thromboembolism, and heart failure. Physical findings include hypotension, and laboratory findings can reveal hyperthyroidism. AF is most common in patients older than 60 but affects only approximately 5% of this age group.
What is the nurse's response when Mr. Griffin asks, "What is the biggest worry about having atrial fibrillation?"
- The blood tends to pool in your heart's upper chamber, increasing the risk of developing a clot. In atrial fibrillation, or A-Fib, the signals to the upper part of the heart are very fast and not regular. Instead of beating as usual, the atria just quiver. The blood does not empty fully from the upper chambers. It can just pool in the atria. Clots may form, which puts the patient at risk for a stroke. Atrial fibrillation is not responsible for causing dysfunctional valves, triggering an MI, or weakening the cardiac muscle itself.
A community nurse makes a scheduled home visit for a family of five, which includes the parents and three young children, on a hot, humid summer day. Which of the following observations would make the nurse suspect abuse?
- The children are wearing long-sleeve shirts and pants. Long-sleeve shirts and pants worn in warm weather may be an attempt to cover bruising or other injuries. A pool that needs to be cleaned is not a sign of abuse. The male spouse speaking occasionally is not indicative of abuse; usually abusers apeak predominantly and control the conversation. The female spourse making eye contact with the male spouse before speaking may be an indicator of intimate partner abuse but is not the best answer.
A nurse in the emergency department is utilizing the SAD PERSONS assessment guide during the mental status assessment of a client. What is the most likely rationale for the nurse's choice of this assessment tool?
- The client may have a high risk for suicide. SAD PERSONAS is an assessment tool that can be used to screen for suicide risk. It does not directly address the signs and symptoms of depression, schizophrenia, psychosis, or substance abuse.
A client has sustained a brain stem injury and is being treated in the intensive care unit. What would the nurse need to consider when assessing this client's respiratory status?
- The client will have a loss of involuntary respiratory control. The brain stem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory function. Cheyne-Stokes respirations are an abnormal pattern of rhythmic breathing. The client's breathing will not be characterized by increased effort.
Which statement regarding the location of landmarks is associated with the assessment of the respiratory system?
- The inferior tip of the scapula usually lies at the level of the 7th rib. The inferior tip of the scapula is another useful bony landmark—it usually lies at the level of the 7th rib or intercostal space. The sternal angle, also termed the angle of Louis, is approximately 5 cm above the horizontal bony ridge joining the manubrium to the body of the sternum. The lower end of an endotracheal tube is usually at the level of T4. The spinous processes of the vertebrae are also useful anatomic landmarks. When the neck is flexed forward, the most protruding process is usually the vertebra of C7, known as the vertebral prominens.
Based on the nursing assessment, the nurse has formulated a nursing diagnosis of risk for post-trauma syndrome for an older adult. Which assessment data supports this nursing diagnosis? Select all that apply.
- The older adult rarely makes eye contact when interacting with the nurse. - The caregiver of a cognitively intact older adult answers the nurse's questions. - The older adult provides vague answers to questions without elaboration. Risk factors for post-trauma syndrome include poor self-esteem and ineffective support system. An older adult who rarely makes eye contact and provides vague answers suggest low self-esteem. A caregiver of a cognitively intact older adult who answers the nurse's questions may be attempting to direct and monopolize the conversation with the nurse and divert attention from the older adult. A caregiver who allows private interaction between the older adult and the nurse suggests respect for the older adult and someone having nothing to hide. An explanation that is plausible and consistent with the extent of injury is not a red flag.
The nurse is examining a 4-year-old girl who is being treated for a burn. When determining whether the burn may be the result of abuse, what assessment parameters should the nurse consider? Select all that apply.
- The presence of other scars on the child's skin. - The pattern or shape of the burn. - The location of the burn. - The child's explanation of how she got the bur. When assessing a child's burn, the nurse must consider evidence of pervious burns, the shape of the burn, the location of the burn, and the child's explanation. The recovery prognosis does not help the nurse ascertain the presence or absence of abuse.
A pediatric nurse is assessing a 7-year-old boy who is suspected of being the victim of psychological abuse by his stepfather. What criterion would the nurse use to determine whether the stepfather's actions constitute abuse?
- The stepfather's behavior is a threat to the child's well-being. Psychological abuse is characterized by varied actions that threaten a child's well-being. Punishment is not necessarily abusive in all cases, and a dislike for a stepparent is not always rooted in abuse. A lack of consideration for growth and development is likely inappropriate, but does not always denote psychological abuse.
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
- Unequal expansion of the chest. Unequal expansion of the chest indicates atelectasis or lung collapse. The inhaled air is unable to inflate the diseased lung; therefore, there is an unequal expansion of the chest. Crepitus on palpation can be found in clients with an open thoracic injury or with a tracheostomy. Sunken sternum and adjacent cartilages are seen in funnel chest. Retraction of intercostal spaces occurs in labored breathing.
The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Complete the following sentences by choosing from the lists of options.
- Upon inspection, the client is in the tripod position, has a barrel chest and the nails are clubbed. Crackles are heard on auscultation. The tripod position facilitates lung expansion for a client with chronic obstructive pulmonary disease (COPD). The client in the tripod position is seated, leaning forward with the arms supported on the knees or over the bed table. (The supine and prone positions would be uncomfortable and restrict oxygenation in the client with COPD.) A barrel chest is associated with COPD. The AP-to-transverse ratio approximates 1:1, giving the chest a round appearance. Also, with COPD, the expanded ribs slope more horizontally. A funnel chest (sunken sternum and rib cartilages) and pigeon chest (protruding sternum) are considered congenital malformations and are not associated with COPD. Fingernails at an angle of 180 degrees or more is called clubbing of the fingers. This finding is associated with long-term (chronic) hypoxia, which occurs in COPD. Normal nails are pink and smooth. Crackles are high-pitched, short, popping sounds heard on inspiration and are not cleared with coughing. The sounds are not continuous and are associated with chronic lung diseases such as COPD. Wheezes are high-pitched musical sounds heard on inspiration or expiration and are associated with asthma. Continuous sounds are low-pitched, dry, grating sounds that occur during both inspiration and expiration. Continuous sounds are associated with a pleural friction rub or pleuritis.
The nurse is able to identify which vertical reference line of the thorax as a reference line for the posterior thorax?
- Vertebral line. The reference lines for the posterior thorax include the vertebral line, and right and left scapular lines. The midaxillary line is a reference line for the lateral aspect of the thorax. The right midclavicular line and sterna line are reference lines for the anterior thorax.
A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?
- Vision and hearing. When assessing the mental status of an older adult, the nurse should first check vision and hearing before assuming the client has a mental problem. Speech may be affected by a decrease in hearing. Vital signs and nutritional status give the nurse an impression of overall hemodynamic stability. Ability to follow commands and moving the extremities is a part of a client's cognitive ability.
The nurse notes that an older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, the nurse should use which term to describe this client's speech?
- Wernicke's aphasia. Wernicke's aphasia is rapid speech that lacks meaning. It is caused by a lesion in the posterior superior temporal lobe. Dysphonia is a voice volume disorder, caused by an issue within the larynx or impairment of cranial nerve X. Dysarthria is a defect in the muscles that control speech. Cerebellar dysarthria is irregular uncoordinated speech caused by multiple sclerosis.
A client with advanced chronic obstructive pulmonary disease (COPD) is very fatigued and has minimal stamina. Clustering of care has become necessary. When should the nurse auscultate this client's lungs?
- When turning the client. A client may be clinically stable but be unable to fully cooperate in the assessment process because of fatigue. Consider clustering care. Auscultate the lungs when turning the client or getting the client up in a chair.
A nurse is providing care for a client who has hepatic encephalopathy secondary to chronic alcohol abuse. The nurse's assessment reveals that the client often provides incorrect answers to assessment questions. The client also makes statements that are not grounded in reality. The nurse should prioritize a care plan for which condition first?
- acute confusion. Statements like those described in the scenario suggest acute confusion, a condition that is consistent with the client's medical diagnosis. A care plan for coping impairment, knowledge deficiency, and denial may be needed, but the assessment data do not directly indicate the need to prioritize a care plan for these conditions at this time.
The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client
- answered "yes" to three of the four CAGE questions. The CAGE assessment is a quick questionnaire used to determine if an alcohol assessment is needed. If two or more of these questions is answered yes, then further assessment is advised.
When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of
- aphasia.
The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should
- ask the client to breathe deeply through her mouth. To best assess lung sounds, you will need to hear the sounds as directly as possible. Ask the client to breathe deeply through the mouth for each area of auscultation.
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
- chronic bronchitis. Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.
The nurse is observing an older adult client dress and groom as part of a mental health assessment. Which finding indicates that the client may need further follow-up related to a cerebral vascular accident (CVA)?
- extreme unilateral neglect. The nurse should anticipate further follow-up related to a possible cerebral vascular accident (CVA) if the client exhibits extreme unilateral neglect, as this is characteristic of a CVA. Unusually meticulous grooming may be seen in obsessive-compulsive disorder. Bizarre dress may be seen in schizophrenia or manic disorders. Loose clothing held up by a belt suggests recent weight loss.
After reviewing a client's completed danger assessment questionnaire, the nurse determines that the client is in significant danger of intimate partner violence (IPV) leading to homicide. The client says that she would prefer to return home and that she does not have a safety plan. Which of the following nursing interventions should the nurse implement at this point? Select all that apply.
- have the client complete assessment tool: safety plan. - schedule follow up appointment. - provide them with contact information for shelters and groups. - encourage to call with any concerns. If screening for IPV is positive and the client's answers on the danger assessment questionnaire indicate a high probability for serious violence, the nurse should ask the client if she has a safety plan and where she would like to go when she leaves the nurse's agency, and should schedule a follow-up appointment and/or refer the client as appropriate. If the client says she prefers to return home, the nurse should ask her whether it is safe for her to do so and have her complete Assessment Tool 10-2. The nurse should also provide the client with contact information for shelters and groups, and encourage her to call with any concerns. The nurse should not encourage the client to return home, as it may not be safe for her to do so. The nurse should also not call the police and ask them to pick up the abuser, as there may not be sufficient legal grounds on which to arrest and incarcerate him. In doing so, the client could be put at further risk of abuse.
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
- inflammation of the parietal pleura. Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.
The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should
- make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication. A consequence of elder mistreatment is the inability to get food or medication because of neglect.
The clavicles extend from the acromion of the scapula to the part of the sternum termed the
- manubrium. The clavicles extend from the manubrium to the acromion of the scapula.
A patient is diagnosed with atrial fibrillation (AF) based on an electrocardiogram (ECG). Which of the following nursing assessment findings could also be demonstrated by a patient experiencing AF? (Select all that apply.)
-History of chest pain -Jugular vein distension -Tachycardia -An irregular pulse Irregular pulse, tachycardia, elevated jugular venous pressure (leading to jugular vein distension), and a history of chest pain are assessment findings that support a diagnosis of AF. An audible carotid bruit is not associated with AF.
The nurse is preparing a patient for a cardiovascular assessment. When providing the patient with information concerning the examination, which physical positions will the nurse indicate will be used during the examination? (Select all that apply.)
-Sitting upright while leaning forward -------Supine -Left lateral Rationale: The positions commonly used to facilitate this assessment include supine, left lateral, and sitting upright while leaning forward. Neither the right lateral nor prone position is useful.
The CAGE test is a screening questionnaire that helps to identify: A) unhealthy lifestyle behaviors. B) personal response to stress. C) excessive or uncontrollable drinking. D) depression.
C) Excessive or uncontrollable drinking.
The AUDIT assesses
Current alcohol problems; alcohol consumption (quantity and frequency), alcohol dependence, alcohol-related problems.
A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience?
- "I will be asking you a series of questions that I ask of all of my clients." It is important to establish rapport and trust prior to beginning the interview process. If there is not time to establish this rapport and trust, the nurse can begin the interview by letting the client know that the questions are being asked of all clients who are interviewed. Questions in mental health are designed to elicit information about various mental health risks and problems.
The nurse notes that a client has had an 8 kg weight loss over the last 3 months. On which mental health issue should the nurse focus when assessing this client? Select all that apply.
- Anxiety, Eating disorder, Early dementia. A decrease in weight may be seen in anxiety, eating disorders, and early dementia. Poor appetite may be seen in substance abuse. Psychosis is not associated with any particular change in appetite or weight.
A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following aspects of cognitive function?
- Judgment. Asking a client about what he or she does or would do if he or she has pain evaluates a client's judgment. Asking about the client's name, time, and place evaluates his or her orientation. Asking a client to compare and contrast things evaluates abstract reasoning. Asking the client about recent and past events evaluates memory.
Kevin is conducting an interview with a psychiatric-mental health client and notices the client is using made-up words. This is known as which of the following?
- Neologisms. Clients with thought disorders (e.g., schizophrenia) may rhyme (clang associations) or use made-up words (neologisms).
The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age?
- Provides a reference point for psychosocial developmental level. The client's age is used as a reference point with which the client's psychosocial developmental level can be compared. Age is not used to assess long-term memory, the ability to cope with mental disorders, or the likelihood of participating in a healthy lifestyle.
The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next?
- Refer for further evaluation. A score of 22 denotes very severe depression; referral is clearly warranted. Dementia is not indicated by this score.
Which nursing action is essential in caring for the victim of violence?
- Validating the abuse experience. The essential nursing action when caring for the victim of violence is validating the abuse experience, maintaining confidentiality, acknowledging the abuse, and avoiding normalization of the victimization.
When observing a client diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following?
-Euphoric . Terms used to describe mood include euthymic (normal), euphoric (elated), labile (changeable), and dysphoric (depressed, disquieted, restless).
CAGE test
Have you ever thought you should Cut down your drinking? Have you ever been Annoyed by criticism of your drinking? Have you ever felt Guilty about your drinking? Do you drink in the morning, an Eye opener?
Comorbidity
The coexistence of two or more disorders.
Mini-Cog Test
■ Quick method for assessing dementia. If abnormal, screen further with MMSE. ■ Use these two methods: the clock drawing test with word recall test (three unrelated words). ■ Instruct patient to draw a clock and mark it with the hands showing a certain time. ■ Example: Instruct patient to "Draw a clock that shows 20 minutes past 4." - Scoring clock test: Hands point to the correct time and numbers on clock are in correct sequence.
A nurse is educating a victim of intimate partner violence about a safety plan. The nurse should include which of the following?
- "Have a code word to use with your children, family, and friends that indicates you need help." A victim of intimate partner violence should have a code word they can use when a disruption occurs so that children, family, or friends know they need assistance. Telling people about the abuse, such as close friends and neighbors, can save the victim's life. Staying at a neighbor's house is not recommended because it is too close to the home. It is recommended that weapons be removed from the home to prevent injury.
A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?
- "He tells me that he'll tell child services I'm a bad mother." The statement about telling child services that the client is a bad mother reflects coercion and threats. The statement about the abuse never happening reflects power and control through minimizing, denying, and blaming. The statement about whom the client can and cannot see reflects power and control through the use of isolation. The statement about the partner being the master of his castle reflects power and control through the use of the male privilege.
A nurse is caring for a client who is a victim of intimate partner violence. The nurse determines further education is required regarding a safety plan when the client makes which of the following statements?
- "I feel uncomfortable asking the neighbors to call the police when they hear a disturbance at my house." Notifying the neighbors of intimate partner violence and requesting they act by calling the police when a disturbance is heard could save the client's life. The client requires further education on this matter. Knowing how to call 911, call collect, gathering important paperwork, and telling the children to keep themselves safe during a disturbance is all part of a safety plan.
The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation?
- "I have not seen my parents in 6 months; they live only 30 minutes away." Isolation refers to controlling what victims do or read, whom they see or talk to, or where they go. Intimidation makes the victim afraid through the use of looks, action, or gestures. Emotional abuse refers to the victim being put down or made to feel bad about them self. A perpetrator uses children to relay messages to exert power or control the victim.
The nurse is listening to a client recount their story about how an abusive relationship escalated to domestic violence. Which statement by the client corresponds with stage 2 of Walker's cycle of violence?
- "I was 15 minutes late coming home, and my partner beat me throughout the rest of that evening. There was nothing I could do or say that could stop it." The statement, "I was 15 minutes late coming home, and my partner beat me throughout the rest of that evening. There was nothing I could do or say that could stop it" by the client corresponds with phase 2 of Walker's cycle of violence theory, during which battering occurs with violence lasting up to 24 hours and may be triggered by something minor. Phase 1 is characterized by the abuser making unrealistic demands and responding with criticism or ridicule, sometimes escalating to shoving or slapping. The statements "My partner demanded that I text message them every 10 minutes and tell them where I was whenever I would leave the home" and "If my partner tried to call me and I didn't pick up on the first ring, they would shove me and shout at me" correspond to phase 1. In phase 3, the honeymoon phase, the abuser is loving, promises never to abuse the victim again, and is very attentive to the victim following an incident of battery. The statement "After my partner would beat me up, they would be very sorry, and shower me with gifts and attention. They would promise to never do it again" corresponds with phase 3.
The nurse is assessing the client's ability to make sound judgments. Which question would be best for the nurse to ask?
- "If you lost your job, how would you plan to pay your rent or mortgage?" The nurse can often assess judgment by asking questions about family situations, jobs, money management, and interpersonal conflicts. An open-ended question that asks the client to make a plan for a hypothetical situation, such as a loss of income, will elicit more information about judgment than asking a yes/no question. The questions about whether the client eats breakfast or can manage money are yes/no questions and will reveal little information about the client's judgment. "How many dimes are in one dollar?" is a knowledge question that does not elicit information about judgment.
Susan, 6 years old, is hospitalized for a respiratory illness. Based on the nursing assessment, the nurse has formulated a nursing diagnosis of risk for dysfunctional family processes. Which comments by the nurse would be most appropriate to for this nursing diagnosis?
- "It can be very frightening when your child is ill."; "Tell me about your support system." Risk for dysfunctional family processes suggests changes may occur in family relationships, family functioning, or both. Acknowledging the parents' feelings during this stressful time of illness may minimize their emotional response. Knowledge of the family's social support system is essential, because the nurse may need to assist the parents in reaching out to their support system or in creating a support system to help them during this stressful time. Taking the child's blood pressure, ordering food trays for the parents, and informing the parents of the treatment regimen are expected nursing actions regardless of the nursing diagnosis.
The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?
- "It looks like someone has hurt you. Tell me about it." The nurse should say to the client, "It looks like someone has hurt you. Tell me about it." This is an open-ended statement and allows the client to verbalize her thoughts and feelings. Asking if the partner is being mean or why the client thinks the husband has beaten her already assume that the client has been abused. Asking about the person who did this to the client would be ineffective be survivors of violence are unlikely to disclose sensitive information unless they perceive the nurse to be trustworthy and nonjudgmental. Additionally, this question is a closed question that does not allow the client to verbalize her thoughts and feelings openly.
A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression?
- "It usually takes me over an hour to fall asleep." Based on the depression questionnaire, routinely taking a long time to fall asleep, such as an hour, would suggest possible depression. Difficulty concentrating such that it interferes with even minor decision making, not occasional mind wandering, would be an indicator of depression. Appetite changes, either significantly increased or decreased, would be a signal for possible depression. Sleeping too much, waking up too early, or awaking during the night if frequent or excessive can suggest depression.
A nurse is assessing a client for elder abuse. Which statement should the nurse ask first?
- "Tell me about your typical day." Asking the client to tell the nurse about their typical day allows the nurse to understand the client's routine. Asking about medications and how often they bathe may reveal that the client has been neglected but this is not the best answer in this situation. The client may not feel comfortable talking about their caregiver for fear of retribution.
As part of the mental status examination, the nurse assesses the cognitive abilities of the client. Which questions should the nurse ask to assess the judgment ability in the client?
- "What do you do if you have pain?" To assess judgment ability in a client, the nurse should ask the client what he or she does when in pain. Asking about the first job and the last hospitalization helps in assessing remote memory. Asking the client about the difference between an apple and an orange elicits abstract reasoning.
A nurse is assessing a client's spirituality. Which question would be most appropriate to ask?
- "What gives your life meaning?" Spirituality refers to a unifying force of a person that is unique to each individual. Thus, asking a client about what gives meaning to his or her life addresses this area. Asking about self-harm provides information about suicidal ideation. Asking about the importance of family provides information about the social system of the family. Asking about how the client defines good and evil reflects the client's cultural beliefs.
A nurse is preparing to discuss the cycle of violence with a group of women who have been victims of abuse. Which of the following would the nurse include as part of phase 3 of this cycle?
- A reconciliation period. Phase 3 or the honeymoon phase is described as a period of reconciliation and begins after an incident of battery. Shoving and slapping and victim separation from support group are typical of phase 1, the tension-building phase. Acute battering occurs in phase 2.
A nurse is counseling a woman who has been abused by her husband and who is at risk for serious injury and even death. The woman has two school-aged children at home. Which of the following should the nurse tell the woman to make sure her children know? Select all that apply.
- A safe place to go when abuse of the client occurs, How and when to call 911, Who is safe to tell when they are unsafe. As presented in Assessment Tool 10-2: Assessing a Safety Plan, the client should ask her children whether they know the following: a safe place to go, who is safe to tell they are unsafe, how and when to call 911, and how to make a collect call. The client should inform the children that it is their job to keep themselves, not their mother, safe; they should not interject themselves into adult conflict.
A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary?
- A situation that involves danger of harm to self or others. An acute mental health assessment includes questions about harm to self or others. Acute situations include a risk for injury that accompanies psychotic states, depression, dementia, or delirium. It is important to ask the safety questions first and leave the presenting problem last. Clients with schizophrenia do not always present with risk for harm to self or others. A client with severe depression is not necessarily at risk of harm to self or others nor is a delirious client.
Which of the following principles would guide the nurse's assessment when caring for a client with suspected physical abuse?
- Abuse may start at any time during a relationship. With physical abuse, it is important to remember that it can start at any time during a relationship. The abuse may not be part of the presenting problem for which the client is being seen, but may be cause or etiology of the presenting problem. Consistent risk factors for women at risk have not been identified. Therefore, both abused and nonabused women require routine screening by health care providers. The recommendation is that all female clients age 14 and older be screened for abuse when seen in emergency departments, urgent care centers, or primary health care clinics.
A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care?
- Anxiety related to awareness of increasing memory loss. The client is demonstrating signs of anxiety as evidenced by nervousness and fear. The most appropriate diagnosis would be Anxiety related to awareness of increasing memory loss. There is no evidence that the client has dementia. There is not enough information to determine if the client is disabled or has a hearing loss.
When a nurse suspects that a client may have been abused, the first action should be to:
- Ask the client about the injuries and if they are related to abuse. The first step is to screen for abuse and identify the connection between the woman's injuries and abuse. Once abuse is detected, the nurse should immediately isolate the woman to provide privacy and prevent retaliation by the abuser. Encouraging the woman to leave the batterer immediately is not realistic. Setting up an appointment with a counselor would be appropriate once the abuse is detected and the woman is safe. Questioning the suspected abuser might worsen the situation.
The nurse suspects that a client is experiencing violence from an intimate partner. The nurse asks the client to complete the Danger Assessment tool and the client scores 13. Which of the following actions should the nurse take?
- Ask the client if they have a safety plan in place. The Danger Assessment tool score ranges from 0 (no danger) to 20 (extreme danger). A score of 13 places the client in increased danger. The nurse should ensure the client has a safety plan in place. Because the client scored 13, safety is not ensured. The nurse would not request social services to remove the children from the home at this time. The nurse would not instruct the client to leave their spouse.
Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?
- Ask, "Have you ever been physically hurt by your partner?" If violence is suspected, the nurse must used direct or indirect questions to screen for abuse. Asking the woman if she has ever been physically hurt by her partner is most appropriate. Offering her a pamphlet, calling her at home, or waiting until she returns are inappropriate and do not validate the suspicion.
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. What would be the priority assessment at this time?
- Asking whether the client often feels cold. Dress typically is appropriate for occasion and weather. Dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat, resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.
The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. What would be the nurse's priority assessment at this time?
- Asking whether the client often feels cold. Dress typically is appropriate for occasion and weather. Dress varies considerably from person to person. Some older adults may wear excess clothing because of slowed metabolism and loss of subcutaneous fat, resulting in cold intolerance. The nurse needs to determine this first before performing any other assessments.
A home health nurse visits an 80-year-old client with mild Alzheimer disease who recently moved in with a caregiver. Which observation(s) would cause the nurse to suspect neglect? Select all that apply.
- Client has lost 10 pounds in the past 2 months. - Client's clothes are soiled. - Client's prescriptions have expired. Neglect or abuse is suspected when the caregiver does not provide appropriate care to the person they are supposed to be caring for, such as assisting with activities of daily living like eating, bathing, and dressing, and ensuring they have the medications they need. This client has soiled clothes, has lost a significant amount of weight in the past two months, and seems hesitant to speak when the caregiver is present. These are all indicators of abuse or neglect. Eye contact is usually avoided in clients who have experienced neglect or abuse.
A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point?
- Conduct a forensic interview. If a nurse discovers signs of sexual abuse, including rape, on assessing a client, the nurse should conduct a forensic interview to gather data for potential legal proceedings. The other answers are of lesser priority than conducting a forensic interview.
A 75-year-old male client is admitted to the hospital with confusion. The client's adult child states that their father has been becoming more confused for the past few months. The child states "they keep forgetting to pay their bills and are unable to manage a budget, and they are constantly making poor decisions. I don't know what to do." The client is able to state their name and date of birth but appears confused about where they are and why, and the current date. The client also has difficulty with word finding and carrying on a conversation. For each finding, click to specify if the finding indicates an age-related change or Alzheimer Disease. Findings may support more than one classification.
- Constantly making poor decisions: Alzheimer Disease - Difficulty carrying on a conversation: Alzheimer Disease - Unable to state where they are or why or the current date: Alzheimer Disease. - Unable to manage a budget: Alzheimer Disease - Forgetful at times: Age-Related Change, Alzheimer Disease. Being forgetful once in a while, such as forgetting to pay bills but then remembering later, is a normal age-related change. Being forgetful occurs in the early stages of Alzheimer Disease. As Alzheimer Disease worsens, the client forgets things like paying bills often and cannot manage a budget, consistently makes poor decisions, may forget where they are and why they are there, and may have difficulty carrying on a conversation.
A nurse performs a focused neurological assessment on a client who was involved in a motor vehicle accident. The initial Glasgow Coma Scale (GCS) at the scene was recorded as 11. On arrival at the hospital, the nurse records the client's GSC as 13. What is the best action of the nurse?
- Continue to monitor the client. The GCS measures level of consciousness; the scale ranges from 3 to 15; 3 being the worst with decerebrate posturing and unresponsiveness, 15 being the best with no deficits. The client has a score of 13, which does not require any interventions except to continue to monitor for deterioration. Because there has been an improvement in the client's score, the nurse does not have to notify the health care provider or alert rapid response. There is no indication that oxygen is needed. However, if the client's GCS were 8 or less, the client would have to be intubated to protect the airway.
When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population?
- Death. Failure to diagnose depression can have fatal consequences-suicide rates among clients with major depression are eight times higher than in the general population.
When assessing a client for human violence, what basic technique would the nurse need to apply?
- Demonstrating compassion. When assessing for violence demonstrate compassion, not judgment.
The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?
- Do you have any thoughts of wanting to harm or kill yourself? The priority is for the nurse would be to conduct a suicide assessment. The best question for the nurse to ask first is Do you have any thoughts of wanting to harm or kill yourself? The risk for suicide is not assessed using 0 to 10 scale. Asking about having a sense of hope for the future would be included in a spirituality assessment. The question, "Do you hear voices that tell you what to do?" assesses for auditory hallucinations.
The nurse is caring for a woman being seen for possible pregnancy. When would nurse screen the woman for intimate partner violence?
- During the woman's first prenatal visit to the clinic. Screening for pregnant mothers should be started at the initial prenatal visit and continued periodically and postnatally. The partner should not be present during screening.
A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse?
- Economic abuse. Economic abuse, also known as financial abuse, is the improper exploitation of another person's personal assets, properties, or funds. Examples of this type of abuse include the cashing of another person's checks without authorization or permission, forging signatures, and misusing or stealing money or possessions. Humiliating, depriving, and intimidating the victim is an example of psychological abuse. Elder mistreatment—also known as elder abuse—includes neglect and various types of abuse committed against those over the age of 65 years. Child abuse is neglect or abuse of a child under the age of 18.
A nurse is admitting a 30-year-old female client and recognizes the need to screen the client for abuse. What would the nurse do next?
- Ensure a private setting. Creating a safe and confidential environment is essential. For any client over the age of 3 years, ask screening questions in a secure, private setting with no one else present in the room. Physical assessment should not precede screening, and signed consent is not required. Teaching about IPV may or may not be warranted at this early stage.
The spouse of a client believed to be a victim of intimate partner violence refuses to leave the room for the nurse to complete an assessment. What should the nurse do first?
- Ensure for personal safety. One of the greatest risks for violence in the workplace is caring for victims of intimate partner violence. Injured victims are often accompanied to the emergency department by the batterer. As the batterer has already shown the ability to inflict injury, the batterer should be considered dangerous. The nurse's priority is to ensure for personal safety first. There is no reason to call the police or ask Security to remove the spouse since violence has not yet occurred. Keeping the room door open may cause the batterer to become agitated or violent.
Which technique should a nurse implement when interviewing with a child who has suffered physical abuse by the father?
- Establish a reassuring environment. The nurse should provide a reassuring environment during the interview. The nurse should not offer rewards for answering questions. The nurse should ask open ended questions and avoid questions that can be answered as "yes" or "no." The nurse should not provide a lot of information when asking questions so that the child will provide more information when answering.
A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. What would the nurse consider when assessing the client's facial expression and eye contact?
- Eye contact is strongly influenced by cultural norms. Eye contact and facial expressions, such as smiling, differ widely between cultures. Reduced eye contact is not an age-related physiological change. Informing the client that his facial expression is being assessed will likely confound the assessment results. Mental illness does not preclude assessment of eye contact and facial expression.
During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?
- Eye-openers. The client drinking alcohol in the morning would be applicable to the area on eye-openers specifically the question "Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? This information is not applicable to the other areas of the CAGE questionnaire, specifically, annoyance, cutting down, or guilty feelings.
The nurse is screening an older adult client who is exhibiting signs of depression. Which screening tool would be best for the nurse to use during the assessment?
- Geriatric Depression Scale. The screening tool that would be best for the nurse to use during the assessment is the Geriatric Depression Scale, which is for older adult clients. The nurse should always use the screening tool best suited for the client's age. The Primary Care PTSD screening tool is used in primary care and medical facilities, including the Veterans Affairs network, to identify people exposed to traumatic events that may need assistance. The Patient Health Questionnaire is commonly used for screening adults for depression. The Mini-Mental State Examination is used to screen adult clients for cognitive dysfunction and dementia.
The nurse has made a nursing diagnosis of self-esteem disturbance. Which assessment data supports the nursing diagnosis?
- Guilt and negative comments about self. Guilt and negative comments about self are indicative of self-esteem disturbance. Impaired social interaction is characterized by feeling ill-at ease during social situations. Expressions of hopelessness and loneliness are indicators of risk for suicide. A nursing diagnosis of sensory-perceptual alterations is characterized by poor concentration and hallucinations.
The client states, "I don't know why God as abandoned me; I am a good person." Which tool would be most appropriate for the nurse to administer?
- HOPE. The HOPE tool is used to assess spirituality. The CAGE is used to assess for substance abuse. The MMSE and the Mini-Cog are used to assess cognitive function.
A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?
- Hallucination. A hallucination is a subjective sensory perception without real external stimuli. The client can hear, see, smell, taste, or feel something that does not exist in reality. In this case, his sister has passed away and cannot be speaking to him, although in his mind he can hear her. This is an example of an auditory hallucination, but hallucinations can occur with any of the five senses.
The client states, "I just know I have cancer. My doctor has run every test in the book and says there is nothing wrong with me. I don't believe any test. I know how sick I am!" This client is exhibiting what type of thought process disturbance?
- Hypochondriasis. This client is exhibiting hypochondriasis. Although there is no medical basis for the belief, the client has a morbid concern about health as well as feelings of being ill.
Which of the following is not a true statement about intimate partner violence?
- Intimate partner violence is caused by the "victim" refusing her husband's desire for sex. It is important to establish rapport and trust prior to beginning the interview process. If there is not time to establish this rapport and trust, the nurse can begin the interview by letting the client know that the questions are being asked of all clients who are interviewed. Questions in mental health are designed to elicit information about various mental health risks and problems.
The nurse begins a health history with a middle-aged female adult client. Why should the nurse ask if there a history of abuse in the client's family?
- It explains if abuse is carried over from one generation of the family to the next. The reason the nurse asks if about a history of abuse in the client's family is because a history of abuse often is carried over from one generation of a family to the next. The nurse is not asking the question because it is "routine." The question will not necessarily narrow the focus on who might be abusing the client. This question does not help determine if the client is currently being abused.
A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?
- Lethargy. Opening the eyes, answering questions, and falling back asleep describes lethargy. Being completely unresponsive to all stimuli with the eyes closed describes a coma. Being awakened with vigorous or painful stimuli describes stupor. Opening the eyes to loud voices, responding slowly with confusion, and being unaware of the environment describes obtunded.
The nurse is helping a client who is a victim of intimate partner violence (IPV) develop a safety plan. Which of the following should be included in the safety plan? Select all that apply.
- Locations to go to if it becomes necessary to leave. - What to pack and where to hide a bag or suitcase. - A code word to use with kids, family, and friends that alerts them to danger. - A process for having weapons removed from the house. A safety plan for a victim of intimate partner violence should include the following: what to pack and where to hide a bag or suitcase; a code word to use with kids, family, and friends that alerts them to danger; locations to go to if it becomes necessary to leave; and a process for having weapons removed from the house. A list of signs that indicate risk for IPV is not needed, as it has already been established that the client is a victim of IPV. The client should not keep the abuse a secret from neighbors but should tell them about it and have them call the police when they hear a disturbance.
A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would be best?
- Low self-esteem related to lack of confidence in ability. The client's statements indicate that the client's self-esteem is low due to her feelings of not being able to survive outside the violent relationship. The client may be anxious, but this anxiety would most likely be related to her low self-esteem, not the escalation of the violence. Although impaired parenting might apply, the client's statements are more reflective of her feelings of low self-esteem, which would in turn contribute to her feelings about whether or not she was a good parent. The partner, not the client, would most likely have a nursing diagnosis of risk for violence.
The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?
- Nerve damage caused by repeated eye injuries. Unilateral ptosis of an eye would occur because of repeated injuries to the eye causing nerve damage to the eyelids. This finding does not indicate an undiagnosed eye or neurologic disease. This finding does not indicate the need for corrective lenses.
A nurse uses the Alcohol Use Disorders Identification Text (AUDIT) assessment tool to assess a client for risk of alcohol dependence. The client scores 15. What action should the nurse take?
- Notify the health care provider. The AUDIT (Alcohol Use Disorders Identification Text) has 10 items. Each item is scored 0-4 for a range of 0-40. Scores of 8 or more are recommended as indicators of hazardous and harmful alcohol use, as well as possible alcohol dependence. Because the client scored 15, the action of the nurse would be to notify the health care provider of the score so that the provider can refer the client to a mental health professional trained in substance use disorder. The mental health professional will develop a treatment plan that may include inpatient rehabilitation. Instructing the client to cut their drinking in half is not being a client advocate or promoting health and disease prevention. Encouraging the client to continue with usual habits will lead to serious health problems.
As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?
- Orientation to time is usually lost first and orientation to person is usually lost last. When assessing orientation to time, place, and person remember that orientation to time is usually lost first and orientation to person is usually lost last.
A female client and her partner come to the emergency department. The client has bruising on both upper extremities and a fracture of the left arm. The client states that she fell down the stairs. What finding would lead the nurse to suspect that the client is a victim of violence?
- Partner states that client is very clumsy and accident prone. The statement by the partner about the client being very clumsy and accident prone is a negative statement that criticizes the client. This negative statement suggests that the partner is unsupportive of the client and not sensitive to the client's needs, suggesting possible violence. Other signs of possible violence include the partner attempting to speak for or answer the questions for the client, refusing to leave the client's presence, and being nonsupportive. The client would appear anxious and afraid of the partner or submissive or passive to the partner's negative comments.
The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?
- Patient advocate. The nurse may assess the change in the client and will be the advocate and detective, determining when the change occurred and what was new in the treatment.
The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client?
- Patient demonstrates flight of ideas. Flight of ideas is an almost continuous flow of accelerated speech in which a person changes abruptly from topic to topic. Changes are usually based on understandable associations, plays on words, or distracting stimuli, but the ideas do not progress to sensible conversation.
What are some basic rules for nurses to follow when assessing for violence? Select all that apply.
- Perform assessment and screening only when the client is alone in a safe, private environment-Be very patient when the client talks-Demonstrate compassion, not judgment. Nurses assessing for violence should perform assessment and screening only when the client is alone in a safe, private environment. The nurse needs to establish rapport and connection by showing interest in the client and by listening. The nurse also needs to demonstrate compassion, not judgment. The nurse needs to start with general, open-ended questions and move to specific questions later. Having a family member present is the opposite of performing assessment with the client alone.
During a comprehensive assessment, the nurse identifies signs of possible dementia. What is the best action of the nurse?
- Perform the SLUMS examination to assess cognitive function. The nurse would further investigate the client's symptom of forgetfulness using COLDSPA and tools such as the SLUMS (St. Louis University Mental Status) examination to identify cognitive deficits. The nurse may ask the family, if they are present during the interview, if there has been a change in mental status to validate what the client is stating, but that is not the best action. After completing the entire assessment, the nurse may recommend laboratory work and a computed tomography of the head to rule out other conditions.
A nurse is admitting a client with self-inflicted lacerations to the arms and abdomen. The nurse also notes healed, small, circular scars on the client's arms. What nursing interventions should the nurse include in the plan of care for this client? (Select all that apply.)
- Provide medical treatment for the lacerations. - Have the client contract with staff to notify them when there is a desire to mutilate. The use of restraints is not indicated for this client. The client should be supervised when smoking, especially in light of the "small, circular, healed marks" on the arms. Lit cigarettes can be an instrument used to mutilate. Medical treatment should be delivered immediately to address the lacerations and possible blood loss. A contract with the staff to prevent self-inflicted mutilation can facilitate early access to help for the client. Sedation is not indicated for a client with self-inflicted mutilation.
The nurse has identified that a female client desires to leave her abusive husband and move with her children to her parent's house. Which nursing diagnosis would be most appropriate for this client?
- Readiness for enhanced family processes. Because the client expressed a desire to leave her husband and start over, there is a readiness for enhanced family processes. Grieving may be appropriate if the client stated feelings related to the loss of the relationship. Disturbed personal identity would be appropriate if the client demonstrated an inability to function effectively outside the victimized role. Impaired parenting would be appropriate if the client had decided to remain in the abusive relationship with her children.
A client who is a victim of intimate partner violence (IVP), after undergoing a physical assessment of injuries she recently received from her husband, tells the nurse that she has had enough and is ready leave him, taking the children with her. She asks the nurse if the nurse knows of any safe places for her to go. Which of the following nursing diagnoses would be most appropriate for this client?
- Readiness for enhanced self-health management related to request for information on safe locations to go after leaving her home. This client is clearly ready to improve her situation, as indicated by her expressed intention to leave her husband and her request for information on safe locations. Thus, the diagnosis related to readiness for enhanced self-health management is appropriate. The client is demonstrating the opposite of powerlessness or low self-esteem by seeking to improve her situation. There is no indication that the client is at risk for self-directed violence due to being abused.
A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behavior has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighborhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings?
- Schizophrenia. Onset of schizophrenia generally happens in the late teens to early 20s. It often is seen in other family members. Symptoms must be present for at least 6 months and must have at least two features of (1) delusions (thieves are stealing his programs), (2) hallucinations (technicians sending telepathic signals), (3) disorganized speech, (4) disorganized behavior, and (5) negative symptoms such as a flat affect. The catalysts of delirium and substance ingestion that denote a psychotic disorder due to medical illness and substance-induced psychotic disorder are absent. Generalized anxiety is not present.
The nurse is conducting an admission assessment of the client. The client is alert and oriented x 3, has obviously bathed recently, and is dressed in clean clothes. The client reports living alone and having one good friend, who is occasionally a confidant for the client. The client answers questions but describes self in negative terms. The nurse makes a tentative nursing diagnosis of:
- Self-esteem disturbance. Individuals who evaluate themselves negatively are demonstrating a disturbance in self-esteem. Ineffective individual coping is characterized by individuals ignoring their problems, lack of concentration, and sleep disturbances. The individual with altered thought processes demonstrates nonreality-based thinking and inaccurately perceives their surroundings. The individual with sensory-perceptual alterations is irritable an agitated and experiences auditory or visual hallucinations.
The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client?
- Slight delays in mental processing are normal in older adults. Slight delays in information processing are considered to be an age-related change and are not necessarily pathologic. There is no indication that the client may be trying to anticipate the nurse's desired response.
Which of the following is true about violence against women?
- Some experts purport that cultural attitudes influence violence. Culture, race, ethnicity, and the economy must be considered in the evaluation for suspected family violence. One needs to conduct a cultural assessment (using assessment guidelines) before attempting to understand a client's particular case of family violence, especially for members of families of a different ethnic origin from the primary ethnic background with which the nurse is familiar.
The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability?
- Speak to the client clearly from a close distance. When assessing the level of consciousness, always begin with the least noxious stimulus: verbal, tactile, to painful.
While conducting a mental status history, the nurse notes that the client is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?
- Speech and language. Articulation of words, spontaneous comments, and rate of speech are elements of the speech and language part of the mental status history. These characteristics are less likely to be a part of the appearance and behavior, mood, and thoughts and perceptions portion of the mental status history.
When assessing a client, the nurse notes that he is delusional. The nurse would know that delusional thinking can lead to what?
- Suicide. Other risk factors are prior suicide attempts; delusional or psychotic thinking; family history of suicide, mental disorders, or substance abuse; family violence, including physical or sexual abuse; firearms in the home; and incarceration.
The nurse is assisting a client who has been physically abused with developing a safety plan. The client prefers to return home. What should the nurse review with the client to ensure the safety plan is effective? Select all that apply.
- Tell the neighbors about the abuse and ask them to call the police if they notice a disturbance. - Have a place to go if leaving urgently is required. - Have a packed back ready, hidden, but easy to grab quickly. - Establish a code word to use with children, family, and friends in case help is needed. The nurse should review having a packed back ready, hidden, but easy to grab quickly; telling the neighbors about the abuse and asking them to call the police if they notice a disturbance; having a place to go if leaving urgently is required; and establishing a code word to use with children, family, and friends in case help is needed. These are all components of an effective safety plan. Ensuring that there are no weapons in the home is part of an effective safety plan, not keeping a weapon in the home.
The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?
- The exam can provide clues about the validity of the client's responses now and throughout. Assessing mental status at the very beginning of the head-to-toe examination provides clues regarding the validity of the subjective information provided by the client during the history and throughout the exam. Thus it is best to determine validity of client responses before completing the entire physical exam only to learn that the client's answers to questions may have been inaccurate. Assessing mental status first will not necessarily lessen a client's anxiety or fears about a serious illness. The exam can provide data about mental health problems. However, this is not the primary reason for performing the exam at the very beginning.
A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principles would guide the nurse's assessment of the client's mental status?
- The nurse must differentiate between age-related changes and the signs and symptoms of dementia. Aging has common forms of decline that are often mistaken for dementia or that resemble dementia. These include slower thinking, problem solving, learning, and recall; decreased attention and concentration; more distractedness; and need for hints to jog memory. It is important to differentiate dementia from common cognitive changes that occur with age. It is a fallacy, however, to expect older adults to naturally become "senile." There is no obvious need to exclude reading and writing from assessment. Suggestions regarding long-term care would be premature and anxiety-provoking.
Why is it important for the nurse to wait until the end of the assessment interview to ask questions about violence in the client's life?
- This allows time to build rapport and to ask less sensitive questions first. Psychosocial histories often include violence assessment, but they can be very sensitive areas for the client to discuss. Moving into this area of assessment toward the end of the client history allows time to build rapport and to ask less sensitive questions first. The other options are, therefore, incorrect.
The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach?
- Validates the information the client provides during the rest of the assessment. Many assess mental status at the beginning of a head-to-toe assessment because it provides clues regarding the validity of the subjective information provided by the client throughout the examination. This assessment is not done first because it takes less energy for the nurse to complete it. This assessment can be quite lengthy. It is not done first because the client may become fatigued.
The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty?
- attention. A client having difficulty with attention has difficulty responding to questions. Mood is a sustained emotion that provides information about the client's view of the world. Insight is an awareness that symptoms or behaviors are normal or abnormal. Orientation is an awareness of person, place, and time.
The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because
- depression often mimics signs and symptoms of dementia. The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because
CAGE questionnaire
C - have u tried to CUT down on your drinking A- have you ever felt ANNOYED by criticism about drinking G- have you felt GUILT about your drinking E- have you ever had an EYE opener
Depression Questionnaire
Falling asleep Sleep during the night Waking up too early Sleeping too much Feeling sad Decreased or increased appetite Decreased or increased weight (within last 2 weeks) Concentration/decision making View of oneself Thoughts of death or suicide General interest Energy level Feeling slowed down Feeling restless
hypochondriasis (illness anxiety disorder)
a disorder in which a person interprets normal physical sensations as symptoms of a disease.
mania
a mood disorder marked by a hyperactive, wildly optimistic state. obsessive preoccupation.
ptosis
drooping
Glasgow Coma Scale
eyes, verbal, motor Max- 15 pts, below 8= coma mild - 13-15; moderate - 8-12; and severe <8. Fifteen is the highest possible score and indicates no neurologic disabilities.
Hepatic encephalopathy
impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. Rx: lactulose, low protein, safety, rest.
elated
in high spirits, jubilant; extremely pleased, joyful.
