Quiz 3

A nurse is gathering subjective data from an adult client about the client's daily food intake. Which question should the nurse ask the client first? "Do you do your own shopping?" "Have you ever heard of MyPlate?" "Can you tell me what you ate and drank over the last 24 hours?" "Do you have adequate income to purchase the foods you need?"

"Can you tell me what you ate and drank over the last 24 hours?" RATIONALE: The first question the nurse should ask the client would provide data about the client's typical daily intake. Once this has been determined, the nurse would collect data regarding who shops and prepares the food and whether the client has adequate income to purchase healthy food. The nurse might ask the client about MyPlate before teaching the client about healthy eating habits; however, the nurse would use it as a guide for teaching nutrition regardless of whether the client has heard of it.

A nurse has provided information to a client about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information? "I need to reduce my salt intake." "I need to cut down on my smoking." "I need to start a regular exercise program." "I need to watch my weight and cut down on my saturated fat."

"I need to cut down on my smoking." RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not "cut down" on the smoking.

What objective assessment would determine that the tympanic membrane finding is normal? A red membrane A white membrane A yellow-amber membrane A shiny, translucent membrane

A shiny, translucent membrane RATIONALE: The normal tympanic membrane is translucent, shiny, and pearly gray. It is free of tears and breaks. A bulging pink or red membrane indicates inflammation. A white membrane denotes the presence of pus behind the membrane. A yellow-amber color indicates serous otitis media. TEST-TAKING STRATEGY: Focus on the subject, a normal finding on tympanic membrane examination. Recalling that the tympanic membrane is normally translucent, shiny, and pearly gray will direct you to the correct option. Remembering the significance of a red, white, or yellow membrane will also help you answer correctly. Review: normal findings on otoscopic examination.

Which are characteristics of the Brown-Séquard syndrome? Select all that apply. The injury affects the entire spinal cord. It is a type of injury that results from penetrating injuries. Pain sensation is lost on the same side of the body as the injury. Motor function is lost on the same side of the body as the injury. Light touch sensation is affected on the opposite side of the body from the injury.

Motor function is lost on the same side of the body as the injury. Light touch sensation is affected on the opposite side of the body from the injury. It is a type of injury that results from penetrating injuries.

A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? Select all that apply. Fruits Red meats Vegetables Foods low in fiber High-nitrate foods

fruits vegetables RATIONALE: Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer.

The nurse has educated Shannon about BSE. The nurse realizes the education was effective if Shannon states that she will perform this examination how frequently? The first day of each month 7 days after the start of menstruation 14 days after the start of menstruation The 10th day of each month

7 days after the start of menstruation RATIONALE: Breast self-examination (BSE) should be performed monthly at a regular time when the breasts are not tender. In premenopausal women, the best time is 7 days after the start of menstruation. At this time, hormonal stimulation of the breasts is at its lowest point. Postmenopausal clients and clients who have undergone hysterectomy should select a specific day of the month and perform BSE each month on that day. First day of each month, 14 days after the start of menstruation, and the 10th day of each month are incorrect times to perform BSE.

What factors put Rudy at a higher risk for COVID-19? Select all that apply. Male sex Older age Veteran status Black American race Low body mass index (BMI)

Black American race Older age

A nurse reviewing laboratory results sees that the serum phenytoin level of a client who is taking oral phenytoin, 300 mg/day, is 22 mcg/mL. Which action should the nurse take first on the basis of this finding? Call the client's health care provider Administer the next scheduled dose Place the laboratory result form in the client's record Inform the client that the result is within the therapeutic range

Call the client's health care provider RATIONALE: The therapeutic serum range of phenytoin is 10 to 20 mcg/mL. A level below 10 mcg/mL is too low to control seizures and reflects a need to increase the dosage of phenytoin. A level higher than 20 mcg/mL indicates toxicity and a need to notify the health care provider. The nurse would place the laboratory results in the client's record after notifying the health care provider. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that indicate that the phenytoin level identified in the question is within the therapeutic range. To select from the remaining options, note that the phenytoin level in the question is too high for the therapeutic range. This will direct you to the correct option. Review: serum therapeutic levels of phenytoin.

The nurse is providing preoperative instructions for day surgery scheduled in a week to a client who speaks Spanish only. Which action is the best way for the nurse to ensure that the client understands the instructions? Calling for a hospital-designated interpreter to communicate with the client Asking a family member who speaks English and Spanish to translate for the client Relying on the use of hand signals and demonstrations to teach the client about the preoperative procedures Writing the instructions on a piece of paper so that an English and Spanish speaking neighbor will be able to translate them for the client

Calling for a hospital-designated interpreter to communicate with the client RATIONALE: Arranging for a hospital-designated interpreter is the best practice for communication with a client who speaks a different language. This action will ensure that the client clearly understands the preoperative instructions. Asking a family member or a neighbor is not an appropriate action, because the nurse cannot be sure that the client will receive the correct information. Also, asking a family member or neighbor to translate violates the client's privacy. Likewise, the use of hand signals and demonstrations will not ensure that the client understands the instructions. TEST-TAKING STRATEGY: Note the strategic word "best" in the question. Eliminate the comparable or alike options that violate the client's right to privacy by asking the family member or neighbor to translate. Next remember that a hospital designated translator will be familiar with medical terminology and will be able to explain the instruction accurately in lay terms. Review: the best communication techniques for a client who speaks a different language.

A client who has undergone vascular surgery of the legs suddenly complains of dyspnea and sharp chest pain. The nurse quickly checks the client and notes the presence of tachycardia on the cardiac monitor. Which action should the nurse take immediately? Contact the surgeon Contact the respiratory therapist Check the client's apical heart rate Check the client's peripheral pulses

Contact the surgeon RATIONALE: Any complaint of sudden sharp chest or upper abdominal pain must be reported immediately to the surgeon. Pulmonary embolism is a serious postoperative complication that can cause sudden death. A clot or part of a clot breaks away from a vessel and travels through the heart and into the pulmonary circulation and may occlude a pulmonary vessel, resulting in a pulmonary embolism. Common signs/symptoms include dyspnea, sudden sharp chest or upper abdominal pain, tachypnea and tachycardia, anxiety, and cyanosis. A respiratory therapist may be needed during treatment, but contacting the therapist would not be the immediate action. There is no useful reason for checking the client's apical heart rate, because the client is attached to a cardiac monitor, which displays the heart rate. Likewise, there is no useful reason for checking the peripheral pulses. TEST-TAKING STRATEGY: Focus on the data in the question and note the strategic word "immediately". Recalling the signs/symptoms of pulmonary embolism and remembering that this complication is an emergency will direct you to the correct option.

While the COVID-19 infection is active, what signs/symptoms does the nurse expect Rudy to display? Select all that apply. Cough Fever Loss of taste/smell Weak, thready pulse Shortness of breath

Cough Fever Loss of taste/smell SOB RATIONALE: Signs/symptoms of an active COVID-19 infection include but are not limited to cough, shortness of breath, fever, muscle pain, sore throat, and loss of taste and/or smell. The nurse would not expect a weak, thready pulse in the client unless an underlying health problem exists that causes a weak and thready pulse, or a complication of the infection occurs. TEST-TAKING STRATEGY: Focus on the subject - signs and symptoms of the COVID-19 coronavirus. Use knowledge of the symptoms of a viral infection to assist in answering correctly. Review: COVID-19.

The nurse helps the health care provider perform a Pap test on Shannon. When should the nurse instruct Shannon to receive follow-up testing? Yearly Every 3 years Every 5 years Every 6 months

Every 3 years RATIONALE: The American Cancer Society (ACS) recommends that all women begin cervical cancer screening at 21 years of age; screening should be performed every 3 years until age 29. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 5 years along with a human papillomavirus (HPV) test. Women 65 years or older who have had no abnormal Pap results in the preceding 10 years and no pre-cancers such as CIN2 or CIN3 may choose to stop having Pap tests.

The nurse is developing a plan of care for a client who has a severe intellectual disability. The client has recently begun to suck on her right hand, which is becoming red and raw. She is also refusing to eat some of her favorite foods. Which intervention has the highest priority? Wrapping her hand in gauze Determining if the client has a mouth sore Frequently reminding her it is unsanitary to suck on her hands Giving her a small reward when she does not suck on her hand during meals

Determining if the client has a mouth sore RATIONALE: The nurse should be aware that altered behavior may be caused by illness. The highest priority should be to investigate any condition or illness that could cause altered behavior. Wrapping her hand in gauze is not a priority; an underlying cause of the new behavior needs to be investigated first. Reminding her it is unsanitary to suck on her hands may not be effective if the individual has a severe intellectual disability. Providing her with a small reward for not sucking on her hands would not be effective if the cause of the behavior is a sore mouth. TEST-TAKING STRATEGY: Note the strategic words, "highest priority." Eliminate options 1, 3, and 4 because they are comparable or alike options that focus on aspects other than addressing an underlying condition as the cause of the altered behavior. Wrapping the hand in gauze, giving reminders and rewards do not focus on the underlying illness.

The nurse is admitting a client to the hospital. Which should be included in a discussion of the client's personal history? Select all that apply. Recent hospitalizations Cause of parents' death Health of the client's siblings Previous history of bipolar disorder Hypersensitivity reactions to medications

Previous history of bipolar disorder Hypersensitivity reactions to medications Recent hospitalizations

Shannon tells the nurse that she has never had a mammogram and asks whether she needs one. On the basis of American Cancer Society (ACS) recommendations, which instruction should the nurse provide to Shannon? She will need to start having a yearly mammogram at age 40 Her health care provider will recommend that she have a mammogram done now She will have a baseline mammogram now and another one every 3 years thereafter She will have a baseline mammogram now and then will have one every year thereafter

She will need to start having a yearly mammogram at age 40 RATIONALE: According to ACS recommendations, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Therefore the other options are incorrect.

A nurse has collected subjective and objective data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks "a beer or two" every day, and enjoys sitting around watching sports on television. Which piece of data does the nurse identify as an unmodifiable risk factor? The client is African-American. The client is a cigarette smoker. The client drinks beer every day. The client sits around watching television.

The client is African-American. RATIONALE: Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity.

Rudy's discharge instructions include a follow-up in three months' time, at which point he will receive another COVID test. What information would the nurse obtain that could help with follow-up care for this client? Rudy's preferred diet Rudy's incarceration history Rudy's family history of chronic diseases The name of Rudy's nephew as his emergency contact

The name of Rudy's nephew as his emergency contact RATIONALE: Adherence among members of the homeless population is more successful when the health care team treats the problems the client feels are important. After treating Rudy's reported symptoms, subsequent care would include health maintenance, attention to common problems and concerns, and establishing an emergency contact person if available. Having a contact person on file may help the nurse understand the client's support system and provide an avenue for follow-up. Although preferred diet, incarceration history, and family history of chronic diseases may be helpful, having a contact provides a direct avenue for promoting follow-up. TEST-TAKING STRATEGY: Focus on the subject, follow-up care. Although all options might help the nurse provide care, option 4 is the one that addresses a contact for follow-up.

The nurse completes Sara's physical examination and plans to assist the health care provider in performing a vaginal examination and obtaining a regular Papanicolaou test. The nurse explains the vaginal examination to Sara, informs her that all of the examination findings have been normal, and says that the health care provider will call her when the results of the Pap test are returned. Sara tells the nurse that she has never had this test and asks how frequently the Pap test must be performed. How should the nurse respond? The test should be performed yearly. The test should be performed every 6 months. The test does not need to be performed again if the results are normal. The test may be performed every 5 years because Sara has no family history of cervical cancer.

The test should be performed yearly. RATIONALE: The Papanicolaou (Pap) smear is a painless screening test for cervical cancer. The test is simple, with no side effects. All women should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age; screening should be performed every year with the regular Pap test or every 2 years if the newer liquid-based test is being used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years. Women older than 30 may also be screened every 3 years with the use of either the conventional or liquid-based Pap test, plus the human papillomavirus (HPV) test. TEST-TAKING STRATEGY: Focus on the subject of the question and that Sara is inquiring about a Pap smear. Noting Sara's age with assist in selecting the correct option. Eliminate the option of every 6 months, because this is an unnecessarily short time frame. Next eliminate the option of every 5 years, because this time frame is too long. Finally, note the words "does not need to be performed again," which will assist you in eliminating this option. Review: the Papanicolaou test for cervical cancer.

During her clinic visit, Dianne is instructed to follow the DASH (Dietary Approaches to Stop Hypertension) eating plan and to reduce her intake of sodium and fat. Which of these statements by Dianne indicate a need for further instruction? Select all that apply. "I should avoid milk and milk products." "I'll rinse canned vegetables with water before cooking them." "A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "I will try to eat more fresh fruits and vegetables every day." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

"A packaged food product is safe to eat if it doesn't taste salty." "I don't need to worry about condiments such as ketchup or mustard." "It doesn't matter whether I choose red meat or poultry, as long as it's lean."

The nurse is obtaining a health history on a 15-year-old male who has missed two days of school because of a stomachache. The nurse suspects the client might be experiencing stress related to bullying or victimization, perhaps owing to his sexual orientation. Which questions would the nurse include in the interview? Select all that apply. "Do you do a breast self-examination?" "Do you feel safe at home or where you live?" "Do you have any problems at school? Are you bullied?" "Can you describe your sexual orientation preferences?"

"Do you feel safe at home or where you live?" "Do you have any problems at school? Are you bullied?" "Can you describe your sexual orientation preferences?" "Do you have any problems with depression or anxiety? Have you ever felt suicidal? If so, do you have a plan?" RATIONALE: Important information for this client's care are related to his safety, sexual health, and mental health. Teenage members of the LGBTQ population are at risk for bullying and victimization by peers, and are at risk for abuse by family members. The nurse should assess the client's sexual orientation to determine his unique health and social risks. Depression and suicide are also a concern for this population and careful assessment of this risk is necessary. There is no data in the question that suggests the significance of questioning about a breast self-examination. TEST-TAKING STRATEGY: Focus on the subject - absenteeism potentially related to stress. Think about the health and social risks associated with adolescent members of the LGBTQ community to guide you to the correct answers. Review: LGBTQ individuals.

The nurse is performing an assessment of a client who is Black American. Which question should the nurse ask to elicit information on a health risk associated with this cultural group? "Does anyone in your family have hepatitis?" "Does anyone in your family have tuberculosis?" "Does anyone in your family have hypertension?" "Does anyone in your family have iron deficiency anemia?"

"Does anyone in your family have hypertension?" RATIONALE: Hypertension is a health risk in the Black American population. Other health risks associated with this cultural group include obesity, asthma, diabetes, heart disease, and cancer. Hepatitis is a health risk associated with Native Hawaiians and other Pacific Islanders, Native Americans and Alaska Natives, and Asian American groups. Tuberculosis is a health risk for Native Hawaiians and other Pacific Islanders and Asian American groups. There are many causes of iron deficiency anemia, including some chronic conditions; however, this is not a health risk specific to the Black American population. TEST-TAKING STRATEGY: Knowledge of the subject, health risks associated with the Black American group is needed to answer this question. Remember that members of this group are at risk for hypertension. Review: the health risks of the client who is Black American.

The clinic nurse, performing a physical examination of an adult client, is gathering subjective data about the client's lifestyle. When asked about alcohol, the client tells the nurse that he does drink on a daily basis. Based on this finding, which question should the nurse ask next? "What type of alcohol do you drink?" "Have you ever passed out after drinking alcohol?" "Does your drinking affect your work or home life?" "How frequently do you drink, and how much alcohol do you consume?"

"How frequently do you drink, and how much alcohol do you consume?" RATIONALE: Once it has been determined that the client uses alcohol, the nurse should next determine how frequently the client drinks and how much alcohol is consumed. This information will assist the nurse in determining whether the client has a substance abuse problem and provide a baseline for asking the client additional sensitive questions. Asking the client the type of alcohol he drinks, whether he has ever passed out as a result of drinking alcohol or whether his drinking affects his home life may all be appropriate questions, but the nurse would first ask about frequency and amount of alcohol consumed. TEST-TAKING STRATEGY: Note the strategic word "next." Read each question carefully and select the option that will provide a complete assessment of the client's behavior. Remember that determining the amount and frequency of alcohol intake will provide the nurse with valuable baseline information with which to continue the assessment. Review: alcohol use.

A client who works as a truck driver, delivering food to grocery stores, sustains a lower back strain while lifting boxes of canned goods. During treatment, the nurse provides information to the client regarding lower back care. Which statement by the client indicates a need for further teaching? "I can sleep in my recliner." "I shouldn't sit in low couches and chairs." "I need to sleep on a bed with a firm mattress." "I'll start eating more fiber and drinking more water."

"I can sleep in my recliner." RATIONALE: Lower back care measures are focused on preventing strain on the muscles of the back and, therefore, injury. The client is instructed to sleep on a firm mattress and to avoid sleeping in a chair or partially reclined position. The client should also avoid sitting in low couches and chairs, which cause strain on the lower back muscles, particularly when the occupant moves from the sitting position to a standing one. A diet high in fiber and fluids will result in softer bowel movements, helping eliminate the need for straining. TEST-TAKING STRATEGY: Note the strategic words, "need for further teaching," which indicate a negative event query and the need to select the incorrection statement. Visualize each of the options and think about the strain that each would place on the lower back muscles. This will direct you to the correct option.

A nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a need for further information? "I need to avoid wooded or swampy areas when I'm outdoors." "I don't need to use insect repellent if my clothes are covering my skin." "I should wear clothing that covers all of my skin, and I should wear a hat." "I should stay indoors at dusk and dawn, when mosquitoes are most active."

"I don't need to use insect repellent if my clothes are covering my skin." RATIONALE: West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn.

A child riding a skateboard loses his balance; as he falls, he uses his arm to break the fall, fracturing his ulna. A plaster cast is applied to the boy's arm, and the child's mother is instructed in cast care and complications associated with the cast. Which statement by the mother indicates a need for further teaching? "I need to keep the arm with the cast elevated on a pillow." "The cast needs to dry, so we need to be careful how we touch it." "I need to make sure that he doesn't put anything inside the cast." "I should expect to see swelling, and he'll have pain in the hand below the cast. The swelling might even cause some numbness."

"I should expect to see swelling, and he'll have pain in the hand below the cast. The swelling might even cause some numbness." RATIONALE: After a cast is applied, the affected limb is elevated on pillows or a similar support for at least the first 24 to 48 hours to help prevent swelling. When a wet cast is handled, care is taken to avoid denting it, which might result in the formation of pressure points. The parent should not allow the child to put anything inside the cast. Movement and sensation in the visible part of the extremity are checked frequently. Pain, swelling, discoloration, lack of pulsation and warmth, and numbness or tingling are not expected and should be reported immediately to the primary health care provider as signs/symptoms of circulatory impairment. TEST-TAKING STRATEGY: Note the strategic words "need for further teaching," which indicate a negative event query and the need to select the incorrect statement. Use the ABCs — airway, breathing, and circulation — to answer the question. Remember, signs of circulatory impairment are not expected.

The nurse teaches Shannon about measures to help prevent skin cancer. Which statements by Shannon leads the nurse to conclude that she understands these measures correctly? Select all that apply. "I won't need to wear protective clothing if I wear sunscreen." "I'll examine my body monthly for any changes in my moles." "I'll try to avoid being out in the sun between 9 a.m. and 2 p.m." "I will ask my husband to help me examine the moles on my back." "If I find any changes in my moles, I'll tell the doctor the next time I have an appointment."

"I'll examine my body monthly for any changes in my moles." "I will ask my husband to help me examine the moles on my back."

Allopurinol has been prescribed to treat hyperuricemia in a client with gout, and the nurse provides instructions to the client for the medication. Which statement by the client indicates the need for additional instruction? "I should take the medication with food." "I need to stop putting gravy on my food." "I'll need to limit my fluid intake while I'm taking this medication." "I'll need to have my blood level of the medicine checked while I'm taking it."

"I'll need to limit my fluid intake while I'm taking this medication." RATIONALE: Allopurinol, used to treat gout, reduces the concentrations of uric acid in serum and urine. The client should increase fluid intake to at least 2000 to 3000 mL/day to prevent renal injury. The client should also avoid foods high in purines (e.g., gravy, wine, alcohol, organ meats, sardines, salmon) to help decrease levels of uric acid. The medication should be taken with meals or milk to minimize GI distress. The client should have periodic complete blood cell counts, as well as determinations of serum and blood levels of uric acid, as prescribed. TEST-TAKING STRATEGY: Note the strategic words "need for additional instruction." These words indicate a negative event query and the need to provide additional instruction to the client. Note the client's diagnosis and the purpose of the medication, to treat hyperuricemia. Recalling that a high fluid intake is needed to prevent renal injury will direct you to the correct option. Review: client instructions related to allopurinol.

Lydia is transferred to the ambulatory care unit from the recovery room with plans for discharge home later in the day. She is alert and oriented and is experiencing minimal abdominal pain. The nurse offers Lydia toast and tea, which she is able to tolerate, and Lydia voids 300 mL of clear yellow urine. The nurse determines that Lydia is ready to be discharged and reinforces the discharge instructions with Lydia. Which statements by Lydia indicate that she needs further instruction? Select all that apply. "I should increase my activity slowly." "I'm looking forward to having fried chicken for dinner." "My pain may be severe and may get worse, but this is expected." "I can't take a shower until I'm seen by my surgeon at my follow-up visit." "My incisions are small, but they may drain a little blood, so I'll wear Band-Aids on them." "When I get home, I'll take my baby grandson for a walk and play with him in the swimming pool."

"I'm looking forward to having fried chicken for dinner." "My pain may be severe and may get worse, but this is expected." "I can't take a shower until I'm seen by my surgeon at my follow-up visit." "When I get home, I'll take my baby grandson for a walk and play with him in the swimming pool." RATIONALE: After cholecystectomy, the client should eat a light meal and limit fat intake. Fat will be reintroduced to the diet gradually. Lydia is instructed to notify the surgeon if the pain medication does not control the pain or if the pain suddenly increases. Showering is usually allowed and is helpful in preventing wound infection. Depending on the incision, the client may be instructed to cover the incisions before showering. The incisions may be covered to avoid staining of clothing with serosanguinous fluid, if desired. The nurse instructs Lydia to increase activity slowly, balance rest with activity, and avoid straining the surgical wound or surrounding area. Therefore, play with him in the swimming pool. The nurse will remind Lydia about the signs/symptoms of wound infection, such as redness and drainage, and instruct Lydia to contact the surgeon if signs/symptoms of infection occur. TEST-TAKING STRATEGY: Note the strategic words "needs further instruction". This indicates a negative event query and the need to select the incorrect client statements. Read each option carefully to answer correctly.

A nurse is conducting an interview with a client who has come to the clinic after finding a lump in her right breast during breast self-examination. The client says, "I am so worried. I know that this must be breast cancer. What am I going to do?" Which response should the nurse give the client? "Tell me what worries you." "Most lumps found in the breast aren't cancer." "Let's talk again after the doctor examines you." "You shouldn't be so worried. After all, if it is cancer, you found it at an early stage."

"Tell me what worries you." RATIONALE: The nurse should always focus on the client's feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. "Tell me what worries you" is the only option that gives the client this opportunity. The other options are nontherapeutic and place the client's feelings on hold. TEST-TAKING STRATEGY: Recall therapeutic communication techniques to answer the question. Remembering that the nurse should always focus on the client's feelings will direct you to the correct option. Review: therapeutic communication techniques.

The nurse is counseling the parents of a 5 year-old about environmental hazards. Which statement by the parent indicates the need for further information to prevent injury? "We have our water heater's temperature set at 140°F (60° C)." "We always place our child in a safety car seat when we ride in the car." "We frequently check the smoke detectors in our home to be sure that they work." "I've taught my child about the importance of wearing a helmet when riding a bicycle."

"We have our water heater's temperature set at 140°F (60° C)." RATIONALE: A primary nursing responsibility is to teach the parents about environmental hazards and measures to reduce the risk of injury and illness. These measures include using window and stair guards, using car safety seats, wearing helmets and other protective garb when participating in activities that could result in injury, ensuring that smoke detectors are working properly, and maintaining water heater temperature below 120° F to prevent burns.

Dianne tells the nurse that several of her coworkers have lost weight on a fad diet. How should the nurse respond? "Try one of these fad diets if it will help to take off the weight." "You should try a strict vegetarian diet. That will help you lose weight quickly." "You need to eat foods from all food groups and limit fats, oils, and sweets." "Do whatever you can to get the weight off, because your weight is the cause of the high blood pressure and cholesterol."

"You need to eat foods from all food groups and limit fats, oils, and sweets." RATIONALE: The USDA's MyPlate is a guide to daily food choices and portion sizes. The dieting client should be instructed to eat foods from all food groups, especially fruits, vegetables, and whole grains, and to limit consumption of fats, oils, and sweets, as well as salt. Although weight loss on this program may be slower than that with a fad diet, it is a healthier method of weight loss, and the weight loss with such a program is more likely to be permanent. Fad diets are discouraged because they may be harmful to a person's health. It is not necessary to go on a strict vegetarian diet to lose weight, and this type of diet must be well planned to avoid problems resulting from protein deficiency. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that do not include foods from all food groups. Also, note the words "all food groups" in the correct option. Review: appropriate weight-loss diets.

Lydia is told that the surgery must be performed while she is under general anesthesia, and the anesthesiologist explains this type of anesthesia to her. The nurse tells Lydia that because she will be undergoing general anesthesia and because her surgery is scheduled for 7 a.m., she may not eat after what time? 3 a.m. on the day of surgery 7 a.m. on the day before surgery Noon on the day before surgery 11 p.m. on the night before surgery

11 p.m. on the night before surgery RATIONALE: The client must refrain from eating or drinking (nothing-by-mouth, or NPO, status) for 8 hours before a surgical procedure if general anesthesia is planned. Therefore, the remaining options are incorrect. TEST-TAKING STRATEGY: Focus on the subject, after what time the client cannot eat before having surgery under general anesthesia. Eliminate the options that represent an unreasonable amount of time for Lydia to refrain from eating and drinking before surgery. To select from the remaining options, recall that the administration of general anesthesia is planned; this will direct you to the correct option.

A nurse performing a skin assessment of a client with heart failure notes that the client's ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. Moderate pitting is present, but the indentation subsides rapidly. How should the nurse document this finding? 1+ edema 2+ edema 3+ edema 4+ edema

2+ edema RATIONALE: Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment for edema. Noting the words "indentation subsides rapidly" and knowing the grading scale used to assess edema will direct you to the correct option. Review: the grading scale used to assess edema.

A nurse is using a Snellen chart to assess a client's visual acuity. The client stands 20 feet from the chart, and each eye is tested separately. The client is able to read the line comprising the letters P, E, C, F, and D with each eye. The nurse encourages the client to read the next smallest line with each eye, but the client is unable to do so. How does the nurse document the client's vision? 20/40 40/20 20/30 60/20

20/40 RATIONALE: The Snellen chart is placed in a well-lit spot and the client stands 20 feet away, with the chart at eye level. Each eye is tested separately (one eye is covered), and the client is asked to read through the chart to the smallest line of letters possible. The client is also encouraged to read the next smallest line also. Findings are recorded as a comparison between what the client can read at 20 feet and the distance at which a person with normal vision can read the same line. A reading of 20/40 means that the client is able to see at 20 feet from the chart what a healthy eye can see at 40 feet. Normal visual acuity is 20/20. TEST-TAKING STRATEGY: First recall that normal visual acuity is 20/20. Next focus on the subject - the letters the client can read and note the measurement of this line. This will help direct you to the correct option. Review: Snellen chart.

A nurse performing a breast examination is preparing to palpate the client's breasts. Into which position should the nurse assist the client to perform palpation? A standing position, with the client holding both arms above her head A standing position, with the client holding her hands firmly on her hips A supine position, with the arm on the side being examined positioned across the chest A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side

A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client's arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue. TEST-TAKING STRATEGY: Eliminate comparable or alike options (standing) are the position for inspection of the breasts. To select from the remaining two options visualize each and select the one that allows for optimal palpation of the breast. Review: clinical breast examination.

Aneurysm precautions are instituted for a hospitalized client with a cerebral aneurysm. Which nursing interventions should the nurse include in the precautions? Select all that apply. Administering stool softeners to the client Limiting the number of visitors and keeping visits short Encouraging restful activities such as listening to quiet music Keeping the client's room well lit, especially during the daytime hours Encouraging the client to dress in street clothes and shoes every day Urging the client to perform activities of daily living (e.g., bathing and dressing) independently

Administering stool softeners to the client Limiting the number of visitors and keeping visits short Encouraging restful activities such as listening to quiet music

A nurse is preparing to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to minimize the potential for a local reaction to the vaccine? Using a 1.5-inch (3.8 cm) needle for injection Administering the injection in the deltoid muscle Administering the injection in the vastus lateralis muscle Changing the needle on the syringe after drawing up the vaccine

Administering the injection in the vastus lateralis muscle RATIONALE: To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older). Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction.

A client being treated for a middle ear infection is unable to close the left eye. After an assessment the client is diagnosed with Bell's palsy. Which information should the nurse give to the client? The eye paralysis is permanent. Artificial tears should be instilled into the left eye. It usually takes about 6 months for the disease to resolve. Intravenous corticosteroids are required, along with intensive physical therapy of the facial muscles.

Artificial tears should be instilled into the left eye. RATIONALE: Bell's palsy is an acute paralysis of cranial nerve VII that may occur as a result of trauma, infection, hemorrhage, meningitis, or a tumor. It results in paralysis of one side of the face. Recovery usually occurs in a few weeks, without residual effects. Eye care is essential because the client is unable to blink or close the eyelid on the affected side. The client is instructed to instill artificial tears in the eye and to place a patch over the eye when outdoors and at night to protect it from abrasion, wind, and light damage. Corticosteroids are not normally prescribed, and intensive physical therapy is not necessary. TEST-TAKING STRATEGY: Focus on the subject, Bell's palsy. Note the relationship between the strategic words "unable to close the left eye" in the question and the correct option.

The nurse teaches Shannon how to perform BSE. What is the best way for the nurse to confirm that Shannon understands how to perform the BSE? Asks Shannon to verbalize how to perform the examination Asking Shannon to perform BSE and observing her performance Asking Shannon to read the pamphlet on performing BSE and to write down any questions she might have Asking Shannon to view a computer tutorial on performing BSE and to write down any questions she might have

Asking Shannon to perform BSE and observing her performance RATIONALE: To best determine Shannon's learning and understanding of how to perform a procedure, the nurse would ask her to perform the procedure and observe her performance. Verbalizing how to perform the examination, reading pamphlets and viewing computer tutorials are not the best ways of ensuring that the client knows how to perform BSE.

A clinic nurse is performing a mental status examination of a client. Which action should the nurse take to test the client's remote memory? Asking about the client's first job Asking what time the client left home to come to the clinic Asking what method of transportation the client used to get to the clinic Reciting four unrelated words and asking the client to repeat them at various points later in the assessment

Asking about the client's first job RATIONALE: Remote memory involves past events, whereas recent memory involves day-to-day experiences. Asking about the client's first job requires the client to recall a past event. Asking the client what time he or she left home and what method of transportation was used requires the client to recall recent events. Asking the client to recite four unrelated words and asking him or her to repeat them at various points later in the assessment is a test of new learning. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that involve recall of recent events. To select from the remaining options, focus on the subject, remote memory. This will direct you to the correct option. Review: the components of the mental status assessment.

The nurse has demonstrated the technique for a surgical wound dressing change to the wife of a client who will be discharged after hip replacement surgery. Which action should the nurse take to best confirm that the wife understands the procedure? Asking the wife to perform the dressing change Asking the wife whether she has any questions about the procedure Asking the wife whether she feels comfortable performing the procedure Asking the wife whether she understands what items need to be obtained from the surgical supply store

Asking the wife to perform the dressing change RATIONALE: The nurse would best evaluate the wife's learning by observing the wife's performance of the activity. Although asking the wife whether she has any questions, feels comfortable, or understands the procedure may be appropriate, these questions do not best reveal the wife's ability to perform the dressing change.

The nurse is developing the plan of care for a family of seven who are recently arrived refugees from Central America. The nurse would prioritize the plan of care to take which action first? Provide vaccinations for the entire family. Assess the three-year-old child who has a rash, a cough and a high fever. Advise the mother with a seven-month-old child to continue breastfeeding. Obtain stool samples to determine if the family has a gastrointestinal illness.

Assess the three-year-old child who has a rash, a cough and a high fever. RATIONALE: The nurse should prioritize the plan of care and first assess the three-year-old child who has a rash, a cough, and a fever. These could be the symptoms of a communicable disease. Providing vaccinations is important, but the child's current symptoms take priority. It is important to continue breastfeeding the seven-month-old child, but this is not as high a priority as the symptoms of rash, a cough, and a fever. Obtaining stool samples may not be necessary as there is no indication of gastrointestinal symptoms. TEST-TAKING STRATEGY: Note the strategic words, "prioritize" and "first". Utilize knowledge of Maslow's Hierarchy of Needs Theory to answer this question. Actual physiological needs, such as the child with symptoms of rash, a cough, and fever, take precedence over potential needs. Vaccinations, breastfeeding instructions, and obtaining stool samples are all comparable or alike options, which address potential, rather than actual needs.

On a follow-up visit to the clinic, Dianne tells the nurse she has been attending a stress-management program and that it has been extremely helpful in helping her manage stress. Dianne says she feels less fatigued at the end of the workday and that she would like to begin an exercise program. The nurse should tell Dianne that which exercise would best facilitate weight loss? Ask the instructor of the stress-management program Begin walking 20 to 30 minutes at least three times a week Avoid exercise until she loses some weight to avoid stressing her heart Obtain a membership at a health club and hire a personal trainer to help get started in an exercise program

Begin walking 20 to 30 minutes at least three times a week RATIONALE: Regular exercise such as walking or other aerobic movement results in improved circulation, increased release of endorphins, and an enhanced sense of well-being. Exercise is also an effective stress-management technique. Telling Dianne to ask the instructor of the stress-management program places Dianne's question on hold and is a nontherapeutic response. Obtaining a membership at a health club is unnecessary; additionally, Dianne may not have the financial resources to hire a personal trainer. Telling Dianne to avoid exercise until she loses weight is incorrect. Exercise should be combined with dieting for overall effectiveness of weight loss. TEST-TAKING STRATEGY: Focus on the strategic word, "best." First eliminate the option that places Dianne's question on hold (asking the instructor). Next eliminate the option that will require money for participation (joining a health club); there is no information in the question regarding Dianne's financial status, and this option may increase Dianne's stress if Dianne is on a limited budget. To choose between the remaining options, recall the importance of combining diet with exercise for weight loss. Review: exercise/diet and stress management.

A nurse is preparing an ambulatory male client for a rectal examination. After the examination has been explained to the client, into what position should the nurse assist the client? Sims Supine Left lateral Bending forward resting upper body on exam table

Bending forward resting upper body on exam table RATIONALE: In a rectal examination, the male client is asked to bend forward, with his hips flexed and his upper body resting on the examination table. The lithotomy position may be used for this examination in a woman after examination of the genitalia is complete. A nonambulatory client may be examined while in the left lateral (Sims) position. A rectal examination could not be performed if the client were in the supine position. TEST-TAKING STRATEGY: First eliminate comparable or alike options, in this case the left lateral and Sim's position. To select from the remaining options, visualize each and note the strategic word "ambulatory" in the question. Also eliminate the supine position, because a rectal examination could not be performed if the client were in this position. Review: positioning of male client for a rectal examination.

A nurse collects subjective and objective data from a client who underwent surgery after sustaining a leg fracture in a motor vehicle accident and is now in skeletal traction. The nurse identifies which findings as objective data? Select all that apply. Temperature is 99.9° F (37.2°C). The client complains of leg pain. Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. The client tells the nurse that he feels warm.

Blood pressure is 128/86 mm Hg. Pin sites are red but without drainage. Temperature is 99.9° F (37.2°C). RATIONALE: Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also include information from the client's health record and the results of laboratory and diagnostic studies. The client's temperature and blood pressure readings are objective data, as is the nurse's observation of the pin sites. The other options constitute subjective data. TEST-TAKING STRATEGY: Focus on the subject, objective data. Recalling that objective data are what the nurse observes will direct you to the correct options. Review: the difference between subjective and objective data.

Lydia arrives at the ambulatory care unit of the hospital on the day of surgery with her husband, and the nurse begins preparing Lydia for the procedure. Identify the nursing interventions in the order that they will be performed, with 1 indicating the first nursing intervention and 5 denoting the intervention performed just before the surgery:

Checking Lydia's chart for the signed informed consent form Taking Lydia's vital signs Completing the checklist, including checking for allergies Asking Lydia to void in the bathroom Administering preoperative anesthetic medications RATIONALE: The first nursing intervention is ensuring that a signed informed consent form is in Lydia's chart. If the form is not present, surgical preparation may not be implemented. The nurse next checks Lydia's vital signs (temperature, pulse, respirations, blood pressure) and records her height and weight. The vital signs provide a baseline for further assessment, and the height and weight will be used to calculate the dosages of anesthetic medications. Next the nurse completes any parts of the surgical checklist that were not completed at the preoperative visit, including documentation of allergies and the results of laboratory and other diagnostic tests. Next, the nurse asks Lydia to void. Preoperative anesthetic medications are administered last to help avoid confusion and injury of the client. Once the medications have been administered, Lydia is not allowed to get out of bed because of the risk of injury. TEST-TAKING STRATEGY: Focus on the subject, preoperative care. Review each of the identified interventions. Recalling that informed consent is needed before a surgical intervention can be carried out will assist you in identifying the first nursing intervention. Next, recalling that safety is a concern once the client receives preoperative anesthetic medications will assist in identifying the last intervention. To place the remaining options in the correct order, use the ABCs — airway, breathing, and circulation. Vital signs are a reflection of airway, breathing, and circulation.

The nurse is volunteering with an outreach program to provide basic health care for people experiencing homelessness. Which finding, if noted in a client, should be addressed first? Blood pressure 154/72 mmHg Visual acuity of 20/200 in both eyes Random blood glucose level of 206 mg/dL (11.77 mmol/L) Complaints of pain associated with numbness and tingling in both feet

Complaints of pain associated with numbness and tingling in both feet RATIONALE: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. The nurse needs to focus on reported symptoms first because this will encourage adherence to the treatment plan and return for follow-up. Subsequent care would include health maintenance and attention to common problems and concerns such as blood pressure, visual acuity, and blood glucose readings. If the client perceives value to the service provided, they will be more likely to return for follow up care. While the blood pressure, blood glucose and vision results are concerning, the client's stated concern should be addressed first. TEST-TAKING STRATEGY: Note the subject, the finding to be addressed, and focus on the strategic word, first. Recalling that adherence is a problem for this population will direct you to the correct option, the option that addresses the client's immediate complaint. Also note, the correct option is the only subjective finding.

Which type of data base is the most appropriate for the nurse to utilize when collecting information from Sara? Focused Complete Follow-up Emergency

Complete RATIONALE: A complete database consists of a complete health history, including physical examination findings. It describes the client's current and past health status and serves as a baseline against which all future changes may be measured. A focused database is constructed to address a limited or short-term problem (e.g., one problem or body system). A follow-up database is focused on evaluating a client's progress. An emergency database comprises a rapid collection of information that is often obtained during lifesaving measures. Because Sara has not been examined by a health care provider in 10 years and this is her first visit to the clinic, the nurse would collect a complete database. TEST-TAKING STRATEGY: Note the use of the strategic words "most appropriate". Recall the information in the case study. Knowing that Sara has not been examined by a health care provider in 10 year should direct you to the correct option, a complete database. Review: types of databases.

The nurse is monitoring a client who sustained a closed head injury in a motor vehicle accident for signs/symptoms of increased intracranial pressure (ICP). Which early sign/symptom does the nurse watch for? Confusion Slowed pulse rate Widened pulse pressure Increased systolic blood pressure

Confusion RATIONALE: The earliest and most sensitive sign/symptom of increased ICP is a change in the client's LOC. Other early signs/symptoms include headache and pupil changes. The Cushing triad—increased systolic blood pressure with widening pulse pressure and bradycardia—is a late sign/symptom of increased ICP. TEST-TAKING STRATEGY: Note the strategic word "early." Eliminate the options that are comparable or alike in that they involve vital signs. To select from the remaining options, recall that a change in LOC is the most sensitive and earliest sign/symptom of increased ICP.

A client is brought to the emergency department after sustaining a fall, complaining of severe pain in the right arm. The nurse carefully cuts off the clothing that is covering the arm and notes an open wound with bone protruding from it. Which action should the nurse take immediately? Covering the open area with a sterile dressing Obtaining a prescription for pain medication Placing the cut-off shirt sleeve over the open area Irrigating the open area with half strength hydrogen peroxide

Covering the open area with a sterile dressing RATIONALE: If the client has sustained an open fracture, the nurse must cover the open area with a dressing, preferably sterile. The shirt sleeve would not be used, because it is unclean and presents a risk for infection. Obtaining a prescription for pain medication is the next action after covering and protecting the open area. The nurse would not irrigate the open area without a prescription to do so. TEST-TAKING STRATEGY: Note the strategic word "immediately." Next focus on the data in the question. Noting that the client has an open wound will direct you to the correct option.

A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client's posture as the client stands. After noting an exaggeration of the posterior curvature of the client's thoracic spine, how does the nurse document this finding? Lordosis Scoliosis Kyphosis Osteoporosis

Kyphosis RATIONALE: Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased lumbar curvature. A lateral spinal curvature is called scoliosis. Loss of height is frequently an early sign of osteoporosis. TEST-TAKING STRATEGY: Focus on the subject - posterior curvature of the thoracic spine. Apply knowledge of the common postural abnormalities to assist you to answer this question. Review: postural abnormalities.

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? Cranial nerve II Cranial nerve IX Cranial nerve VII Cranial nerve VIII

Cranial nerve VIII RATIONALE: Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client's visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve). TEST-TAKING STRATEGY: Focus on the subject - the cranial nerve associated with balance and equilibrium. Recalling that cranial nerve VIII is the acoustic nerve should direct you to this option. Review: functions of cranial nerves.

An anticholinesterase medication has been prescribed for a client with myasthenia gravis, and the nurse teaches the client how to recognize a cholinergic crisis. Which should the nurse tell the client is a sign/symptom of this type of crisis? Diarrhea Bladder incontinence Difficulty swallowing Decreased urine output

Diarrhea RATIONALE: Cholinergic crisis is caused by overmedication with anticholinesterase medication. Signs/ symptoms include restlessness, weakness, dysphagia, dyspnea, nausea and vomiting, diarrhea, abdominal cramps, blurred vision, pallor, facial muscle twitching, pupil constriction, and hypotension. Interventions include withholding the anticholinesterase medication. Atropine sulfate, the antidote for an overdose of anticholinesterase medication, may be administered. Myasthenic crisis is an acute exacerbation of the disease. Signs/ symptoms include increased pulse, quickened respiration, increased blood pressure, anoxia, cyanosis, bowel and bladder incontinence, decreased urine output, and absence of cough and swallow reflexes. Interventions for this type of crisis include increasing the dosage of anticholinesterase medication. TEST-TAKING STRATEGY: Focus on the subject, cholinergic crisis. Think about the pathophysiology associated with cholinergic crisis. Recalling that it is caused by overmedication with anticholinesterase medication and thinking about the effects of anticholinesterase medication will assist in answering the question.

A nurse is preparing a client for a Papanicolaou test. Into which position does the nurse assist the client for this examination? Sims Supine Lateral Lithotomy

Lithotomy RATIONALE: A Papanicolaou test (a.k.a. "Pap smear") is performed during the speculum examination of the internal genitalia. In this test, a smear of tissue is obtained and then tested for cervical or vaginal cancer. The client is placed in the lithotomy position for this examination. The positions in the other options would not allow the examiner to perform the speculum examination, which is necessary for the smear to be obtained. TEST-TAKING STRATEGY: Focus on the subject of the question, which is positioning for a procedure. The Sims position is a lateral position. Next, thinking about the procedure and the purpose of the Papanicolaou test will assist you in identifying the best client position for this test. Review: client preparation for the Papanicolaou test.

The nurse provides home care instructions to a client who has been fitted with a halo traction device. Which instructions should the nurse include on the list? Select all that apply. Eat foods high in protein and calcium. Remember that a clicking sound heard at the pin site is normal. Tighten the ring bolts on the vest with a wrench if they loosen. Each day, check the skin under the vest with a flashlight for breakdown. Check the tightness of the vest by ensuring that one finger can be placed between it and the skin. When getting out of bed, roll onto the side and push up from the mattress with the arms.

Each day, check the skin under the vest with a flashlight for breakdown. Check the tightness of the vest by ensuring that one finger can be placed between it and the skin. When getting out of bed, roll onto the side and push up from the mattress with the arms. eat foods high in protein and calcium RATIONALE: The client wearing a halo traction device must be provided with instructions on care to ensure safety and maintenance of intactness of the device. Foods high in protein and calcium should be consumed, because they will promote healing. The client is taught to clean the pin site daily; to check the skin under the vest daily for breakdown, using a flashlight; and to notify the primary health care provider if redness, swelling, drainage, broken skin, pain, tenderness, or a clicking sound is noted at the pin site. These findings may indicate infection or disruption or displacement of the pins. Additionally, if the ring bolts on the vest loosen, the primary health care provider is notified; the client must never attempt to tighten the ring bolts on his or her own. The tightness of the vest may be checked by ensuring that one finger can be placed between it and the skin. The metal frame of the device is never pulled on or used to reposition the client. When getting out of bed, the client is taught to roll onto the side and push up from the mattress with the arms.

The nurse, obtaining subjective data, asks Dianne about her perception of her health. Dianne again tells the nurse that the stress of her job is the reason for her not being able to take good care of herself. After gathering additional information about Dianne's stressful life, what action should the nurse take next? Suggesting that Dianne find another job Telling Dianne to ignore the stress at work Encouraging Dianne to participate in a stress-management program Telling Dianne how important it is for her to forget about her work once the workday is over

Encouraging Dianne to participate in a stress-management program RATIONALE: Assessment of health perception is focused on the client's perceived level of health and well-being and on personal practices for maintaining health. Because Dianne has said that stress is the cause of her health problems, the nurse would suggest and encourage participation in a stress-management program. Finding another job is an unrealistic expectation and could cause even more stress. Although trying to forget about her work at the end of the workday and ignoring stress at work are strategies for alleviating stress, both are easier said than done. This client needs to learn methods for managing the stress. TEST-TAKING STRATEGY: Focus on the strategic word "next". Note that Dianne indicates that the stress of her job is what prevents her from caring for herself. Select the option. Review: stress management.

Which factors increase the risk of osteoporosis? Select all that apply. Obesity Late menopause Cigarette smoking Sedentary lifestyle African heritage

Family history of osteoporosis Cigarette smoking Sedentary lifestyle RATIONALE: Osteoporosis is a metabolic disease characterized by bone demineralization, with loss of calcium and phosphorus salts leading to bone fragility and an increased risk for fractures. Risk factors include cigarette smoking; early menopause; excessive use of alcohol; family history; female sex; increasing age, insufficient intake of calcium, sedentary lifestyle; a thin, small frame; and European or Asian descent. TEST-TAKING STRATEGY: Focus on the subject, the risk factors for osteoporosis. Thinking about the pathophysiology associated with this disorder will assist in answering correctly.

The nurse begins the physical examination by taking Sara's vital signs and her height and weight; on noting that these measurements are within the normal ranges, she proceeds with the physical examination. The nurse assesses Sara's vision and prepares to perform the confrontation test. Sara asks the nurse about the purpose of this test. What should the nurse tell Sara about the test? It is used to assess near vision. It is used to assess color vision. It is used to assess distant vision. It is used to assess peripheral vision.

It is used to assess peripheral vision. RATIONALE: The confrontation test is a measure of peripheral vision in which the client's peripheral vision is compared with the nurse's under the assumption that the nurse's peripheral vision is normal. The client covers one eye and looks straight ahead, and the nurse (positioned 2 feet away) covers his or her own eye opposite the client's covered eye. The nurse advances a finger or another small object in from the periphery from several directions; the client should see the object at the same time the nurse does. Near vision is tested with the use of a hand-held vision screener or by asking the client to read from a magazine or newspaper. The Ishihara chart is a tool used to assess color vision. It reveals the client's ability to distinguish a pattern of color (a number) in a series of color plates. Distant vision is measured with the use of the Snellen eye chart. TEST-TAKING STRATEGY: Focus on the subject - confrontation test. Recall the test that is performed for each vision issue in each option. To answer correctly it is essential to know that the confrontation test assesses peripheral vision. Review: visual testing.

The nurse examines Sara's breasts and informs her that no masses were felt. The nurse provides teaching on self-breast examination and recommendations of the American Cancer Society (ACS) for early detection of breast cancer. What should the nurse include in the teaching? Have a yearly mammogram starting at the age of 40 Have had a baseline mammogram performed at the age of 20 Have a yearly breast examination by a health care provider beginning at the age of 40 Perform a monthly breast self-examination and have a baseline mammogram when she reaches the age of 50

Have a yearly mammogram starting at the age of 40 RATIONALE: According to the ACS, yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health. Clinical breast exams (CBEs) are recommended about every 3 years for women in their twenties and thirties and every year for women 40 and older. Breast self-exams (BSEs) should be performed monthly (starting at the age of 20 is an option), and women should know how their breasts normally look and feel and promptly report any changes to a health care provider. The ACS also recommends that some women, because of their family history, a genetic tendency, or certain other factors, be screened with the use of magnetic resonance imaging (MRI) in addition to mammography. TEST-TAKING STRATEGY: Focus on the subject - early detection of breast cancer. Knowledge of the ACS recommendations is required to answer this question correctly. Next focus on the examination and age identified in each of the options. Recall that yearly mammograms are recommended yearly starting at age 40 and continuing for as long as the woman is in good health. Review: ACS recommendations for early detection of breast cancer.

Lydia has undergone the laparoscopic cholecystectomy and is in the immediate postoperative stage of recovery. During assessment, Lydia states that she is in pain, is cold, and feels sick to her stomach; she has diminished lung sounds and a small amount of bleeding from the incisional wound sites. Which actions by the nurse are appropriate? Select all that apply. Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths

Having Lydia lie on her left side Covering Lydia with a warm blanket Administering the prescribed analgesic Encourage slow deep breaths Removing the dressings to evaluate how much bleeding is occurring RATIONALE: The nausea that Lydia is experiencing could lead to vomiting. In the immediate postoperative stage of recovery, the gag reflex may not have returned. If Lydia vomits, she could aspirate the vomitus, which in turn could lead to pneumonia. Having Lydia lie on her left side will help prevent aspiration and help move the gas pocket of carbon dioxide that was used for the surgery away from the diaphragm. Covering Lydia with a blanket will help prevent the hypothermia that may occur during the postoperative period. Prescribed pain medication should be administered if Lydia is in pain and if the prescribed analgesic is due. The diminished lung sounds could lead to atelectasis if Lydia does not perform coughing and deep breathing or use her incentive spirometer. Bleeding may indicate a problem, but the amount of bleeding that would place the client at risk of hypovolemia or shock would be evident before the nurse removed the dressing. TEST-TAKING STRATEGY: Focus on the subject, care of the client in the immediate postoperative period of recovery. Note the data in the question and think about the complications that may occur after laparoscopic cholecystectomy. This will assist you in answering correctly.

Based on Rudy's status as a homeless veteran, which part of his health history is a priority for the nurse to assess? Housing status Mental health status History of substance use Sexual activity and history of STIs

History of substance use RATIONALE: Among both homeless and veteran populations, substance use disorders with tobacco, alcohol, or other drugs are more common. While clients in these groups are also at a higher risk for communicable diseases (including STIs) and mental health problems, the presence of a substance use disorder poses the most immediate threat to the client's health. Use of screening tools in identifying substance use disorder will help to plan appropriate care. Although housing status should also be addressed, this is not a priority from the options presented. TEST-TAKING STRATEGY: Note the strategic word, priority. This indicates that all options are important and are most likely correct. It is necessary to recall that substance use disorders can be detrimental to cardiopulmonary health and other organ system function, and that withdrawal from alcohol, benzodiazepines, and other substances put the client at risk for seizures. Therefore, identifying the presence of a substance use disorder is a priority.

The nurse is participating in a planning session for public health services that promote primary prevention. The nurse should guide the group into selecting to focus on which aspects? Select all that apply. Immunizations Pollution control An exercise regimen Cardiac rehabilitation Self-examination practices Diabetes mellitus management

Immunizations Pollution control An exercise regimen RATIONALE: Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management.

A nurse is preparing to perform the Weber test in a client who reports loss of hearing in one ear. In which anatomic area should the nurse place the tuning fork for this test to be performed accurately? In front of the ear In the midline of the skull On the mastoid process At the temporal lobe on the side with hearing loss

In the midline of the skull RATIONALE: In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client's skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In the Rinne test, the stem of a vibrating tuning fork is placed on the client's mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test. TEST-TAKING STRATEGY: Focus on the subject - the Weber test. Try to visualize both the Weber and Rinne tests to answer correctly. Remember that in the Weber test the stem of the vibrating tuning fork is placed in the midline of the client's skull. Review: the tuning fork tests.

A client who has had a stroke is experiencing left-sided unilateral neglect syndrome. Which intervention should the nurse include in the plan of care to manage this effect of the stroke? Instructing the client to primarily scan the left side of the environment Encouraging the client to use the right side only because it is the unaffected side Informing the client that it is best to visualize the environment by looking straight ahead as much as possible Moving personal items to the affected side as the client demonstrates ability to compensate for the neglect

Moving personal items to the affected side as the client demonstrates ability to compensate for the neglect RATIONALE: Neglect syndrome, also known as unilateral neglect, is a syndrome in which the client is unaware of his or her paralyzed side. Management of the disorder includes helping the client acknowledge the affected side as being integral to his or her self. Once the client demonstrates an ability to compensate for the neglect, the nurse moves the client's personal items to the affected side so that the client will use the neglected side. The nurse also places the client's personal objects within his or her visual field and teaches the client to touch and use both sides of the body. The client with visual problems is taught to turn the head from side to side to scan the environment. TEST-TAKING STRATEGY: Focus on the subject, unilateral neglect syndrome. Next focus on the client's problem and think about what it involves. Keeping safety in mind will assist you in answering correctly.

Neurological disorder NCLEX

NCLEX Tips Monitor a client with a neurological disorder for signs/symptoms of increased intracranial pressure. The earliest indicator of increased intracranial pressure is deterioration in the level of consciousness. Airway is always a priority for a client with a neurological disorder. A client with a head injury should be placed in a head-elevated position. The victim of an accident should not be moved until it has been determined that the person has not sustained a spinal cord injury. Measures to ensure safety are a priority for the client with a neurological disorder. Promote independence in regard to self-care activities as much as possible. Encourage discussion about the psychosocial issues that may occur as a result of the neurological disorder (e.g., body image alterations, altered sexual function).

The nurse is watching for indications of autonomic dysreflexia in a client who sustained a spinal cord injury in a fall from a roof. Which sign/symptom of this complication should the nurse monitor closely? Constricted pupils Tachycardia Hypotension Nasal stuffiness

Nasal stuffiness RATIONALE: Autonomic dysreflexia, a complication of spinal cord injury, is a neurological emergency and must be treated immediately to prevent hypertensive stroke. It generally occurs after spinal shock resolves in the presence of injuries above T6 and in cervical lesions. It is commonly caused by visceral distention resulting from bladder distention or fecal impaction. Clinical manifestations include sudden onset of severe throbbing headache, severe hypertension, bradycardia, flushing above the level of injury, pale extremities below the level of injury, nasal stuffiness, nausea, dilated pupils, blurred vision, sweating, piloerection (gooseflesh), restlessness, and a feeling of apprehension. TEST-TAKING STRATEGY: Focus on the subject, autonomic dysreflexia. Remember that in this disorder the client experiences nasal stuffiness. Review: signs/symptoms of autonomic dysreflexia.

The nurse, now performing the abdominal assessment, is listening to Sara's bowel sounds. Which descriptor does the nurse document in the health record after hearing these sounds? Select to listen to the audio clip. Borborygmus Normal sounds Hypoactive sounds Hyperactive sounds

Normal sounds RATIONALE: Normal bowel sounds are high-pitched, gurgling sounds that occur irregularly between 5 and 30 times a minute. Borborygmus, a type of hyperactive bowel sound, indicates hyperperistalsis. Hypoactive, or infrequent, bowel sounds are most often noted after abdominal surgery or with inflammation of the peritoneum. Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that indicate increased motility. TEST-TAKING STRATEGY: Eliminate borborygmus and hyperactive sounds first because they are comparable or alike options. To select from the remaining options, listen to the sound and note that it is high-pitched and gurgling. Review: normal and abnormal bowel sounds.

A client is fitted with a cast after being hit by a car and sustaining a fracture of the left leg. The client has been hospitalized, and the nurse is monitoring the client for other injuries that may have resulted from the accident. Three hours after admission to the surgical unit, the client calls the nurse to report numbness and tingling in the toes of the left foot. Which action should the nurse take? Administer pain medication. Notify the primary health care provider. Tell the client that the signs/symptoms will be reassessed in 1 hour. Tell the client that this is expected because of the swelling from the fracture.

Notify the primary health care provider. RATIONALE: Circulatory impairment may occur after application of a cast as a result of pressure from the cast and swelling of the tissue in the area of the fracture. The client should undergo neurovascular assessments every hour for 24 hours after cast application so that swelling or pressure of the cast on the nerves or vessels may be detected early. If the client experiences signs/symptoms of vascular impairment (e.g., numbness or tingling of the extremity) or if the nurse notes changes in the circulatory status of the casted extremity, the primary health care provider is notified immediately. The cast may need to be bivalved to relieve the pressure. Therefore, the other options are incorrect. TEST-TAKING STRATEGY: Focus on the subject, numbness and tingling in the toes of the left foot. Use the ABCs — airway, breathing, andcirculation — and recall that these signs indicate circulatory impairment. This will direct you to the correct option.

A nurse performing an examination of a male client's genitalia notes the presence of a foul-smelling white discharge from the urethral meatus. Which action is the most appropriate response to this finding? Obtaining a culture of the discharge Informing the client that the discharge is normal Asking the client about the possibility of the presence of an STI Informing the client that his sexual partners will need examinations

Obtaining a culture of the discharge RATIONALE: When a discharge is noted during examination of the male genitalia, a culture of the discharge is obtained. A foul-smelling white discharge from the urethral meatus is not a normal finding. Informing the client that his sexual partners will need an examination is premature; however, if an STI is diagnosed, this will be an important intervention. Asking the client about the possibility of an STI is a component of obtaining subjective data, so this information should have been obtained before objective data were collected. TEST-TAKING STRATEGY: First note the strategic words "most appropriate". Also consider the words "foul-smelling discharge". Realizing that this is not a normal finding should direct you to select the most appropriate action to carry out first. Review: examination of the male genitalia.

What health problem would the nurse most likely suspect is related to Rudy's wartime experiences? Bipolar disorder Dental problems Posttraumatic stress disorder (PTSD) Human Immunodeficiency Virus (HIV)

PTSD RATIONALE: PTSD is common among military veterans and others who have experienced traumatic events. Although the other disorders listed in the options may be concerns, they are not the most likely health problem related to the client's wartime experiences. TEST-TAKING STRATEGY: Note the strategic words, "most likely" and focus on the subject, a health problem related to Rudy's status as a combat veteran. Recall that individuals in this special population group may have PTSD. The use of questioning in a variety of ways may be necessary to obtain the necessary assessment data.

A nurse is performing an abdominal assessment of a client who complains of right upper quadrant pain. Which technique should the nurse use to palpate the abdomen? Palpating tender or painful areas last Tapping the client's skin with short, sharp strokes Using both hands and knead deeply into the abdomen Starting with deep palpation, then performing light palpation

Palpating tender or painful areas last RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched. The nurse then performs deeper palpation, first asking the client about any tender areas so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client's skin with the use of short, sharp strokes to assess underlying structures. TEST-TAKING STRATEGY: Focus on the subject, palpation. Eliminate the option that describes percussion, not palpation. Next, eliminate the comparable or alike options that address deep palpation. Review: the procedure for palpating the abdomen.

The nurse percusses Sara's posterior chest. Which sound does the nurse expect to note over lung tissue in this area if the tissue is normal? Tympany Resonance A dull sound Hyperresonance

Resonance RATIONALE: For percussion of the posterior chest, the client should sit leaning forward with the arms folded. Percussion of the posterior chest should yield resonance (a low-pitched sound) over lung tissue to the level of the diaphragm. Tympany — a drumlike, loud, empty quality — is heard over a gas-filled stomach or intestine and in cases of pneumothorax. A dull sound is heard over areas of abnormal density, as in pneumonia, pleural effusion, atelectasis, or tumor. Hyperresonance is a loud sound, lower-pitched than normal resonance, that is heard over hyperinflated lungs, such as in chronic obstructive pulmonary disease. TEST-TAKING STRATEGY: First recalling that tympany is a drumlike sound and that dull sounds are noted over areas of dense tissue will assist you to eliminate this options. From the remaining options, focus on the subject - a normal sound over lung tissue, and eliminate the option that indicates hyperresonance. Review: normal lung percussion tone.

The nurse reviews the data from Sara's physical examination (refer "Chart" below). The nurse concludes that which findings are abnormal? Select all that apply. Vital SignsTemperature: 98.9° F (oral)Pulse: 94 beats/min, regular rhythmRespiratory rate: 18 breaths/min, laboredBlood pressure: 122/78 mm Hg Breath SoundsBronchial breath sounds heard over the tracheaBilateral vesicular breath sounds heard over the periphery of the lungsBronchovesicular breath sounds heard posteriorly between the scapulae NeurologicPatellar tendon reflexes: 1+ bilaterallyBabinski reflex: negativeRomberg test: positiveNo muscle weaknessRange of motion: equal bilaterally Positive result on Romberg test Temperature 98.9° F (37.2°C) (oral) Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored Bronchial breath sounds heard over the trachea

Patellar tendon reflexes 1+ bilaterally Respiratory rate of 18 breaths/min, labored Positive result on Romberg test RATIONALE: The normal oral temperature in a resting person is 98.6 °F, with a range of 96.4 °F to 99.1° F. The usual pulse for adults ranges from 60 to 100 beats/min. The normal respiratory rate is 12 to 20 breaths/min, and breathing should be unlabored. The average blood pressure in a young adult is 120/80 mm Hg. Bronchial breath sounds are expected over the trachea, vesicular breath sounds are expected over the periphery of the lungs, and bronchovesicular breath sounds are expected between the scapulae posteriorly. Babinski and Romberg test results are normally negative. Range of motion should be equal bilaterally, and there should be no muscle weakness. Tendon reflexes are rated as 2+ if normal; a 1+ rating indicated diminished response. TEST-TAKING STRATEGY: Recall the normal findings for vital signs, breath sounds, and neurologic examination. Focus on the subject - abnormal data from the physical examination. For the data in each indicate abnormal findings. Review: normal assessment findings.

A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment? Placing an object in the client's hand and asking the client to identify it Tracing a number on the client's hand and asking the client to identify it Moving the client's finger up and down and asking the client which way it is being moved Making two simultaneous pinpricks on the skin and asking the client to distinguish them

Placing an object in the client's hand and asking the client to identify it RATIONALE: Stereognosis is the client's ability to recognize objects placed in his or her hand. Graphesthesia is the client's ability to identify a number traced on the client's hand. Position sense (kinesthesia) is tested by moving the client's finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client's ability to discriminate two simultaneous pinpricks on the skin. TEST-TAKING STRATEGY: Focus on the subject - assessment of stereognosis. Then focus on the description of each option. It is necessary to recall that stereognosis is the client's ability to recognize objects placed in his or her hand to answer the question. Review: stereognosis.

Levodopa is prescribed for a client with Parkinson disease. Which vitamin does the nurse instruct the client to avoid while taking the levodopa? Thiamine Riboflavin Pyridoxine Ascorbic acid

Pyridoxine RATIONALE: Pyridoxine can decrease the amount of levodopa that reaches the CNS. As a result, the therapeutic effect of levodopa is reduced. The client taking levodopa should be informed about this interaction and instructed to avoid multivitamin preparations containing pyridoxine. Thiamine, riboflavin, and ascorbic acid do not need to be avoided by the client taking levodopa; these medications do not affect the amount of levodopa reaching the CNS. TEST-TAKING STRATEGY: Knowledge regarding the subject, medication interactions associated with levodopa, is needed to answer this question. Remember that pyridoxine must be avoided because it will decrease the amount of levodopa reaching the CNS. Review: the interactions associated with levodopa.

A nurse is administering the hepatitis B vaccine to a newborn. Which anatomic site should the nurse select for the injection? Deltoid Dorsogluteal Rectus femoris Vastus lateralis

RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections.

The nurse is observing a new nurse employee who is performing an abdominal assessment of a client and preparing to auscultate for bowel sounds. The nurse determines the new nurse employee is using correct technique if which part of the abdomen is auscultated first? Left upper quadrant Left lower quadrant Right upper quadrant Right lower quadrant

Right lower quadrant RATIONALE: To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the remaining three quadrants. TEST-TAKING STRATEGY: Focus on the strategic word "first". Remember, auscultation should be begun in the right lower quadrant. Review: the procedure for auscultating bowel sounds.

The nurse prepares to listen to Sara's heart sounds. What heart sound is audible? Select to listen to the audio clip. S1 and S2 Split S2 sound S1 and S2 with a systolic murmur Physiologic S3 4. S1 and S2 with a systolic murmur

S1 and S2 RATIONALE: The pair of heart sounds that are close together ("lub-dup"), the S1 and S2 sounds, are considered normal heart sounds. A split S2 sound, a normal variation, occurs near the end of expiration ("lub-T-DUP"). A physiologic S3, which occurs after the S2 sound, is a dull, soft, low-pitched sound. A murmur is a blowing or swishing heart sound that may be considered "innocent" or may reflect a serious defect of blood flow in the heart. A systolic murmur may occur in a normal heart or accompany heart disease. TEST-TAKING STRATEGY: Focus on the subject, heart sounds. Listen to the sound and note the "lub-dup." Next recall what normal heart sounds should sound like, including the presence of S1 and S2 sounds. Review: the characteristics of normal heart sounds, murmurs, and S3 heart sounds.

The health care provider recommends that Dianne undergo a physical examination, including laboratory studies, before she starts exercising. Which tests are appropriate for assessment of Dianne's nutritional status? Select all that apply. Hemoglobin Serum creatinine Serum transferrin Serum triglycerides Total thyroxine (T4)

Serum glucose level (fasting) Serum transferrin Serum triglycerides hemoglobin RATIONALE: The hemoglobin blood test is used to detect iron-deficiency anemia and serum transferrin is an iron-transport protein; these laboratory result indicates a person's visceral protein status. Serum triglyceride readings are used to screen for hyperlipidemia (recall that Dianne has high cholesterol levels); the fasting serum glucose level, if increased, may indicate the presence of diabetes mellitus. The serum creatinine level reflects renal excretory function; the total thyroxine (T4) level reflects thyroid function. Although the serum creatinine and T4 levels may be checked, they are not directly related to nutritional status. TEST-TAKING STRATEGY: Focus on the subject, assessment of nutritional status. Focus on the laboratory studies, such as serum triglycerides, hemoglobin, fasting glucose level, and serum transferrin, used to reveal nutritional status. Review: laboratory studies used in nutritional assessment.

Which interventions apply in the care of a child who is experiencing a seizure? Select all that apply. Time the seizure. Restrain the child. Stay with the child. Insert an oral airway. Place the child in a supine position. Loosen clothing around the child's neck.

Stay with the child. Time the seizure. Loosen clothing around the child's neck. RATIONALE: During a seizure, the child is placed on his or her side in a lateral position. The position will prevent aspiration because saliva will drain from the corner of the child's mouth. The child is not restrained because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action could cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and observe and time the seizure. TEST-TAKING STRATEGY: Focus on the subject, nursing care during a seizure. Visualize this clinical situation. Recalling that airway patency and safety are the highest priorities will help you identify the appropriate interventions.

After seven days of inpatient care, Rudy is apyretic and his other symptoms have improved. Fortunately, his treatment did not require mechanical ventilator support. Nasopharyngeal testing indicates that he is no longer shedding the virus, and the provider has cleared him for discharge. However, the latest guidelines from the state Department of Health indicate that Rudy must self-isolate for at least 14 days after the onset of symptoms. Because he lacks adequate housing, the county services personnel have arranged for Rudy to stay in a hotel. He will be given a mask and a paper bag in which to store the mask while not in use. His discharge instructions include monitoring for a recurrence of symptoms, staying in the hotel room, cleaning "high touch" surfaces, laundry procedures, and hand hygiene. Which method of teaching hand hygiene is most effective for this client? Teach-back Demonstration Showing a video Providing a pamphlet

Teach-back RATIONALE: When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be helpful to incorporate with the teach-back method. TEST-TAKING STRATEGY: Note the strategic words, most effective. Note that the correct option—the teach-back method—is the umbrella option, which encompasses all other options. Recall that asking the client to perform a return demonstration is the best way to confirm his or her understanding.

A nurse performing a neck assessment of a client is testing the status of cranial nerve XI. Which of the following best indicates that the client has adequate function of this nerve? The client can smile. The client can lift the eyebrows. The client can stick out the tongue. The client can shrug the shoulders against resistance.

The client can shrug the shoulders against resistance. RATIONALE: Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse's hand and to turn the head to each side as the nurse tries to resist the client's movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate the comparable or alike options that are tests of the facial nerve. To select from the remaining options, recalling that cranial nerve XI is the spinal accessory nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XI.

A nurse preparing to perform a respiratory assessment of an adult client is reading the client's medical record. The nurse sees that the health care provider noted resonance on percussion of the client's posterior chest. What interpretation does the nurse make of this finding? The client has normal, healthy lungs. The client may have a pneumothorax. The client most likely has a lung tumor. An excessive amount of air is present in the lungs.

The client has normal, healthy lungs. RATIONALE: Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate comparable or alike options. Excessive air in the lungs will produce hyperresonance while pneumothorax will also produce the same tone as excess air is trapped in the pleural space. To select from the remaining options, recall that dullness would be noted in the presence of an abnormal density such a lung tumor. Review: normal and abnormal percussion tones.

A nurse performing a physical assessment of a client is checking the client's mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve XII. Which of the following best indicates adequate functioning of this nerve? The client is able to frown. The client is able to show the teeth. The client is able to stick out the tongue. The client is able to say "ah" as the tongue is depressed with a tongue blade.

The client is able to stick out the tongue. RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client's tongue with a tongue blade and noting pharyngeal movement as the client says "ah." To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. TEST-TAKING STRATEGY: Focus on the subject of the question, which is assessment of cranial nerves. Eliminate comparable or alike options that both test the facial nerve. To select from the remaining options, recalling that cranial nerve XII is the hypoglossal nerve will direct you to the correct option. Review: the procedure for testing cranial nerve XII.

A nurse has taught a young adult male client about testicular self-examination. Which statement indicates to the nurse that the teaching was effective? The client states he will perform the self-examination at least every 2 weeks. The client indicates the need to use both hands and palpate both testes at the same time. The client states that it is important to contact the health care provider immediately if any lumps are felt. The client states that he should always perform the self-examination just before getting into the shower.

The client states that it is important to contact the health care provider immediately if any lumps are felt. RATIONALE: Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate.

A nurse conducting a physical examination of a Chinese-American client is gathering subjective data about the client's health care practices. What is the nurse's primary reason for asking the client about the use of herbal products and dietary supplements? To determine whether these are acceptable forms of treatment To determine whether the client's health care provider approves of their use To determine whether they have been approved by the U.S. Food and Drug Administration To determine whether they will interact adversely with medications being prescribed for the client

To determine whether they will interact adversely with medications being prescribed for the client RATIONALE: Regardless of their cultural origins, many people use cultural remedies such as herbal products and dietary supplements in addition to prescription medications to treat their medical illnesses. Problems may arise when prescription medications interact with these substances. Therefore, it is most important for the nurse to ask the client about the use of any other substances. The nurse must be culturally sensitive to the needs and beliefs of the client, and if the client uses an alternative remedy to treat a problem, this remedy needs to be a component of the plan of care if possible. Although the other options may be considerations for the plan of care, the primary reason for asking the client about the use of herbal products and dietary supplements is to determine whether any might interact adversely with medications being prescribed for the client. TEST-TAKING STRATEGY: The nurse note the strategic word "primary" in the query of the question. Recalling that herbal products and dietary supplements may have side effects or interact adversely with prescription medications will direct you to the correct option. Also use Maslow's Hierarchy of Needs theory. The correct option relates to physiological integrity. Review: adverse effects of herbal products.

Although Rudy did not experience delirium tremens (the seizures associated with alcohol withdrawal) during his inpatient stay, the nurse's screening did meet the criteria for alcohol use disorder, which can occur as a comorbidity with PTSD. Which organization would the nurse contact as the best choice for the treatment of this dual diagnosis? Veteran's Affairs A homeless shelter A rehabilitation facility A community outreach program

Veteran's Affairs RATIONALE: Substance use disorder frequently can occur alongside PTSD. In fact, treatment of PTSD or moral injury may help to address substance use disorders. Veterans' Affairs services can assist in managing some of the health problems experienced by these individuals. A homeless shelter is not equipped to treat disorders. Community outreach programs address certain specific needs in its community and provide services to the people who need it. A rehabilitation facility is helpful in returning the person back to a normal healthy condition but the Veteran's Affairs will be able to provide this service in addition to other services. TEST-TAKING STRATEGY: Note the strategic word, best. Recalling that Veterans' Affairs has support services designed to meet the sometimes-complicated comorbidities of this population will guide you to the right answer. Also, note that Veteran's Affairs is also the umbrella option.

The nurse prepares to care for a client who has undergone supratentorial cranial surgery. In which position should the nurse plan to place the client in the postoperative period? Flat Flat on the side that has been operated on With the head of the bed elevated 30 degrees On the back, with a small pillow under the head for support

With the head of the bed elevated 30 degrees RATIONALE: Supratentorial surgery is surgery above the brain's tentorium. After this type of surgery, the client is positioned with the head of the bed elevated 30 degrees or as tolerated to promote venous drainage from the head. Therefore, the remaining options are incorrect. TEST-TAKING STRATEGY: Focus on the subject, positioning after a craniotomy and note the word "supratentorial." Also note that the incorrect options are comparable or alike in that they are all flat positions.

At the end of the breast examination, Shannon tells the nurse that she has several moles and is worried about skin cancer. She states that her father has had "several skin cancers" removed. Which of these lesions would need to be examined more closely for skin cancer? Select all that apply. A scar that has an overgrowth of skin An irregularly shaped, pigmented papule A firm, nodular lesion that is topped with dry, scaly skin A firm, movable flesh-colored nodule that contains liquid A mole that was previously flat but now, the client states, is "larger and bumpy"

a scar that has an overgrowth of skin a firm, nodular lesion that is topped with dry, scaly skin a mole that was previously flat but now, the client states, is larger and bumpy RATIONALE: The ABCD guide can be used to assess a skin lesion for characteristics associated with cancer. In this guide, A stands for asymmetry shape, B represents border irregularity, C stands for color variation within one lesion, and D denotes diameter greater than 6 mm. Every suspicious skin lesion should be examined carefully, and a person who has a lesion with one or more of the ABCD characteristics should be evaluated by a surgeon or dermatologist. An overgrowth of skin over a scar is a keloid, which is benign. Skin lesions that are irregularly shaped or have changed in color, elevation, or size may be cancerous or precancerous. A firm, nodular lesion that is covered with a dry or rough scale may be actinic keratosis, which is a premalignant lesion. A firm, movable flesh-colored nodule that contains liquid is a cyst, which is benign.