Rodney Quiz From WhatsApp
Which clinical indicator(s) would the nurse expect a client with hyperkalemia to exhibit? Select all that apply. a) Tetany b) Seizures c) Confusion d) Weakness e) Dysrhythmias
c) Confusion d) Weakness e) Dysrhythmias
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. Which describes the character of this documentation? a) Diminished b) Normal c) Full d) Bounding
c) Full
Which finding is inferred from a grade 4 intensity of heart murmurs? a) Thrill is easily palpable b) Quiet and clearly audible thrill c) Loud murmur associated with thrill. d) Moderately loud murmur without thrill
c) Loud murmur associated with thrill.
A client asks the nurse about immunizations against tetanus. Before responding, which would the nurse consider about the benefits of tetanus antitoxin? a) It stimulates plasma cells directly. b) A delayed titer of antibodies is generated. c) It provides immediate active immunity. d) A passive immunity is produced.
d) A passive immunity is produced.
A client complains of chronically recurring ulcers on the lower leg. Upon assessment, the nurse finds the absence of hair growth on the legs and asks the client to consult the primary health care provider immediately. Which condition would the nurse suspect? a) Phlebitis b) Clubbing c) Occlusion d) Circulatory insufficiency
d) Circulatory insufficiency
The registered nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statements) made by the student nurse is/are correct? Select all that apply. a) "The axilla is recommended to measure body temperature in unconscious clients." b) "The oral cavity is suitable for clients with epilepsy to measure body temperature." c) "The tympanic membrane is a preferred site of measuring body temperature in infants." d) "The rectum is a preferred site of measuring body temperature in clients who underwent rectal surgeries." f) "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature.
a) "The axilla is recommended to measure body temperature in unconscious clients." c) "The tympanic membrane is a preferred site of measuring body temperature in infants." f) "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature.
The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume? a) 70 mL b) 60 mL c) 50 mL d) 40 mL
a) 70 mL
The nurse is assessing a client who reports shortness of breath. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error? a) Assess the client's lungs. b) Assess the client for pain. c) Obtain details of smoking habits. d) Ask about the onset of shortness of breath.
a) Assess the client's lungs.
The nurse is evaluating the effectiveness of a treatment for a client with excessive fluid volume. Which clinical finding indicates that treatment was successful? a) Clear breath sounds b) Positive pedal pulses c) Normal potassium level d) Decreased urine specific gravity
a) Clear breath sounds
The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning? a) "The client claims to feel fat despite being underweight." b) "The client experiences recurrent episodes of binge eating. c) "The client exhibits intense fear of gaining weight although underweight." d) "The client refuses to maintain body weight over a minimal ideal body weight."
b) "The client experiences recurrent episodes of binge eating.
During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a) Spiritual belief b) Family practices c) Emotional factors d) Cultural background
b) Family practices
While auscultating the heart, a health care provider notices S 3 heart sounds in four clients. Which client is at highest risk for heart failure? a) Child client b) Pregnant client c) Older adult client d) Young adult client
c) Older adult client
Which involuntary physiologic response in a client experiencing pain should the nurse monitor for? a) Crying b) Splinting c) Perspiring d) Grimacing
c) Perspiring
Which assessment would the nurse exclude when dealing with a client with receptive and expressive aphasia? a) Ask the client to read simple sentences aloud. b) Point to a familiar object and ask the client to name it. c) Test the mental status by asking for feedback from the client. d) Ask the client to respond to simple verbal commands such as "stand up."
c) Test the mental status by asking for feedback from the client.
The nurse is performing an eye assessment in an older adult. The older adult is unable to see near objects. Which conditions would be suspected in this older adult? Select all that apply. a) Cataract b) Glaucoma c) Hyperopia d) Presbyopia e) Macular degeneration
c) Hyperopia d) Presbyopia
A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. Which could be the possible reason for this sound? a) Inflammation of the pleura b) Muscular spasms in the larger airways c) Sudden reinflation of groups of alveoli d) High velocity airflow through an obstructed airway
d) High velocity airflow through an obstructed airway
A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk would be assessed? a) Lung cancer b) Cerebrovascular disease c) Cardiopulmonary alterations d) Human immunodeficiency virus (HIV) infection
d) Human immunodeficiency virus (HIV) infection
The nurse is assessing a client who was admitted with a head injury. The nurse finds that the client is unable to understand written or verbal speech. Which condition would the nurse suspect? a) Aphasia b) Dysarthria c) Borborygmi d) Dysphagia
a) Aphasia
The nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would describe the nurse's finding? a) Lordosis b) Kyphosis c) Presbycusis d) Osteoporosis
b) Kyphosis
Which action would the nurse take upon entering an examination room for assessment of a confused client? a) Perform an assessment quickly. b) Plan a focused physical assessment. c) Skip the examination until the client is reoriented. d) Leave the room to find the health care provider.
b) Plan a focused physical assessment.
The nurse is caring for a client who has experienced a near-drowning. Which potential danger would the nurse assess the client? a) Alkalosis b) Renal failure c) Hypervolemia d) Pulmonary edema
d) Pulmonary edema
Which type of interview is correct when the nurse admits a client to a clinic? a) Directive b) Exploratory c) Problem-solving d) Information giving
a) Directive
Which client body temperatures are indicative of moderate hypothermia? Select all that apply. a) 80°F (26.7°C) b) 84°F (28.9°C) c) 88°F (31.1°C) d) 92°F (33.3°C) e) 96°F (35.6°C
c) 88°F (31.1°C) d) 92°F (33.3°C)
The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. a) Dyspnea b) Flushed face c) Precordial pain d) Increased pulse rate e) Increased blood pressure
b) Flushed face d) Increased pulse rate
The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. a) Dyspnea b) Flushed face c) Precordial pain d) Increased pulse rate e) Increased blood pressure
b) Flushed face d) Increased pulse rate
Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. a) Back of the neck b) Back of the hand c) Palm of the hand d) On the sternal area e) Back of the forearm
d) On the sternal area e) Back of the forearm
The nurse is caring for an unconscious client who underwent head surgery. Which site would be correct to monitor body temperature? a) Skin b) Oral c) Axilla d) Rectal
d) Rectal
While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess a pulse deficit? a) Radial and apical pulse b) Apical and carotid pulse c) Radial and brachial pulse d) Apical and temporal pulse
a) Radial and apical pulse
A nursing student is conducting an assessment of a client who does not speak English. No interpreter is available. Which action by the student nurse is incorrect? a) Using medical terminology b) Proceeding in an unhurried manner c) Speaking in a low and moderate voice d) Pantomiming words and simple actions while verbalizing them
Using medical terminology
The registered nurse (RN) measures the blood pressure in a client as 130/80 mm Hg. When the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. Which could be the possible reasons for this difference? Select all that apply. a) Poor fitting of the cuff b) Inflating the cuff too slowly c) Deflating the cuff too quickly d) Inflating the cuff inadequately e) Applying the stethoscope too firmly.
a) Poor fitting of the cuff c) Deflating the cuff too quickly
Which question would the nurse ask a client who has developed pneumonia when assessing risk factors? a) "Are you diabetic?" b) "Have you traveled recently?" c) "What do you use for contraception?" d) "Do you have a history of intravenous [IV] drug abuse?"
a) "Are you diabetic?"
A nursing student is recording the radial pulse rate in a client with dysrhythmias and documented a radial pulse of 80 beats per minute. The registered nurse (RN) reassesses the client and notices a pulse deficit of 15. Which would be the client's apical pulse? a) 95 b) 85 c) 65 d) 75
a) 95
Which clinical finding would the nurse anticipate when admitting a client with an extracellular fluid volume excess? a) Rapid, thready pulse b) Distended jugular veins c) Elevated hematocrit level d) Increased serum sodium level
b) Distended jugular veins
While caring for four different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration? Chart Exhibit 1 a) Client 1 b) Client 2 c) Client 3 d) Client 4
c) Client 3
The nursing student has prepared pulse assessment plans for several clients. Which client's assessment plan is correct and will yield effective results? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
c) Client C
When interviewing and assessing a 17-year-old client, which findings alert the nurse to explore substance abuse with the adolescent? Select all that apply. a) Failing grades b) Blood spots on clothing c) Absenteeism from school d) Long-sleeved shirts in warm weather e) Separating emotionally from the family
a) Failing grades b) Blood spots on clothing c) Absenteeism from school d) Long-sleeved shirts in warm weather
Which assessment findings would help the nurse support the diagnosis of the condition of orthostatic hypotension? Select all that apply. a) Fainting b) Headache c) Weakness d) Light headedness e) Shortness of breath
a) Fainting c) Weakness d) Light headedness
Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? a) Inflating the cuff too slowly b) Wrapping the cuff too loosely c) Applying the stethoscope too firmly d) Repeating the assessment too quickly
a) Inflating the cuff too slowly
A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best site(s) to assess this condition? Select all that apply. a) Lips b) Sclera c) Mouth d) Sacrum e) Nail beds f) Shoulders
a) Lips c) Mouth e) Nail beds
A client is admitted with metabolic acidosis. Which two body systems would the nurse assess for compensatory changes? a) Skeletal and nervous b) Circulatory and urinary c) Respiratory and urinary d) Muscular and endocrine
c) Respiratory and urinary
The registered nurse (RN) is teaching the student nurse about various sites for assessing body temperature. Which statement(s) made by the student nurse is/are correct? Select all that apply. a) "The axilla is recommended to measure body temperature in unconscious clients." b) "The oral cavity is suitable for clients with epilepsy to measure body temperature." c) "The tympanic membrane is a preferred site of measuring body temperature in infants." d) "The rectum is a preferred site of measuring body temperature in clients who underwent rectal surgeries." e) "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."
a) "The axilla is recommended to measure body temperature in unconscious clients." c) "The tympanic membrane is a preferred site of measuring body temperature in infants." e) "The temporal artery is a preferred site of thermometer placement to measure rapid changes in core temperature."
The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. a) "I had a late onset of menarche." b) "My first child was born when I was 32." c) "I noticed a slight discharge from a nipple." d) "I perform breast self-examinations frequently." e) "I consume two to four glasses of alcohol a day."
b) "My first child was born when I was 32." c) "I noticed a slight discharge from a nipple." e) "I consume two to four glasses of alcohol a day."
While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. Which might the client's body temperature be? a) 29°C b) 33°C c) 36°C d) 38°C
b) 33°C
Which clients suffer from impaired near vision? Select all that apply. a) A client with myopia b) A client with presbyopia c) A client with hyperopia d) A client with retinopathy e) A client with macular degeneration
b) A client with presbyopia c) A client with hyperopia
Which action would the nurse take during a falls risk assessment after learning that the client experienced a recent fall? a) Applying restraint to prevent ambulating without assistance b) Discontinuing all medications to remove the risk of polypharmacy c) Assessing the circumstances of the fall, including feelings and setting d) Requiring that family members remain at the bedside to watch over the client
c) Assessing the circumstances of the fall, including feelings and setting
While performing a physical assessment of a female client, the nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition? a) Aging b) Poor nutrition c) Endocrine disease d) Arterial insufficiency
c) Endocrine disease
When nurses are conducting health assessment interviews with older clients, which step would be included? a) Leave a written questionnaire for clients to complete at their leisure. b) Ask family members rather than the client to supply the necessary information. c) Spend time in several short sessions to elicit more complete information from the clients. d) Keep referring to previous questions to ascertain that the information given by clients is correct.
c) Spend time in several short sessions to elicit more complete information from the clients.
The registered nurse (RN) notices reddish linear streaks in the nail bed of the client. Which systemic condition would the RN suspect in the client based on these assessment findings? a) Syphilis b) Iron-deficiency anemia c) Subacute bacterial endocarditis d) Chronic obstructive pulmonary disease
c) Subacute bacterial endocarditis
Which scenario would contribute to health disparities? a) An English-speaking critical care nurse assesses a Hispanic client in a coma. b) An English-speaking nurse plans the nursing procedures for a black Latino client. c) An English-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing. d) An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.
d) An English-speaking nurse conducts the admission interview of a Puerto Rican immigrant with limited knowledge of English.
The nurse discovers several palpable elevated masses on a client's arms. Which term accurately describes the assessment findings? a) Erosions b) Macules c) Papules d) Vesicles
c) Papules
The nurse suspects that a client has a distended bladder. Which method is correct to assess for this condition? a) Inspect and palpate in the epigastric region. b) Auscultate and percuss in the inguinal areas. c) Percuss and palpate in the hypogastric region. d) Percuss and palpate bilaterally in the lumbar areas
c) Percuss and palpate in the hypogastric region.
After assessment, the nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which would be the cause of these sounds? a) Parietal pleura rubbing against visceral pleura b) Random, sudden reinflation of groups of alveoli c) Turbulence due to muscular spasm and fluid or mucus in the larger airways d) High-velocity airflow through severely narrowed or an obstructed airway
c) Turbulence due to muscular spasm and fluid or mucus in the larger airways
Which questions would the nurse ask the client when obtaining the health history? Select all that apply. a) "Tell me about your food habits." b) "Do you use alcohol or tobacco?" c) "Have you sustained any personal loss recently?" d) "Have you ever experienced any allergic reactions?" e) "Does any family member have a long-term illness?"
a) "Tell me about your food habits." b) "Do you use alcohol or tobacco?" d) "Have you ever experienced any allergic reactions?"
A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit? a) Presence of dry skin b) Loss of body weight c) Decrease in blood pressure d) Altered general appearance
b) Loss of body weight
The nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? a) Pulse rate b) Tissue turgor c) Specific gravity d) Body temperature
b) Tissue turgor
The nurse is providing postoperative care to a client who had surgery to repair a deviated septum. The nurse would monitor for which complication associated with this type of surgery? a) Occipital headache b) Periorbital crepitus c) Expectoration of blood d) Changes in vocalization
c) Expectoration of blood
Which involuntary physiologic response in a client experiencing pain should the nurse monitor for? a) Crying b) Splinting c) Perspiring Grimacing
c) Perspiring
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. Which is this condition known as? a) Osteoarthritis b) Osteoporosis c) Muscle atrophy d) Contracture
d) Contracture
When preparing to assess a client with active tuberculosis, which piece of protective equipment is necessary for the nurse before entering the client room? a) Isolation gown b) Surgical mask c) Shoe covers d) N95 respiratory mask
d) N95 respiratory mask
While caring for a client with heat stroke, the nurse measured the temperature and noted it as 39°C. What is this temperature in Fahrenheit? Record your answer and round to tenths.
102.2 F
A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. Which would be the client's total score? Record your answer using a whole number.
13
A 16-year-old client has a blood pressure reading of 119/75 mm Hg. What is the approximate pulse pressure? Record your answer using a whole number.
44mm hg
A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be correct to obtain the client's temperature? a) Oral b) Axilla c) Temporal artery d) Tympanic membrane
Axilla
The nurse is performing an assessment of the client's reproductive system. Which finding in the past medical history indicates the client is at risk of cervical cancer? a) Vaginal discharge b) Ovarian dysfunction c) Human papilloma virus infection d) Hematuria and urinary incontinence
Human papilloma virus infection
A client has a heart rate of 72 beats/min and stroke volume of 70 mL. What is the client's cardiac output? Record your answer using a whole number.
5040 mL/min
Arrange the steps taken by the nurse while assessing the visual level of a client in sequential order. 1-Direct the client to stand or sit 60 cm away from eye level. 2-Ask the client to close his or her left or right eye gently and look directly at the nurses opposite eye. 3-Move a finger equidistant between the nurse and the client outside the field of vision. 4-Close the opposite eve to superimpose the held of vision. 5-Ask the client to report when he or she is able to see the finger.
58- Arrange the steps taken by the nurse while assessing the visual level of a client in sequential order. 1-Direct the client to stand or sit 60 cm away from eye level. 2-Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye. 3-Move a finger equidistant between the nurse and the client outside the field of vision. 4-Close the opposite eve to superimpose the held of vision. 5-Ask the client to report when he or she is able to see the finger.
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressures. Which is the most important nursing intervention for this client? A) Educate the client on managing stress. b) Teach the client to maintain a balanced diet. c) Instruct the client to have regular health checkups. d) Ask the client to use sunscreen when working outdoors.
A) Educate the client on managing stress.
While performing a physical assessment of a female client, the nurse positions the client in Sims position. Which body system would be assessed in this position? Select all that apply. a) Heart b) Vagina c) Rectum d) Female genitalia e) Musculoskeletal system
b) Vagina c) Rectum
A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting for 5 days. Upon further assessment, the primary health care provider finds that the symptoms occurred after the client ate eggs, salad dressings, and sandwich fillings. Which food-borne disease would be suspected in this client? a) Listeriosis b) Shigellosis c) Salmonellosis d) Staphylococcus
Salmonellosis
The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term correctly describes the findings? a) Rhonchi b) Wheezes c) Pleural friction rub d) Bronchovesicular
Wheezes
A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which calcium-rich food would the nurse suggest for clients who do not tolerate milk? a) Oats b) Yogurt c) Potatoes d) Applesauce
Yogurt
While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning? a) " will ask the client to move his or her arm toward the body." b) "I will ask the client to bend his or her limb by decreasing the angle." c) "I will ask the client to move his or her hand so that the ventral surface faces downward." d) "I will ask the client to move his or her head beyond its normal resting extended position."
a) " will ask the client to move his or her arm toward the body."
A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which questions when completing the initial assessment? a) "Does walking for long periods of time increase your pain?" b) "Does standing without moving decrease your pain?" c) "Have you had your potassium level checked recently?" d) "Have you had any broken bones in your lower extremities?"
a) "Does walking for long periods of time increase your pain?"
20- A registered nurse (RN) instructed the nursing assistive personnel (NAP) to measure the temperature of a client who reports chills and coldness. The nurse believes that the reading is inaccurate. Which observations may have led to this conclusion? Select all that apply. a) The client has a habit of breathing through his or her mouth. b) The client smoked 40 minutes after his or her temperature was taken. c) The client ingested juice 20 minutes before his or her temperature was taken. d) The client ingested food 20 minutes after having his or her temperature was taken. e) The client ingested medications 10 minutes after having his or her temperature was taken.
a) The client has a habit of breathing through his or her mouth. c) The client ingested juice 20 minutes before his or her temperature was taken.
The nursing student under the supervision of the registered nurse (RN) is performing a pulse assessment. While preparing to assess the client, the RN asks the nursing student to check the apical pulse after assessing the radial pulse. Which would be the reason behind for this change? a) The client may have a dysrhythmia. b) The client may have physiologic shock. c) The client underwent surgery earlier in the day. d) The client may have peripheral artery disease.
a) The client may have a dysrhythmia.
A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student is incorrect? a) "I'll compare the two sides of the body for symmetry." b) "I'll record quick notes during the examination to avoid delays." c) "I'll perform painful procedures at the beginning of the examination." d) "I'll record assessments in specific terms in the electronic or paper record."
c) "I'll perform painful procedures at the beginning of the examination."
While assessing a client, the nurse finds bluish coloration of the skin. Which condition would be suspected? a) Anemia b) Liver disease c) Heart disease d) Autoimmune
c) Heart disease
The nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STIs). Which statement by the client indicates effective learning? a) "I will use condoms when having sex with an infected partner." b) "I will perform a genital self-examination every month before bathing." c) "I will refrain from getting the human papilloma virus vaccine (HPV) before the age of 27 years." d) "I will consult with my primary health care provider when there is a rash or ulcer on my genitalia."
d) "I will consult with my primary health care provider when there is a rash or ulcer on my genitalia."
The nurse performs lung assessments of four clients. The details are given below. Which client has inflamed pleura? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
d) Client D
The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing interventions? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
a) Client A
Which clients would be considered for assessing the carotid pulse? Select all that apply. a) Client with cardiac arrest b) Client indicated for Allen test c) Client under physiological shock d) Client with impaired circulation to foot e) Client with impaired circulation to hand
a) Client with cardiac arrest c) Client under physiological shock
Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. a) Client with corneal arcus b) Client with periorbital edema c) Client with decreased skin turgor d) Client with paleness of conjunctivae e) Client with yellow lipid lesions on eyelids.
a) Client with corneal arcus e) Client with yellow lipid lesions on eyelids.
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload? a) Crackles in the lungs b) Decreased heart rate c) Decreased blood pressure d) Cyanosis of nailbeds
a) Crackles in the lungs
The nurse is caring for an older adult with a hearing loss secondary to aging. Which would the nurse expect to identify when assessing this client? Select all that apply. a) Dry cerumen b) Tears in the tympanic membrane c) Difficulty hearing high pitched voices d) Decrease of hair in the auditory canal e) Overgrowth of the epithelial auditory lining
a) Dry cerumen c) Difficulty hearing high pitched voices
Which client would the nurse anticipate needing a referral for a support group for people with vision loss? a) Cloudy vision b) Crossing of the eyes c) Obstruction of central vision d) Difficulty seeing things that are far away
c) Obstruction of central vision
A registered nurse is teaching a nursing student about precautions to be taken for physical examination of a client. Which statements made by the nursing student indicate effective learning? Select all that apply. a) "I would examine the client in noise-free areas." b) "I would use latex gloves during the physical examination." c) "I would perform a physical examination in a cool room." d) ' would leave a combative client alone during a physical examination. e) "I would wear eye shields while examining a client with excessive drainage."
a) "I would examine the client in noise-free areas." e) "I would wear eye shields while examining a client with excessive drainage."
The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
a) Client A
The heartbeat assessment of four clients is given below. Which client is at an increased risk for right-sided heart failure? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
a) Client A
The nurse is teaching a client about different prevention and detection practices to ensure breast health. Which statement made by the client indicates the need for further teaching? a) "I will increase my meat consumption." b) "I will perform a self-breast examination every week." c) " will schedule routine mammograms." d) "I will reduce my caffeine and theophylline intake."
a) "I will increase my meat consumption."
Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. a) Nursing diagnoses involve the client when possible. b) Nursing diagnoses are based on results of diagnostic tests and procedures. c) Nursing diagnoses are the identification of a disease condition in the client. d) Nursing diagnoses involve the sorting of health problems within the nursing domain. e) Nursing diagnoses involve clinical judgment about the client's response to health problems.
a) Nursing diagnoses involve the client when possible. d) Nursing diagnoses involve the sorting of health problems within the nursing domain. e) Nursing diagnoses involve clinical judgment about the client's response to health problems.
The nurse assesses the vital signs of a 50-year-old female client and documents the results. Which are considered within normal range for this client? Select all that apply. a) Oral temperature of 98.2°F (36.8°C) b) Apical pulse of 88 beats/min and regular c) Respiratory rate of 30 breaths/min d) Blood pressure of 116/78 mm Hg while in a sitting position e) Oxygen saturation of 92%
a) Oral temperature of 98.2°F (36.8°C) b) Apical pulse of 88 beats/min and regular d) Blood pressure of 116/78 mm Hg while in a sitting position
An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? a) Oxygen saturation: 89% b) Body temperature: 101°F c) Blood pressure: 130/80 mm Hg d) Respiratory rate: 26 beats/minute
a) Oxygen saturation: 89%
Which assessment items need to be documented on a client in restraints? Select all that apply. a) Pulse near the restrained area b) Temperature of the restrained area c) Convenience of restraining the client d) Skin integrity surrounding the restraint Behavior leading to the need for restraint
a) Pulse near the restrained area b) Temperature of the restrained area d) Skin integrity surrounding the restraint Behavior leading to the need for restraint
Which assessment items need to be documented on a client in restraints? Select all that apply. a) Pulse near the restrained area b) Temperature of the restrained area c) Convenience of restraining the client d) Skin integrity surrounding the restraint e) Behavior leading to the need for restraint
a) Pulse near the restrained area b) Temperature of the restrained area d) Skin integrity surrounding the restraint e) Behavior leading to the need for restraint
The nurse is caring for an older adult client with dementia. Which client need would the nurse prioritize while providing care? a) Safety b) Self-esteem c) Self-actualization d) Love and belonging
a) Safety
The nurse teaches an obese client measures to calculate the body mass index. Which of these statements by the client indicates effective learning? Select all that apply. a) "I should include sugared beverages in my diet." b) "I should lose at least half a pound to a pound each week." c) "My daily nutritional fat intake should be more than 30%." d) "I'll make sure to eat foods that meet my daily nutritional requirement." e) "I should stay away from unhealthy foods between meals and after dinner."
b) "I should lose at least half a pound to a pound each week." d) "I'll make sure to eat foods that meet my daily nutritional requirement." e) "I should stay away from unhealthy foods between meals and after dinner."
A registered nurse (RN) is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition is incorrect? a) "The client may have deterioration of the cochlea." b) "The client may have thinning of the tympanic membrane." c) "The client may have an inability to hear high-frequency sounds." d) "The client may have an inability to differentiate between consonants."
b) "The client may have thinning of the tympanic membrane."
While assessing a client, the nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. Which is indicated by this finding? Select all that apply. a) Client has lordosis. b) Client is an older adult. c) Client has osteoporosis. d) Client has a history of smoking. e) Client has chronic lung disease.
b) Client is an older adult. d) Client has a history of smoking. e) Client has chronic lung disease.
While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other finding(s) in the client confirm(s) the diagnosis as strabismus? Select all that apply. a) Impaired near vision b) Crossed appearance of eyes c) Elevated intraocular pressure d) Impaired extraocular muscles e) Degeneration of central retina
b) Crossed appearance of eyes d) Impaired extraocular muscles
While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. Which could be the reason for this dryness? a) Applying moisturizing lotion between toes b) Cutting nails after soaking them for 10 minutes in warm water c) Cutting nails straight across and even with the tops of the fingers or toes d) Using sharp objects to poke or dig under the toenail or around the cuticle
b) Cutting nails after soaking them for 10 minutes in warm water
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls which expected sensory losses associated with aging? Select all that apply. a) Difficulty in swallowing b) Diminished sensation of pain c) Heightened response to stimuli d) Impaired hearing of high frequency sounds e) Increased ability to tolerate environmental heat
b) Diminished sensation of pain d) Impaired hearing of high frequency sounds
Which landmark is correct for the nurse to use when auscultating the mitral valve? a) Left fifth intercostal space, midaxillary line b) Left fifth intercostal space, midclavicular line c) Left second intercostal space, sternal border d) Left fifth intercostal space, sternal border
b) Left fifth intercostal space, midclavicular line
When the nurse is assessing an older client as he or she walks into the examination room, which finding is documented as abnormal? a) The client is wearing extra layers of clothing. b) The client is wearing an excessive amount of cologne. c) The client walks smoothly with arms swinging at the side. d) The client is bent over slightly with the elbows and knees bent.
b) The client is wearing an excessive amount of cologne.
Which client would have a health promotion nursing diagnosis? a) The client with acute pain due to appendicitis b) The client who is willing to take a 30-minute walk daily c) The older adult client with dementia admitted to the health care facility d) The client with reduced cognitive ability while recovering from surgery
b) The client who is willing to take a 30-minute walk daily
A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident is incorrect? a) "Type I immune response to latex has an immediate onset." b) "Type I immune reaction to latex leads to release of IgE antibodies." c) "Type IV immune reaction to latex occurs with first exposure." d) "Type IV immune response to latex occurs after 12 to 48 hours after exposure
c) "Type IV immune reaction to latex occurs with first exposure."
The nurse enters the examination room of a female client and her spouse. Which action would the nurse take when the female client is withdrawn and appears fearful of the spouse? a) Ask if there are concerns at home. b) Call the client later to ensure safety. c) Find a way to interview the client in private. d) Assume the client is nervous in medical settings.
c) Find a way to interview the client in private.
Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? a) The nurse understands that the client has pain due to a tracheostomy. b) The nurse identifies that the client is anxious about the cardiac catheterization. c) The nurse realizes that the client has diarrhea and needs the bedpan frequently. d) The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.
d) The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.
A client who does not understand English requires an interpreter. Which action by the student nurse may exacerbate health disparities? a) The student expects the interpreter to act as the client's advocate. b) The student expects the interpreter to have a health care background. c) The student maintains steady eye contact with the client. d) The student talks only to the interpreter about the client
d) The student talks only to the interpreter about the client
While assessing a client who sustained a road traffic accident, the nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected? a) Facial nerve b) Trochlear nerve c) Abducens nerve d) Trigeminal nerve
d) Trigeminal nerve
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse would document the assessment finding as which stage of pressure ulcer? a) Stage I b) Stage II c) Stage III d) Unstageable
d) Unstageable
While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? a) Malabsorption b) Bladder cancer c) Diabetic ketoacidosis d) Urinary tract infection
d) Urinary tract infection
Place them in the correct order. 1. Place stethoscope earpieces in the ears and be sure the sounds are clear. 2. Relocate the brachial artery and place the bell or diaphragm chest piece of the stethoscope over it. 3. Close the pressure bulb valve and quickly inflate the cuff to 30 mm Hg above the client's systolic pressure. 4. Slowly release the pressure bulb valve and allow the needle of the manometer gauge to fall at a rate of 2 to 3 mm Hg/sec. 5. Note the point on the manometer when you hear the first clear sound. 6. Continue to deflate the cuff, noting the point at which muffled or dampened sound appears.
1. Place stethoscope earpieces in the ears and be sure the sounds are clear. 2. Relocate the brachial artery and place the bell or diaphragm chest piece of the stethoscope over it. 3. Close the pressure bulb valve and quickly inflate the cuff to 30 mm Hg above the client's systolic pressure. 4. Slowly release the pressure bulb valve and allow the needle of the manometer gauge to fall at a rate of 2 to 3 mm Hg/sec. 5. Note the point on the manometer when you hear the first clear sound. 6. Continue to deflate the cuff, noting the point at which muffled or dampened sound appears.
Which actions by the nurse help set the stage for a client-centered interview? Select all that apply. a) Close the door after entering the room. b) Greet the client using his or her last name. c) Open the curtains to allow plenty of light in the room. d) Introduce oneself with a smile and explain the reason for the visit. e) Obtain an authorization from the client after the interview.
a) Close the door after entering the room. b) Greet the client using his or her last name. d) Introduce oneself with a smile and explain the reason for the visit.
The nurse is assessing an older adult male client. Which clinical finding(s) are expected response(s) to the aging process? Select all that apply. a) Slowed neurological responses b) Lowered intelligence quotient c) Long-term memory impairment d) Forgetfulness about recent events e) Reduced ability to maintain an erection
a) Slowed neurological responses d) Forgetfulness about recent events e) Reduced ability to maintain an erection
The nurse is assessing a client after abdominal surgery. Which assessment findings would the nurse use to form a data cluster? Select all that apply. a) The client reports pain with movement. b) The client has pain over the surgical area. c) The client wants to know when he can go home. d) The client rates the pain as 8 on a scale of 0 to 10. e) The client has concerns about caring for the wound.
a) The client reports pain with movement. b) The client has pain over the surgical area. d) The client rates the pain as 8 on a scale of 0 to 10.
While assessing a client's skin, the nurse notices that the client's skin is dry. Which is the probable cause of this condition? Select all that apply. a) Use of hard soap b) Frequent bathing c) Use of tanning pills d) Presence of an allergy e) Use of petroleum products
a) Use of hard soap b) Frequent bathing
A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result? a) "The result indicates that you have active tuberculosis." b) "The result indicates that you are infected with the tuberculosis organism." c) "The result indicates that there are no tuberculin antibodies in your system." d) "The result indicates that you have a secondary infection related to the tuberculin organism."
b) "The result indicates that you are infected with the tuberculosis organism."
Which statements) related to initial assessment of blood pressure by the nurse require(5) correction? Select all that apply. a) "Deflating the cuff too slowly will show false high diastolic readings." b) "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." c) "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable." d) "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." e) "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80mm Hg In the right arm.
b) "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." d) "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure."
The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate? a) Venous insufficiency b) Arterial insufficiency c) Phlebitis d) Lymphedema
b) Arterial insufficiency
The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? a) Wait until a family member is also present. b) Assess the client's barriers to learning self-injection techniques. c) Begin with simple written instructions describing the technique. d) Wait until the client has accepted the new diagnosis of type 1 diabetes mellitus.
b) Assess the client's barriers to learning self-injection techniques.
Which are important components of a neurovascular assessment performed by the nurse? Select all that apply. a) Orientation b) Capillary refill c) Pupillary response d) Respiratory rate e) Pulse and skin temperature f) Movement and sensation
b) Capillary refill e) Pulse and skin temperature f) Movement and sensation
A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and has hypovolemic shock. Which site(s) would be used to obtain the client's pulse rate? Select all that apply. a) Apical b) Carotid c) Brachial d) Femoral e) Popliteal
b) Carotid d) Femoral
A client complains of sudden muscle weakness during times of anger or laughter that may occur at any time during the day. Which condition would be suspected in this client? a) Insomnia b) Cataplexy c) Narcolepsy d) Sleep apnea
b) Cataplexy
The nurse is assessing the level of consciousness of four different clients. Which client would have the lowest neurological function? Chart/Exhibit 1 a) Client 1 b) Client 2 c) Client 3 d) Client 3
b) Client 2
The nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
b) Client B
The nurse is reviewing the data of clients with prehypertension. Which client is at risk of stage 1 hypertension based on the given data? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
b) Client B
Which client is suspected of having hypertension based on the given data? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
b) Client B
Which interventions would the nurse suggest after a home assessment for fall risk in the older adult? Select all that apply. a) Dimming lighting to avoid squinting b) Securing rugs to prevent movement c) Removing excessive pieces of furniture d) Wearing corrective lenses for distance vision e) Performing exercises to strengthen lower extremities
b) Securing rugs to prevent movement c) Removing excessive pieces of furniture d) Wearing corrective lenses for distance vision e) Performing exercises to strengthen lower extremities
Which related factor is appropriate for a nursing diagnosis? a) Prostatectomy b) Trauma of incision c) Acute renal failure d) Knee replacement surgery
b) Trauma of incision
The nurse is assessing the body temperature of four febrile clients over 4 days. Which client is suffering from remittent fever? Chart/Exhibit 1 a) Client A b) Client B c) Client C d) Client D
c) Client C Rationale In remittent fever, body temperature spikes and falls without a return to normal temperature levels. In client C, the temperature for 4 days is febrile with fluctuations, and the temperature does not return to normal. Client A has sustained fever, with a constant body-temperature continuously above 100.4°F (38°C) that has little fluctuation. Client B has intermittent fever, in which the fever spikes interspersed with normal temperature levels. Client D has relapsing fever, which has periods of febrile episodes and periods with acceptable temperature values, often for longer than 24 hours.
A mother is worried about the sudden behavioral changes in her child. The child has suddenly developed a fear of certain people and places. The child's school performance is declining rapidly, and the child has developed poor relationships with his or her peers. After assessing the physical findings of the child, the nurse suspects child abuse. Which physical findings would have led the nurse to this suspicion? a) Sunken eyes and loss of weight b) Uncommunicative and not interacting with others c) Foreign bodies in the rectum, urethra, or-vagina d) Strangulation marks on neck from rope burns or bruises
c) Foreign bodies in the rectum, urethra, or-vagina
When preparing to assess a client with Clostridium difficile, which piece of protective equipment is necessary for the nurse before entering the client room? a) Head covering b) Clear eye mask c) Full plastic gown d) N95 respiratory mask
c) Full plastic gown
Which would the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? Select all that apply. a) Reassess the client. b) Reject all diagnoses. c) Gather more information. d) Identify related factors. e) Review all defining characteristics.
c) Gather more information. d) Identify related factors. e) Review all defining characteristics.
A client reports to the hospital with skin lesions. Upon physical examination, the nurse notices circumscribed elevations of the skin filled with serous fluid, measuring about 0.5 x 0.5 cm. Which is the suspected cause of these skin lesions? a) Venous stasis ulcer b) Staphylococcal infection c) Herpes simplex infection d) Arterial insufficiency
c) Herpes simplex infection
Which age-related change would the nurse consider when formulating a plan of care for an older adult? Select all that apply. a) Difficulty in swallowing b) Increased sensitivity to heat c) Increased sensitivity to glare d) Diminished sensation of pain e) Heightened response to stimuli
c) Increased sensitivity to glare d) Diminished sensation of pain
The nurse recognizes that a common conflict experienced by older adults is the conflict between which? a) Youth and old age b) Retirement and work c) Independence and dependence d) Wishing to die and wishing to live
c) Independence and dependence
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. a) Diplopia b) Skin rash c) Leg cramps d) Tachycardia e) Muscle weakness
c) Leg cramps e) Muscle weakness
A senior high school student asks the school nurse which immunizations will be included in the precollege physical. Which vaccine would the nurse tell the student to expect to receive? a) Hepatitis C (HepC) b) Influenza type B (HIB) c) Measles, mumps, rubella (MMR) d) Diphtheria, tetanus, pertussis (DTaP)
c) Measles, mumps, rubella (MMR)
After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. Which side effect of radiation would the nurse expect to find? a) Dry mouth b) Skin reactions c) Mucosal edema d) Bone marrow suppression
c) Mucosal edema
The nurse is assessing several clients. Which client will require parenteral nutrition? a) A client with brain neoplasm b) A client with anorexia nervosa c) A client with inflammatory bowel disease d) A client with severe malabsorption disorder
d) A client with severe malabsorption disorder
While assessing a client, the nurse finds adventitious breath sounds. Upon further evaluation, the nurse finds loud, low-pitched, rumbling coarse sounds during inspiration. This sound can be clearly heard while the client is coughing. Which could be the reason behind these sounds? a) Inflammation of the pleura b) Reinflation of groups of alveoli c) Muscular spasms in the larger airways High-velocity airflow through an obstructed airway
c) Muscular spasms in the larger airways
The nurse assesses a client who complains of rapid, involuntary movement of the eyes after a minor eye injury. Which condition would the nurse suspect? a) Cataract b) Glaucoma c) Nystagmus d) Strabismus
c) Nystagmus
A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client? a) Skin b) Axilla c) Oral cavity d) Temporal artery
c) Oral cavity
After reviewing otoscope use for assessment of the ear with the nursing staff, which response from a participant reflects safe follow-up care for when there is earwax covering the tympanic membrane? a) "I will leave the wax in place." b) "I will use a cotton-tipped swab to remove the wax." c) " will insert the tip of a hemostat to remove the wax." d) "I will perform warm water irrigation to remove the wax.
d) "I will perform warm water irrigation to remove the wax.
A registered nurse (RN) is teaching a nursing student how to assess for edema. Which statement made by the student is incorrect? a) "Edema results in the separation of skin from pigmented and vascular tissue." b) "Pitting edema leaves an indentation on the site of application of pressure." c) "Trauma or impaired venous return should be suspected in clients with edema." d) "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
d) "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."
A registered nurse (RN) is teaching a nursing student about skin assessment. Which statement made by the nursing student is incorrect? a) "Skin assessments are best performed in daylight." b) "Skin assessments performed at cool room temperatures can result in canosis." c) "Skin assessment performed at warm room temperatures can result in vasodilatation." d) "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."
d) "In the absence of sunlight, skin assessments are performed best with other sources of light instead of fluorescent light."
The registered nurse notices that the student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. Which is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg? a) 130/80 mm Hg b) 150/100 mm Hg c) 140/100 mm Hg d) 130/100 mm Hg
d) 130/100 mm Hg
The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8-mm depression after release. How would the edema be documents. a) 1+ b) 2+ c) 3+ d) 4+
d) 4+
An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Which describes the nurse's responsibility in this situation? a) The nurse's judgment was adequate, and the client was treated accordingly. b) The possibility of tetanus was not foreseen because the client was immunized. c) Nurses would routinely administer immunization against tetanus after such an injury. d) Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
d) Assessment by the nurse was incomplete and, as a result, the treatment was insufficient.
While performing a physical assessment of a client, the nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. Which is the probable cause for this condition? a) Anemia b) Pregnancy c) Lung disease d) Autoimmune disease
d) Autoimmune disease
The nurse is caring for an older adult client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment information best reflects the fluid balance of this client? a) Skin turgor b) Intake and output results c) Client's report about fluid intake d) Blood lab results
d) Blood lab results
A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client? a) Cranial nerve X b) Cranial nerve IX c) Cranial nerve XII d) Cranial nerve VII
d) Cranial nerve VII
After conducting a falls risk assessment education session for the staff and observing falls risk assessment on the unit, which staff action needs review for correction? a) Using a fall risk assessment tool b) Assessing the environment for fall hazards c) Inquiring about the client's history of falls d) Delegating falls assessment to assistive personnel
d) Delegating falls assessment to assistive personnel
Which site would be monitored for a pulse to assess the status of circulation to the foot? Select all that apply. a) Carotid artery b) Femoral artery c) Popliteal artery d) Dorsalis pedis artery e) Posterior tibial artery
d) Dorsalis pedis artery e) Posterior tibial artery
A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is correct to check the client's pulse rate? a) Ulnar b) Radial c) Brachial d) Femoral
d) Femoral
While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. Which would be the possible diagnosis? a) Cancer b) Thyroid disease c) Tracheal displacement d) Human immunodeficiency virus (HIV) infection
d) Human immunodeficiency virus (HIV) infection
The nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock? a) Respirations of 10 b) Urine output of 30 mL/hour c) Lethargy d) Restlessness
d) Restlessness
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Which would the nurse consider teaching about how gamma globulin provides passive immunity? a) It increases production of short-lived antibodies. b) It accelerates antigen-antibody union at the hepatic sites. c) The lymphatic system is stimulated to produce antibodies. d) The antigen is neutralized by the antibodies that it supplies.
d) The antigen is neutralized by the antibodies that it supplies.
The nurse is caring for a client who has lost an arm in a motor vehicle accident. Which reaction cues the nurse to realize that the client is in the withdrawal phase of adjusting to the change in body image? a) The client is going through a grieving period. b) The client talks as if another person is affected. c) The client is willing to learn techniques to adapt. d) The client recognizes the reality and becomes anxious.
d) The client recognizes the reality and becomes anxious.
