EAQ Set # 5

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A client in labor states that she feels the urge to push. After a vaginal examination, the nurse determines that the cervix is 10 cm dilated. Which breathing pattern does the nurse encourage the client to use?
1
Expulsion breathing
2
Rhythmic chest breathing
3
Continuous blowing-breathing
4
Accelerated-decelerated breathing

Expulsion breathing (pushing) should be encouraged when the cervix is fully dilated; doing it before 10 cm of dilation may cause cervical trauma and fatigue. Rhythmic chest breathing is used in the early active phase of labor for relief of discomfort; it is not used to overcome the desire to push. A breathing pattern consisting of continuous blowing can assist in overcoming the urge to push when a client is in transition. Accelerated-decelerated breathing is not effective in overcoming the urge to push.

A nurse advises the father of a toddler to encourage pretend play in the child. What are the reasons behind this advice? Select all that apply.
1
To help improve sleeping habits
2
To help develop fine muscle skills
Correct 3
To help the child become more creative
Correct 4
To help the child develop social problem-solving skills
Correct 5
To help the child learn to understand other points of view

Pretend play helps children become more creative, develop skills in solving social problems, and to learn to understand other points of view. Parents should help their children slow down before bedtime to develop better sleeping habits. Scribbling and drawing help a child develop fine muscle skills.

When nurses are conducting health assessment interviews with older clients, what step should be included?
1
Leave a written questionnaire for clients to complete at their leisure.
2
Ask family members rather than the client to supply the necessary information.
Correct3
Spend time in several short sessions to elicit more complete information from the clients.
4
Keep referring to previous questions to ascertain that the information given by clients is correct.

Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at their leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

A client seeking advice regarding contraception asks a nurse to explain how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond?
1
"It covers the entrance to the cervical os."
2
"The openings to the fallopian tubes are blocked."
3
"The sperm are kept from reaching the vagina."
Correct4
"It produces a spermicidal intrauterine environment."

Intrauterine devices produce a spermicidal intrauterine environment. A copper IUD inflames the endometrium, damaging or killing sperm and preventing fertilization and/or implantation. A levonorgestrel-releasing IUD damages sperm and causes the endometrium to atrophy, thus preventing fertilization and/implantation. A diaphragm blocks the cervical os. The IUD does not act by blocking the openings to the fallopian tubes. Preventing sperm from reaching the vagina is the function of a condom.

The nurse is preparing a client for epidural anesthesia. Which client statement would cause the nurse to stop the placement of the epidural catheter?
Correct1
"I’m not exactly sure how an epidural works."
2
"I understand that the epidural might or might not take my pain away."
3
"I signed the consent form for an epidural at my last clinic appointment."
4
"I’m aware that the epidural could cause my contractions to slow down."

A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman received information about analgesia and anesthesia earlier in her pregnancy. Nurses play a significant role in the informed consent process by clarifying and describing procedures or by acting as the woman’s advocate and asking the primary healthcare provider for further explanation. There are three essential components of an informed consent. First, the procedure and its advantages and disadvantages must be thoroughly explained. Second, the woman must agree with the plan of labor pain management as explained to her. Third, her consent must be given freely without coercion or manipulation from the healthcare provider.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person’s adjustment to the period of senescence will depend largely on adjustment to which developmental stage?
1
Industry versus inferiority
2
Identity versus role confusion
Correct3
Generativity versus stagnation
4
Autonomy versus shame/doubt

The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.

After assessing a 2-year-old child, the nurse concludes that the child lacks physical readiness for toilet training. Which assessment finding supports the nurse’s conclusion?
Incorrect1
The child wets two diapers per day.
Correct2
The child stays dry for 1 hour during the day.
3
The child behaves impatiently with soiled diapers.
4
The child sits on the toilet for 6 minutes without fussing.

The child develops voluntary control of the anal and urethral sphincters by the age of 22 to 30 months, allowing the child to remain dry for at least 2 hours. If the child is unable to remain dry for 2 hours, it indicates a lack of physical readiness for toilet training. The number of wet diapers decreases as the child attains physical readiness for toilet training. Therefore, if a 2-year-old child wets two diapers per day, it is a normal finding. If the child becomes impatient with soiled diapers and has the desire to change the diapers immediately, it indicates psychological readiness for toilet training. Sitting on the toilet for 5 to 8 minutes without fussing or getting off also indicates psychological readiness for toilet training.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse may identify which ocular problem common to persons at this client’s developmental level?:
1
Tropia
2
Myopia
3
Hyperopia
4
Presbyopia

Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.
Correct
1.
Immune system response is triggered
Incorrect
2.
Body temperature is increased
Incorrect
3.
The set point of the hypothalamus is raised
Incorrect
4.
Heat loss responses are initiated
Incorrect
5.
Pyrogens are destroyed

A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

What is the appropriate blood pressure of a 12-year-old client?
1
95/65 mm Hg
2
105/65 mm Hg
Correct3
110/65 mm Hg
Incorrect4
119/75 mm Hg

A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.

A client complains of pain in the ear. While examining the client, a nurse finds swelling in front of the left ear. Which lymph node does the nurse expect to be involved?
1
Mastoid
2
Occipital
3
Submental
Correct4
Pre-auricular

The pre-auricular lymph node is located in front of the ear and in this situation would be edematous. The mastoid or posterior auricular lymph node is present behind the ear. The occipital lymph nodes are located in the back of the head, near the occipital bone of the skull. Submental lymph nodes are located below the chin.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults?
1
Increased skin elasticity and a decrease in libido
Incorrect2
Impaired fat digestion and increased salivary secretions
Correct3
Increased blood pressure and decreased hormone production
4
An increase in body warmth and some swallowing difficulties

With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse’s action?
Correct1
Data collection
Incorrect2
Data validation
3
Data clustering
4
Data interpretation

The nurse is gathering objective data to support the subjective data. The client’s report of difficulty breathing is subjective data that needs to be supported by data from physical examination. The nurse reviews the database after data collection to decide if it is accurate and complete. This step is called data validation. Grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.
Correct 1
Ptosis and blurred vision
Incorrect 2
Agitation and hyperactivity
Incorrect 3
Confusion and disorientation
4
Increased sensitivity to pain
Correct 5
Decreased auditory alertness

Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

How does the World Health Organization (WHO) define "health"?
1
A condition when people are free of disease
2
A condition of life rather than pathological state
3
An actualization of inherent and acquired human potential
Correct4
A state of complete physical, mental, and social well-being

The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Pender explains that all people free of disease are not healthy. Pender, Murdaugh, and Parsons suggest that for many people, health is a condition of life rather than pathological state. Life conditions such as environment, diet, or lifestyle choices can have positive or negative effects on health long before an illness is evident. Pender, Murdaugh, and Parsons (2011) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others.

While assessing the muscle tone of a client, the client demonstrates a full range of muscle motion against gravity with some resistance. What score on the Lovett scale can be given to the client?
1
Fair (F)
Correct2
Good (G)
3
Trace (T)
4
Normal (N)
According to the Lovett score, a full range of motion against gravity with some resistance can be categorized as G (good). F (fair) can be given if the client exhibits a full range of motion with no resistance. T (trace) score is given when the client exhibits slight contractility with no movement. N (normal) on the Lovett scale indicates full range of motion against gravity with full resistance.

What is the inflammation of the skin at the base of the nail called?
Correct1
Paronychia
2
Koilonychia
3
Beau’s lines
4
Splinter hemorrhage
Paronychia is the inflammation of skin at the base of nail. Concavely curved nails are called koilonychias. Transverse depressions in nails indicating a temporary disturbance of nail growth are called Beau lines. Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute endocarditis, or trichinosis and are called splinter hemorrhages.

Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding?
1
There is absence of a pulse.
2
The pulse strength is normal.
3
The pulse strength is bounding.
Correct4
The pulse strength is barely palpable.
A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is bounding, then it is documented as 4+.

A nurse notices cyanosis in a client with heart disease. Which site would the nurse assess to confirm cyanosis?
Correct1
Lips
2
Sclera
Incorrect3
Conjunctiva
4
Mucus membrane
The lips and nail beds are the best sites to assess for cyanosis. The sclera and mucous membrane are assessed in jaundice. The conjunctiva is assessed for the presence of pallor.

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?
1
Skin condition
Correct2
Fluid and electrolyte balance
3
Food intake
4
Fluid intake and output
Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and therefore not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and therefore not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and therefore is not the best choice.
Topics

A nurse is planning to provide self-care health information to several clients. Which client should the nurse anticipate will be most motivated to learn?
1
A 55-year-old client who had a mastectomy and is very anxious about her body image
2
An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking
Correct3
A 56-year-old client who had a heart attack last week and is requesting information about exercise
4
A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain
A client who is requesting information is indicating a readiness to learn. When a nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse should encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?
1
Headache
2
Pallor
Correct3
Paresthesias
4
Blurred vision
Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

Which statement best describes a diagnostic label?
1
It is a condition that responds to nursing interventions.
Correct2
It describes the essence of the client’s response to health conditions.
3
It describes the characteristics of the client’s response to health conditions.
Incorrect4
It is identified from the client’s assessment data and associated with the diagnosis.
A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client’s response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client’s response to health conditions. The related factor of a nursing diagnosis is identified from the client’s assessment data and associated with the diagnosis.

Which statement is true for collaborative problems in a client receiving healthcare?
1
They are the identification of a disease condition.
2
They include problems treated primarily by nurses.
3
They are identified by the primary healthcare provider.
Correct4
They are identified by the nurse during the nursing diagnosis stage.
The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client’s health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem. A medical diagnosis is the identification of a disease condition. Problems that require treatment by the nurse are referred to as nursing diagnoses. A medical diagnosis is identified by the primary healthcare provider based on the results of diagnostic tests.

While assessing a client’s vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation?
Correct1
1+
Incorrect2
2+
3
3+
4
4+
A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?
1
Eczema
2
Hypersensitivity
Correct3
Contact dermatitis
4
Anaphylactic shock
A client who is allergic to latex may experience an allergy after a physical examination with latex gloves. Itching is one of the clinical signs of latex allergy. Contact dermatitis is a delayed immune response that occurs 12 to 48 hours after exposure. Eczema is a skin condition that can be worsened with excessive drying. Hypersensitivity is an immediate allergic reaction that occurs due to chemicals that are used to make gloves. Anaphylactic shock is also an immediate allergic reaction that occurs due to natural rubber latex.

Which type of breathing pattern alteration is manifested with hypercarbia?
1
Eupnea
2
Tachypnea
Correct3
Hypoventilation
4
Kussmaul’s respiration
Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul’s respirations.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment findings observed by the nurse would relate to this diagnosis? Select all that apply.
Correct 1
Fainting
2
Headache
Correct 3
Weakness
Correct 4
Lightheadedness
5
Shortness of breath
Head trauma may cause blood loss and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.

Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of what?
1
A food allergy
2
Noncompliance with medications
3
Side effects from medications
Correct4
A nutritional deficiency
All of the signs listed are classic for a poor nutritional state lacking in basic nutrients such as vitamins and protein. A specific food allergy or medication is not described; therefore there is not enough information to assume the signs and symptoms are related to either or to noncompliance with medications.

The nurse finds that the client’s fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?
1
Relapsing
2
Sustained
Correct3
Remittent
4
Intermittent
In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
1
Burns
Incorrect2
Vasculitis
3
Diaphoresis
Correct4
Red and dry skin
Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.

Which pulse site is used for the Allen’s test?
Correct1
Ulnar
2
Popliteal
3
Brachial
4
Femoral
The ulnar site is used for the Allen’s test. The popliteal pulse is used to assess status of circulation to lower leg. The status of the circulation in the lower arm and blood pressure are assessed using the brachial pulse. The femoral pulse is used to assess the character of the pulse during physiological shock or cardiac arrest when other pulses are not palpable.

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
Correct1
Planning
2
Evaluation
3
Assessment
Incorrect4
Implementation
The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client’s problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.

Which positioning should be avoided while assessing a client with a history of asthma?
1
Sitting
2
Supine
3
Dorsal recumbent
Correct4
Lateral recumbent
The lateral recumbent position is used to assess heart function. A client with asthma or other respiratory problems may not tolerate the lateral recumbent position. The sitting position is used to assess the heart, thorax, and lungs; this position should be avoided in physically weakened clients. The supine position is used to assess the heart, abdomen, extremities, and pulses. The dorsal recumbent position is used for an abdominal assessment and to assess the head, neck, and lungs.

Which physical skin finding indicates opioid abuse?
Incorrect1
Diaphoresis
2
Red, dry skin
Correct3
Needle marks
4
Spider angiomas
Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?
1
Sims position
Correct2
Prone position
3
Supine position
4
Knee-chest position
Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

Which activity by the community nurse can be considered an illness prevention strategy?
1
Encouraging the client to exercise daily
Correct2
Arranging an immunization program for chicken pox
3
Teaching the community about stress management
4
Teaching the client about maintaining a nutritious diet
An illness prevention program protects people from actual or potential threats to health. A chickenpox immunization program is an illness prevention program. It motivates the community to prevent a decline in health or functional levels. A health promotion program encourages the client to maintain the present levels of health. The nurse promotes the health of the client by encouraging the client to exercise daily. Wellness education teaches people how to care for themselves in a healthy manner. The nurse provides wellness education by teaching about stress management. The nurse promotes the health of the client by teaching the client to maintain a nutritious diet.

When should the nurse consider family members as the primary source of information? Select all that apply.
Incorrect 1
The client is an elderly adult.
Correct 2
The client is an infant or child.
Correct 3
The client is brought in as an emergency.
Correct 4
The client is critically ill and disoriented.
5
The client visits the outpatient department.
The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The elderly adult who is conscious, alert, and able to answer the nurse’s questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse’s questions. This client is the primary source of information during assessment.

A client experiencing chills and fever is admitted to the hospital. After assessing the client’s vitals and medical history, the nurse concluded that the client’s fever pattern is remittent. Which assessment finding led to this conclusion?
1
The client’s temperature returns to an acceptable value at least once in the past 24 hours
Correct2
The client’s fever spikes and falls without a return to normal temperature levels
3
Periods of febrile episodes and periods with acceptable temperature values occur
4
The client has a constant body temperature continuously above 38°C with minimal fluctuation
In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in a 24 hour interval, the fever has an intermittent pattern. Periods of febrile episodes and periods with acceptable temperature values is a relapsing type of fever. In a sustained fever, the body temperature is constantly above 38°C and has little fluctuation.

Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Which response by the nurse during a client interview is an example of back channeling?
Correct1
"All right, go on…"
2
"What else is bothering you?"
3
"Tell me what brought you here."
4
"How would you rate your pain on a scale of 0 to 10?"
Back channeling involves the use of active listening prompts such as "Go on…", "all right", and "uh-huh." Such prompts encourage the client to complete the full story. The nurse uses probing by asking the client, "What else is bothering you?" Such open-ended questions help to obtain more information until the client has nothing more to say. The statement, "Tell me what brought you here" is an open-ended statement that allows the client to explain his health concerns in his or her own words. Closed-ended questions such as, "How would you rate your pain on a scale of 0 to 10?" are used to obtain a definite answer. The client answers by stating a number to describe the severity of pain.

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?
1
"You will need to ask your healthcare provider; it is not part of the usual tests for people your age."
2
"There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test."
Correct3
"It is performed routinely starting at your age as part of an assessment for colon cancer."
4
"There must have been a positive finding after a digital rectal examination performed by your healthcare provider."
The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age of 40. Age, family history of polyps, and a positive finding after a digital rectal examination are factors related to colon cancer and secondary reasons for the occult blood test (guaiac test).

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising five days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?
1
Action
2
Preparation
3
Maintenance
Correct4
Precontemplation
The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to six months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins six months after the change has started and continues indefinitely.

When teaching about aging, the nurse explains that older adults usually have what characteristic?
1
Inflexible attitudes
2
Periods of confusion
Correct3
Slower reaction times
4
Some senile dementia
A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

AirwayBreathingCirculation
Maslow’s Heirarchy of Needs
– 1st – Need to be met to sustain life O2, temp control, food, waste elimination, sexuality, rest
– 2nd (lower level needs) – Hand hygeiene, proper eqip, meds, skills for ambulatiob, trusting others, enourage spirutality, automony, explain unfamilarity
– 3rd – love and belonging, communicaition, or will feel isolation
– 4th self esteem, recognize their accomplishment, concentr.ate on strenght
– 5th self acutalization
Assessment Diagonsis Planning Implementing Evaluating care

A nurse is assessing a client’s degree of edema and finds 8 mm of depth. How does the nurse document this condition?
1
1+
2
2+
3
3+
Correct4
4+
Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

Which integumentary finding is related to skin texture?
Incorrect1
Elasticity
2
Vascularity
3
Fluid buildup
Correct4
Character of the surface
Assessing for texture refers to the character of the surface of the skin. Assessing for elasticity determines the turgor of the skin. Assessing for vascularity determines skin circulation. Fluid buildup in the tissues indicates edema.

While assessing a neonate’s temperature, the nurse observes a drop in the body temperature. What is the most appropriate reason for this temperature drop?
1
Increased basal metabolic rate
Incorrect2
Decreased involuntary shivering
3
Increased voluntary movements
Correct4
Decreased nonshivering thermogenesis
Neonates are susceptible to heat loss or cold stress. Nonshivering thermogenesis is a natural mechanism of heat production that occurs to minimize heat loss in a neonate. This mechanism’s failure may lead to a drop in body temperature. The basal metabolic rate (BMR) accounts for heat production; an increased BMR may raise the body temperature. Shivering is an involuntary movement that produces heat, which may not be seen in neonates. Voluntary movements cause increases in body temperature.

The nurse pulls up on the client’s skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for?
1
Pain tolerance
Correct2
Skin turgor
3
Ecchymosis formation
4
Tissue mass
Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms?
Incorrect1
"Can you describe the pain?"
2
"Where exactly do you feel the pain?"
3
"Which activities make the pain worse?"
Correct4
"What other discomfort do you experience?"
Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain. The nurse assesses the quality of the pain by asking the client to describe it. The nurse gathers information about the location of the illness by asking the client to identify the exact location. The nurse tries to understand the precipitating factors by asking the client about the activities that aggravate the pain.

client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke?
Correct1
Increased heart rate
Incorrect2
Increased blood pressure
3
Decreased respiratory rate
4
Increased circulatory damage
Prolonged exposure to the sun or a high environmental temperature overwhelms the body’s heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.

Which term refers to a blowing sound created by turbulence caused by narrowing of arteries while assessing for carotid pulse?
Correct1
Bruit
2
Ectropion
3
Entropion
4
Borborygmi
A bruit is an audible vascular blowing sound associated with turbulent blood flow through a carotid artery. Ectropion is a condition in which the eyelid is turned outwards away from the eyeball. Entropion is a malposition resulting in an inversion of the eyelid margin. Borborygmi are rumbling or gurgling noises made by the movement of fluid and gas in the intestines

STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be?
1
Papule
Correct2
Vesicle
3
Nodule
4
Pustule
A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule and of 1-2 cm in diameter. A pustule is a circumscribed elevation of the skin that is similar to a vesicle but filled with pus and varies in size.

Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A nurse suspects that a client has interacted with poison ivy. Assessment findings reveal vesicles on the arms and legs. Which is the description of a vesicle?
1
A lesion filled with purulent drainage
2
An erosion into the dermis
3
A solid mass of fibrous tissue
Correct4
A lesion filled with serous fluid
A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule, an erosion into the dermis is known as an excoriation or ulcer, and a solid mass of fibrous tissue is known as a papule.

Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what?
1
Vesicular
2
Bronchial
Correct3
Crackles
4
Rhonchi
Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?
1
Contusion
Incorrect2
Thrombosis
Correct3
Atherosclerosis
4
Tourniquet effect
In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that causes mechanical obstruction to blood flow indicates thrombosis. The tourniquet effect may be caused by the application of constricting devices, which may lead to impaired blood flow to areas below the site of constriction.

Which factor can elevate the oxygen saturation during an assessment?
1
Nail polishes
Correct2
Carbon monoxide
3
Intravascular dyes
4
Skin pigmentation
Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestimate the saturation.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved?
1
Wheal
2
Papule
3
Vesicle
Correct4
Macule
A macule is a flat, nonpalpable change in skin color, which is smaller than 1 cm. A wheal is a localized edema, usually caused by a mosquito bite. Wheals are irregular in shape and have elevated surfaces. Papules are palpable, circumscribed solid elevations in the skin, smaller than 1 cm. Vesicles are small, circumscribed skin elevations, filled with serous fluid.

Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

A client shows an increase in rate respirations that are abnormally deep and regular. What condition would the nurse expect?
1
Hypoventilation
2
Biot’s respiration
Correct3
Kussmaul’s respiration
4
Cheyne-Stokes respiration
Kussmaul’s respiration is an alteration in the breathing process that is characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot’s respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respiration.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply.
Correct 1
Loss of turgor
Incorrect 2
Urinary incontinence
Correct 3
Decreased night vision
Correct 4
Decreased mobility of ribs
5
Increased sensitivity to odors
In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

Which pulse site is used to perform Allen’s test?
Correct1
Ulnar
2
Brachial
3
Femoral
4
Dorsalis pedis
The ulnar pulse site is used to perform Allen’s test. The brachial pulse site is used to assess the status of circulation to the lower arm and to auscultate blood pressure. The femoral site is used to assess the character of the pulse during physiological shock or cardiac arrest. The dorsalis pedis site is used to assess the status of circulation in the foot.

Which term refers to the exaggeration of the posterior curvature of the thoracic spine?
1
Lordosis
2
Scoliosis
Correct3
Kyphosis
4
Osteoporosis
Kyphosis is an excessive outward curvature of the spine that causes hunching of the back. Lordosis is the excessive inward curvature of the lumbar part of the spine. Scoliosis is the abnormal lateral curvature of the spine. Osteoporosis is characterized by a loss of bone mass and a deterioration of bone tissues.

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?
Correct1
Perform an assessment of the client before resuming the change-of-shift report.
2
Continue the change-of-shift report and include the decrease in blood pressure.
3
Lower the diastolic pressure limits on the monitor during the change-of-shift report.
4
Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure.
The cause of the alarm should be investigated and appropriate intervention instituted; after the client’s needs are met, then other tasks can be performed. An alarm should never be ignored; the client’s status takes priority over the change-of-shift report. The diastolic pressure limit has been prescribed by the primary healthcare provider and should not be changed for the convenience of the nurse. Alarms always should remain on; the alarm indicates that the client’s blood pressure has decreased and immediate assessment is required.

STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.

The nurse must understand the process of changing behaviors to be able to support difficult behavioral changes in clients. Arrange the Stages of Health Behavior Change as described by DiClemente and Prochaska (1998) in the transtheoretical model of change.
Correct
1.
Precontemplation
Correct
2.
Contemplation
Correct
3.
Preparation
Correct
4.
Action
Correct
5.
Maintenance stage
The first stage of behavioral change is the precontemplation stage. During this stage, the client may be defensive when confronted with information about the behavior. The client does not intend to make any changes within the next six months. The second stage is the contemplation stage. The client begins to consider a change within the next six months as he or she develops more belief in the value of change. The third stage is preparation when the client believes that advantages outweigh disadvantages of behavior change. The client needs assistance planning for a change in the next month. The fourth stage is action, which will last up to six months. During this stage the client is actively engaged in strategies to change behavior while the nurse identifies barriers to change. The fifth stage is the maintenance stage, which begins six months after the change has started and continues indefinitely.

The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source?
1
X-ray reports
Correct2
Severity of pain
3
Results of blood work
4
Family caregiver interview
The primary source of information during an assessment is the client. The nurse gathers information about the client’s pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client’s family caregiver is a secondary source of information.

While inspecting the external eye structure of a client, a nurse finds bulging of the eyes. Which condition can be suspected in the client?
1
Eye tumors
2
Hypothyroidism
Correct3
Hyperthyroidism
4
Neuromuscular injury
Bulging eyes may indicate hyperthyroidism. Tumors are characterized by abnormal eye protrusions. Hypothyroidism can be revealed by the coarseness of the hair of the eyebrows and the failure of the eyebrows to extend beyond the temporal canthus. Crossed eyes or strabismus may result from neuromuscular injury or inherited abnormalities.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client?
1
Apnea
Correct2
Bradypnea
3
Tachypnea
4
Hyperpnea
In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern does the assessment include?
1
Value-belief pattern
2
Role-relationship pattern
3
Cognitive-perceptual pattern
Correct4
Self-perception-Self-tolerance pattern
The nurse is applying Gordon’s Self-perception-Self-tolerance pattern to assess the client. This functional pattern describes the client’s self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client’s choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply.
1
Axilla
2
Fingers
3
Ear lobes
4
Forehead
5
Upper thorax

Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

Which of the following is a description of the percussion technique?
1
Listening to sounds that the body makes
2
Using the sense of touch to assess and collect data
3
Carefully looking for abnormal findings
4
Tapping the skin with the fingertips to vibrate underlying tissues

Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves using the sense of touch to assess and collect data. Generally during an inspection, the nurse should carefully look for abnormal findings.

What would be the respiratory rate in two-year-old child?

1. 20
2. 30
3. 40
4. 50

The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow.
Incorrect
1.
Self-esteem
Incorrect
2.
Self-actualization
Incorrect
3.
Safety and security
Incorrect
4.
Physiological needs
Incorrect
5.
Love and belonging needs

Maslow’s hierarchy of needs helps the nurse understand the interrelationships of basic human needs. These basic needs are a major factor in determining a person’s level of health. The first level includes basic physiological needs such as oxygen, fluids, nutrition, body temperature, elimination, shelter, and sex. The second level is safety and security needs, which involve physical and psychological security. The third level is the need of love and belonging. The fourth level encompasses self-esteem needs. The fifth level is the need for self-actualization. It is the highest expression of one’s individual potential and allows for continual discovery of self.

While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate?
1
Relapsing
2
Sustained
3
Remittent
4
Intermittent

Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38oC with little fluctuations. In a remittent fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once in 24 hours, the fever is termed intermittent.

What is the correct order of phases a client experiences in the event of a change in body image following an illness?
Correct
1.
Shock
Correct
2.
Withdrawal
Correct
3.
Acknowledgement
Incorrect
4.
Rehabilitation
Incorrect
5.
Acceptance

When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgement phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use prosthesis, or change lifestyles or goals.

The nurse is gathering a client’s health history. Which information does should the nurse classify as biographical information? Select all that apply.
1
Symptoms
Correct 2
Client’s age
Incorrect 3
Family structure
Correct 4
Type of insurance
Correct 5
Occupation status

Biographical information is factual demographic data about the client usually obtained by the admitting office staff. The client’s age, types of insurance, and occupation status are considered biographical information. If the client presents with an illness, the nurse gathers details about the symptoms of the illness, which is descriptive information, not biographical information. The nurse obtains information about family structure while assessing the family history of the client. It is not biographical information.

A student nurse is assessing the blood pressure of a client with the client’s arm unsupported. What are the expected errors in the obtained readings?
Correct1
False high reading
2
False low diastolic reading
3
False high systolic reading
4
False high diastolic reading

If the client’s arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic reading. Repeated assessments of blood pressure too often result in a false high systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.

Which sites would be safe and inexpensive for temperature measurement? Select all that apply.

1. Skin
2. Oral
3. Axilla
4. Rectal
5. Tympanic membrane

The skin and axilla are safe and inexpensive sites of the body for temperature measurement. The oral route is an easily accessible site for temperature measurement but it may not be the safest route because of the exposure to body fluids. The rectal route may not be easily accessible and safe because a measurement via this route may increase the risk of body fluid exposure. The tympanic membrane is an easily accessible site for temperature measurement but care should be taken when used in neonates, infants, and children.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?
1
The nurse notes nonverbal signs of discomfort.
2
The nurse observes the client’s position in bed.
3
The nurse asks the client to explain the surgery.
4
The nurse asks the client to rate the severity of pain.

The nurse must assess the client’s knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients may not state that they are in pain. The nurse observes the client’s positioning in bed to determine any abnormal signs such as discomfort or pain. The nurse asks the client to rate the severity of pain to determine a nursing diagnosis of pain related to a surgical wound.

The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client?
1
Frostbite
2
Heatstroke
3
Hypothermia
4
Hyperthermia

Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.

A client with a head injury underwent a physical examination. The nurse observes that the client’s temperature assessments do not correspond with the client’s condition. An injury to which part of the brain may be the reason for this condition?
1
Pons
2
Medulla
3
Thalamus
4
Hypothalamus

The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.

Which statement best describes a diagnostic label?
1
It is a condition that responds to nursing interventions.
2
It describes the essence of the client’s response to health conditions.
3
It describes the characteristics of the client’s response to health conditions.
4
It is identified from the client’s assessment data and associated with the diagnosis.

A diagnostic label is the name of the nursing diagnosis as approved by the North American Nursing Diagnosis Association International (NANDA-I). It describes the essence of the client’s response to health conditions in as few words as possible. The etiology of a nursing diagnosis is a condition that responds to nursing interventions. All NANDA-I approved diagnoses have a definition that describes the characteristics of the client’s response to health conditions. The related factor of a nursing diagnosis is identified from the client’s assessment data and associated with the diagnosis.

Arrange the sequence of events occurring during a fever secondary to pyrogens in chronological order.
Incorrect
1.
The set point of the hypothalamus is raised
Incorrect
2.
Immune system response is triggered
Correct
3.
Body temperature is increased
Correct
4.
Pyrogens are destroyed
Correct
5.
Heat loss responses are initiated

A true fever results from an alteration in the hypothalamic set point. Pyrogens act as antigens that trigger the immune system response. The hypothalamus reacts by raising the set point, thereby increasing the body temperature. Once the pyrogens are removed, the third phase of a febrile episode occurs. Heat loss responses are initiated when the hypothalamus set point drops.

Which type of breathing pattern alteration is manifested with hypercarbia?
1
Eupnea
2
Tachypnea
3
Hypoventilation
4
Kussmaul’s respiration

Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul’s respirations.

What does a nurse consider the most significant influence on many clients’ perception of pain when interpreting findings from a pain assessment?
1
Age and sex
2
Physical and physiological status
3
Intelligence and economic status
4
Previous experience and cultural values

Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress; however, unless the nervous system is involved, it will not greatly affect perception. Intelligence is a factor in understanding pain so it can be tolerated better, but it does not affect the perception of intensity; economic status has no effect on pain perception.

The nurse assessed a client’s pulse rate and recorded the score as 3+. What is the strength of the pulse?
1
Strong
2
Bounding
3
Expected
4
Diminished

A pulse strength of 3+ is considered full or strong. A bounding pulse is 4+. A pulse strength is considered normal and expected when it is 2+. The pulse strength is diminished or barely palpable when the score is 1+.

What is the sequence of techniques used while assessing the abdomen?
Correct
1.
Inspection
Correct
2.
Auscultation
Incorrect
3.
Palpation
Incorrect
4.
Percussion

The order of an abdominal assessment begins with inspection of the contour, symmetry, and surface motion of the abdomen. The nurse will note any masses, bulging, or distention. The second step is auscultation, which is done before palpation to reduce the chance of altering the frequency and character of bowel sounds. The third step is percussion, which is used to assess kidney inflammation. The fourth step is palpation, which detects areas of abdominal tenderness, distention, or masses.

The nurse applies the nursing process while caring for clients. What is the correct order of steps of the nursing process?
1.
Assessment
2.
Diagnosis
3.
Planning
4.
Implementation
5.
Evaluation

The nursing process is a critical thinking process that the nurse uses to apply the best available evidence to caregiving and promote health functions. The first step of the process is assessment. In this step, the nurse gathers and analyzes information about the client’s health status. The second step of the process is diagnosis. The nurse uses assessment findings to make clinical judgments and identify the client’s response to health problems in the form of nursing diagnoses. The third step of the process is planning. In this step, the nurse sets goals and expected outcomes for the client’s care. The nurse selects interventions (nursing and collaborative) individualized to each of the client’s nursing diagnoses. The fourth step of the process is implementation, which involves performing the planned interventions. In the fifth step, the nurse evaluates the client’s response and whether the interventions were effective. The nursing process is dynamic and continuous.

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition?
1
Heroin
2
Atropine
3
Morphine
4
Pilocarpine

The intake of eye medications such as atropine will cause dilatation of the pupils. Heroin, morphine, and pilocarpine cause pupillary constriction.

The nurse finds that the client’s fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of?
1
Relapsing
2
Sustained
3
Remittent
4
Intermittent

In a remittent pattern, fever spikes and falls without returning to normal temperature levels. Periods of febrile episodes coupled with periods of acceptable temperature values are called a relapsing pattern. A constant body temperature continuously above 38° C (100.4° F) with little fluctuation refers to a sustained pattern. In an intermittent pattern, fever spikes are interspersed with normal temperature levels.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. How can the nurse best assess the client’s pain level?
Incorrect1
Asking the client’s parent
Correct2
Using Wong’s "Pain Faces"
3
Observing the client’s body language
4
Explaining the use of a 0 to 10 pain scale
An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong’s "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but it may not accurately reflect the client’s level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?
1
"Scratch the itchy area gently."

2
"Put an ice pack on the affected area."
3
"Sprinkle a layer of powder around the itchy spots."
4
"Ask your doctor for a prescription for an antihistamine."
An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.

Which functional level of trauma center is involved in providing a full continuum of trauma services?
Correct1
Level I
2
Level II
3
Level III
Incorrect4
Level IV
Level I trauma centers provide a full continuum of trauma services for all clients. Level II trauma centers provide care for most injured clients. Level III centers are able to stabilize clients with major injuries, but must transport clients if needs exceeds resource capabilities. Level IV trauma centers are usually involved in providing basic trauma client stabilization and advanced life support within the resource capabilities. They are also responsible for the transfer of clients if need exceeds the resource competencies.

Which nursing theory focuses on the client’s self-care needs?
1
Roy’s theory
Correct2
Orem’s theory
3
Watson’s theory
Incorrect4
Leininger’s theory
Orem’s self-care deficit theory focuses on the client’s self-care needs. According to Roy’s theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson’s theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger’s theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care.

A nurse is assessing the urine of a client with a urinary tract infection. Which assessment finding is consistent with a urinary tract infection?
1
Smoky
Correct2
Cloudy
3
Orange-amber
4
Yellow-brown
Cellular debris, white blood cells, bacteria, and pus can cause the urine to become cloudy. Dark, smoky urine usually suggests hematuria. Orange-amber color of urine may indicate concentrated urine; also, it can be caused by phenazopyridine or foods such as beets. Yellow-brown to dark color of urine indicates excessive bilirubin.

A nurse is caring for an infant with developmental dysplasia of the hip. What is the priority intervention for this child?
Incorrect1
Flexion of the hip
2
Extension of the hip
3
Adduction of the hip
Correct4
Abduction of the hip
Abduction will enable the head of the femur to fit into the acetabulum, thereby correcting the dysplasia. Flexion causes the head of the femur to move away from the acetabulum. Extension causes the head of the femur to move away from the acetabulum. Adduction causes the head of the femur to move away from the acetabulum.

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse’s next action?
1
Returning the aspirate and withholding the feeding
Incorrect2
Discarding the aspirate and administering the full feeding
Correct3
Returning the aspirate and subtracting the amount of the aspirate from the feeding
4
Discarding the aspirate and adding an equal amount of normal saline solution to the feeding
The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant’s fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant’s fluid and electrolyte balance.

A client with gastroesophageal reflux disease (GERD) is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend?
Correct1
Apple
Incorrect2
Orange
3
Tomato
4
Grapefruit
Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is most appropriate for the nurse to teach the client about meal management?
1
Snack daily in the evenings
Correct2
Divide food into four to six meals a day
3
Eat the last of three daily meals by 8:00 PM
4
Suck a peppermint candy after each meal
The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter. Snacking in the evening can cause reflux. The last meal should be eaten at least three hours before bedtime; individual bedtimes vary. Peppermint promotes reflux because it relaxes the lower esophageal sphincter, allowing food to be regurgitated into the esophagus.

A child has cystic fibrosis. Which verbalization by the parents about their plan for the child’s dietary regimen provides evidence that they understand the nurse’s instructions?
1
Restrict fluids during mealtimes.
Incorrect2
Discontinue the use of salt when cooking.
Correct3
Provide high-calorie foods between meals.
4
Add whole-milk products from the diet.
The caloric intake should be 150% to 200% more than the expected intake for size and age because absorption of fats and nutrients is compromised by the disease process. Fluids are encouraged to keep bronchial secretions from becoming too thick and tenacious. Salt is added to the diet to compensate for excessive sodium losses in saliva and perspiration. Whole milk may not be tolerated because of its high fat content; skim milk products should be substituted.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow?
Correct1
Low fat
2
Low carbohydrate
3
Soft-textured and bland
4
High protein and kilocalories
The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a diet high in protein and kilocalories might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed.

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