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Health Assessment

A set of questions, answered by patients, that asks about personal behaviors, risks, life-changing events, health goals and priorities, and overall health.

patients

clinicians

health care teams

health

illness concerns

assessment

diagnosis

planning

implementation

evaluation

time-lapsed assessment

emergency assessment

inspection

palpation

percussion

auscultation

Short febrile periods of few days are interspersed within a period of 1 – 2 days

  • Constant fever
  • Intermittent fever
  • Remittent fever
  • Relapsing fever

High pitched, louder in neck than over chest wall, originating in larynx or upper airway obstruction from swollen, inflamed tissues or lodged foreign body.

  • [No Answer]

The symptoms occurring with lactose intolerance include:

  • anorexia.
  • bloating and flatulence.
  • hematemesis.
  • gray stools.

Ethnicity is a term often interchangeably used with race. Ethnicity may be viewed as a relationship among individuals who believe that they have distinctive characteristics that make them a group

  • Race
  • Diversity
  • Ethnicity
  • Culture

A 50 year old patient who had surgery 8 hours ago has a blood pressure of 126/86 while lying down. The BP is 94/54 when sitting up at 2 minute. The patient states that he is light-headed and you see that he has become pale. What is the most likely cause for the change in the blood pressure?

  • Orthostatic hypotension

Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?

  • Do nothing, because this is an expected finding
  • Immediately clamp the chest tube and notify the physician
  • Check for an air leak because the bubbling should be intermittent
  • Increase the suction pressure so that the bubbling becomes vigorous

Two nurses are taking an apical-radial pulse and note a difference in pulse rate of 8 beats per minute. The nurse would document this difference as which of the following?

  • Pulse deficit

The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is:

  • Replaced every 4 weeks
  • Thin and nonstratified
  • Thick and tough
  • Highly vascular

The following labels are found in the: “related to” ,followed by "manifested by”.

  • Implementation
  • Nursing Diagnosis
  • Planning
  • Assessment

A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium:

  • Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect.
  • Stimulates production of the body’s own thrombolytic substances, but it takes 2-4 days for it to begin.
  • Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.
  • Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this is exhibit an anticoagulant effect.

Enlargement of male breasts

  • Gynecomastia

Menopause occurring after which age increases the risk of breast cancer?

  • women over 50 years old have increased the risk of breast cancer.

Breast Composed of glandular tissue, fibrous tissue & adipose tissue.

  • True
  • False

In which portion of the breast tissue is it the most common place for breast cancer to be found?

  • [No Answer]

A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?

  • “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”
  • “When at the beach, sit in the shade to prevent sunburn.”
  • “Apply sunscreen even on overcast days.”
  • “Use a sunscreen with a sun protection factor of 6 or higher.”

Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

  • A hyperinflated chest noted on the chest x-ray
  • A widened diaphragm noted on the chest x-ray
  • Hypocapnia
  • Increased oxygen saturation with exercise

Which of the following characteristics is typical of the pain associated with DVT?

  • Sudden onset
  • No pain
  • Dull ache
  • Tingling

When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:

  • Keep the patient flat in bed
  • Keep the tracheostomy cuff fully inflated
  • Develop an alternative communication method
  • Encourage oral feeding as soon as possible

For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

  • Administering a sedative, as prescribe
  • Encouraging the patient to drink three glasses of fluid daily
  • Using a high-flow venture mask to deliver oxygen as prescribe
  • Keeping the patient in semi-Fowler’s position

Normal adult respiratory rate

  • 30 – 80 cycles per minute
  • 20 – 40 cpm
  • 10 – 20 cpm
  • 15 – 25 cpm

Mrs. Bagapayo who had abdominal surgery 3 days earlier complains of sharp, throbbing abdominal pain that ranks 8 on a scale of 1 (no pain) to 10 (worst pain). Which intervention should the nurse implement first?

  • Explaining to the client that the pain should not be this severe 3 days postoperatively
  • Checking the client’s chart to determine when pain medication was last administered
  • Assessing the client to rule out possible complications secondary to surgery
  • Obtaining an order for a stronger pain medication because the client’s pain has increased

Light Palpation of the abdomen

  • Hold your hand slightly below the client’s abdomen, with your fingers parallel to the abdomen.
  • Note the tenderness and for superficial pain, masses, and muscle guarding. To determine areas of tenderness, ask the client tell you about them and watch for changes in the client’s area of tenderness.
  • If the client is excessively ticklish, begin by pressing your hand on top of the client’s hand while pressing lightly. Then slide your hand off the client’s and onto the abdomen to continue the examination
  • Depress the abdominal wall lightly, about 1 cm or to the depth of the subcutaneous tissue, with the pads of your fingers. Move the finger pads in a slight circular motion.

The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care?

  • Imbalanced nutrition
  • Anxiety
  • Disturbed sensory perception
  • Self-care deficit

A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

  • Drawing blood for a hematocrit and hemoglobin level
  • Applying a dressing over the wound and taping it on three sides
  • Preparing a chest tube insertion tray
  • Preparing to start an I.V. line

The _____ is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.

  • Database

A patient tells the nurse that he is nervous, nauseated and feels hot. These types of data would be _____.

  • Introspective

Joseph, a 12-year-old child, complains to the school nurse about nausea and dizziness. While assessing the child, the nurse notices a black eye that looks like an injury. This is the third time in 1 month that the child has visited the nurse. Each time, the child provides vague explanations for various injuries. Which of the following is the school nurse’s priority intervention?

  • Contact the child’s parents and ask about the child’s injury.
  • Encourage the child to be truthful with her.
  • Report suspicion of abuse to the proper authorities.

Which term would the nurse use to document pain at one site that is perceived in other site?

  • Referred pain
  • Aftermath of pain
  • Intractable pain
  • Phantom pain

It is a term with many definitions, often used interchangeably with the terms ethnicity and culture

  • Diversity
  • race
  • Culture
  • Ethnicity

Edema of the breast tissue gives the breast a specific appearance. What is this termed?

  • [No Answer]

The client’s vision is tested with a Snellen’s chart. The results of the tests are documented as 20/60. The nurse interprets this as:

  • The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
  • The client’s vision is normal
  • The client can read only at a distance of 20 feet what a client with normal vision can read at 60 feet.
  • The client is legally blind.

In planning pain reduction interventions, which pain theory provides information most useful to nurses?

  • Central-control theory
  • Specificity theory
  • Pattern theory
  • Gate-control theory

The carotid arteries:

  • Supply oxygenated blood to the head and neck.
  • When cardiac output is diminished, the peripheral pulses may be difficult or impossible to feel, but the carotid pulse should be felt easily.
  • All of the above
  • None of the above

The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis:

  • Contains sensory receptors
  • Is replaced every 4 weeks
  • Consists mostly of keratin
  • Contains mostly fat cells

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?

  • Subcutaneous fat deposits are high in the newborn.
  • The newborn's skin is more permeable than that of the adult.
  • Sebaceous glands are over productive in the newborn.
  • The amount of vernix caseosa dramatically rises in the newborn

Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?

  • Mitral area
  • Aortic arch
  • Tricuspid area
  • Pulmonic area

A darkly pigmented surrounds nipple 1-2 cm smooth muscle fibers that cause nipple erection when stimulated is called mongomer’s glands.

  • True
  • False

Mr. J is admitted in the hospital after suffering from coughs for 5 days. He is 68 years old and known to be a diabetic for 20 years. The diagnosis is pneumonia. Which data would be of greatest concern to the nurse when completing the nursing assessment of the patient?

  • Clear breath sounds and nonproductive cough
  • Buccal cyanosis and capillary refill greater than 3 seconds
  • Hemoglobin concentration of 13 g/dl and leukocyte count 5,300/mm3
  • Alert and oriented to date, time, and place

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:

  • Stay very still
  • Perform the Valsalva maneuver
  • Inhale and exhale quickly
  • Exhale slowly

Vertigo, tinnitus, pain, anxiety, nausea, weakness, fatigue, anorexia , thirst, nervousness are:

  • Subjective Data
  • Assessment Data
  • Source Data
  • Objective Data

The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?

  • Speak frequently
  • Speak loudly
  • Speak directly into the impaired ear
  • Speak in a normal tone

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?

  • Calcium deficiency
  • An acute obstruction in the vessels of the legs
  • Peripheral vascular problems in both legs
  • Diabetes

Hypercapnea is:

  • The strongest stimulus to breathe is an increase of carbon dioxide in the blood
  • Relaxation of the intercostal muscles and the diaphragm
  • Increases respiration but is less effective than a rise in carbon dioxide levels
  • An involuntary control of respiration in response to emotional changes such as fear
  • or excitement

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?

  • Increased possibility of bruising
  • Lack of availability of glucose-monitoring supplies
  • Skin sensitivity as a result of exposure to salt water
  • Importance of sunscreen and avoiding direct sunlight

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

  • Phagocytes
  • Melanocytes
  • Fungacytes
  • Metrocytes

The abdomen normally moves when breathing until the age of ____ years.

  • 7
  • 75
  • 14
  • 4

Mr. Lim, who has chronic pain, loss of self-esteem, no job, and bodily disfigurement from severe burns over the trunk and arms, is admitted to a pain center. Which evaluation criteria would indicate the client’s successful rehabilitation?

  • The client experiences decreased frequency of acute pain episodes.
  • The client develops increased tolerance for severe pain in the future.
  • The client continues normal growth and development with intact support systems.
  • The client remains free of the aftermath phase of the pain experience.

Buerger’s disease is characterized by all of the following except:

  • Redness or cyanosis in the limb when it is dependent
  • Venous inflammation and occlusion
  • Arterial thrombosis formation and occlusion
  • Lipid deposits in the arteries

Inspect the muscles for tremors, for.

  • Inspect the muscles for strength.
  • Inspect the muscles and tendons for contractures (shortening).
  • All of the above
  • None of the above

This consists of the mediastinum and the lungs. The mediastinum refers to a central area in the thoracic cavity that contains the trachea, esophagus, heart, and great vessels.

  • Thoracic vertebrae
  • Thoracic cage
  • Thorax
  • Thoracic cavity

Abdominal landmarks

  • 1. Midline 2. Umbilical 3. Epigastric

This involves sense of sight.

  • Inspection

Body temperature alternates at a regular intervals between periods of fever and normal temperature.

  • Constant fever
  • Remittent fever
  • Relapsing fever
  • Intermittent fever

This systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery.

  • Nursing Documentation
  • Progress Notes
  • Electronic Nursing Documentation
  • Collection of Objective Data

Perform the procedure using cephalo – caudal sequence, means;

  • From median to laterals
  • From front to back
  • From head to toe
  • From laterals to median

Pyloric stenosis is aNo:

  • abnormal enlargement of the pyloric sphincter.
  • congenital narrowing of the pyloric sphincter.
  • abnormal opening in the pyloric sphincter.
  • inflammation of the pyloric sphincter.

Ryan who is a chronic alcohol abuser is being assessed by Nurse Gina. Which problems are related to thiamin deficiency?

  • CNS symptoms, such as ataxia and peripheral neuropathy
  • Cardiovascular symptoms, such as decreased hemoglobin and hematocrit levels
  • Gastrointestinal symptoms, such as nausea and vomiting
  • Respiratory symptoms, such as cough and sore throat

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to an aneurysm?

  • Subjective sensation of “heart beating” in the abdomen.
  • Hyperactive bowel sounds in that area
  • Pulsatile abdominal mass
  • Systolic bruit over the area of the mass

In a female client with burns on the legs, which nursing intervention helps prevent contractures?

  • Applying knee splints
  • Hyperextending the client’s palms
  • Performing shoulder range-of-motion exercises
  • Elevating the foot of the bed

Which assessment data should the nurse include when obtaining a review of body systems

  • Information about the client’s sexual performance and preference
  • The client’s name, address, age, and phone number
  • Brief statement about what brought the client to the health care provider
  • Client complaints of chest pain, dyspnea, or abdominal pain

All of the following are nursing interventions, except:

  • Ordered Intervention
  • Independent Interventions
  • Dependent Intervention
  • Interdependent Intervention

A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient’s condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

  • A disconnected ventilator tube
  • A change in the oxygen concentration without resetting the oxygen level alarm
  • An endotracheal cuff leak
  • Kinking of the ventilator tubing

Depressing the nail edge to blanch, keep on pressing until skin becomes cyanotic

  • Depressing the nail edge to blanch, noting the return of color for about 5-8 seconds
  • Capillary refill is an index of peripheral perfusion and cardiac output.
  • Depressing the nail edge to blanch, then release, noting the return of color – color return is instant, within 1 to 3 seconds.

Portion of the body extending from base of neck superiorly to level of diaphragm inferiorly.

  • Thorax

Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using?

  • Undoing
  • Denial
  • Suppression
  • Compensation

Having two first-degree family members with breast cancer doubles the risk for the patient.

  • True
  • False

A significant cause of venous thrombosis is:

  • Vessel wall injury
  • All of the above
  • Altered blood coagulation
  • Stasis of blood

This developer proposed 8 major stages of psychosocial development and expected tasks along the life span from infancy to old age.

  • Jean Piaget
  • Erik Erickson
  • Sigmund Freud
  • Abraham Maslow

Wide range of temperature fluctuations over 24 hour period

  • Relapsing fever
  • Constant fever
  • Remittent fever
  • Intermittent fever

Vitamin taken to reduce breast edema and tenderness.

  • Vitamin E

When using Snellen’s Eye Charts:

  • Ask the patient to cover one eye with opaque card. Test right eye first, then the left eye.
  • If the patient wears eye glasses or contact lenses, leave them on. Remove only reading glasses because they will blur distance vision.
  • Is used to measure visual acuity. It has lines of letters arranged in decreasing size.
  • Position the patient 25 feet away from the chart.

A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?

  • Activity intolerance related to fatigue
  • Risk for infection related to retained secretions
  • Anxiety related to actual threat to health status
  • Impaired gas exchange related to airflow obstruction

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

  • Strengthen the diaphragm
  • Promote carbon dioxide elimination
  • Strengthen the intercostal muscles
  • Promote oxygen intake

Expiration is mostly passive in nature and occurs with relaxation of the intercostal muscles and the diaphragm.

  • The resultant increase in the size of the chest cavity creates a positive pressure, forcing air into the lungs.
  • Forces air into the lungs
  • Mostly passive in nature and occurs with relaxation of the intercostal muscles and the diaphragm.
  • As the diaphragm relaxes, it resumes a domed shape.

Angle of Louis Connects with 2nd rib Tracheal bifurcation Upper boarder of atria.

  • sternal angle

A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as _____.

  • protuberant

Nurse Tara is teaching a community group about substance abuse. She explains that a genetic component has been implicated in which of the following commonly abused substances?

  • Alcohol
  • Heroin
  • Barbiturates
  • Marijuana

The general sequence of performing physical examination techniques is as follows:

  • Inspection, Palpation, Percussion, Auscultation.
  • Auscultation, Percussion, Palpation, Inspection
  • Inspection, Percussion, Auscultation, Palpation
  • Inspection, Auscultation, Palpation, Percussion

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ______ of the underlying tissue.

  • Density
  • Texture
  • Consistency
  • Turgor

The major axillary lymph nodes consist of:

  • The anterior (pectoral), interior (subscapular), lateral (brachial), and central (midaxillary) nodes
  • The anterior (pectoral), posterior (subscapular), lateral (brachial), and central (midaxillary) nodes.
  • The anterior (pectoral), posterior (subscapular), uni-lateral (brachial), and central (midaxillary) nodes.
  • The interior (pectoral), posterior (subscapular), lateral (brachial), and central (midaxillary) nodes.

When inspecting the nipples.

  • Note the size and direction of the nipples of both breasts.
  • Note any dryness, lesions, bleeding, or discharge
  • None of the above
  • All of the above

It is a milk produced by the acini cells empties into the lactiferous ducts.

  • [No Answer]

Clear nipple discharge.

  • [No Answer]

M is for: ____

  • Manifestation
  • Material
  • Measurable
  • Maintain

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

  • Diminished breath sounds
  • A low respiratory rate
  • The presence of a barrel chest
  • A sucking sound at the site of injury

Which nursing intervention can help a client maintain healthy skin?

  • Avoid bathing the client with mild soap.
  • Recommend wearing tight-fitting clothes in hot weather.
  • Remove adhesive tape quickly from the skin.
  • Keep the client well hydrated.

Illnesses or cause of death of blood relatives such as parents, grandparents, siblings. This may indicate genetic predisposition

  • [No Answer]

Reflects the balance between heat produced and heat loss from the body

  • Body temperature
  • Fever
  • Posture and gait
  • Defervesence

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for:

  • At least 12 hours
  • The first 24 hours
  • 2-3 days
  • 1 week

What is actually said or written, the body language that accompanies the words, and how the message is transmitted.

  • [No Answer]

A nurse assesses an oral temperature for an adult patient. The patient's temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?

  • Afebrile

While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur?

  • Palpation with the nurses palm of the hand
  • Diaphragm of the stethoscope
  • Bell of the stethoscope
  • Electrocardiogram

When assessing abdomen, the nurse must divide the abdomen into:

  • 4
  • 8
  • 2
  • 12

This is performed when a database exists for a client and she comes to the health care agency with specific health concern

  • [No Answer]

Which term refers to the pain that has a slower onset, is diffuse, radiates, and is marked by somatic pain from organs in any body activity?

  • Deep pain
  • Superficial pain
  • Chronic pain
  • Acute pain

This is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process.

  • Nursing record

Ascites is defined as:

  • an abnormal accumulation of serous fluid within the peritoneal cavity.
  • an abnormal enlargement of the spleen.
  • a proximal loop of the large intestine.
  • a bowel obstruction.

Heart rate less than the normal.

  • Pulse Deficit
  • Dysrythmia/Arythmia
  • Bradycardia
  • Tachycardia

This is complex, with multiple definitions, and the term is often used interchangeably with other terms such as race, ethnicity, and nationality.

  • Ethnicity
  • Culture
  • Diversity
  • Race

_____ include information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies.

  • Objective data

Organs at the Left Upper Quadrant :

  • 1. Spleen 2. Stomach 3. Body of the Pancreas 4. Left lobe if the liver 5. Left Adrenal Gland 6. Part of the left kidney 7. A portion of the transverse

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

  • Alopecia
  • Pruritus
  • Seborrhea
  • Xerosis

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class?

  • Thyroid replacement hormone for hypothyroidism
  • Proton pump inhibitors for heartburn
  • Tetracyclines for acne
  • Nonsteroidal anti-inflammatory drugs for pain

Cancer can cause changes in what component of Virchow’s triad?

  • Blood viscosity
  • Vessel walls
  • Blood flow
  • Blood coagulability

It contains the principal clinical information source to meet legal and professional requirements and one of the most significant components in nursing care

  • Progress Notes
  • Nursing Documentation
  • Collection of Objective Data
  • Electronic Nursing Documentation

Pyrosis is:

  • a burning sensation in the upper abdomen.
  • an inflammation of the peritoneum.
  • a congenital narrowing of the pyloric sphincter.
  • an abnormally sunken abdominal wall.

Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?

  • Pain is an objective sign of a more serious problem
  • Intractable pain may be relieved by treatment
  • Pain sensation is affected by a client’s anticipation of pain
  • Psychological factors rarely contribute to a client’s pain perception

This abuse involves the use of constant insults or criticism, blaming the victim for things that are not the victim’s fault, threats to hurt children or pets, isolation from supporters (family, friends or coworkers), deprivation, humiliation, and intimidation.

  • Psychological abuse
  • Physical abuse
  • Sexual abuse
  • Economic abuse

In preparation for the discharge of a client with arterial insufficiency and Raynaud’s disease, client teaching instructions should include:

  • Walking several times each day as an exercise program.
  • Keeping the heat up so that the environment is warm
  • Wearing TED hose during the day
  • Using hydrotherapy for increasing oxygenation

During the nursing assessment, which data represent information concerning health beliefs?

  • Use of prescribed and over-the-counter medications
  • Promotive, preventive, and restorative health practices
  • Educational level and financial status
  • Family role and relationship patterns

Inspiration is:

  • Horizontal expansion occurs as intercostal muscles lift the sternum and elevate the ribs
  • A result of this enlargement of the chest cavity
  • A slight positive pressure is created in the lungs in relation to the atmospheric pressure
  • An outflow of air into the lungs.

The nurse has notes that the physician has a diagnosis of presbycusis on the client’s chart. The nurse plans care knowing the condition is:

  • A conductive hearing loss that occurs with aging.
  • A sensorineural hearing loss that occurs with aging
  • Nystagmus that occurs with aging
  • Tinnitus that occurs with aging

This line runs down from the apex of the axilla and lies between and parallel to the other two.

  • [No Answer]

The following are purposes of percussion

  • Detecting abnormal mass. Percussion vibrations penetrate about 5 cm deep
  • Mapping out a location and size of an organ
  • If underlying structure is inflamed, it will not elicit pain
  • Detecting the density (air, fluid, or solid) of a structure by a characteristic note.

Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:

  • Dyspnea
  • A cough with the expectoration of mucoid sputum
  • A bloody, productive cough
  • Chest pain

Maybe performed using these part of the hands: a. Fingertips – best for tactile discrimination like skin texture, swelling pulsation and determination of presence of lumps. b. Grasping action of the fingers and thumb to detect position, shape, and consistency of an organ or mass

  • [No Answer]

Additional nipples are present at birth along embryonic milk line.

  • Supernumerary nipples

The following are methods of validation, except:

  • Compare findings with subjective findings to uncover discrepancies.
  • Recheck data through repeat assessment.
  • Verify data from another health care professional
  • Clarify data by asking additional questions.

Pain is:

  • Displayed by patient
  • Observations by the nurse
  • Descriptions based on manifestations of patients
  • Complaints of patient

The clinic nurse is preparing to test the visual acuity of a client using a Snellen chart. Which of the following identifies the accurate procedure for this visual acuity test?

  • Both eyes are assessed together, followed by the assessment of the right and then the left eye.
  • The client is asked to stand at a distance of 40ft. from the chart and is asked to read the largest line on the chart.
  • The right eye is tested followed by the left eye, and then both eyes are tested.
  • The client is asked to stand at a distance of 40ft from the chart and to read the line than can be read 200 ft away by an individual with unimpaired vision.

_____ is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been identified, including setting priorities.

  • Critical thinking

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:

  • Contralateral side in hemothorax
  • Affected side in a hemothorax
  • Contralateral side in a simple pneumothorax
  • Affected side in a tension pneumothorax

This involves collection of subjective data about the client’s perception of health of all parts or systems, past health history, family history, lifestyle and health practices, as well as objective data gathered during step-by-step examination. A total health assessment is needed when a client first enters a health care system to establish baseline data which future health status change can be compared and measured.

  • Focused or Problem-oriented
  • Comprehensive Health Assessment
  • Initial comprehensive Assessment
  • On-going Partial Assessment

Miggy, a 6-year-old boy, received a small paper cut on his finger, his mother let him wash it and apply small amount of antibacterial ointment and bandage. Then she let him watch TV and eat an apple. This is an example of which type of pain intervention?

  • Control and distraction
  • Pharmacologic therapy
  • Environmental alteration
  • Cutaneous stimulation

Often referred to as the father of psychotherapy, developed the concepts of id, ego and superego, the psychological defense mechanisms such as sublimation and suppression

  • Sigmund Freud
  • Erik Erickson
  • Abraham Maslow
  • Jean Piaget

The general sequence of performing physical examination techniques is?

  • [No Answer]

This data is described only by the person experiencing it

  • Qualitative data

The organ in the right upper quadrant of the abdomen is the _____.

  • liver

The nurse has conducted discharge teaching for a client who had a fenestration procedure for the treatment of otosclerosis. Which of the following, if stated by the client, would indicate that teaching was effective?

  • “I can resume my tennis lessons starting next week.”
  • “It’s ok to take a shower and wash my hair.”
  • “I should drink liquids through a straw for the next 2-3 weeks.”
  • “I will take stool softeners as prescribed by my doctor.”

Menarche is:

  • First week of menstruation
  • Menstruation before menopausal stage
  • First menstruation
  • First 3 days of menstruation

Before doing any procedures, the nurse must:

  • Begin by measuring height, weight then record
  • Perform cephalo-caudal
  • Hand wash before the procedure
  • Check vital signs

A male, who is 30 years old is diagnosed with dehydration and underwent series of tests. Which laboratory result would warrant immediate intervention by the nurse?

  • Serum glucose level of 120 mg/dl
  • Serum creatinine level of 0.6 mg/100 ml
  • Serum sodium level of 138 mEq/L
  • Serum potassium level of 3.1 mEq/L

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

  • Having the client take deep breaths
  • Asking the client to obtain the specimen after eating
  • Limiting fluid
  • Asking the client to spit into the collection container

Answer

  • Assessment
  • is the collection of subjective and objective data about a patient's health.

The part of the body that maintains a balance between heat production and heat loss, regulating body temperature, is the Answer

  • [No Answer]

During a home visit to a family of three: a mother, father, and their child, The mother tells the community nurse that the father (who is not present) had hit the child on several occasions when he was drinking. The mother further explains that she has talked her husband into going to Alcoholics Anonymous and asks the nurse not to interfere, so her husband won’t get angry and refuse treatment. Which of the following is the best response of the nurse?

  • The nurse agrees not to interfere if the husband attends an Alcoholics Anonymous meeting that evening.
  • The nurse commends the mother’s efforts and also contacts protective services.
  • The nurse commends the mother’s efforts and agrees to let her handle things.
  • The nurse confronts the mother’s failure to protect the child.

Nurse Mary is acquiring information from a client in the emergency department. Which is an example of biographic information that may be obtained during a health history?

  • Past health status
  • The chief complaint
  • Location of an advance directive
  • History immunizations

Goals and outcomes are formulated that directly impact patient care. These patient-specific goals and the attainment of such assist in ensuring a positive outcome.

  • Planning
  • Implementation
  • Evaluation
  • Nursing Diagnosis

Inquire if the client has any history of the following:

  • Muscle strength: onset, location, character, associated phenomena (e.g., redness and swelling of joints), and aggravating and alleviating factors; limitations to movement or ability to perform activities of daily living; previous sports injuries; loss of function without pain.
  • Muscle pain: onset, location, character, associated phenomena (e.g., redness and swelling of joints), and aggravating and alleviating factors; limitations to movement or inability to perform activities of daily living; previous sports injuries; loss of function without pain.

A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the nurse is correct?

  • Vitamin D minimizes the risk of kidney stones
  • Vitamin D helps prevent constipation from increased calcium intake
  • Vitamin D improves the absorption of calcium
  • Vitamin D reduces excretion of calcium in the kidneys

The nurse is performing an assessment in a client with a suspected diagnosis of cataract. The chief clinical manifestation that the nurse would expect to note in the early stages of cataract formation is:

  • Diplopia
  • Eye pain
  • Floating spots
  • Blurred vision

This abuse involves forcing the victim to perform acts against her or his will, pursuing activity after victim has said no, using violence, and using weapons vaginally, orally, or anally.

  • Sexual abuse
  • Psychological abuse
  • Economic abuse
  • Physical abuse

The patient is the first priority of the nurse. The role of the nurse is to advocate for the best interests of the patient and to maintain the patient’s dignity throughout treatment and care

  • [No Answer]

Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?

  • Administering pain medication as prescribed
  • Removing all glaring lights and excessive noise
  • Using transcutaneous electric nerve stimulation
  • Referring the client for hypnosis

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?

  • Elevated arterial PaO2
  • Low arterial PaO2
  • Pallor
  • Decreased respiratory rate

A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne

  • Is contagious
  • Has no known cause
  • Has been found to be related to poor hygiene
  • Is caused by increased sebum production

A person or group who wishes to communicate a message to another, can be considered the

  • Sender
  • Receiver
  • Message
  • Response

Data that can be observed and measured.

  • Objective Assessment
  • Assessment Data
  • Source Data
  • Subjective Assessment

What type of medications can cause abnormal nipple discharge or breast discomfort?

  • [No Answer]

A patient tells the nurse that he is nervous, nauseated and feels hot. These types of data would be _____ .

  • Subjective

Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause:

  • Hyperkalemia
  • Nasal congestion
  • Nervousness
  • Lethargy

The costochondral junctions are not palpable.

  • True
  • False

Beginning in their 20s, women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?

  • One half of all breast cancer deaths occur in women ages 35 to 45
  • The tail of Spence area must be included in self-examination
  • The position of choice for the breast examination is supine
  • A pad should be placed under the opposite scapula of the breast being palpated

The following are types of Fever, except:

  • Hyperthermia
  • Hyperpyrexia
  • Afebrile
  • Pyrexia

What type of database is most appropriate for an individual who is admitted to a long-term care facility?

  • Complete

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

  • Scale
  • Ulcer
  • Scar
  • Crust

The characteristics of sounds are the same as for percussion: intensity, pitch, duration, and quality.

  • Percussion

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is _____.

  • peritonitis

Chuck, who is in the hospital, complains of abdominal pain that ranks 9 on a scale of 1 (no pain) to 10 (worst pain). Which interventions should the nurse implement?

  • Encouraging the client to turn, cough, and deep breathe
  • Notifying the health care provider
  • Obtaining a pulse oximeter reading
  • Determining the last time the client received pain medication
  • Taking the client’s blood pressure and apical pulse
  • Assessing the client’s bowel sounds

Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is:

  • Gray
  • Yellow
  • Clear
  • Green

During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?

  • Tipping the client’s head away from the examiner and pulling the ear up and back
  • Inserting the otoscope superiorly into the proximal two-thirds of the external canal
  • Bracing the examiner’s hand against the client’s head
  • Inserting the otoscope inferiorly into the distal portion of the external canal

Data are gathered through the senses – sight, smells, touch and hearing.

  • Verbalized by patients
  • Subjective data
  • Objective data
  • Patient’s complaints

This line extends down from the anterior axillary fold where the pectoralis major muscle inserts.

  • [No Answer]

It is a process which result to a diagnostic statement. It is an act to identify problems.

  • Assessment
  • Nursing Diagnosis
  • Implementation
  • Evaluation

Site of most breast tumors.

  • Upper outer quadrant

During a well-child checkup, a mother tells the Nurse Rio about a recent situation in which her child needed to be disciplined by her husband. The child was slapped in the face for not getting her husband breakfast on Saturday, despite being told on Thursday never to prepare food for him. Nurse Rio analyzes the family system and concludes it is dysfunctional. All of the following factors contribute to this dysfunction except:

  • Rigid, authoritarian roles.
  • Conflictual relationships of parents.
  • Inconsistent communication patterns.
  • Use of violence to establish control.

The clinic nurse notes that the following several eye examinations, the physician has documented a diagnosis of legal blindness in the client’s chart. The nurse reviews the results of the Snellen’s chart test expecting to note which of the following?

  • 20/40 vision
  • 20/60 vision
  • 20/20 vision
  • 20/200 vision

For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

  • Teaching the patient how to perform controlled coughing
  • Enforcing absolute bed rest
  • Administering prescribe sedatives regularly and in large amounts
  • Restricting fluid intake to 1,000 ml per day

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike’s symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably:

  • Impaired mobility related to stress associated with pain
  • Impairment in muscle use associated with pain on exertion.
  • Alteration in tissue perfusion related to compromised circulation
  • Dysfunctional use of extremities related to muscle spasms

The nurse is aware that body temperature that remains relatively constant is the _____

  • Core

Which type of fever is a client experiencing when the body temperature alternates at a regular intervals between periods of fever and periods of normal or subnormal temperatures?

  • Intermittent fever

A client arrives at the emergency room with a foreign body in the left ear that has been determined to be an insect. Which intervention would the nurse anticipate to be prescribed initially?

  • Instillation of antibiotic ear drops
  • Instillation of corticosteroids ear drops
  • Irrigation of the ear
  • Instillation of diluted alcohol

During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear with the Weber test. The nurse analyzes this result as:

  • A sensorineural or conductive loss
  • The presence of nystagmus
  • A normal finding
  • A conductive hearing loss in the right ear

A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?

  • Finger movement
  • Fighting the ventilator
  • Leg movement
  • Lip movement

This abuse includes pushing, shoving, slapping, kicking, choking, punching and burning. It may also involve holding, tying or other methods of restraint. The victim may be left in a dangerous place without resources. The abuser may refuse to help the victim when sick, injured or in need.

  • Psychological abuse
  • Sexual abuse
  • Physical abuse
  • Economic abuse

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:

  • Encourage coughing and deep breathing
  • Milk the chest tube every 2 hours
  • Clamp the chest tube once every shift
  • Monitor fluctuations in the water-seal chamber

Effect of pain on activities, for example:

  • Mobility, sleep
  • Moping skills
  • Immobility, sleeplessness
  • Medical and drug history.

How many lobes does the right lung has?

  • Three lobes

A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

  • Respiratory alkalosis
  • Increased pulmonary capillary permeability
  • Renal failure
  • Cardiogenic pulmonary edema

Requires good lighting, adequate exposure of the body. Expose one part of the body at a time

  • [No Answer]

What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?

  • A cotton ball
  • A penlight
  • A tongue depressor and flashlight
  • An ophthalmoscope

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is:

  • Hormonal secretion
  • Independent arterial wall activity.
  • The sympathetic nervous system
  • The influence of circulating chemicals

Older adults have:

  • increased liver size.
  • decreased salivation leading to dry mouth.
  • decreased incidence of gallstones.
  • increased gastric acid secretion.

A female client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate (Garamycin) by the I.V. route. The nurse should assess the client for which adverse reaction to this drug?

  • Seizures
  • Cardiac arrhythmias
  • Aplastic anemia
  • Ototoxicity

This is a non-invasive technique to measure the percent to which Haemoglobin is filled with oxygen of arterial blood. It does not replace measurement of arterial blood gases for assessment of abnormalities.

  • Arterial oxygen metry
  • Pulse-oxygen meter
  • Pulse oxymetry
  • Oxygen pulse meter

Best position for palpating both axilla

  • Sitting upright

Romberg’s test is about to perform to Pierro. To ensure the safety, which intervention should a nurse implement?

  • Allowing the client to keep his eyes open
  • Having the client hold on to furniture
  • Letting the client spread his feet apart
  • Standing close to provide support

The message that the receiver returns to the sender. It is also called feedback.

  • Sender
  • Response
  • Receiver
  • Message

This levels of cognitive development from birth until 12 years of age are used for the assessment of children up to this age, after which the cognitive development of the child is complete is developed by:

  • Abraham Maslow
  • Jean Piaget
  • Erik Erickson
  • Sigmund Freud

A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?

  • Related to percutaneous absorption of the topical corticosteroid
  • Related to topical corticosteroid application to the face, neck, and intertriginous sites
  • Related to vasodilatory effects of the topical corticosteroid
  • Related to potential interactions between the topical corticosteroid and other prescribed drugs

A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

  • “Apply one applicator of tioconazole intravaginally at bedtime for 7 days.”
  • “Apply acyclovir ointment to the lesions every 3 hours, six times a day for 7 days.”
  • “Apply one applicator of terconazole intravaginally at bedtime for 7 days.”
  • “Apply sulconazole nitrate twice daily by massaging it gently into the lesions.”

Chronological record of seeking care, from the time the symptoms appear until now

  • [No Answer]

When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?

  • Risk for infection related to breaks in the skin
  • Impaired physical mobility related to the disease process
  • Ineffective airway clearance related to edema of the respiratory passages
  • Disturbed sleep pattern related to facility environment

Symptoms associated with the pain, can help to identify an underlying cause for pain and also identify the need for symptom management.

  • Joint swelling
  • Anorexia
  • Blotted stomach
  • Nausea

The left lung is narrower than the right lung because the heart bulges to the right.

  • True
  • False

A 52-year-old woman complains of palpitations resulting from anxiety over her impending surgery. Her pulse rate is found to be 110 per minute. One possible description of her heart rate is _____.

  • [No Answer]

This is membranous covering of the inside of the upper and lower lids. Contains blood vessels.

  • Bulbar conjunctiva
  • Conjunctiva of the iris
  • Scleral conjuctiva
  • Palpebral conjunctiva

Uses silence, touch, eye movement, facial expression, body posture. Types of Health Assessment in Nursing Practice

  • [No Answer]

_____ is the process of analyzing health data and drawing conclusions to identify diagnoses.

  • Diagnostic reasoning

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:

  • Moderately impaired, and the surgeon should be called.
  • Adequate from the arterial approach, but venous complications are arising.
  • Slightly deteriorating and should be monitored for another hour
  • Normal because of the increased blood flow through the leg

Milk producing cells.

  • Epithelial cells

Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case?

  • Flexible role functioning between parents
  • History of the parent having been abused as a child.
  • Single-parent home situation
  • Presence of parental mental illness

A 50-year-old widower has arthritis and remains in bed too long because it hurts to get started. Which intervention should the nurse plan?

  • Telling the client to strictly limit the amount of movement of his inflamed joints
  • Teaching the client’s family how to transfer the client into a wheelchair
  • Teaching the client the proper method for massaging inflamed, sore joints
  • Encouraging gentle range-of-motion exercises after administering aspirin and before rising

NPO is required for upper and lower gastrointestinal tract procedures. NPO is:

  • Nothing prompt obtained
  • No personal orders
  • Nothing by mouth
  • None per order

Nurse Rob has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co-worker?

  • Make general statements about safety issues at the next staff meeting.
  • Ignore the co worker’s behavior, and frequently assess the clients assigned to the co-worker.
  • Warn the co-worker that this practice is unsafe.
  • Report the coworker’s behavior to the appropriate supervisor.

The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?

  • Stand 4 feet away from the client to ensure that the client can hear at this distance.
  • Whisper a statement while the client blocks both ears.
  • Whisper a statement with the examiners back facing the client
  • Whisper a statement and ask the client to repeat it.

When listening to a patients’ breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to immediate notify the doctor.

  • True
  • False

Which technique is considered the gold standard for diagnosing DVT?

  • Doppler flow study
  • MRI
  • Ultrasound imaging
  • Venography

This is the record of nursing actions and observations in the nursing care process. It helps nurses to monitor and control the course of nursing care.

  • Physical Examination
  • Collection of Objective Data
  • Progress Notes
  • Nursing Documentation

An 8.5 lb, 6 oz infant is delivered to a diabetic mother. Which nursing intervention would be implemented when the neonate becomes jittery and lethargic?

  • Administer oxygen
  • Feed the infant glucose water (10%)
  • Place infant in a warmer
  • Administer insulin

What do nurses use to assess the musculoskeletal system?

  • Evaluating

When assessing the lower extremities for arterial function, which intervention should the nurse perform?

  • Assessing the Homans’ sign
  • Assessing the medial malleoli for pitting edema
  • Performing Allen’s test
  • Palpating the pedal pulses

Methods to enhance abdominal wall relaxation during examination include:

  • having the patient place arms above the head.
  • a cool environment.
  • positioning the patient with the knees bent.
  • examining painful areas first.

This is the principal clinical information source to meet legal and professional requirements, and is one of the most significant components in nursing care.

  • Physical Examination
  • Nursing Documentation
  • Collection of Objective Data
  • Progress Notes

Older children and teens experience hormonal and physical changes that can affect self-image and self-esteem. Puberty and social stress can contribute to ________. Menstruation before menopausal stage, which in turn poses risk for substance abuse, risky behaviours, and suicide.

  • Suppression
  • Deliirum
  • Depression
  • Isolation

In the areola are small elevated sebaceous glands called?

  • Montgomery's glands

It is the membranous covering of the sclera. Contains blood vessels.

  • Scleral conjuctiva
  • Palpebral conjunctiva
  • Bulbar conjunctiva
  • Conjunctiva of the iris

Moles on the abdomen:

  • are common.
  • are uncommon.
  • require a biopsy.
  • are no cause for concern

A client is being seen for follow-up care after surgery for a fracture in which an external fixation device was placed. What is the most important part of the assessment?

  • Clean and thoroughly dry the skin under the traction
  • Monitor the pin sites for signs of infection
  • Ensure that nothing touches the outside of the fixation device
  • Assure that the traction weights hang freely

It recheck your data via repeat assessment & clarify data with client by asking additional questions

  • Methods to Validate Data

All of these are pupils features, except:

  • Reaction to light
  • Accommodation
  • Color
  • Size, shape, symmetry

Beginning menstruation before the age of WHAT increases the risk of breast cancer?

  • 12

A 70-year-old client has been diagnosed with osteoporosis after undergoing a bone mineral density test. When reviewing the results of the test, the nurse explains to the client that the T score is which of the following?

  • The amount of bone density compared to that of a healthy 30-year-old
  • The level of calcium found in a particular bone in the body
  • The test results of the DEXA scan, expressed in mg/mL
  • The amount of radiation used with the tes

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:

  • 6 L/min
  • 1 L/min
  • 2 L/min
  • 10 L/min

This observe patient as a whole & inspect both sides of the body symmetry.

  • Inspection

Novice nurse Liza is excited to perform her very first physical assessment with a 19-year-old client. Which assessment examination requires Liza to wear gloves?

  • Breast
  • All of the above
  • . Integumentary
  • Oral
  • Ophthalmic

Depending on their size and shape, the breasts:

  • Extend vertically from the second to the sixth rib and vertically from the sternum to the midaxillary line
  • Extend horizontally from the first to the sixth rib and horizontally from the sternum to the midaxillary line
  • Extend vertically from the second to the sixth rib and horizontally from the sternum to the midaxillary line
  • Extend horizontally from the second to the sixth rib and horizontally from the sternum to the midaxillary line

_____ consist of information provided by the affected individual.

  • [No Answer]

The thorax;

  • A thorough assessment of the upper respiratory system focuses on the external chest
  • The outer structure is referred to as the respiratory components.
  • Distal portion of the trachea, and the bronchi, are located in the thorax and constitute the lower respiratory system.
  • Identifies the portion of the body extending from the base of the neck superiorly to the level of the diaphragm inferiorly.

For which time period would the nurse notify the health care provider that the client had no bowel sounds?

  • 5 minutes
  • 2 minutes
  • 4 minutes
  • 3 minutes

Occurs with trauma, inflammation, infection, and benign breast disease.

  • [No Answer]

A personal history of ovarian, endometrial or colon cancer increases the risk of breast cancer.

  • True
  • False

Check for capillary refill by:

  • Capillary refill is an index of peripheral perfusion and cardiac output.
  • Depressing the nail edge to blanch, noting the return of color for about 5-8 seconds
  • Depressing the nail edge to blanch, keep on pressing until skin becomes cyanotic
  • Depressing the nail edge to blanch, then release, noting the return of color – color return is instant, within 1 to 3 seconds.

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

  • Stridor
  • A few basilar lung crackles on the right
  • Respiratory rate 24 breaths/min
  • Occasional pink-tinged sputum

Irregular pulse rhythm.

  • Tachycardia
  • Pulse Deficit
  • Bradycardia
  • Dysrythmia/Arythmia

Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?

  • These measures decrease input to large fibers.
  • These measures block transmission of type C fiber impulses.
  • These measures potentiate the effects of analgesics.
  • These measures are more effective than analgesics.

This reveals the sounds produced by the body, usually from movement of organs and tissues.

  • [No Answer]

This final step of the nursing process is vital to a positive patient outcome. Whenever a Health care provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met.

  • Evaluation
  • Intervention
  • Nursing Diagnosis
  • Planning

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?

  • Venturi mask
  • Face tent
  • Tracheostomy collar
  • Aerosol mask

Course and low pitched, two pieces of leather being rubbed together, grating or rubbing sound, caused when pleurae become inflamed and lose their normal lubricating fluid.

  • friction rub

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for:

  • Smoking history
  • History of insect bites
  • Recent exposures to allergens
  • Familial tendency toward peripheral vascular disease

Uses silence, touch, eye movement, facial expression, body posture collection of Subjective Data through Interview and Health History

  • Hand Movement
  • Non-Verbal Communication
  • Body Gesture
  • Verbal Communication

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

  • Nausea or vomiting
  • Abdominal pain or diarrhea
  • Lightheadedness or paresthesia
  • Hallucinations or tinnitus

A nurse is caring for a client who has suffered a fracture to the humerus after falling on their outstretched arm. The ends of the bone were driven into each other during the fall. This type of fracture is best described as which of the following?

  • Impacted fracture
  • Greenstick fracture
  • Oblique fracture
  • A. Comminuted fracture

While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to:

  • Grasp the retention sutures to spread the opening
  • Call the physician to reinsert the tube
  • Call the respiratory therapy department to reinsert the tracheotomy
  • Cover the tracheostomy site with a sterile dressing to prevent infection

The _____ has no experience with specific patient populations and uses rules to guide performance.

  • Novice nurse

With peripheral arterial insufficiency, leg pain during rest can be reduced by:

  • Placing the limb in a plane horizontal to the body
  • Elevating the limb above heart level
  • Lowering the limb so it is dependent
  • Massaging the limb after application of cold compresses

During assessment of the abdomen, what is the sequence methods of examination?

  • Inspection, auscultation, palpation, and percussion.
  • Inspection, auscultation, percussion and palpation.
  • Inspection, palpation, percussion. and auscultation
  • Inspection, auscultation, percussion, and palpation,

Varicose veins can cause changes in what component of Virchow’s triad?

  • Blood coagulability
  • Blood flow
  • Blood viscosity
  • Vessel walls

In the correct sequential order, Jean Piaget's levels of cognitive development include, except:

  • Informal operations
  • Sensorimotor thought
  • Preoperational and symbolic functioning
  • Concrete operations

Breasts lie between which ribs.

  • Anterior to pectoralis major and anterior muscles.

On auscultation, which finding suggests a right pneumothorax?

  • Absence of breaths sound in the right thorax
  • Inspiratory wheezes in the right thorax
  • Bilateral pleural friction rub.
  • Bilateral inspiratory and expiratory crackles

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:

  • Has brown pigmentation around it.
  • Has little granulation tissue
  • Is deep, with even edges
  • Has a pale colored base

Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for:

  • Patients under age 6
  • Patients with narcolepsy
  • Elderly patients
  • Patients with an acute asthma attack

When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?

  • The client distracts himself during pain episodes.
  • The client denies the existence of any pain.
  • The client reports no need for family support.
  • The client reports pain reduction with decreased activity.

Physical assessment is being performed to Geoff by Nurse Tine. During the abdominal examination, Tine should perform the four physical examination techniques in which sequence?

  • Auscultation immediately after inspection and then percussion and palpation
  • Inspection and then palpation, percussion, and auscultation
  • Percussion, followed by inspection, auscultation, and palpation
  • Palpation of tender areas first and then inspection, percussion, and auscultation

Previous illness like childhood illnesses, accidents or injuries, serious or chronic, hospitalizations, operations, OB history (female), allergies

  • [No Answer]

Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?

  • “Do you understand what is happening?”
  • “Would you describe your overall health as good?”
  • “What brought you to the clinic today?”
  • “Is there anything else you would like to tell me?”

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?

What are the functions of the musculoskeletal system?

  • To support your body's weight and help you move

Tapping of the patient’s skin with short, sharp strokes to assess underlying structures, the characteristic sound produced during percussion depicts the location, size and density of underlying organ.

  • Palpation
  • Auscultation
  • Inspection
  • Percussion

Body temperature fluctuates minimally but always remains above normal.

  • Remittent fever
  • Constant fever
  • Intermittent fever
  • Relapsing fever

The four layers of large, flat abdominal muscles form the:

  • rectus abdominus.
  • ventral abdominal wall.
  • viscera
  • linea alba.

Planning has guide to follow, acronym SMART: "S" is for_____

  • Sense
  • Scientific
  • Systematic
  • Specific

A female client is brought to the emergency department with second- and third-degree burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

  • 27%
  • 18%
  • 30%
  • 36%

Nurse Julie recommends that the family of a client with substance-related disorder attend a support group, such as Al-Anon and Alateen. The purpose of these groups is to help family members understand the problem and to:

  • Prevent substance problems in vulnerable family members.
  • Learn how to assist the abuser in getting help.
  • Maintain focus on changing their own behaviors.
  • Change the problem behaviors of the abuser.

A nurse has the order to begin administering warfarin sodium (Coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin?

  • Vitamin K
  • Aminocaproic acid
  • Protamine sulfate
  • Potassium chloride

The nursing process is a sequential method of problem solving that nurses use and includes which steps:

  • Admission, diagnosis, treatment, evaluation. & discharge planning
  • Assessment, treatment, planning, evaluation, discharge, & follow-up
  • Assessment. Diagnosis, outcome identification, planning, implementation, & evaluation
  • Admission, assessment, diagnosis, treatment, & discharge planning

The experienced nurse understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it.

  • Experienced Nurse

The purpose of respiration is:

  • To maintain an adequate oxygen level in the blood to support cellular life. By providing oxygen and eliminating carbon dioxide, respiration assists in the rapid
  • Changes in the respiratory pattern can cause acid–base balances.
  • Compensation for metabolic acidosis ;
  • Cause acid–base imbalance balance

The nurse is examining an infant and prepares to elicit the moro reflex at which time during the examination?

  • Before auscultation of the thorax
  • Halfway through the examination
  • When the infant is sleeping
  • At the end of the examination

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

  • Encourage the client to deep breathe
  • Reinforce the occlusive dressing
  • Inform the physician
  • Continue to monitor the client

Organs located at the Midline:

  • 1. Pancreas 2. Small Intestine 3. Bladder 4. Spine

Which method of measuring temperature reveals core temperature?

  • pulmonary artery catheter

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?

  • An increased loss of elastin and a decrease in subcutaneous fat
  • Increased vascularity of the skin
  • Increased numbers of sweat and sebaceous glands
  • An increase in elastin and a decrease in subcutaneous fat

The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body

  • Dorsalis pedis artery
  • Femoral artery
  • Popliteal artery
  • Posterior tibial artery

Ryan underwent an open reduction and internal fixation of the left hip. One day after the operation, the client is complaining of pain. Which data would cause the nurse to refrain from administering the pain medication and to notify the health care provider instead?

  • Left leg in functional anatomic position
  • Left hip dressing dry and intact
  • Blood pressure of 114/78 mm Hg; pulse rate of 82 beats per minute
  • Left foot cold to touch; no palpable pedal pulse

The nurse is providing discharge teaching to a patient who has recently been diagnosed with a cardiac condition. In teaching this patient how to assess the radial pulse, the nurse will instruct him to palpate the _____.

  • [No Answer]

T is for: ___

  • Truth
  • Total
  • Time Bounded
  • Term

Which structure is located in the left lower quadrant of the abdomen?

  • sigmoid colon

Tonometry is performed on the client with a suspected diagnosis of glaucoma. The nurse analyzes the test results as documented in the client’s chart and understands that normal intraocular pressure is

  • 10-21 mmHg
  • 22-30 mmHg
  • 2-7 mmHg
  • 31-35 mmHg

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of:

  • Bleeding and infection
  • Bleeding and wound dehiscence.
  • Wound dehiscence and evisceration.
  • Thrombosis and infection

A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

  • A client with genital herpes lesions can have sexual contact but must use a condom.
  • Herpetic keratoconjunctivitis usually is bilateral and causes systemic symptoms.
  • During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature delivery.
  • Genital herpes simplex lesions are painless, fluid-filled vesicles that ulcerate and heal in 3 to 7 days

Mostly passive in nature and occurs w/ relaxation of intercostal muscles and the diaphragm;

  • [No Answer]

A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss?

  • Evaporation

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:

  • Immediately replace the chest tube system
  • Call the physician
  • Place the tube in bottle of sterile water
  • Place a sterile dressing over the disconnection site

Albert who suffered severe burns 6 months ago is expressing concern about the possible loss of job-performance abilities and physical disfigurement. Which intervention is the most appropriate for him?

  • Providing cutaneous stimulation and pharmacologic therapy
  • Staying with the client as much as possible and building trust
  • Referring the client for counseling and occupational therapy
  • Providing distraction and guided imagery techniques

John Lucas went to medical center for an scheduled physical assessment. When percussing the client’s chest, the nurse would expect to find which assessment data as a normal sign over his lungs?

  • Tympany
  • Hyperresonance
  • Resonance
  • Dullness

A person or group who wishes to communicate a message to another, can be considered the source-encoder.

  • Response

This indicates the patient’s exact words. Ex. “Chest pain for 3 hours”; “Difficulty of breathing for 2 days”

  • [No Answer]

It is the person's sense of self that provides the person with the ability to control oneself and one's behaviours.

  • Ego
  • Id
  • Alter ego
  • Super ego

Another component of the communication process. Person or group who must listen, observe and attend.

  • Receiver
  • Message
  • Sender
  • Response

When providing for privacy, the nurse must:

  • Provide adequate information about the procedure.
  • Curtain the unit as necessary.
  • Prepare the patient physically and psychologically to allay anxiety
  • Provide a new and clean gown

Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit?

  • Vitamin K
  • Potassium chloride
  • Aminocaproic acid
  • Protamine sulfate

A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned?

  • Family violence rarely occurs during pregnancy.
  • Family violence predominantly occurs in lower socioeconomic levels.
  • Family violence affects every socioeconomic level.
  • Family violence is caused by drugs and alcohol abuse.
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