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A set of questions, answered by patients, that asks about personal behaviors, risks, life-changing events, health goals and priorities, and overall health.
A personal history of ovarian, endometrial or colon cancer increases the risk of breast cancer.
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?
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?
The following are methods of validation, except:
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?
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.
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
This line runs down from the apex of the axilla and lies between and parallel to the other two.
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:
It is a milk produced by the acini cells empties into the lactiferous ducts.
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?
_____ include information obtained by the health care provider through physical assessment, the patient's record, and laboratory studies.
Previous illness like childhood illnesses, accidents or injuries, serious or chronic, hospitalizations, operations, OB history (female), allergies
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 _____.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:
The nursing process is a sequential method of problem solving that nurses use and includes which steps:
During assessment of the abdomen, what is the sequence methods of examination?
The nurse is caring for a client that is hearing impaired. Which of the following approaches will facilitate communication?
This is complex, with multiple definitions, and the term is often used interchangeably with other terms such as race, ethnicity, and nationality.
Before doing any procedures, the nurse must:
M is for: ____
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?
Depending on their size and shape, the breasts:
On auscultation, which finding suggests a right pneumothorax?
The _____ has no experience with specific patient populations and uses rules to guide performance.
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.
Inspect the muscles for tremors, for.
When providing for privacy, the nurse must:
Irregular pulse rhythm.
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?
Menopause occurring after which age increases the risk of breast cancer?
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?
The costochondral junctions are not palpable.
The part of the body that maintains a balance between heat production and heat loss, regulating body temperature, is the Answer
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:
The major axillary lymph nodes consist of:
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?
All of these are pupils features, except:
Which nursing intervention can help a client maintain healthy skin?
It contains the principal clinical information source to meet legal and professional requirements and one of the most significant components in nursing care
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?
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?
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?
Best position for palpating both axilla
When assessing abdomen, the nurse must divide the abdomen into:
The following are purposes of percussion
In planning pain reduction interventions, which pain theory provides information most useful to nurses?
During an otoscopic examination, which action should be avoided to prevent the client from discomfort and injury?
What is actually said or written, the body language that accompanies the words, and how the message is transmitted.
The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is:
Breasts lie between which ribs.
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?
It is the person's sense of self that provides the person with the ability to control oneself and one's behaviours.
For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
Reflects the balance between heat produced and heat loss from the body
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:
The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body
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?
A male client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?
A darkly pigmented surrounds nipple 1-2 cm smooth muscle fibers that cause nipple erection when stimulated is called mongomer’s glands.
It is a term with many definitions, often used interchangeably with the terms ethnicity and culture
Organs located at the Midline:
In the correct sequential order, Jean Piaget's levels of cognitive development include, except:
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?
The left lung is narrower than the right lung because the heart bulges to the right.
This data is described only by the person experiencing it
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?
What do nurses use to assess the musculoskeletal system?
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:
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.
In the areola are small elevated sebaceous glands called?
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:
Occurs with trauma, inflammation, infection, and benign breast disease.
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?
Wide range of temperature fluctuations over 24 hour period
Which method of measuring temperature reveals core temperature?
Edema of the breast tissue gives the breast a specific appearance. What is this termed?
Organs at the Left Upper Quadrant :
Enlargement of male breasts
Pyloric stenosis is aNo:
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?
Data that can be observed and measured.
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur?
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:
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne
Beginning menstruation before the age of WHAT increases the risk of breast cancer?
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?
The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the ______ of the underlying tissue.
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?
When using Snellen’s Eye Charts:
Depressing the nail edge to blanch, keep on pressing until skin becomes cyanotic
A group of nursing students at Nurseslabs University is currently learning about family violence. Which of the following is true about the topic mentioned?
It is the membranous covering of the sclera. Contains blood vessels.
Clear nipple discharge.
This observe patient as a whole & inspect both sides of the body symmetry.
Vertigo, tinnitus, pain, anxiety, nausea, weakness, fatigue, anorexia , thirst, nervousness are:
While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to:
Body temperature fluctuates minimally but always remains above normal.
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?
When inspecting the nipples.
This indicates the patient’s exact words. Ex. “Chest pain for 3 hours”; “Difficulty of breathing for 2 days”
Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for:
It is a process which result to a diagnostic statement. It is an act to identify problems.
A significant cause of venous thrombosis is:
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 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?
The carotid arteries:
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is _____.
The nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?
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 abdomen normally moves when breathing until the age of ____ years.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
Moles on the abdomen:
Inquire if the client has any history of the following:
All of the following are nursing interventions, except:
What are the functions of the musculoskeletal system?
A patient tells the nurse that he is nervous, nauseated and feels hot. These types of data would be _____ .
The purpose of respiration is:
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?
A person or group who wishes to communicate a message to another, can be considered the source-encoder.
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:
This involves sense of sight.
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
Requires good lighting, adequate exposure of the body. Expose one part of the body at a time
When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for:
Light Palpation of the abdomen
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
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:
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?
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?
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.
A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?
Data are gathered through the senses – sight, smells, touch and hearing.
With peripheral arterial insufficiency, leg pain during rest can be reduced by:
Angle of Louis Connects with 2nd rib Tracheal bifurcation Upper boarder of atria.
Which technique is considered the gold standard for diagnosing DVT?
Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?
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?
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?
The general sequence of performing physical examination techniques is as follows:
The following are types of Fever, except:
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.
Ascites is defined as:
Having two first-degree family members with breast cancer doubles the risk for the patient.
In a female client with burns on the legs, which nursing intervention helps prevent contractures?
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.
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
In which portion of the breast tissue is it the most common place for breast cancer to be found?
The nurse is examining an infant and prepares to elicit the moro reflex at which time during the examination?
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
Pain is:
Pyrosis is:
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?
Which structure is located in the left lower quadrant of the abdomen?
Planning has guide to follow, acronym SMART: "S" is for_____
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.
Romberg’s test is about to perform to Pierro. To ensure the safety, which intervention should a nurse implement?
This is performed when a database exists for a client and she comes to the health care agency with specific health concern
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:
Symptoms associated with the pain, can help to identify an underlying cause for pain and also identify the need for symptom management.
A patient tells the nurse that he is nervous, nauseated and feels hot. These types of data would be _____.
A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
Inspiration is:
Check for capillary refill by:
This is membranous covering of the inside of the upper and lower lids. Contains blood vessels.
The message that the receiver returns to the sender. It is also called feedback.
_____ is the process of analyzing health data and drawing conclusions to identify diagnoses.
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.
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
How many lobes does the right lung has?
A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:
Hypercapnea is:
Milk producing cells.
Perform the procedure using cephalo – caudal sequence, means;
The following labels are found in the: “related to” ,followed by "manifested by”.
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:
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.
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?
In preparation for the discharge of a client with arterial insufficiency and Raynaud’s disease, client teaching instructions should include:
Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:
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.
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?
Breast Composed of glandular tissue, fibrous tissue & adipose tissue.
Menarche is:
Answer
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:
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?
When assessing the lower extremities for arterial function, which intervention should the nurse perform?
Cancer can cause changes in what component of Virchow’s triad?
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.
Abdominal landmarks
_____ consist of information provided by the affected individual.
NPO is required for upper and lower gastrointestinal tract procedures. NPO is:
_____ is the multidimensional thinking process needed for sound diagnostic reasoning and clinical judgment. Seventeen critical thinking skills have been identified, including setting priorities.
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?
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?
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?
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.
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
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:
Another component of the communication process. Person or group who must listen, observe and attend.
The symptoms occurring with lactose intolerance include:
A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?
High pitched, louder in neck than over chest wall, originating in larynx or upper airway obstruction from swollen, inflamed tissues or lodged foreign body.
Portion of the body extending from base of neck superiorly to level of diaphragm inferiorly.
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:
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:
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?
Site of most breast tumors.
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?
Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?
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?
Normal adult respiratory rate
Body temperature alternates at a regular intervals between periods of fever and normal temperature.
This developer proposed 8 major stages of psychosocial development and expected tasks along the life span from infancy to old age.
This line extends down from the anterior axillary fold where the pectoralis major muscle inserts.
Effect of pain on activities, for example:
Buerger’s disease is characterized by all of the following except:
Illnesses or cause of death of blood relatives such as parents, grandparents, siblings. This may indicate genetic predisposition
The thorax;
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?
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?
This is the principal clinical information source to meet legal and professional requirements, and is one of the most significant components in nursing care.
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:
It recheck your data via repeat assessment & clarify data with client by asking additional questions
The general sequence of performing physical examination techniques is?
For which time period would the nurse notify the health care provider that the client had no bowel sounds?
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:
Uses silence, touch, eye movement, facial expression, body posture collection of Subjective Data through Interview and Health History
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?
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:
The characteristics of sounds are the same as for percussion: intensity, pitch, duration, and quality.
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.
Older adults have:
Which intervention should the nurse include as a nonpharmacologic pain-relief intervention for chronic pain?
A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as _____.
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?
Chronological record of seeking care, from the time the symptoms appear until now
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:
This reveals the sounds produced by the body, usually from movement of organs and tissues.
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?
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?
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.
Ryan who is a chronic alcohol abuser is being assessed by Nurse Gina. Which problems are related to thiamin deficiency?
Expiration is mostly passive in nature and occurs with relaxation of the intercostal muscles and the diaphragm.
When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
What type of medications can cause abnormal nipple discharge or breast discomfort?
Vitamin taken to reduce breast edema and tenderness.
Varicose veins can cause changes in what component of Virchow’s triad?
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.
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:
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?
A person or group who wishes to communicate a message to another, can be considered the
Which term would the nurse use to document pain at one site that is perceived in other site?
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?
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?
During the nursing assessment, which data represent information concerning health beliefs?
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
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?
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?
Which assessment data should the nurse include when obtaining a review of body systems
The nurse is aware that body temperature that remains relatively constant is the _____
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?
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.
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 _____.
The four layers of large, flat abdominal muscles form the:
Heart rate less than the normal.
T is for: ___
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?
Additional nipples are present at birth along embryonic milk line.
Mostly passive in nature and occurs w/ relaxation of intercostal muscles and the diaphragm;
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?
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?
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:
The organ in the right upper quadrant of the abdomen is the _____.
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:
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?
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?
Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?
A client with osteoporosis asks the nurse why it is important to take vitamin D. Which response by the nurse is correct?
The _____ is the totality of information available about the patient. The purpose of assessment is to make a judgment or diagnosis.
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?
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?
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?
Which of the following characteristics is typical of the pain associated with DVT?
Uses silence, touch, eye movement, facial expression, body posture. Types of Health Assessment in Nursing Practice
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:
What equipment would be necessary to complete an evaluation of cranial nerves 9 and 10 during a physical assessment?
A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:
When evaluating a client’s adaptation to pain, which behavior indicates appropriate adaptation?
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?
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?
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?
Methods to enhance abdominal wall relaxation during examination include:
Short febrile periods of few days are interspersed within a period of 1 – 2 days
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