The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate?
1. Yin/Yang balance
2. Biomedical belief
3. Determinism belief
4.
4. Magicoreligious belief
While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place.
42.8 C
A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?
1. Respirations of 10
2. Urine output of 30 mL/hour
3. Lethargy
4. Restlessness
4. Restlessness
A nurse is assessing several clients. Which client will require parenteral nutrition?
1. A client with brain neoplasm
2. A client with anorexia nervosa
3. A client with inflammatory bowel disease
4. A client with severe malabsorption disorder
4. A client with severe malabsorption disorder
The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume?
1. 70 mL
2. 60 mL
3. 50 mL
4. 40 mL
1. 70 mL
Cardiac output is obtained by multiplying the heart rate and the stroke volume. Therefore to obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?
1. Skin condition
2. Fluid and electrolyte balance
3. Food intake
4. Fluid intake and outp
2. Fluid and electrolyte balance
A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as what?
1. Vesicular
2. Bronchial
3. Crackles
4. Rhonchi
3. Crackles
Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli
A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk?
1. Eggs
2
2. Yogurt
Yogurt, which contains calcium, is digested more easily than milk because it contains the enzyme lactase, which breaks down milk sugar
The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning?
1. "The client claims to feel fat despite being underweight."
2. "The client experiences rec
2. "The client experiences recurrent episodes of binge eating."
Bulimia nervosa is an eating disorder in which the client has an obsessive desire to lose weight. In this condition, bouts of extreme overeating are followed by fasting or self-induced vomiti
The symptoms of four clients with different levels of impaired vision are given below:
Which client is expected to be diagnosed with macular degeneration?
1. Client A: impaired near vision
2. Client B: loss of central vision
3. Client C: cross appearance
2. Client B: loss of central vision
Client B's loss of central vision is caused by macular degeneration. Impaired near vision in client A is due to presbyopia or hyperopia. Strabismus is a congenital condition in which both eyes do not focus on an object
A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?
1. Presence of dry skin
2. Loss of body weight
3. Decrease in blood pressure
4. Altered general appearan
2. Loss of body weight
Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (
The nurse is aware that the nursing diagnosis should follow the North American Nursing Diagnosis Association International (NANDA-I) label. How should the nurse document the nursing diagnosis in a three-part format?
1. NANDA-I label, related factor, and e
4. NANDA-I label, related factor, and defining characteristics
While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding?
1. There is absence of a pulse.
2. The pulse strength is normal.
3. The pulse strength is bounding.
4. The pulse strength i
4. The pulse strength is barely palpable.
A pulse strength of 1+ indicates a diminished or barely palpable pulse and requires immediate intervention. Absence of pulse is documented as 0. Normal pulse strength is documented as 2+. If the pulse strength is
A client who has been admitted to the hospital with chest pain complains of shortness of breath, weakness, and vomiting. The nurse suspects cardiac arrest. Which site is the most appropriate place to check the client's pulse rate?
1. Ulnar
2. Radial
3. Br
4. Femoral
because other pulses may not be palpable at this time. The ulnar site is used to assess the status of circulation to the hand and also used to perform the Allen test. The radial site is commonly used to assess the character of the pulse periphe
While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client
1. Poor fitting of the cuff
3. Deflating the cuff too quickly
Which physical assessment technique involves listening to the sounds of the body?
1. Palpation
2. Inspection
3. Percussion
4. Auscultation
4. Auscultation
Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?
1. Contusion
2. Thrombosis
3. Atherosclerosis
4. Tourniquet effect
3. Atherosclerosis
In atherosclerosis, there may be changes in the integrity of the walls of the arteries and smaller blood vessels. Direct manipulation of vessels or localized edema that impairs blood flow will lead to a contusion. Blood clotting that ca
While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation?
1. 1+
2. 2+
3. 3+
4. 4+
1. 1+
A diminished or barely palpable pulse is documented as 1+. A normal and expected pulse strength is documented as 2+. A full, strong pulse is documented as 3+. A bounding pulse is documented as 4+.
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?
1. Occipital headache
2. Periorbital crepitus
3. Expecto
3. Expectoration of blood
After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is cau
A client experiencing chills and fever is admitted to the hospital. After assessing the client's vitals and medical history, the nurse concluded that the client's fever pattern is remittent. Which assessment finding led to this conclusion?
1. The client's
2. The client's fever spikes and falls without a return to normal temperature levels
In a remittent pattern of fever, the fever spikes and falls without a return to normal temperature levels. If the temperature returns to an acceptable value at least once
The nurse documents the data gathered during the assessment in a client's medical record. What should the nurse do to ensure that the data is meaningful to other healthcare providers?
1. Record subjective information in own words.
2. Form judgments throug
3. Record objective information using accurate terminology.
The nurse should document all objective information using accurate terminology. The nurse should pay attention to the facts and report findings exactly as seen, felt, or smelled. If the informati
A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Choose all that apply)
1. Oral temperature of 98.2� F (36.8� C)
2. Apical pulse of 88 be
1. Oral temperature of 98.2� F (36.8� C)
2. Apical pulse of 88 beats per minute and regular
4. Blood pressure of 116/78 mm Hg while in a sitting position
A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience?
1. Visceral pain
2. Somatic pain
3. Referred pain
4. Intractable pain
1. Visceral pain
Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching o
Which finding is inferred from a grade 4 intensity of heart murmurs?
1. Thrill is easily palpable
2. Quiet and clearly audible thrill
3. Loud murmur associated with thrill
4. Moderately loud murmur without thrill
3. Loud murmur associated with thrill
Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized
A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? (Choose all that apply)
1. Fainting
2. Headache
3. Weakness
4. Light headedness
5. Shortness of breath
1. Fainting
3. Weakness
4. Light headedness
Which client assessment finding should the nurse document as subjective data?
1. Blood pressure 120/82 beats/min
2. Pain rating of 5
3. Potassium 4.0 mEq
4. Pulse oximetry reading of 96%
2. Pain rating of 5
The nurse recognizes that a common conflict experienced by older adults is the conflict between what?
1. Youth and old age
2. Retirement and work
3. Independence and dependence
4. Wishing to die and wishing to live
3. Independence and dependence
A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The
When should the nurse consider family members as the primary source of information? (Choose all that apply)
1. The client is an elderly adult.
2. The client is an infant or child.
3. The client is brought in as an emergency.
4. The client is critically il
2. The client is an infant or child.
3. The client is brought in as an emergency.
4. The client is critically ill and disoriented.
An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediat
1. Oxygen Saturation: 89%
An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature in
What are the benefits of using standard formal nursing diagnostic statements? (Choose all that apply)
1. Fosters development of nursing knowledge
2. Allows nurses to communicate with the client
3. Provides precise definition of the client's problem
4. Dis
1. Fosters development of nursing knowledge
3. Provides precise definition of the client's problem
4. Distinguishes the nurse's role from that of other care providers
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload?
1. Crackles in the lungs
2. Decreased heart rate
3. Decreased blood pressure
4. Cyanosis
1. Crackles in the lungs
Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased
What clinical finding indicates to the nurse that a client may have hypokalemia?
1. Edema
2. Muscle spasms
3. Kussmaul breathing
4. Abdominal distention
4. Abdominal distention
Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a si
A registered nurse (RN) is instructed to assess the body temperature of a neonate. Which site for placing the thermometer is contraindicated in these clients?
1. Axilla
2. Oral cavity
3. Temporal artery
4. Tympanic membrane
2. Oral cavity
The oral cavity is the preferred site for temperature measurement in adult clients. This site is contraindicated for neonates and unconscious or uncooperative clients. The axilla is a safe site for placing a thermometer in neonates. The tem
The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? (Choose all that apply)
1. "I had a late onset of menarche."
2. "My first child was born when I was 32."
3. "I noticed a slight discharge
2. "My first child was born when I was 32."
3. "I noticed a slight discharge from a nipple."
5. "I consume two to four glasses of alcohol a day.
The nurse asks the client to shrug the shoulders and to turn the head against passive resistance. Which cranial nerve is involved in this action?
1. Cranial nerve II
2. Cranial nerve XI
3. Cranial nerve VI
4. Cranial nerve VII
2. Cranial nerve XI
Cranial nerve XI (the spinal accessory nerve) is the motor nerve that coordinates the movement of head and shoulders. Cranial nerve II (optic nerve) is a sensory nerve for visual acuity. Cranial nerve VI (abducens nerve) is a motor ner
A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82,
3. Respiratory rate: 14
4. Blood pressure: 110/70
5. Oxygen saturation: 92%
A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?
1. "You will need to ask your healthcare pr
3. "It is performed routinely starting at your age as part of an assessment for colon cancer."
The primary reason for a stool specimen for guaiac occult blood testing is that it is part of a routine examination for colon cancer in any client over the age
While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition?
1. Anemia
2. Pregnancy
3. Lung disease
4. Autoimmune disease
4. Autoimmune disease
Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the
A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a young school-age child?
1. Avoid answering questions.
2. Give the child a list of expectations.
3. Be consistent about established rules.
4. Allow the ch
3. Be consistent about established rules.
Because of a short attention span and distractibility, consistent limit setting is essential toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts. Questions shou
The student nurse prepares a concept map while caring for a client recovering from surgery. What is the first step that the student nurse should take when preparing the concept map?
1. Assess the client and gather information.
2. Arrange cues into cluster
2. Arrange cues into clusters that form patterns.
A concept map is a visual representation of the connection between the client's many health problems. The first step is to arrange all the cues into clusters that form patterns. This helps the nurse identi
A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings?
1. False high reading
2. False low diastolic reading
3. False high systolic reading
4. False high diastol
1. False high reading
If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a false low diastolic readi
Which clients should be considered for assessing the carotid pulse? (Choose all that apply)
1. Client with cardiac arrest
2. Client indicated for Allen test
3. Client under physiologic shock
4. Client with impaired circulation to foot
5. Client with impai
1. Client with cardiac arrest
3. Client under physiologic shock
Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?
1. Stage I
2. Stage II
3. Stage III
4. Unstag
4. Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II press
Which assessment is expected when a client is placed in the lithotomy position during physical examination?
1. Assessment of the heart
2. Assessment of the rectum
3. Assessment of the female genitalia
4. Assessment of the musculoskeletal system
3. Assessment of the female genitalia
Lithotomy position in female clients is used to assess and examine female genitalia and genital tracts. The lateral recumbent position is indicated in clients to assess the heart. The knee-chest position and Sims posi
While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? (Choose all that apply)
1. Presence of hyoid bone damage
2. Presence of cognitive impa
3. Presence of burns from cigarettes
4. Presence of bed sores.
5. Presence of unexplained bruises on the wrist(s)
A nurse teaches an obese client measures to calculate the body mass index. Which of these statements by the client indicate effective learning? (Choose all that apply)
1. "I should include sugared beverages in my diet."
2. "I should lose at least half a p
2. "I should lose at least half a pound to a pound each week."
4. "I'll make sure to eat foods that meet my daily nutritional requirement."
5. "I should stay away from unhealthy foods between meals and after dinner.
The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's s
3. Maintenance
The client is in the maintenance stage of human behavior change. During this stage, the client has managed to incorporate the changes in to the lifestyle. This stage begins six months after the action has started and continues indefinitely.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Choose all that apply)
1. Tetany
2. Seizures
3. Diarrhea
4. Weakness
5. Dysrhythmias
3. Diarrhea
4. Weakness
5. Dysrhythmias
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhe
While assessing a client with chills and fever, the nurse observes that the febrile episodes are followed by normal temperatures and that the episodes are longer than 24 hours. Which fever pattern does the nurse anticipate?
1. Relapsing
2. Sustained
3. Re
1. Relapsing
Periods of febrile episodes coupled with periods of acceptable temperature values is a relapsing type of fever. These periods are often longer than 24 hours. In a sustained fever, the body temperature remains constantly above 38 oC with littl
While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be?
1. 29� C
2. 33� C
3. 36� C
4. 38� C
2. 33� C
A body temperature in the range of 36� to 38 � C is normal. When skin temperature drops below 35� C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower
While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be?
1. Papule
2. Vesicle
3. Nodule
4. Pustule
2. Vesicle
A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, and has a solid elevation and a size smaller than 1 cm. A nodule is an elevated
A client is admitted to the hospital with severe diarrhea, abdominal cramps, and vomiting after eating. These symptoms have lasted 5 days. Upon further assessment, the primary healthcare provider finds that the symptoms occurred after the client ate eggs,
3. Salmonellosis
A client with salmonellosis will experience severe diarrhea, abdominal cramps, and vomiting; these symptoms last as long as 5 days after the intake of contaminated food. This disorder may be caused by Salmonella typhi or Salmonella paraty
A client arrives at a health clinic stating, "I am here to have my tuberculin skin test read." The nurse notes that there is a 7-mm indurated area at the injection site. Which statement made by the nurse correctly describes this result?
1. "The result ind
2. "The result indicates that you are infected with the tuberculosis organism.
A client presents with a shiny appearance of abdominal skin. The skin also has a taut appearance. Which condition may the client have?
1. Ascites
2. Cyanosis
3. Accidental injury
4. Bleeding disorder
1. Ascites
Symptoms of ascites include a shiny and taut appearance of the abdominal skin. Cyanosis occurs when there is a bluish discoloration of the skin. Accidental injury and different types of bleeding disorders are characterized by bruises or needle
Which of the following is a description of the percussion technique?
1. Listening to sounds that the body makes
2. Using the sense of touch to assess and collect data
3. Carefully looking for abnormal findings
4. Tapping the skin with the fingertips to vi
4. Tapping the skin with the fingertips to vibrate underlying tissues
A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning?
1. "I will assess my own pulse rate after exercising."
2. "I will follow my hypertension treatment plan consistently."
3. "I wi
1. "I will assess my own pulse rate after exercising."
2. "I will follow my hypertension treatment plan consistently."
4. "I will perform a self-assessment of my heart rate using the carotid pulse.
A registered nurse (RN) is performing a physical examination of a client with chronic obstructive pulmonary disease. Which abnormal nail bed patterns can be expected in this client?
1. Spoon-shaped nails
2. Transverse depressions in nails
3. Softening of
3. Softening of nail beds and flat nails
Softening of the nail bed and enlarged finger tips with flattened nails are signs of clubbing of the nails. Clubbing results in a change of the angle between the nail and nail base, and is seen in conditions of oxy
While assessing a 7-month-old infant, the nurse advises the mother to avoid regular cow's milk. Which of these are valid reasons for the suggestion? (Choose all that apply)
1. Cow's milk is not tolerated by infants.
2. Cow's milk is a potential source of
3. Cow's milk increases the risk of milk product allergies.
4. Cow's milk is a poor source of iron and vitamins C and E.
5. Cow's milk is too concentrated for an infant's kidneys to manage.
Which physical skin finding indicates opioid abuse?
1. Diaphoresis
2. Red, dry skin
3. Needle marks
4. Spider angiomas
3. Needle marks
Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment?
1. Pain history, including location, intensity, and quality of pain
2. Client's purposeful body mo
1. Pain history, including location, intensity, and quality of pain
3. Pain pattern, including precipitating and alleviating factors
A nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer?
1. Client A: Age 60, family hx of breast cancer, 2 children, age of onset of menopause at 45
2. Clie
2. Client B: Age 60, family hx of breast cancer, no children, age of onset of menopause at 50
An elderly client is admitted to the healthcare facility following a stroke. What should the nurse do when the client's relative who arrived much later asks to see the client's health record?
1. Confirm the client's relationship first.
2. Ask the client's
4. Explain that medical health records are confidential.
A nurse is assessing four different clients. Which findings depict that the client is at risk for heart disease?
1. Client A: color assessed - red, location assessed - face, area of trauma, sacrum, shoulders
2. Client B: color assessed - blue, location as
2. Client B: color assessed - blue, location assessed - nail beds, lips, mouth, skin
While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?
1. Radial and apical pulse
2. Apical and carotid pulse
3. Radial and brachial pulse
4. Apical and te
1. Radial and apical pulse
Pulse deficit may be associated with an abnormal rhythm. Pulse deficit is the difference between the radial and apical pulse. The carotid pulse is measured when a client's condition worsens suddenly. The brachial pulse is used t
Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds?
1. Parietal pleura rubbing against visceral pleura
2. Random, sudden r
3. Turbulence due to muscular spasm and fluid or mucus in the larger airways
Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways.
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?
1. Multipara in active labor
2. Middle-aged woman with substernal chest pain
3. Older adult male with a
3. Older adult male with a partially amputated finger
Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening, and the client can wait for care. A woman in active labor should be assessed immediate
While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?
1. Syphilis
2. I
3. Subacute bacterial endocarditis
Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia
Which type of breathing pattern alteration is manifested with hypercarbia?
1. Eupnea
2. Tachypnea
3. Hypoventilation
4. Kussmaul's respiration
3. Hypoventilation
Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration is interrupted while singing. The rat
How does the World Health Organization (WHO) define "health"?
1. A condition when people are free of disease
2. A condition of life rather than pathological state
3. An actualization of inherent and acquired human potential
4. A state of complete physical
4. A state of complete physical, mental, and social well-being
A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching?
1. "Type I immune response to latex has an imm
3. "The client's first exposure to latex will cause a type IV allergic reaction.
The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?
1. The nurse notes nonverbal signs of discomf
3. The nurse asks the client to explain the surgery.
The nurse must assess the client's knowledge about the surgery to determine if the client is aware of the outcome of surgery. The nurse observes for nonverbal signs of discomfort because some clients ma
When teaching about aging, the nurse explains that older adults usually have what characteristic?
1. Inflexible attitudes
2. Periods of confusion
3. Slower reaction times
4. Some senile dementia
3. Slower reaction times
A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple
The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care?
1. Meet
3. Participate in the bedside rounds.
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what?
1. Diminished
2. Normal
3. Full
4. Bounding
3. Full
The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is
Which physical assessment of the skin indicates that a client is addicted to phencyclidine?
1. Burns
2. Vasculitis
3. Diaphoresis
4. Red and dry skin
4. Red and dry skin
Red and dry skin is associated with phencyclidine abuse. A client with alcohol abuse will have burns on the skin. Vasculitis is associated with cocaine abuse. Diaphoresis is associated with chronic abuse of sedative hypnotics.
A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition?
1. Sims position
2. Su
3. Lithotomy position
Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinati
A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails?
1. Client A: subacute endocarditis
2. Client B: Iron deficiency ane
2. Client B: Iron deficiency anemia
Conditions such as iron deficiency anemia and syphilis cause concave curvature of the nails, which is called koilonychia (spoon nails). Red or brown linear streaks in the nail bed are caused by minor trauma to nails, su
The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? (Choose all that apply)
1. The client reports pain with movement.
2. The client has pain over the surgical area.
3. The cli
1. The client reports pain with movement.
2. The client has pain over the surgical area.
4. The client rates the pain as 8 on a scale of 0 to 10.
A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been in
4. Cranial nerve VII
Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which cause
While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness?
1. Applying moisturizing lotion between toes
2. Cutting nails after soak
2. Cutting nails after soaking them for 10 minutes in warm water
Which factor can elevate the oxygen saturation during an assessment?
1. Nail polishes
2. Carbon monoxide
3. Intravascular dyes
4. Skin pigmentation
2. Carbon monoxide
Carbon monoxide artificially elevates the oxygen saturation during assessment. Nail polishes interfere with the ability of the oximeter. Intravascular dyes will artificially lower the oxygen saturation. Skin pigmentation will overestima
A registered nurse is teaching a nursing student about when a client with high blood pressure should follow up with the primary healthcare provider. Which statement made by the nursing student indicates effective learning?
1. "I will advise a client with
1. "I will advise a client with a blood pressure of 130/80 mm Hg to follow up in a year.
What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique?
1. "Effectiveness depends on the child's age."
2. "Spanking is strongly suggestive of negative role behavior."
3. "Spanking may
2. "Spanking is strongly suggestive of negative role behavior.
A nurse is teaching a male client about measures to maintain sexual health and prevent transmission of sexually transmitted infections (STI). Which statement of the client indicates effective learning?
1. "I will use condoms when having sex with an infect
4. "I will consult with my primary healthcare provider when there is a rash or ulcer on my genitalia.
While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected?
1. Facial nerve
2. Trochlear nerve
3. Abducens nerve
4. Trigeminal nerve
4. Trigeminal nerve
The trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. A client with a damaged trigeminal nerve will be unable to clench his teeth. The facial nerve provides sensory and mo
The nurse is performing a weight assessment for different people in a community. Which question should the nurse ask a client to determine a disease-related change in weight?
1. Do you follow a strict calorie intake?
2. Have you notices any changes in the
4. Have you noticed any unintentional weight loss in the past six months?
The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?
1. "You need to receive the pneumococcal vaccine every other year."
2. "T
4. "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose.
Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's
2. Sharp increase in serosanguineous drainage
Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (eviscer
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client?
1.
1. Educate the client on managing stress.
What would be the respiratory rate in two-year-old child?
1. 20
2. 30
3. 40
4. 50
2. 30
The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The
While performing a physical assessment of a female client, a nurse notices hair on the client's upper lip, chin, and cheeks. Which condition may result in this condition?
1. Aging
2. Poor nutrition
3. Endocrine disease
4. Arterial insufficiency
3. Endocrine disease
Endocrine diseases such as hirsutism will result in excessive hair growth on the upper lip, chin, and cheeks. Aging and poor nutrition will result in decreased hair growth. Arterial insufficiency will result in decreased hair growth d
The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III?
1. Client A: drooping eyelids
2. Client B: near sightedness
3. Client C: Cross eyes
4. Client D: Prot
1. Client A: drooping eyelids
Injury to the third cranial nerve may result in edema or impairment of the third cranial nerve. This results in the abnormal drooping of the eyelids, a condition called ptosis. Myopia is nearsightedness, a refractive error in
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
1. Planning
2. Evaluation
3. Assessment
4. Implementation
1. Planning
A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?
1. Headache
2. Pallor
3. Paresthesias
4. Blurred vision
3. Paresthesias
Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to t
A client has a history of a persistent cough, hemoptysis, unexplained weight loss, fatigue, night sweats, and fever. Which risk should be assessed?
1. Lung cancer
2. Cerebrovascular disease
3. Cardiopulmonary alterations
4. Human immunodeficiency virus (H
4. Human immunodeficiency virus (HIV) infection
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? (Choose all that apply)
1. Axilla
2. Fingers
3.Ear lobes
4. Forehead
5. Upper thorax
2. Fingers
3.Ear lobes
Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to di