Test Bank for Health And Physical Assessment In Nursing 4th Edition by Fenske, Watkins, Saunders, Barbarito Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 1 Health Assessment 1) A client with a self-reported history of type 2 diabetes mellitus and an ulcer wound on the left foot states to the nurse, "I am healthy, I don't know why I have to be here to get a check-up." Which statement by the nurse is the most appropriate? 1. "I feel that you are in denial about your health status." 2. "Tell me about your definition of being healthy." 3. "Do you understand what diabetes is?" 4. "Is there anything else you are not telling me?" Answer: 2 Explanation: 1. More information would be needed before the nurse could attribute the client's viewpoint as denial or lack of knowledge. 2. During the process of gathering the subjective data from the client, the nurse must be attuned to what the patient says, along with the signs, symptoms, behaviors, and cues offered by the patient. This situational awareness and focused data collection will enable the nurse to create a comprehensive database about the patient. 3. The client's history of type 2 diabetes requires further investigation but the nurse must first ascertain the client's definition of what healthy means. 4. There is not enough information to determine the client's withholding of information to the nurse. Page Ref: 4 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Illness Management Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
2) The nurse is preparing to provide teaching to a client at risk for diabetes. During which time should the nurse recognize is the most effective moment for teaching? 1. During health promotion. 2. When the client is ready to learn. 3. During the discussion of disease prevention. 4. When a knowledge deficit has been identified. Answer: 2 Explanation: 1. Health promotion is important; however, if the client is not ready to learn new information, the teaching may be ineffective. 2. A client must be ready to learn new information or the teaching may be ineffective. 3. Disease prevention is important; however, if the client is not ready to learn new information, the teaching may be ineffective. 4. Once the knowledge deficit is identified, it is important that client is ready to learn or the teaching may be ineffective. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship Centered Care: Factors thatNcUoRnStIrNibGuTtBe.CtoOoMr threaten health; communicate information effectively; and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.
3) The nurse is conducting a workshop on wellness and health promotion using the initiatives of Healthy People 2020. After the session, which statement by a participant indicates an understanding of the initiatives? 1. "It will allow healthcare providers to lobby legislators for more funding." 2. "The primary goal of Healthy People 2020 is to assist healthcare providers in determining risk factors for premature birth." 3. "Healthy People 2020 seeks to promote health, prevent illness, disability, and premature death." 4. "The initiatives will outline standards of care for providers in managing diseases." Answer: 3 Explanation: 1. Healthcare providers and other persons interested in programs to promote health have found the document to be a useful source of information in their efforts to gain funding. 2. The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. The document identifies leading health indicators that reflect public health concerns. Risk factors for premature birth may be part of those health indicators, but the scope of the document covers broad areas of concern. 3. The Healthy People 2020 initiative is a 10-year strategy intended to promote health, prevent illness, disability, and premature death. 4. Standards of care in disease management is not a component of the document. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care; patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
4) The nurse is reviewing the advanced practice roles in nursing. Which role should the nurse recognize is most likely to provide indirect patient care? 1. Nurse Researcher. 2. Nurse Administrator. 3. Nurse Educator. 4. Nurse Anesthetist. Answer: 2 Explanation: 1. A nurse researcher may provide direct care through their work in a clinic, hospital, or laboratory focusing on patient care outcomes, administering treatments for clinical trial, or collecting data to help understand population based outcomes. 2. The nurse administrator does not provide direct patient care but may be utilized for consultation. Other responsibilities vary and could include management of complex patient care areas, staffing, budgets, organizational and staff performance, and ensuring that the goals of the agency are being accomplished. 3. The nurse educator is responsible for didactic and clinical teaching, curriculum development, clinical placement, and evaluation of learning. Direct patient care occurs during clinical teaching. 4. The nurse anesthetist has direct patient care by providing a full range of anesthesia services. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Management of Care; Concepts of Management Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals; function competently within one's own scope of practice as leader or member of the healthcare team; and manage delegation effectively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.
5) The nurse conducts a health history while admitting a client to the acute care facility. When collecting primary subjective data, which source should the nurse use? 1. The client's physical assessment. 2. The client's self-reports. 3. The client's healthcare provider. 4. The client's significant other. Answer: 2 Explanation: 1. The physical assessment will be recorded as objective data. 2. Subjective data are gathered from the interview. The interview includes the health history and focused interview of the patient which is considered primary subjective data. 3. The client's healthcare provider and significant other may contribute in the data collection process. The information obtained from friends and family members is considered subjective. This source of information is termed secondary. 4. The client's significant other may contribute in the data collection process but that input is classified as secondary data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, NanUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2: Explain evidence-based practice and its significance in nursing. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
6) The nurse is reviewing a client's medical records. Which should the nurse recognize as subjective data? 1. The client tells the nurse their abdomen hurts on the left side after eating. 2. The client's abdomen is tender on the left side during palpation. 3. The CAT scan reveals a large mass in the left lower quadrant of the abdomen. 4. The client's hemoglobin is 14.1 gm/dL.Answer: 1 Explanation: 1. Subjective reports by the client are those feelings or symptoms that cannot be observed by others. The statement "My abdomen hurts," is subjective data. 2. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. 3. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. 4. Physical examination findings, radiographic findings, and laboratory analysis reports are objective data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, N anUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment.
7) The nurse is reviewing a client's medical record. Which documented data should the nurse recognize is objective? 1. The client states, "fell and hurt myself." 2. The client states, "I am six years old." 3. "Six-year-old child observed holding a towel to her forehead." 4. "Client states that she was running and fell at the playground." Answer: 3 Explanation: 1. Statements the client makes are subjective data. 2. Statements the client makes are subjective data. 3. Objective data are data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head. 4. Statements the client makes are subjective data. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems; Contribute to assessment of outcome achievement. | NNUuRrsSiInNgG/ITnBte.CgOraMted Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment.
8) The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. Which action should the nurse take? 1. Report the lack of achievement of the goals to the healthcare provider. 2. Review the data and modify the plan. 3. Reformulate the nursing diagnosis to a more realistic one. 4. Request a consult for the client to be seen by a pulmonologist. Answer: 2 Explanation: 1. Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be. 2. The plan of care should be evaluated periodically at established time frames to determine achievement of the goals. If goals have not been achieved, revisions should be made which may include adding, changing, or discontinuing nursing diagnoses or nursing interventions. 3. Reformulating the nursing diagnosis to a more realistic one is not the best course of action, as the diagnosis established came from subjective and objective data specific to that diagnosis. 4. There is no data to support the need for additional medical consultations. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Illness Management Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLNNCUoRmSpINete eO s:MPersonal and Professional GTnBc.iC Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
9) The preceptor has created a teaching plan about the concepts of health and wellness for a new nurse. Which statement by the nurse indicates an understanding of health? 1. "Health is the absence of illness, disease, and symptoms." 2. "Health is a state of well-being and when the client feels good." 3. "Health is the state when a person is viewed as a holistic being." 4. "Health is a state of complete physical, mental, and social well-being." Answer: 4 Explanation: 1. Health extends beyond the absence of illness and disease. 2. Defining health as a state of well-being is limiting as it does not encompass all of the elements of an individual's being. 3. While health does require a holistic approach, this definition does not explore the context of health. 4. Health is a physical, psychosocial, and spiritual wellness. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.5; IX.7. Use evidencebased practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy consideNraUtRioSnIN s GtoTBfo.CstOeM r patient engagement in their care. | NLN Competencies: Knowledge and Practice: Health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
10) The nurse is caring for a client who is recovering from abdominal surgery. Which goal should the nurse include in this client's plan of care? 1. The client will verbalize pain relief using an intensity rating in 1 hour. 2. The client will state that they feel fine in 1 hour. 3. The nurse will observe fewer signs of pain in the client's every 1 hour. 4. The nurse will re-evaluate the client's pain level every 1 hour. Answer: 1 Explanation: 1. The goal s is directly related to the nursing diagnosis. Goals are stated in a positive fashion and have measurable criteria. 2. This statement is not related directly to the diagnosis and is not measurable. 3. A goal must be reflective of client activities. This is an incorrect answer because it reflects activities of the nurse and not the client. 4. A goal must be reflective of the client's activities. This is an incorrect answer because it reflects activities of the nurse and is not client directed. Although there is a time frame listed, it is not correct as it is related to nursing actions. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences inNpUlaRnSnINinGgT, Bim and evaluating outcomes of .CpOlementing, M care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
11) The nurse is developing the plan of care for a client who is recovering from abdominal surgery. Which intervention should the nurse implement to address this client's pain? 1. The healthcare provider will prescribe additional analgesics. 2. The client will have reduced pain after administration of analgesics. 3. The client will vocalize reduced levels of pain within 1 hour. 4. The client will be assisted with guided imagery to manage pain levels. Answer: 4 Explanation: 1. The prescribing of additional analgesics does not determine the characteristics of the pain and does not provide for the assessment of subjective information. 2. This is a goal statement, not an intervention. 3. This is a goal statement, not an intervention. 4. Nursing interventions, such as assisting the client with guided imagery, are geared to assist in meeting client goals. The interventions are based upon nursing actions. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Non-Pharmacological Comfort Interventions Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and ProfessionaNlUDReSvIeNlop : Identify problems and contribute to GTm B.e Cn OtM assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
12) A new nurse asks the preceptor how the Healthy People 2020 goals can affect a hospitalized client. Which response by the educator is the most appropriate? 1. "Healthy People 2020 is a tool for the healthcare providers to offer information to their clients." 2. "Healthy People 2020 seeks to improve health and prevent illness, disability, and premature death." 3. "The purpose of Healthy People 2020 is to reduce healthcare costs for hospitalized clients." 4. "Healthy People 2020 is seen as a tool by hospitals to reduce length of stay." Answer: 2 Explanation: 1. Healthy People 2020 is a resource tool for all healthcare professionals but its purpose is not to provide patient education between the healthcare provider and client. 2. Healthy People 2020 presents a 10-year strategy with objectives intended to enhance health and prevent illness, disability, and premature death. 3. Reduction of hospital costs is the not the primary purpose of Healthy People 2020. 4. Reduction of length of stay is the not the primary purpose of Healthy People 2020. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: KNnUoRwSlIeNdGgTeBa.C ndOM Practice: Health promotion/disease prevention. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.7: Examine how national health policy is structured to enhance individual and population health. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
13) The preceptor is reviewing a new nurse's goal statement of, "The client will resume normal bowel elimination patterns," created for the care plan of a client with irritable bowel syndrome. Which feedback should the preceptor provide the nurse? 1. "This plan of care has an appropriate goal statement which meets criteria." 2. "This goal statement requires a time frame to be appropriate." 3. "This goal statement is not reflective of the client's diagnosis." 4. "This care plan is accurate and should be entered in the client's medical record." Answer: 2 Explanation: 1. This goal statement does not meet criteria as it lacks a time frame. 2. Time frames are an important component of goal statements and provide guidelines for when to evaluate the achievement of the goal. 3. The defining characteristics of the diagnosis and the etiology of the diagnosis are components of the diagnostic statement. 4. This goal statement does not meet criteria as it lacks a time frame. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Elimination Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Teamwork: Adapt communication to the team and situatioNnUtRoSsIhNaGrTeBin.CfO orMmation or solicit input; initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
14) The nurse is caring for a newly admitted client with Methicillin-resistant Staphylococcus Aureus (MRSA). Which goals should the nurse include in the initial health assessment? Select all that apply. 1. Determine the client's current state of health. 2. Predict risks to current health status. 3. Use only objective data to determine client allergies. 4. Identify the client's ongoing health activities. 5. Identify the client's ability to adhere to treatment. Answer: 1, 4 Explanation: 1. Health assessment goals are used to determine the client's current state of health. 2. Health assessment activities are used to predict risks to health and identify health status both current and future. 3. The initial health assessment includes both objective and subjective information. 4. Health assessment goals are used to determine ongoing health promoting activities. 5. The health assessment is not focused on the client's compliance to treatment. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessNioUnRaSlIpNeGrTsB pe.CcOtiM ves, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment.
15) During a physical assessment of a client, the nurse notes wheezing and documents the findings in the medical record. Which phase of critical thinking is represented by the nurse's actions? 1. Collection of information. 2. Evaluation. 3. Generation of alternatives. 4. Analysis of the situation. Answer: 1 Explanation: 1. Collection of information is the initial step in the process. During this phase, the nurse will assess available information and document the findings in the medical record. 2. Evaluation is the final step in the process. During evaluation, the nurse will determine the effectiveness of actions taken. 3. When generating alternatives for action, the nurse will use critical thinking skills to determine available options for action. 4. Analysis of the situation occurs when the nurse employs assessment skills to review and analyze the situation. The analysis will provide the nurse with the understanding of what the best plan of action will be. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based on new knowledge. | AACN nTtiBal.C sO Competencies: IX.1. Conduct N URESsIsNeG M comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
16) The nurse is obtaining an admission assessment. Which should the nurse document as subjective data? Select all that apply. 1. The client's mother informs the nurse that her daughter has not been sleeping due to pain. 2. The client states, "I have pain in my belly that is 7 out of 10." 3. Abdominal assessment reveals a firm, hard abdomen. 4. The client is weak and looks pale. 5. The client appears nervous during the data collection period. Answer: 1, 2 Explanation: 1. Subjective data is information the client experiences and communicates to the nurse. This information can be provided by either the client or other individuals. 2. Subjective data is information the client experiences and communicates to the nurse. 3. Objective data is obtained through observation by the examiner. 4. Objective data is obtained through observation by the examiner. 5. Objective data is obtained through observation by the examiner. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment.
17) The nurse is admitting a client to the unit. Which should the nurse consider when regarding the confidentiality of the client? 1. Information sharing is limited to those directly involved in the client care. 2. All members of the unit's healthcare team may have access to the chart. 3. The Health Insurance Portability and Accountability Act (HIPAA) determines who can communicate with the client. 4. The medical records are open to any hospital employee, including administration. Answer: 1 Explanation: 1. Confidentiality means that information sharing is limited to those directly involved in the client care. 2. Access to the chart is limited to only those directly caring for the client, not to all members of the healthcare team on the unit. 3. The Health Insurance Portability and Accountability Act (HIPAA) does not dictate who is allowed to communicate with the client. 4. The medical records are not open to any hospital employee, including administration. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Confidentiality/Information Security Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VIII.10. Protect patient privacy and confidentiality of patient records and other privileged communications. | NLN Competencies: Context and EnvironmenNt:UARcStINinGaTcBc.oCrOdMance with legal and regulatory requirements, including HIPAA, for faculty's students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
18) The preceptor is reviewing the effective use of the nursing process with a new nurse. Which statement by the nurse indicates an understanding of the information? 1. "The correct order of the nursing process is diagnosis, assessment, planning, implementation, and evaluation." 2. "The correct order of the nursing process is assessment, diagnosis, planning, implementation, and evaluation." 3. "The correct order of the nursing process is planning, assessment, diagnosis, implementation, and evaluation." 4. "The correct order of the nursing process is assessment, planning, diagnosis, implementation, and evaluation." Answer: 2 Explanation: 1. The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. 2. The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. 3. The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing N prUoRcSeIsNsGisTdBi.aCgOnMosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. 4. The nursing process is a systematic, rational, dynamic, and cyclic process used by the nurse for planning and providing care for the client. The assessment phase, step 1, involves the collection of data. Step 2 of the nursing process is diagnosis. Step 3 of the process is planning. Implementation is step 4. The final stage in the process, step 5, is evaluation. Page Ref: 5 Cognitive Level: Remembering Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
19) The nurse is reviewing the role of the nurse practitioner. Which should the nurse recognize is the primary role? 1. Manage complex patient care areas. 2. Attend to the health of women of all ages. 3. Engagement in quality improvement. 4. Provide primary care in acute settings. Answer: 4 Explanation: 1. Nurse administrators manage common complex patient care areas. 2. The certified nurse midwife attends to the health of women of all ages. 3. The nurse researcher may be engaged in continuous quality improvement projects in institutions and agencies. 4. The nurse practitioner can provide primary care in acute settings. Page Ref: 3 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively and clarify roles and integrate the contributions of others who play a role iNnUhReSlpINinGgTtBh.eCOpM atient/family achieve health goals | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.
20) The nurse recognizes that there needs to be a change in practice on the unit to improve the client outcomes. Which is the quickest method the nurse should consider to change current practice? 1. Research. 2. Literature review. 3. Quality improvement project. 4. Document patient outcomes. Answer: 3 Explanation: 1. Research can be done to identify evidence-based changes in practice. 2. A literature review can help identify evidence-based changes in practice. 3. A quality improvement project led by nurses has shortened the gap of time it takes to implement evidence-based practice. 4. Documenting patient outcomes is not a formal method for effectively changing practice on a unit. The outcomes should be monitored through a quality improvement project. Page Ref: 3 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Performance Improvement (Quality Improvement) Standards: QSEN Competencies: III.C.5. Value the need for continuous improvement in clinical practice based on new knowledge | AACN Essentials Competencies: III.5. Participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team to improve patieNnU t oRuSItNcoGm NLN Competencies: Quality and Safety: TBe.sC. O|M Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2: Explain evidence-based practice and its significance in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
21) The nurse is reviewing the advanced practice roles of the nurse. Which should the nurse recognize as the primary responsibility of the clinical nurse specialist? 1. Identify problems in regards to patient care, designs plans of study, and develops tools. 2. Provide generalized healthcare services, such as family planning, obstetric, and gynecological care. 3. Provide direct patient care, direct and teach other team members providing care, and conduct research within an area of specialization. 4. Combine expertise in diagnosis and illness with a nurse's understanding of health promotion and prevention. Answer: 3 Explanation: 1. The role of the Nurse Researcher includes the identification of problems in regards to patient care, designing plans of study, and developing tools. 2. The Certified Nurse Midwife is an independent practitioner that provides generalized healthcare services, such as family planning, obstetric, and gynecological care. 3. The role of the Clinical Nurse Specialist includes the provision of direct patient care, directing and teaching other team members, and providing care and conduct research within an area of specialization. 4. The role of the Nurse Practitioner includes combining expertise in diagnosis and illness with a nurse's understanding of health promotion and prevention. Page Ref: 3 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.1: Explain the roles of the professional nurse in healthcare. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.
22) The nurse is preparing to conduct a focused interview on an older adult client who is being admitted for a urinary tract infection (UTI). Which initial action should the nurse take? 1. Obtain a urine sample. 2. Monitor the client's vital signs. 3. Assess the client's about dietary preferences. 4. Assess the characteristics of the client's pain. Answer: 4 Explanation: 1. The client may need to have a urine specimen but that does not directly relate to obtaining more information about the client's chief complaints. 2. The client's vital signs will be taken but they do not directly relate to obtaining more information about the client's chief complaints. 3. Dietary preferences of clients are recorded but are not a part of the focused assessment. 4. The focused interview is used to allow for clarification of information from the initial interview. The focused interview is the portion of the interview in which the nurse asks the patient to clarify points, provide missing information, and elucidate information identified in the health history. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.4: Examine the components of health assessment.
23) The nurse is preparing to obtain a health history. Which should the nurse understand is the main purpose of obtaining a health history before a physical assessment? 1. Allows the nurse to gather objective data. 2. Provides a systematic means of gathering information. 3. Enables a nursing diagnosis to be generated. 4. Assists the examiner in accurately conducting a physical assessment. Answer: 2 Explanation: 1. A purpose of a health history is to obtain information about the client's health in their own words and based on their own perceptions. 2. The main purpose of conducting an interview prior to obtaining a physical assessment is to systematically gather information about the client. 3. A nursing diagnosis is not generated until both subjective and objective data have been obtained. 4. Accurately conducting a physical assessment is based on the nurse's ability to systematically and consistently use evidence-based methods of data collection. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, N anUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Define health assessment and identify key components. MNL Learning Outcome: 1.4: Examine the components of health assessment.
24) The nurse is reviewing the goal statements for a postoperative client. Which goal statements should the nurse recognize needs further development? Select all that apply. 1. The nurse will assess the vital signs every 2 hours. 2. The client will ambulate every 6 hours on the first postoperative day. 3. The client will report feeling better by the end of the day. 4. The client will begin a clear liquid diet on the first postoperative day. 5. The nurse will administer oral analgesics as prescribed. Answer: 1, 3, 5 Explanation: 1. Goal statements are used to provide planned outcomes for the client. Goal statements must be measurable and are reflective of client activities. This statement reflects actions of the nurse, not the client. 2. The goal statement is used to provide planned outcomes for the client. Goal statements must be measurable and reflective of client activities. All elements needed for an appropriate goal statement are represented. 3. Goal statements must be measurable and reflective of client activities. This statement is vague and does not provide a definitive means for measurement. 4. Goal statements are used to provide planned client outcomes. This statement contains the needed elements for a successful goal statement. 5. This statement is not a client-centered goal statement. This statement reflects an intervention performed by the healthcare provider. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
25) The nurse administrator is explaining their role to a new nurse. Which statement made by the new nurse indicates further teaching is required? 1. "You are available for consultation." 2. "You will be conducting research." 3. "You are responsible for staffing." 4. "You will be monitoring the goals of the organization." Answer: 2 Explanation: 1. The nurse administrator may function as a consultant. 2. The nurse administrator is not involved in conducting research. 3. The nurse administrator may be responsible for staffing. 4. The nurse administrator monitors the goals of the organization. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: II.B.4 Function competently within own scope of practice as a member of the healthcare team. | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e. scope of discipline, education, and licensure requirements). | NLN Competencies: Teamwork: Function competently within one's own scope of practice as leader or member of the healthcare team and manage delegation effectively. Clarify roles and integrate the contributions of others who play a role in helping the patient/family achieve health goals. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G EvTaBlu.CaOtiM on Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.1: Distinguish between the various roles of the professional nurse in healthcare.
26) The new nurse is reviewing a client's plan of care with the preceptor. Which statement made by the nurse should the preceptor be concerned with? 1. "I have created one goal per nursing diagnosis." 2. "I have created my goals based on the nursing diagnosis." 3. "I identified measurable goals during the planning." 4. "I have written the interventions based on my goals." Answer: 1 Explanation: 1. A single nursing diagnosis may generate more than one patient goal. 2. The goals for the client are based on the nursing diagnosis. 3. Measurable goals are identified during the stage of planning. 4. Interventions are based on the identified goals. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, andSupervision Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
27) The nurse is reviewing a client's care plan. Which part of the nursing process should the nurse use to determine if new problems exist? 1. Assessment. 2. Evaluation. 3. Implementation. 4. Planning. Answer: 2 Explanation: 1. The assessment process begins during the first encounter of the patient or the chart. The collection, organization, and validation of subjective and objective information are obtained during the assessment. 2. During the evaluation, the nurse determines if a new problem exists. 3. During the implementation of the nursing process, the nurse carries out relevant nursing interventions specific to the patient. 4. During the phase of planning, the nurse identifies measurable goals or outcomes, sets priorities, and selects evidence-based nursing interventions that promote achievement of measurable patient goals or outcomes. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, includN inUgRgSeInNeGtTicBs.,CwOhMich influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Personal and Professional Development: Identify problems. Apply decision-making skills, particularly in the context of uncertainty and ambiguity. | Nursing/Integrated Concepts: Nursing Process: Evaluating Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
28) The preceptor is assessing a new nurse's ability to critically think. Which should the preceptor include in the assessment? Select all that apply. 1. Application of logic. 2. Use of resources. 3. Ability to problem solving. 4. Use of the nursing process. 5. Use of cognitive skills. Answer: 1, 2, 4, 5 Explanation: 1. Critical thinking is a way to apply logic to the complexities of patient care. 2. Critical thinking involves the use of resources. 3. Critical thinking is more than problem solving. 4. Critical thinking parallels the nursing process. 5. Critical thinking is a way to apply cognitive skills to the complexities of patient care. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: II.B.11. Solicit input from other team members to improve individual, as well as team, performance. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Personal and Professional Development: Identify problems and apply decision-making skills, particularly in the context of uncertainty and ambiguity. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.5: Apply the critical thinking process to health assessment in nursing. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
29) The nurse is developing a client's plan of care. Which should the nurse base the plan of care on? 1. The nursing diagnosis. 2. The objective data. 3. The subjective data. 4. Client goals.Answer: 1 Explanation: 1. The plan of care should be based on the nursing diagnosis. 2. Objective and subjective data are collected and used to formulate the nursing diagnosis. 3. Objective and subjective data are collected to formulate the nursing diagnosis. 4. Client goals are developed to help determine the success of the care delivered. Page Ref: 5 Cognitive Level: Remembering Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.4: Examine the components of health assessment.
30) The nurse is preparing to focus on the third step of the nursing process. Which should the nurse anticipate obtaining? 1. Statement of client goals. 2. Collection of subjective data. 3. Performance of care activities. 4. Review of client's achievement of goals. Answer: 1 Explanation: 1. The third step in the nursing process is the planning phase. During the planning phase, care interventions are determined, priorities are set, and client goals are stated. 2. Assessment is the first phase of the nursing process for which collection of subjective data occurs. 3. Implementation is the fourth phase of the nursing process for which care activities are implemented. 4. The client's progress toward achieving the identified goals is evaluated in the final stage of the nursing process. Page Ref: 5 Cognitive Level: Remembering Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomesNoUfRcSaIrNeG. T|BN.CLN Competencies: Personal and OM Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3: Explain the steps of the nursing process. MNL Learning Outcome: 1.3: Examine the steps of the nursing process and their association with critical thinking.
31) The nurse is reviewing the client's record for reports of pain. Which should the nurse consider subjective data? Select all that apply. 1. The client's leg is red and swollen. 2. The client complains of leg tenderness. 3. The client's white blood cell count is elevated 4. The client demonstrates guarding behavior during the assessment 5. The client states they have leg cramps. Answer: 2, 5 Explanation: 1. Objective information is observable by the examiner. The examiner is able to visualize the appearance of the extremity. 2. Subjective information refers to data reported by the client. The client's complaints are an example of subjective data. 3. The laboratory values are objective data based on measurement. 4. Objective information is observable such as the patient exhibiting guarding behavior during an assessment. 5. Subjective information refers to data reported by the client such as in a statement regarding the experience of pain. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. ConNdUuRcStIcNoGm pr.CeO hM ensive and focused physical, TB behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Personal and Professional Development: Identify problems and contribute to assessment of outcome achievement. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4: Define health assessment and identify key components. MNL Learning Outcome: 1.4: Examine the components of health assessment.
32) The nurse is evaluating the risk factors for health disparity. Which social determinant should the nurse consider places the clients in the community at risk? 1. Lack of access to healthcare services. 2. Nonadherence to health prevention. 3. Lack of participation in exercise. 4. Chronic substance abuse. Answer: 1 Explanation: 1. Lack of access to healthcare services is a social determinant associated with health disparity. 2. Nonadherence to health prevention is a behavior. 3. Nonparticipation in exercise is not a health disparity, unless the reason the client cannot participate is due to an unsafe environment or disability. 4. Chronic substance abuse addiction is a behavior or an addiction. Page Ref: 7 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individualsN, UfaRm lieGsT, Bg.rCoOuM ps, communities, and populations. | SIiN NLN Competencies: Context of Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.6: Describe the concepts of health, wellness, and health disparities. MNL Learning Outcome: 1.4: Examine the components of health assessment.
33) Which should the nurse understand is the main focus of the Agency for Health Research and Quality? 1. Nursing practice guidelines. 2. Health promotion. 3. Produce evidence-based reports. 4. Address healthcare disparity. Answer: 3 Explanation: 1. The AHRQ produces evidence reports and technology assessments. 2. The AHRQ produces evidence reports and technology assessments. 3. The AHRQ produces evidence reports and technology assessments. 4. The AHRQ produces evidence reports and technology assessments. Page Ref: 3 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context of Environment: Environmental health; health promotion/disease prevention (e.g., transmission of diseaseN, UdR isSeIaNsGeTpBa.tCtO erMns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.7: Examine how national health policy is structured to enhance individual and population health. MNL Learning Outcome: 1.2: Recognize the significance of evidence-based practice and its usein nursing.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 2 Health and Wellness 1) The nurse has held a smoking cessation class based on the Health Belief Model. According to the model, which statement made by a participant should the nurse recognize indicates the highest level of positive self-efficacy? 1. "I think this time will be different." 2. "I am going to do the best that I can, so that I won't get lung cancer." 3. "I am afraid of getting lung cancer like my father." 4. "I know that this time I will quit smoking permanently." Answer: 4 Explanation: 1. Stating that this attempt at quitting smoking will be different shows a low level of commitment to the action. 2. A statement of fear of getting lung cancer represents an internal cue to action. 3. Referring to a family member with the disease represents an internal cue to action. 4. Based on the Health Belief Model, self-efficacy refers to the level of confidence an individual has about the ability to perform the activity. The client's statement, "I know that this time I will quit smoking permanently," reflects the highest-level of determination and motivation. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.B.3.NBUase ndGiTvBid.CuO alM ized care plan on patient values, clinical RSIiN expertise, and evidence. | AACN Essentials Competencies: VII.3. Clinical Prevention and Population Health: Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.1: Describe the importance of nursing theory to the practice of nursing and health assessment. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
2) During a preconceptual assessment, a couple tells the nurse they have a family history of sickle cell disease. Which statement made by the couple should the nurse recognize indicates the desire to participate in primary prevention? 1. "We need to both be treated for sickle cell anemia before we can have a baby." 2. "We will have blood tests to determine if we are carriers for the disease." 3. "We need to see a genetics counselor to discuss the potential for having a child with sickle cell disease." 4. "We both do not have sickle cell disease, so there is a good chance that our baby will not have it." Answer: 3 Explanation: 1. Secondary and tertiary prevention is associated with the need for treatment. 2. Testing for the disease is a secondary prevention measure. 3. Primary prevention implies health and a high level of wellness for the individual. Seeking out a genetics counselor to discuss the potential for having a child with sickle cell disease is considered primary prevention. 4. Stating that neither has the disease, thus a child would not inherit the disease, indicates no level of prevention. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
3) The nurse is assessing the level of commitment and motivation of a patient seeking to lose weight. Which approach should the nurse recognize is being used to enhance the patient's health? 1. Psychosocial perspective. 2. Illness perspective. 3. Physiologic perspective. 4. Wellness perspective. Answer: 4 Explanation: 1. A psychosocial perspective does not take into account the physiologic alteration necessary for a successful weight loss program. 2. An illness perspective focuses on the illnesses such as hypertension that can result from the weight gain. 3. A physiologic perspective is also considered an illness perspective. 4. When using a wellness perspective, the nurse focuses on the patient's personal strengths and abilities to enhance health. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.3. Clinical Prevention and Population Health: Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NU NRLN CG om ncies: Context SIN TBp.e CtOeM and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
4) The nurse is discharging a patient who was hospitalized for a cerebral vascular accident (CVA). Which statement made by the patient indicates understanding of primary prevention? 1. "I will need instruction on using my walker." 2. "I need to have my flu shot this year." 3. "I must take my blood pressure medications regularly." 4. "I need to have my cholesterol monitored every 2 months." Answer: 2 Explanation: 1. Tertiary prevention involves strategies for rehabilitation such as using a walker after a CVA. 2. A flu shot is a primary prevention. 3. Taking blood pressure medication is secondary prevention since the treatment is aimed at maintaining normal blood pressure and preventing complications from the condition. 4. Monitoring cholesterol is an example of secondary prevention. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Illness Management Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of diseaseN, UdR isSeIaNsGeTpBa.tCtO erMns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
5) The nurse is using the Health Belief Model to conduct a weight loss class for a group of patients. Which should the nurse recognize as mediating factors of the model? Select all that apply. 1. Susceptibility of development of complications from being overweight. 2. Perceived severity of an illness that results from being overweight. 3. The client's cost of the classes. 4. The amount of time commitment for the class. 5. The number of the patients who will be taking the class. Answer: 1, 2, 3, 4 Explanation: 1. Susceptibility refers to how likely an individual is to develop an illness or condition and it is one of the mediating factors according to the Health Belief Model. 2. The perceived severity of an illness is a mediating factor that determines the motivation to participating in health-promotion behaviors. 3. The physical cost of the health-promoting activity is compared to continuing the unhealthy behavior. Physical and psychologic perceived cost is a mediating variable. 4. The psychological cost of the health promoting activity includes the time commitment necessary for the class. Physical and psychological perceived cost is a mediating variable. 5. The number of patients participating in the class is not a mediating factor of the Health Belief Model. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
6) The nurse is using the ecologic model as a framework for preparing a community health program. Which program objective should the nurse understand best reflects the concepts of the model? 1. The participants will recognize health as the absence of disease. 2. The participants will verbalize the role of self-actualization in relation to their health. 3. The participants will define health as the interaction between the agent, host, and the environment. 4. Internal harmony is the foundational basis for health achievement. Answer: 3 Explanation: 1. The absence of disease and internal harmony are not specific concepts related to the ecological model. 2. Self-actualization and health are explored in the eudaemonistic model for health. 3. Leavall and Clark developed the ecologic model for health. This model considers the relationship between the agent, host, and environment as the key determinants for health status. 4. The absence of disease and internal harmony are not specific concepts of the ecological model. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc II..C5O .U RSiIeNsG: TVB Mse evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1: Describe the importance of nursing theory to the practice of nursing and health assessment. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
7) The nurse recognizes the fact that more individuals have become conscious of health and wellness. Based on this factor, which should the nurse place a stronger emphasis on? Select all that apply. 1. Tertiary prevention. 2. Disease prevention. 3. Health Promotion. 4. Secondary prevention. 5. Wellness. Answer: 2, 3, 5 Explanation: 1. The increase in the consciousness of health and wellness is not an indicator the emphasis for health should be placed on tertiary prevention. 2. Due to the increase in the consciousness of health and wellness, a stronger emphasis should be placed on disease prevention. 3. Due to the increase in the consciousness of health and wellness, a stronger emphasis should be placed on health promotion. 4. The increase in the consciousness of health and wellness is not an indicator the emphasis for health should be placed on secondary prevention. 5. Due to the increase in the consciousness of health and wellness, a stronger emphasis should be placed on wellness. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Process Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
8) The nurse is preparing to use the clinical model for care of a patient. Which should the nurse focus upon? 1. Pain. 2. Environment. 3. Patient's potential. 4. Patient's social role. Answer: 1 Explanation: 1. In the clinical model, health is defined as the absence of disease or injury. The aim of the health professional is to relieve the signs and symptoms of the disease such a pain. 2. The patient's environment is a component of the ecological model. 3. Fulfillment of the patient's potential is the focus of the eudaemonistic model. 4. The role performance model focuses on the patient's ability to perform social roles. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guidehealth teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1: Describe the importance of nursing theory to the practice of nursing and health assessment. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
9) The nurse is caring for a client with residual left-sided weakness after a CVA. Which should the nurse focus on to maintain the health of the client? 1. Improvement. 2. Wellness. 3. Prevention. 4. Adaptation. Answer: 1 Explanation: 1. When health is defined in terms of physical change, the practice focuses on improvement of physical function. 2. Wellness is a state of being in good health which does not address the need for the improvement of physical function. 3. Prevention is the act of stopping something from happening. The focus on improvement is needed to assist the client in achieving their highest level of wellness. 4. Adaptation implies the client will adjust to their circumstances. Adaptation does not allow for physical improvement. Page Ref: 10 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of famiN lyUaRnSdINfrGieTnBd.Cs;OaMnd transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
10) The nurse is using the theory of reasoned action/planned behavior to develop a class on nutrition. Which variables should the nurse be aware of that may affect the client's intention to improve their nutritional intake? 1. Self-efficacy. 2. Motivation. 3. Knowledge. 4. Objective norms. Answer: 1 Explanation: 1. According to the theory of reasoned action/planned behavior, self-efficacy is one of three variables that affect the intention to perform the behavior. 2. Motivation is not a variable of theory of reasoned action/planned behavior that affects the intention to perform the behavior. 3. Knowledge is not a variable of theory of reasoned action/planned behavior that affects the intention to perform the behavior. 4. Objective norms are not a variable of the theory of reasoned action/planned behavior that affects the intention to perform the behavior. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: V.II.5. Use evidence-based practices to guide health teaching, health counselNinUgR, SsIcNreGeTnBin.CgO, M outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.1: Recognize the definitions of health, wellness, and health promotion.
11) The nurse is incorporating Dunn's model of wellness in the care of the client's in clinic. Which should the nurse focus treatment on? 1. Relieving signs and symptoms of disease. 2. Assisting the client in restoring harmony to their life. 3. Maximizing the function of the client. 4. Promoting flexibility for environmental adaptation. Answer: 3 Explanation: 1. Relieving signs and symptoms of disease is a focus of the clinical model. 2. The ecological model focuses on restoring harmony to the client's life by examining the interaction among the agent, host, and environment. 3. Dunn's Model of wellness focuses on maintaining a balance of purposeful direction and functioning. Maximizing the client's functional ability is a reflection of Dunn's model of wellness. 4. The adaptive model highlights the individual's abilities and flexibility in a challenging environment. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: V.II.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-upNtUhRroSIuNgGhToBu.tCtOhM e lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
12) A client tells the nurse that they were at the dentist two months prior for a routine cleaning. Which level of prevention should the nurse document the client has taken? 1. Primary. 2. Secondary. 3. Tertiary. 4. Wellness. Answer: 2 Explanation: 1. Primary prevention implies health and a high level of wellness. An example ofprimary prevention includes using fluoridated toothpastes. 2. Early diagnosis of health problems and prompt treatment with the restoration of health is the focus of secondary prevention. Screenings for dental caries during a routine cleaning are an example of secondary prevention. 3. Tertiary prevention is aimed at restoring an individual to the highest possible level of health and functioning. A routine dental cleaning does not restore the health of an individual. 4. Wellness is not a level of prevention but it is a state of balance. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.C.5. Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds. | AACN Essentials Competencies: VII.3. Clinical Prevention and Population Health: Assess health/illness beliefs, values, attitudes, and practices of individNuUaRlsS,IN faGmTiBli.eCsO, groups, communities, and populations. | M NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.1: Recognize the definitions of health, wellness, and health promotion.
13) The nurse is preparing to discuss the goal of care with the client. Which statement should the nurse provide the client that focuses on primary prevention? 1. "The goal of the healthcare team is to prevent any problems from reoccurring." 2. "The goal of the healthcare team is to restore your level of wellness." 3. "The goal of the healthcare team is to focus on your existing problems." 4. "The goal of the healthcare team is to improve your overall health." Answer: 4 Explanation: 1. The focus of tertiary prevention is to prevent a reoccurrence of the problem and return the client to an optimal level of wellness after an illness or injury has occurred. 2. The focus of tertiary prevention is to return the client to an optimal level of wellness after an illness or injury has occurred and prevent a reoccurrence of the problem. 3. The focus of secondary prevention is to focus on treating the existing health problems. 4. The focus of primary prevention is to improve the overall health of the client through health promotion and prevention of illness and injury. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: V.II.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approachNeUsRtSoINyiGeTldBb.CeOsM t practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.1: Recognize the definitions of health, wellness, and health promotion.
14) The nurse is preparing a care plan for a client. Which area of health risk appraisal should the nurse include in the diagnosis and planning? Select all that apply. 1. Medical diagnosis. 2. Sexual activity. 3. Immunization history. 4. Occupation. 5. Laboratory results. Answer: 2, 3, 4 Explanation: 1. Medical diagnosis is not included in a health risk appraisal. Appraisals areconducted in relation to health promotion. 2. Sexuality is an area of health risk assessment. 3. Immunization history is an area of health risk assessment. 4. Occupation is an area of health risk assessment. 5. Laboratory results are not included in a health risk appraisal. Appraisals are conducted in relation to health promotion. Page Ref: 17 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks to identifycurrent and future health problems. | NNLN pTeB te.CnOciM es: Context and Environment: URCSoIm NG Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
15) The nurse is developing a program focusing on breast cancer and secondary prevention. Which topic should the nurse include? 1. Types of mastectomy that are available. 2. Chemotherapy and radiation treatments. 3. Education on the prevention of breast cancer. 4. Techniques for performing self-breast examination. Answer: 4 Explanation: 1. Tertiary prevention is aimed toward treatment of a condition and restoration of health to the highest level of wellness possible. Treatment options for breast cancer, such as a mastectomy, would be considered a form of tertiary prevention. 2. Tertiary prevention is aimed toward treatment of a condition and restoration of health to the highest level of wellness possible. Treatment options for breast cancer, such as chemotherapy and radiation, would be considered a form of tertiary prevention. 3. Primary prevention implies that an individual is healthy and focuses on health promotion and disease prevention. 4. Secondary prevention emphasizes early diagnosis and treatment of health problems and includes screenings such as teaching clients about self-breast examination. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc II..C3O .A RSiIeNsG: TVB Mssess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
16) The manager is reviewing the modifying factors of the Health Belief Model with several nurses. Which statement made by a nurse indicates the understanding of a cue to action? 1. "Education is a cue to action." 2. "Socioeconomic status is a cue to action." 3. "The client's personality is a cue to action." 4. "The cultural practices of a client are a cue to action." Answer: 1 Explanation: 1. Cues to action are modifying factors in the framework of the Health Belief Model. Cues to action include education. 2. Socioeconomic status is a modifying factor in the framework of the Health Belief Model but not a cue to action. 3. The client's personality is not a cue to action 4. The cultural practices are not an identified modifying factor in the Health Belief Model. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Knowledge and Science; Knowledge. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.1: Describe the importance of nursing theory to the practice of nursing and health assessment. MNL Learning Outcome: 2.1: Recognize the definitions of health, wellness, and health promotion.
17) The nurse has provided education based on the Health Promotion Model about the importance of regular exercise to several clients. Which participant should the nurse expect to adhere to regular exercise? 1. An overweight female who has never participated in an exercise program. 2. An adult male who admits frequently to joining and quitting exercise groups. 3. An adolescent male who appears to have a low self-esteem. 4. An adult female who reports she is anxious to begin exercising with her husband. Answer: 4 Explanation: 1. An overweight female who has never participated in an exercise program is less likely to become motivated enough to adhere to a regular exercise program. 2. An adult male who frequently joins and quits exercise groups is less likely to become motivated enough to adhere to a regular exercise program. 3. An adolescent male that appears to have low self-esteem is less likely to become motivated enough to adhere to a regular exercise program. 4. An adult female who reports she is anxious to begin exercising with her husband displays the motivational characteristics of the Health Promotion Model which will result in the most likely to become motivated enough to adhere to a regular exercise program. Page Ref: 13 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processNeUs.R|SIANAGCTNB.ECsOseMntials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
18) The nurse is evaluating the statements made by clients that have completed an exercise and nutrition class. Which statement made by a client should the nurse recognize reflects selfefficacy? 1. "I believe that exercise is the key to health." 2. "My family thinks it is will improve my health if I begin to exercise." 3. "I am confident that I can maintain my commitment to exercise." 4. "My healthcare provider will be very happy if I start an exercise program." Answer: 3 Explanation: 1. The statement, "I believe that exercise is the key to health," reflects an attitude. An attitude refers to a value assigned to a particular behavior. 2. The statement, "My family thinks it is will improve my health if I begin to exercise," is a subjective norm. Subjective norms refer to an individual's perception of what others believe or expect in relation to an individual's performance of behavior. 3. Self-efficacy refers to the level of confidence in one's ability to perform a behavior. The client that states, "I am confident that I can maintain my commitment to exercise," is demonstrating self-efficacy. 4. The statement, "My healthcare provider will be very happy if I start an exercise program," is a subjective norm. Subjective norms refer to an individual's perception of what others believe or expect in relation to an individual's performance of behavior. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: I.C.3. Value the patient's expertise with own health and symptoms. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
19) The nurse is reviewing the history of the clients that had previously participated in an exercise program. Based on the Health Belief Model, which client should the nurse recognize is most likely to participate in a new health promoting behavior? 1. A client that was unable to continue to participate due to time constraints. 2. A client that was unable to afford to participate in the program. 3. A client that had lost weight in a prior exercise program but gained it back. 4. A client that had prior difficulty obtaining childcare to consistently participate. Answer: 3 Explanation: 1. When health promoting activities have been difficult or when barriers to participation have arisen, one is least likely to participate in health promotion in the future. Time constraints that affected prior participation will most likely result in the unlikely success of participating in a new health promoting behavior. 2. When health promoting activities have been difficult or when barriers to participation have arisen, one is least likely to participate in health promotion in the future. Financial constraints affecting prior participation will most likely result in the unlikely success of participating in a new health-promoting behavior. 3. Prior behavior can have a positive or negative effect on health promotion. When one has engaged in health promotion and recognized the benefit, it is likely that health promoting behavior will occur in the future. 4. When health promoting activities have been difficult or when barriers to participation have arisen, one is least likely to participate in health promotion in the future. Difficulty obtaining childcare that has affected prior participNaU tioRnSIw illTm likely result in the unlikely success of NG B.o CsOtM participating in a new health promoting behavior. Page Ref: 14 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
20) The nurse is evaluating the responses of the client's willingness to participate in an exercise program. Based on the Health Belief Model, which client statement should the nurse recognize is reflective of a situational influence? 1. "I don't like where the gym is located." 2. "I don't like feeling so sore the next day." 3. "I feel like this program is too costly." 4. "I really have never exercised before." Answer: 1 Explanation: 1. A situational influence includes perceptions and ideas about situations or contexts. Situational influences on health promoting activities include aesthetics of the environment. The client's statement, "I don't like where the gym is located," reflects a perception of the environment. 2. The statement, "I don't like feeling so sore the next day," reflects an activity-related effect. An activity-related effect refers to subjective feelings before, during, or after an activity. 3. The statement, "I feel like this program is too costly," is a perceived barrier to action. Barriers to participation in health promotion may be real or imagined. 4. The statement, "I really have never exercised before," reflects perceived self-efficacy. Perceived self-efficacy is a judgment of one's ability to successfully participate in a health promoting activity to achieve a desired outcome. Page Ref: 15 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
21) The nurse has created a plan of care for a patient with asthma. Which part of the nursing process should the nurse take on for the role of an educator? 1. Assessment. 2. Planning. 3. Implementation. 4. Evaluation .Answer: 3 Explanation: 1. During the assessment phase of the nursing process, the nurse gathers information and performs a physical assessment. 2. During the planning phase of the nursing process, the nurse works with the client to identify current, ongoing, or potential problems, as well as strengths and supports. 3. During the implementation of the plan, one of the roles the nurse takes on is the educator. As educator, the nurse interprets and informs the patient of the significance of findings from all of the completed assessments. 4. During evaluation, the patient has the option to modify, continue, or discontinue the plan. As a result of evaluation, priorities may be reordered or the methods and tactics may be changed. Page Ref: 18 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, commuNnUicRaStIiN onG,TaBn.CdOeM ducation; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: III.6. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
22) The nurse is collaborating with a client to create a plan for weight loss. During which phase of the nursing process should the nurse help identify the client's strengths? 1. Assessment. 2. Evaluation. 3. Planning. 4. Implementation. Answer: 3 Explanation: 1. During the assessment phase, subjective and objective data are gathered. 2. Outcomes are evaluated during the evaluation phase of the nursing process. 3. During the planning phase of the nursing process, the nurse works with the client to identify the client's strengths. 4. The client's strengths are identified prior to implementation of thee plans. Page Ref: 17 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.I. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: I.I. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/INnUteRgSrIaNtGeTdBC.oCnOcMepts: Nursing Process: Planning Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
23) A client tells the nurse they are concerned that their diabetes will become a serious illness. Which model of health should the nurse recognize the client's statement is most aligned with? 1. The Role Performance Model. 2. The Health Belief Model. 3. The Clinical Model. 4. The Eudaemonistic Model. Answer: 2 Explanation: 1. In the Role Performance Model, health is defined in terms of an individual's ability to perform social roles. 2. A client that recognizes that an illness is serious is expressing an individual perception and belief that will influence the decision to act to prevent illness. 3. In the clinical model, health is defined as the absence of disease or injury. 4. The eudaemonistic model views individuals as civilized and cultured who have the capacity for continued growth. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Illness Management Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes | AACN Essentials Competencies: I.I. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease preveN ntUioRnSI(NeG.gT.,Bt.C raOnMsmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
24) A group of clients attend an educational program focused on prevention and screening activities for breast cancer. Based on the Health Belief Model, which participant should the nurse anticipate will most likely engage in available screenings? 1. The client whose mother and grandmother have a history of breast cancer. 2. The client who is attending the program as a course requirement. 3. The client attending in support of the presenter. 4. The client who agreed to attend in support of another participant. Answer: 1 Explanation: 1. According to the Health Belief Model, mediating variables determine the likelihood of an individual actively participating in the prevention of illness. The client whose family members have a history of breast cancer is most vulnerable to the disease and is thus most likely to engage in the available health screenings. 2. According to the Health Belief Model, the client who is attending the program as a course requirement will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. 3. According to the Health Belief Model, the client who is attending the program in support of the presenter will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. 4. According to the Health Belief Model, the client who agreed to attend the program in support of another participant will be less influenced to participate in the health screenings than the client who has the positive family history of breast cancer. Page Ref: 13 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
25) A client has been prescribed a mammogram. Which level of prevention should the nurse recognize the client is participating in? 1. Primary. 2. Tertiary. 3. Prepathologic. 4. Secondary. Answer: 4 Explanation: 1. Primary prevention implies health and high-level wellness prior to the development of a disease or pathology. Examples of primary prevention include immunizations and eating a healthy diet. Mammograms are a tool for screening and are considered secondary prevention. 2. Tertiary prevention occurs following the development of a disease or pathologic condition and is aimed at restoring an individual to the highest level of health possible. An example of tertiary prevention is physical rehabilitation therapy for a client who has had a stroke. Mammograms are a tool for screening and are considered secondary prevention. 3. Prepathologic prevention is the same as primary prevention, which implies health and highlevel wellness prior to the development of a disease or pathology. Examples of primary prevention include immunizations and eating a healthy diet. Mammograms are a tool for screening and are considered secondary prevention. 4. The goals of secondary prevention are early diagnosis and prompt treatment of health problems. Examples of secondary prevention include tools for screenings such as mammograms and blood tests. Page Ref: 12 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2.4: Demonstrate how to use the nursing process to encourage health promotion. MNL Learning Outcome: 2.4: Utilize the nursing process to encourage health promotion.
26) The nurse is using the Health Belief Model to evaluate the workplace for situational influences that promote health. Which situational influence should the nurse recognize is a demand characteristic? 1. Easy access to the gym. 2. Clean environment. 3. No smoking policy. 4. Availability of healthy snacks. Answer: 3 Explanation: 1. Having a gym nearby is an available option. An available option is a situational influence. 2. A clean environment is an example of the situational influence of aesthetics. 3. Demand characteristics include policies and procedures in employment and public environments. No-smoking policies in public buildings and work environments are demand characteristics that promote health. 4. Availability of healthy snacks is an available option. An available option is a situational influence. Page Ref: 15 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. |NNULRNSICNoGm pe.CtO enMcies: Context and TB Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
27) The nurse is using the Health Belief Model to promote smoking cessation. Which should the nurse recognize will have the greatest impact on the client outcomes? 1. Adaptation. 2. Behaviors. 3. Flexibility. 4. Actualization .Answer: 2 Explanation: 1. Adaptation is not a component of the Health Belief Model. 2. According to the Health Belief Model, a client's behavior influences their decision to prevent illness. 3. The adaptive model highlights the individual's abilities and flexibility in a challenging environment. 4. Actualization is not a component addressed by the Health Belief Model. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and NfaUm icM s. | Nursing/Integrated Concepts: RiSly INdGyTnBa.m CO Nursing Process: Assessment Learning Outcome: 2.2: Describe the concepts of health, wellness, and health promotion. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
28) The nurse is assessing a client for taking self-responsibility in wellness. Which action by the client should the nurse consider reflects good decision making? 1. Planning a menu that includes a variety of foods. 2. Decreasing the number of cigarettes smoked from 3 packs per day to 1.5 packs per day. 3. Practicing sexual abstinence or using a condom during sexual intercourse. 4. Walking at a pace of 3 to 4.5 mph for 15 minutes three times per week. Answer: 3 Explanation: 1. Menu planning should be based on the consumption of adequate portions from the healthy food groups and not just on a variety of foods. 2. Decreasing the number of packs of cigarettes smoked per day from 3 to 1.5 does not significantly lower the health risks of smoking; therefore, this action does not demonstrate the wellness concepts of responsibility and good decision-making skills in regards to healthcare issues. 3. Wellness concepts are demonstrated through individuals being responsible and able to make good decisions regarding areas such as nutrition, physical activity, safety issues, stress management, emotional growth and well-being, and healthcare issues in general. Sexual abstinence or use of a condom during sexual intercourse demonstrates responsibility and good decision-making skills in regards to sexual and reproductive health. 4. Walking at a pace of 3 to 4.5 mph is considered moderate physical activity; walking this pace for 15 minutes three times per week does not meet the CDC recommended 2 hours and 30 minutes per week for moderate physical activity; therefore, this action does not demonstrate the wellness concepts of responsibility aNnUdRgSoIoNdGTdBec.CisOioMn-making skills in regards to healthcare issues. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
29) The nurse using the Health Belief Model is evaluating a client's interpersonal influences. Which statement made by the client reflects an interpersonal influence? 1. "My family responsibilities may interfere with my success." 2. "My Mother is going to help me create healthier recipes." 3. "I feel like some of the recommended dietary changes will be difficult." 4. "I am concerned about the time it will take to grocery shop for the recommended foods." Answer: 2 Explanation: 1. The statement, "My family responsibilities may interfere with my success," reflects a competing demand. Competing demands are alternative activities over which the individual has little control. These demands include family or work responsibilities. 2. The statement, "My Mother is going to help me create healthier recipes," reflects an interpersonal influence. Family, peers, and health professionals are interpersonal influences. 3. The statement, "I feel like some of the recommended dietary changes will be difficult," is a perceived self-efficacy. Perceived self-efficacy is a judgment of one's ability to successfully participate in a health-promoting activity to achieve a desired outcome. 4. The statement, "I am concerned about the time it will take to grocery shop for the recommended foods," is a perceived barrier to action. Barriers to participation in health promotion may be real or imagined. Barriers include the perception of convenience. Page Ref: 15 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community.
30) The nurse using the Health Belief Model is evaluating a client's statement for competing preferences. Which statement should the nurse recognize is a competing preference? 1. "I am going to skip the gym today and have lunch with a friend." 2. "I will have to miss going to the gym because I have to work overtime." 3. "I have to attend a meeting with my child's teacher so I cannot go to the gym. 4. "I cannot make it to the gym because I do not have childcare." Answer: 1 Explanation: 1. The statement, "I am going to skip the gym today and have lunch with a friend," is an example of a competing preference. Competing preferences are alternative behaviors over which the individual has high control. The control is dependent on the ability to self-regulate. 2. Competing demands are alternative activities over which the individual has little control. These demands include family or work responsibilities. Working overtime is a competing demand. 3. Competing demands are alternative activities over which the individual has little control. These demands include family or work responsibilities. A meeting with a child's teacher is a competing demand. 4. Competing demands are alternative activities over which the individual has little control. These demands include family or work responsibilities. Lack of childcare is a competing demand. Page Ref: 15 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: III.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.3: Relate perspectives of health promotion to the individual, family, and community. MNL Learning Outcome: 2.2: Consider how the models of health and theories of wellness relate to patient care.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 3 Cultural and Spiritual Considerations 1) The nurse is preparing an educational program for the staff on cultural considerations. The nurse includes the following definition: "The adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture." Which term should the nursing staff understand this definition is being referred to? 1. Ethnicity. 2. Assimilation. 3. Ethnocentrism. 4. Culture. Answer: 2 Explanation: 1. Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture, such as biology, differentiate the members of one group from another. 2. Assimilation refers to the adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture. 3. Ethnocentrism is the tendency to believe that one's own beliefs, way of life, values, and customs are superior to those of others. 4. Culture is the nonphysical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another. Page Ref: 23 Cognitive Level: Remembering Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values, | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
2) The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate? 1. "What can we do to accommodate your needs during your stay here?" 2. "I will let your healthcare provider know that you need to be discharged." 3. "Fasting may be harmful to your body during your illness." 4. "You must eat a high protein diet during times of illness." Answer: 1 Explanation: 1. Some people will report adhering to a particular faith but will not strictly adhere to certain practices. Further assessment is needed to determine this client's beliefs, desire to adhere to the practice, and extent to which the practice may be altered considering the illness and hospitalization. Making certain assumptions without further assessment would result in actions not respectful or beneficial to the client. 2. Making assumptions such as the healthcare provider discharging the client without further assessment conveys disrespect and is not beneficial to the client. 3. Making assumptions such as fasting being harmful for the body without further assessment is disrespectful and of no benefit to the client. 4. Making assumptions such as the client being unable to fast during illness without further assessment is disrespectful and of no benefit to the client. Page Ref: 25 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
3) The nurse is caring for an older adult Native American client who is experiencing severe chest pain. The client is accompanied by a tribesman at the insistence of the client. The tribesman tells the nurse that their culture teaches acceptance of death as part of the natural cycle of life and that treatments must be stopped. The client's son insists that his father be treated and states he feels the tribe's teachings are antiquated. Which action by the nurse is the most appropriate? 1. Call the social worker to plan a family meeting without the tribesman. 2. Interview the client and ascertain his wishes and beliefs. 3. Convene the hospital ethics committee. 4. Call the nursing supervisor. Answer: 2 Explanation: 1. It would be inappropriate to call a family meeting, with or without an interested second party, if the client is competent and has not asked for such a meeting. 2. The client is an adult and, if capable of expressing his wishes and beliefs, should be encouraged to do so. Sometimes the client must be interviewed alone to be sure the client is actually stating his own wishes and not those of family members who may be present for the interview. Unless an adult is not competent to make and express his own decisions, or is impaired in some way and cannot express his own wishes, then the adult client's wishes are honored over all others who may try to exert influence. 3. At this time, there is not enough reason to consult an ethics committee. 4. There is, at the moment, no behavior exhibited that would warrant notifying hospital administration. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
4) The nurse is assessing an adolescent client fluent in English that immigrated to the United States at the age of 4. When asked what cultural preferences he has, he states "I am American." What should the client's statement indicate to the nurse? 1. He has no interest in the interview. 2. He is embarrassed about his ethnicity. 3. He is assimilated into the American culture. 4. He wishes to deny his Asian heritage. Answer: 3 Explanation: 1. There is no evidence that there is no interest in the interview. 2. There is no evidence that this client is embarrassed about his ethnicity. 3. The adolescent's answer indicates an assimilation into American culture. 4. There is no evidence that this client wishes to deny Asian heritage. Page Ref: 23 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
5) The nurse manager is discussing cultural considerations with a group of staff nurses. Which statements by the staff nurses indicate an appropriate understanding of cultural concepts? Select all that apply. 1. "Culture can best be described as an awareness of belonging to a group in which certain characteristics differentiate the members of one group from another." 2. "A good description of culture is one that recognizes socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides an individual's worldview." 3. "Culture is the certainty that one's own beliefs, way of life, values, and customs are superior to others." 4. "Culture is the identification of an individual or group by shared genetic heritage and biologic characteristics." 5. "Decisions made by an individual are largely influenced by culture." Answer: 2, 5 Explanation: 1. Ethnicity is the awareness of belonging to a group in which certain characteristics differentiate the members of one group from another. 2. Culture is the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision making. 3. Ethnocentrism is the tendency to believe that one's own beliefs, way of life, values, and customs are superior to others. 4. Race is the identification of an individual or group by shared genetic heritage and biologic or physical characteristics. 5. Culture includes one's ability to make decisions that are guided by one's beliefs, values, customs, and way of thinking. Page Ref: 21 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
6) The nurse is evaluating the subculture of a client. Which should the nurse recognize reflects a generational subculture? 1. A client whose parents were born in another country. 2. A client who was born during a specified period of time. 3. A client who was born in the Unites States but whose children are born elsewhere. 4. A client who was born in the United States but siblings were born in another country. Answer: 2 Explanation: 1. A client whose parents were born in another country is an immigrant. 2. A generational subculture is one that spans over generations. A client that was born in a specific time period was born into a generational subculture. 3. A client that was born in the United States but whose children are born elsewhere is an immigrant to a different country. 4. A client that was born in the Unites States is an American citizen. Culture is established in the homes and the community the client lives in. Page Ref: 21 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Lifestyle Choices Standards: QSEN Competencies: I.A.2 Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: N g GPTroBc.CeO ssM: Assessment Nu UrRsSinIN Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
7) The nurse is researching matriarchal cultures to understand how this family pattern affects healthcare. Which culture should the nurse anticipate to research? 1. Appalachian. 2. Italian 3. African American. 4. Filipino . Answer: 3 Explanation: 1. Patriarchal groups are those that are largely headed by a male family figure. Appalachian families are more likely to be patriarchal. 2. Patriarchal groups are those that are largely headed by a male family figure. Italian families are more likely to be patriarchal. 3. Matriarchal groups are those that are largely headed by a female family figure. African American groups are most likely to be matriarchal. 4. Patriarchal groups are those that are largely headed by a male family figure. Filipino families are most likely to be patriarchal. Page Ref: 24 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
8) The nurse is interviewing a client and wishes to determine the roles of various members of an extended family living together in one household. Which statement should the nurse use to assess this information? Select all that apply. 1. "What language is spoken in your house?" 2. "Is every member in your household employed?" 3. "Tell me about the responsibilities of family members in your home." 4. "Who makes the decisions for your family members?" 5. "Are you happy with your place in the family?" Answer: 3, 4 Explanation: 1. The language spoken in the home will not help in the identification of roles within the household members. 2. The employment status of household members does not delineate their roles. 3. The responsibilities of the family members will allow the nurse to assess the various roles each family member. 4. Identification of the decision maker is helpful to the nurse in determining the different roles of the family members. 5. A closed question will not allow the nurse to assess the role of the client. Happiness is not a reflection of a role in the family. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. PNroUvRiSdIeNpGaTtBie.CnOt-M centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
9) The nurse is evaluating the nonmaterial culture of a client. Which should the nurse focus upon? 1. Social structure. 2. Clothing. 3. Heritage. 4. Religious affiliation. Answer: 1 Explanation: 1. Culture is divided into material and nonmaterial culture. Nonmaterial culture is composed of social structures. 2. Clothing is considered material culture 3. Heritage is a component of a subculture. Subcultures exist within larger cultural groups. 4. Cultures can be defined as macrocultures within which microcultures exist. Religious affiliation is recognized as microcultures. Page Ref: 21 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transculturalNhUeRaSltIhNG asTsBe.sCsOmMents and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
10) The nurse is assessing a client's ethnicity. Which statement should the nurse recognize reflects an American subculture? 1. "I am Chinese American." 2. "I am of Irish descent." 3. "I am British." 4. "I am multiethnic." Answer: 1 Explanation: 1. Many individuals refer to themselves according to an ethnic origin, such as Chinese American. These individuals often form associations with others of the same ethnic origin, thereby creating a subculture within the larger American culture. 2. Specifying the descent of the ancestry does not reflect an American subculture. 3. Claiming to be British does not reflect an American subculture. 4. Multiethnicity is not an American subculture. Page Ref: 21 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transculturalNhUeRaSltIhNG asTsBe.sCsOmMents and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
11) The nurse is preparing to obtain a mini heritage assessment on a client. Which question should the nurse include? 1. "What is your religious preference?" 2. "Do you speak English?" 3. "Are you able to adapt with other cultures?" 4. "What ethnicity do you identify with?" Answer: 1 Explanation: 1. Inquiring about a client's religious preference is included in a mini heritage assessment. 2. The heritage assessment is not focused on identifying the client's language. It is focused on the use of the language. A question that is included in the mini heritage assessment is "If your native language is not English, how often do you read and speak in your native tongue? 3. Adapting to other cultures is the process of assimilation and is not an assessment question on the mini heritage assessment tool. 4. Ethnicity is not assessed in the mini heritage assessment tool. Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture and biology differentiate the members of one group from another. Page Ref: 22 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experNieUnRcSeI.N|GATABC.CNOEMssentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.2: Practice using terms related to culture and spirituality. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
12) The nurse is reviewing overall cultural beliefs in relation to health and illness. Which should the nurse recognize is the basis for belief that centers around the cause of illness? 1. Behavior. 2. Germ theory. 3. Scientific theory. 4. Nonscientific theory. Answer: 4 Explanation: 1. Behavior specifically is not the necessary overall cultural belief about the cause of illness 2. The germ theory is a scientific belief that health and illness are affected by germs. 3. In many cultures, beliefs about health and illness are not built around scientific theory. 4. In many cultures, the beliefs about health and illness are built around nonscientific theories. Page Ref: 23 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A G ss T Be.sCsOm Ment Learning Outcome: 3.2: Practice using terms related to culture and spirituality. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
13) The nurse is reviewing the temporal relationships of the Western society. Which should the nurse be mindful of when caring for clients of Western culture? 1. Flexible orientation. 2. Present moment. 3. Traditions of the past. 4. Future oriented. Answer: 4 Explanation: 1. The Western culture is not flexible in their time orientation. They are predominantly future oriented and are concerned with time. 2. The actions of the Western culture are not derived in the present moment. 3. The actions of the Western culture are not derived from traditions of the past. 4. The predominant cultures of the Western society are future oriented as demonstrated by their propensity to invest in the future. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transculturalNhUeRaSltIhNG asTsBe.sCsOmMents and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
14) The educator has discussed with nursing staff the importance of recognizing the culturally specific roles and relationships that exist within a family. Which statement made by a nurse indicates an understanding of the information? 1. "The familial title of the family member will indicate what role they have." 2. "A family member's occupation will indicate what family role they have." 3. "The family member who has the highest educational level has the most significant role." 4. "A family member's age is significant when it comes to cultural roles and relationships." Answer: 4 Explanation: 1. The familial title does not define their specific cultural role and relationship in the family. 2. A family member's occupation does not define their specific cultural role and relationship in a family. 3. The family member's educational level does not define their specific cultural role and relationship in a family. 4. The roles and responsibilities of family members are often culturally specific in terms of age and gender. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, beNhUaR viSoIrNaGl,TpBs.yCcOhM ological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
15) The nurse is assessing the client's ethnicity. Which should the nurse understand is included in the assessment? Select all that apply. 1. Religious preference. 2. Dietary practices. 3. Political beliefs. 4. Marital status. 5. Nationality. Answer: 1, 2, 3, 5 Explanation: 1. Ethnicity is partly defined by religion. 2. Dietary practices are part of a client's ethnicity. 3. Political beliefs are part of a client's ethnicity. 4. Marital status is not part of a client's ethnicity. 5. Nationality is part of a client's ethnicity. Page Ref: 22 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transculturalNhUeRaSltIhNG asTsBe.sCsOmMents and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
16) The new nurse expresses frustration to the preceptor about caring for clients with differing healthcare beliefs and practices. Which action should the preceptor take? 1. Encourage the nurse to reduce expression for the values of others. 2. Encourage the nurse to closely examine their own cultural practices and beliefs. 3. Inform the manager of the concern for the nurse to be able to care for clients. 4. Recommend that the nurse meet with a counselor to discuss ethnic biases. Answer: 2 Explanation: 1. Encouraging the nurse to reduce the expression for the values of others does not convey a caring attitude. 2. Ethnocentrism is the belief of one's personal beliefs to be superior to those held by others. Encouraging the nurses to closely examine their own cultural practices and beliefs fosters the process of self-awareness. 3. Informing the manager of the concern for the nurse to be able to care for clients does not support the nurse's growth or provide the tools to move beyond ethnocentrism. 4. Counseling or even disciplinary action may be warranted later in the process if the behaviors continue or worsen. Page Ref: 22 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Ethical Practice Standards: QSEN Competencies: I.C.5. Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds | AACN Essentials Competencies: VIII.6. Reflect on one's ow nRbSeIlNieGfTs Ba.nCdOvMalues as they relate to professional NU practice. | NLN Competencies: Personal and Professional Development: Ethical comportment and be aware of personal beliefs, values, and biases. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
17) The nurse would like to explore to what extent acculturalization has impacted the diet of a client that has recently immigrated to the United States. Which question should the nurse ask the client? 1. "Are there any foods you avoid for cultural reasons?" 2. "Has your diet changed in any way since you moved here?" 3. "Do you use any dietary health remedies or practices that are related to your culture?" 4. "Is there any time of the year that you change your diet for cultural reasons?" Answer: 2 Explanation: 1. Diversity exists within cultural groups so it is important to avoid applying general knowledge about cultural groups. 2. It is important to explore to what extent any acculturation has taken place and what traditional practices have resulted from living in a new dominant culture. 3. It is important to ask about food practices and special meals for special occasions. 4. Cultural, religious, and traditional beliefs can affect food choices, beliefs, and practices in many ways. Page Ref: 25 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health anNdUiR llnSeINssGpTB ar.Cam eters in patients, using developmentally OM and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
18) The nurse has asked a client if there is anyone else that should be included in the nutritional conversation. Which should the nurse recognize is the cultural importance eliciting this information? 1. The client may defer to an elder when answering questions. 2. The client may not understand the information. 3. The client may not want to discuss nutritional information. 4. The client may not be the person that grocery shops. Answer: 1 Explanation: 1. A client may defer to an elder or authority figure when answering questions about health. 2. Not understanding nutritional information may not be culturally related. 3. Nutritional information should not be addressed with a client that is not ready to discuss it. This is not a culturally related issue. 4. Grocery shopping is not culturally related to a nutritional conversation. Page Ref: 25 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. |NN LN CoGm ncies: Context and Environment: UR SIN TBp.eCtOeM Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
19) The nurse educator discusses the expectations concerning the acceptance of a client's cultural beliefs with new nurses. Which statement made by the nurse should the educator recognize indicates the need for further teaching? 1. "The acceptance of different cultural values is needed to provide quality nursing care." 2. "Cultural values may dictate my client assignments on the nursing unit." 3. "My own cultural values are irrelevant to the acceptance of the values of others." 4. "I understand that my role as a nurse may be viewed differently based on the cultural beliefs." Answer: 3 Explanation: 1. The acceptance of different cultural values indicates self-awareness exists. Failure to have self-awareness can result in ethnocentrism. 2. The cultural values and beliefs of the client may require "sensitive" scheduling. 3. The knowledge and acceptance of one's own cultural values is essential to the acceptance and awareness of the values of the client. 4. How nurses are viewed is dependent on the individual's cultural view of women's roles in society as well as a lack of respect for those viewed as subservient to the healthcare provider. Page Ref: 21 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII.7. Collaborate with otNhUeRr ShIeNaGltThBc.aCrOeMprofessionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
20) During an admission assessment, the client tells the nurse that they have been taking herbsto help lower the blood pressure. Which question should the nurse ask the client? 1. "What herbs have been used to manage your condition?" 2. "Have you shared this with your healthcare provider?" 3. "Where you aware that herbal preparations may interfere with your treatment?" 4. "When was the last dosage of the herbal remedies taken?" Answer: 1 Explanation: 1. The comprehensive assessment of health requires the nurse to obtain as much information as possible. The nurse will need to determine the herbs in use to ensure there are not adverse interactions between the treatments that may be ordered by the healthcare provider. 2. Asking about the client if they shared this information with their healthcare provider is not appropriate during an admission assessment and may imply the client is doing something wrong. 3. Asking the client about their knowledge of the herbal preparations interfering with their treatment is not appropriate during an admission assessment and may imply the client is doing something wrong. 4. Asking about the last dosage of herbal remedies does not provide the names of the herbs the client is using; therefore, this should not be the initial question the nurse asks the client. Page Ref: 25 Cognitive Level: Analyzing Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
21) The nurse is caring for a non-English speaking client suspected of having food borne illness. Which information should the nurse focus on? 1. Inquire as to whether the client has eaten a newer version of a traditional diet. 2. Inquire as to whether new foods have been added to traditional foods. 3. Inquire about the type of food preparation methods that are used. 4. Inquire about common dietary staples used in the food. Answer: 3 Explanation: 1. Eating a new version of a traditional diet reflects acculturation. 2. New foods added to traditional foods are the exploration of acculturation. 3. Food preparation methods may be responsible for the illness. Many different cultures make the same dishes but prepare them in different ways. 4. Common dietary staples may be thought to promote health or cure conditions. Common dietary staples should not necessarily be associated with food borne illness. Page Ref: 25 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Illness Management Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Context and Environment: Transcultural approaches to health. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A ssessment G T B.COM Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
22) The nurse has provided discharge teaching using an interpreter for a non-English-speaking client. Which additional material should the nurse provide the client? 1. A medical language translation dictionary. 2. Instructions written in the client's native language. 3. Discharge information with pictures and drawings. 4. The number for language interpretation. Answer: 2 Explanation: 1. Providing a medical translation dictionary does not ensure the client has adequate information to understand the plan of care. 2. Written instructions should be provided in the client's native language. 3. Drawings and pictures do not ensure the client understands the information. 4. The client does not need the number for language interpretation. An interpreter is obtainedby the nurse when the client requires one. Page Ref: 24 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication. | AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
23) The nurse is caring for a client in a lower socioeconomic group. When caring for the client, which should the nurse understand is a common healthcare practice? 1. The client is more likely to use the emergency room for routine care. 2. Episodic acute care is usually sought. 3. The client has a mistrust of the healthcare system. 4. There is a knowledge deficit about the illness. Answer: 2 Explanation: 1. Routine care is not provided in the emergency department. 2. Access to healthcare impacts one's healthcare practice. Those in lower socioeconomic groups are more likely to seek episodic acute care than those that have higher income and health insurance. 3. Because the client is in a lower socioeconomic group, it does not mean the client has a mistrust of the healthcare system. 4. The client in a lower socioeconomic group does not necessarily have a knowledge deficit about the illness; there are financial constraints that prevent the client from seeking healthcare. Page Ref: 25 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Self-Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, beNhUaR viSoIrNaGl,TpBs.yCcOhM ological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.2: Recognize how cultural phenomena relates to healthcare.
24) The educator is reviewing with a new nurse the factors that ethnicity and culture can influence in a client. Which factors should the educator include? Select all that apply. 1. Roles. 2. Nonverbal communication. 3. Occupation. 4. Health practices. 5. Relationships. Answer: 1, 2, 4, 5 Explanation: 1. Ethnicity and culture can influence the roles of a client. 2. Ethnicity and culture can influence the nonverbal communication that is expressed by a client. 3. Ethnicity and culture do not necessarily influence the occupation of a client. 4. Ethnicity and culture can influence the health practices of a client. 5. Ethnicity and culture can influence the relationships that a client has. Page Ref: 26 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. |NN LN CoGm ncies: Context and Environment: UR SIN TBp.eCtOeM Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
25) The nurse is performing a mini cultural assessment. Which question should the nurse include? 1. "Do you participate in ethnic activities?" 2. "Do you have extended family nearby?" 3. "Do you identify with a specific ethnic or group?" 4. "Where were your parents and grandparents born?" Answer: 3 Explanation: 1. Inquiring about ethnic activities is a question in the mini heritage assessment. 2. Inquiring about nearby extended family is included in the mini heritage assessment. 3. An appropriate question for a mini cultural assessment is inquiring about the client identifying with an ethnic or any other group. The nurse needs to know what group the client identifies with to provide culturally competent care. 4. Inquiring about the birth place of a client's parents and grandparents is a question that is included in the mini heritage assessment. Page Ref: 26 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. |NN LN CoGm ncies: Context and Environment: UR SIN TBp.eCtOeM Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
26) The nurse admitting a client to the unit is obtaining information regarding the client's spiritual practices. Which questions should the nurse include in the assessment? Select all that apply. 1. "Are there any dietary restrictions associated with your spiritual practice?" 2. "Would you feel more comfortable with your family present?" 3. "How do your spiritual beliefs influence your health?" 4. "Do you have any rituals that you perform at certain times of the day?" 5. "Would you like your spiritual leader to be contacted?" Answer: 1, 4, 5 Explanation: 1. The client may have dietary restrictions associated with their spiritual practice. 2. The presence of family may be a cultural practice, not necessarily related to a spiritual practice. 3. Asking a client about how their spiritual beliefs influence their health is part of a cultural assessment. 4. The client may have certain times that they have prayer or perform other rituals related to their spiritual practice. 5. The client should be asked if they would like their spiritual leader to be contacted. Page Ref: 29 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experNieUnRcSeI.N|GATABC.CNOEMssentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
27) The educator is reviewing the nursing staff's spiritual care competence. Which statement made by a nurse should the educator be concerned with? 1. "I have provided care for a client that was experiencing spiritual distress." 2. "I do not think that clients are comfortable talking about their spiritual preferences." 3. "I am not comfortable praying with a client so when a client requests to pray, I offer to call the Chaplain." 4. "I will ask the client to explain their prayer ritual if I do not understand it." Answer: 2 Explanation: 1. The nurse acknowledging, recognizing, and providing care for a client in spiritual distress demonstrates spiritual care competence. 2. The nurse that assumes clients are uncomfortable talking about their spiritual preferences is most likely not competent in supporting a client's spiritual needs. 3. The nurse that is taking an active part in supporting the client in prayer by offering to contact the chaplain for prayer is demonstrating spiritual care competence. 4. The nurse that tries to understand a client's prayer ritual by seeking the information from the client is demonstrating spiritual care competence. Page Ref: 29 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Ethical Practice Standards: QSEN Competencies: I.C.5. Recognize personally held attitudes about working with patients from different ethnic, cultural, and social backgrounds. | AACN Essentials Competencies: VIII.6. Reflect on one's ow nRbSeIlNieGfTs Ba.nCdOvMalues as they relate to professional NU practice. | NLN Competencies: Personal and Professional Development: Ethical Comportment and be aware of personal beliefs, values, and biases. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
28) The nurse receiving report on a patient is told the client is experiencing spiritual distress. Which should the nurse understand the client may exhibit? 1. Withdrawal. 2. Aggression. 3. Hostility. 4. Emptiness. 5. Nightmares. Answer: 1, 3, 4, 5 Explanation: 1. Spiritual distress can be expressed in many ways. A characteristic of spiritual distress is withdrawal. 2. Aggression is a behavior that is not an identified characteristic of spiritual distress. 3. Spiritual distress can be expressed in many ways. A characteristic of spiritual distress is hostility. 4. Spiritual distress can be expressed in many ways. A characteristic of spiritual distress is a feeling of emptiness. 5. Spiritual distress can be expressed in many ways. Nightmares can be a characteristic of spiritual distress. Page Ref: 28 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experNieUnRcSeI.N|GATABC.CNOEMssentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4: Demonstrate cultural and spiritual sensitivity when interacting with patients. MNL Learning Outcome: 3.4: Recognize the factors, assessment, and effects of spirituality on health and wellness.
29) The nurse is assessing a client's spiritual strengths using the interpretive framework from a narrative spiritual assessment. Which question should the nurse ask the client to assess their communion? 1. "How does your spirituality affect your joy, sorrow, and coping?" 2. "What is your relationship with God?" 3. "Describe your values?" 4. "Have you experienced any spiritual hunches?" Answer: 2 Explanation: 1. The assessment for the relationship between spirituality and joy, sorrow, and coping is an assessment for the "affect" of the interpretive framework. 2. Inquiring about a client's relationship with God is an assessment question for "communion." Communion is the exchange of thoughts and feelings on a spiritual level. 3. The description of a client's values addresses the assessment for "conscience." 4. The experience of spiritual hunches addresses the "Intuition" portion of the interpretive framework." Page Ref: 30 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health anNdUiR llnSIeNssG pTB ar.Cam eters in patients, using developmentally OM and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3: Describe the impact of culture and spirituality on health and wellness. MNL Learning Outcome: 3.3: Determine the components of a cultural assessment within a comprehensive health assessment.
30) The nurse educator is presenting information on culture and ethnicity to the nurses on the unit. Which statement by a nurse should the educator recognize indicates further teaching is required? 1. "I noticed that clients of different cultures have more than one different belief." 2. "When identifying individuals of the same race, they will have shared genetic heritage, biologic and physiologic characteristics." 3. "Ethnic groups share common values over generations." 4. "An individual may self-identify with an ethnic group that is different from the ethnic group of their birth or race." Answer: 2 Explanation: 1. Different cultures have various beliefs and practices. 2. Genetic heritage and biologic and physiologic characteristics may not all be shared between all members of the same race. 3. The awareness of belonging to a group in which certain characteristics or aspects such as culture and biology differentiate the members of one group from another is the concept of ethnicity. It is defined by a shared interest, heritage, religion, food, politics, or geography and nationality. 4. Inclusion in an ethnic group may be self-directed. An individual may share the viewpoints, geography, and nationality of an ethnic group by personal choice. Page Ref: 22 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality. MNL Learning Outcome: 3.1: Examine the components included in the definitions of culture and spirituality.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 4 Health Disparities 1) The community health nurse wants to promote services that are available at a local free clinic for vulnerable populations within the community. Which client is considered vulnerable? 1. A married mother of two children. 2. A single male with a full-time job. 3. A divorced female. 4. A married male veteran. Answer: 4 Explanation: 1. A married mother of two children is not considered a vulnerable client. 2. A single male with a full-time job is not considered to be a vulnerable client. 3. A divorced female is not considered to be a vulnerable client. 4. Vulnerable populations are groups that are not well integrated into the U.S. healthcare system because of racial, ethnic, cultural, economic, geographic, or health characteristics. Veterans have been identified as a vulnerable population. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processNeUs.R|SIANAGCTNB.ECsOseMntials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
2) Which is a goal of Healthy People 2020 for vulnerable populations? 1. To provide insurance for all citizens. 2. To improve access to quality of care. 3. To ensure all clients have a primary care provider. 4. To eliminate co-payments for services. Answer: 2 Explanation: 1. While having insurance will help eliminate health disparities, this is not a goal of Healthy People 2020. 2. The goal of Healthy People 2020 is to eliminate health disparities by improving access to quality of care among identified vulnerable populations. 3. While having a primary care provider will help eliminate health disparities, this is not a goal of Healthy People 2020. 4. Eliminating co-payments for services is not a goal of Healthy People 2020. Page Ref: 40 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: Patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: RNeUlaRtSioIN nsGhTiB p.C Ce OnMtered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Identify strategies to reduce and eliminate health disparities. MNL Learning Outcome: 4.4: Implement strategies to reduce and eliminate health disparities.
3) Which vulnerable population has high death rates from heart disease? 1. African Americans. 2. Asian Americans. 3. Hispanics. 4. Pacific Islanders. Answer: 1 Explanation: 1. The African American population has a high death rate from heart disease. 2. Asian Americans do not have a high death rate from heart disease. 3. Hispanics do not have a high death rate from heart disease. 4. Pacific Islanders do not have a high death rate from heart disease. Page Ref: 36 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: Patient/family/ community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
4) The nurse is incorporating the use of the Omaha system into a home health practice. Which should the nurse anticipate obtaining from the use of the system? 1. Nursing diagnosis. 2. Medical diagnosis. 3. Identification of cultural needs. 4. Identification of teaching needs. Answer: 4 Explanation: 1. The Omaha system is not used to create a nursing diagnosis. The Omaha system is a research-based system that documents patient assessment and nurse interventions directed toward wellness, support systems, and coping skills. Using the system can help identify education needs. 2. The Omaha system is not used to create a medical diagnosis. The Omaha system is a research-based system that documents patient assessment and nurse interventions directed toward wellness, support systems, and coping skills. Using the system can help identify education needs. 3. The Omaha system is not used to create a nursing diagnosis. The Omaha system is a research-based system that documents patient assessment and nurse interventions directed toward wellness, support systems, and coping skills. Using the system can help identify education needs. 4. The Omaha system is not used to identify cultural needs. The Omaha system is a researchbased system that documents patient assessment and nurse interventions directed toward wellness, support systems, and coping sN kiUllsR.SUINsiGnTgBt.hCeOsMystem can help identify education needs. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Knowledge and Science: Practice-Know-How | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups andtheir impact on the nurse's role in health assessment. MNL Learning Outcome: 4.4: Implement strategies to reduce and eliminate health disparities.
5) Which factors may lead to health disparities among vulnerable populations? Select all that apply. 1. Race. 2. Geography. 3. Disability status. 4. Age. 5. Marital status. Answer: 1, 2, 3, 4 Explanation: 1. Vulnerable populations are defined by race. 2. Vulnerable populations are defined by geography. 3. Vulnerable populations are defined by disability status. 4. Vulnerable populations are defined by age. 5. Vulnerable populations are not defined by marital status. Page Ref: 35 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
6) The nurse is reviewing the data on community populations that experience more issues with preventable diseases. Which should the nurse recognize is a contributing factor for the minority population of these communities? 1. Genetic predisposition for disease. 2. Educational level of the population. 3. Poor patient provider interaction. 4. Nutritional status of the community. Answer: 3 Explanation: 1. Genetic predisposition for disease is not a contributing factor to the minority population experiencing more issues with preventable diseases. 2. Educational level is not specifically identified as a contributing factor to the minority population experiencing more issues with preventable diseases. 3. Poor patient provider interaction is a contributing factor to the minority population experiencing more issues with preventable diseases. 4. The nutritional status of the community is not specifically identified as a contributing factor to the minority population experiencing more issues with preventable diseases. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factorsNtoURthSeINcGaTreB.oCfOdMiverse populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
7) The nurse is obtaining information from a parent of a child that is of low socioeconomic status. Which question should the nurse ask the parent? 1. "Who lives in your household?" 2. "Do have enough food in your home?" 3. "Do you have access to transportation?" 4. "Does anyone use alcohol in the home?" Answer: 2 Explanation: 1. The members that live in the household are not significant; however, households of children of a low socioeconomic status experience more overcrowding. 2. Children of lower economic status may experience household crowding, inadequate nutrition, and more exposure to second hand smoke. 3. Inadequate transportation is not a primary concern for a child of low socioeconomic status. 4. Alcohol use by other household members is not a primary concern for a child of low socioeconomic status. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: I.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G Ass TBe.sCsOm Ment Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.3: Recognize how geography, disability status, and socioeconomic status can influence health disparities in vulnerable populations.
8) The nurse is planning an educational session for clients who are at an increased risk for health disparities. When using information from Racial and Ethnic Approaches to Community Health (REACH), which topics will the nurse include in the session? 1. Weight loss information. 2. Safer sex practice. 3. Shelters for the homeless. 4. Sun safety. Answer: 1 Explanation: 1. Heart disease, obesity, and diabetes are the most common health issues that are experienced among most ethnicities that have been identified by REACH. Therefore, the nurse will include information regarding weight loss. 2. Sexually transmitted diseases are not common health issues that are experienced among most ethnicities. Therefore, safer sex practices are not an appropriate topic to include in the educational session. 3. Homelessness is not a health issue, but it could lead to health issues. However, education on shelters is not an appropriate topic to include in the educational session. 4. Skin cancer is not a common health issue experienced by most ethnicities. Therefore, education on sun safety is not appropriate to include in the educational session. Page Ref: 40 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.2.NDUeRscr ibGeTEBB.C POtoMinclude the components of research SIN evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Identify strategies to reduce and eliminate health disparities. MNL Learning Outcome: 4.4: Implement strategies to reduce and eliminate health disparities.
9) When assessing a client who is considered vulnerable, which is a priority before beginning the assessment process? 1. Review of the health history. 2. Review of psychosocial history. 3. Awareness of other races. 4. Awareness of own cultural beliefs. Answer: 4 Explanation: 1. Review of the health history is important but is not the priority. 2. Review of the psychosocial history is important but is not the priority. 3. Awareness of other races is important but is not the priority. 4. Nurses working with vulnerable populations must develop an awareness of their own cultural beliefs and cultural competency to effectively care for vulnerable individuals. Page Ref: 35 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: Patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VIII.6. Reflect on one's own beliefs and values as they relate to professional practice. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrate ceTpBt.C s:ONMursing Process: Assessment NUdRC So INnG Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
10) The nurse is caring for an adolescent patient who has been identified as vulnerable. When assessing this patient, which should the nurse be most concerned with? Select all that apply. 1. Use of alcohol. 2. Use of prescription drugs. 3. Participation in sports. 4. Participation in after school activities. 5. Use of tobacco products. Answer: 1, 5 Explanation: 1. The use of alcohol and tobacco products are risky behaviors identified in adolescents. The use of prescription drugs, participation in sports, and after school activities should not be the most concerning to the nurse. 2. The use of alcohol and tobacco products are risky behaviors identified in adolescents. The use of prescription drugs, participation in sports, and after school activities should not be the most concerning to the nurse. 3. The use of alcohol and tobacco products are risky behaviors identified in adolescents. The use of prescription drugs, participation in sports, and after school activities should not be the most concerning to the nurse. 4. The use of alcohol and tobacco products are risky behaviors identified in adolescents. The use of prescription drugs, participation in sports, and after school activities should not be the most concerning to the nurse. 5. The use of alcohol and tobacco products are risky behaviors identified in adolescents. The use of prescription drugs, participation in sports, and after school activities should not be the most concerning to the nurse. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: Patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
11) The nurse is obtaining information from a parent prior to assessing the child in a community clinic. Which statement made by the parent should be most concerning for the nurse? 1. "I have been receiving food from the local pantry." 2. "My husband only smokes in the house after the children go to bed." 3. "My mother said she would take my children to get their immunizations." 4. "I am going to sign my child up to receive breakfast and lunch at school." Answer: 2 Explanation: 1. The parent has not indicated they are not receiving enough food from the food pantry. 2. Children of lower socioeconomic status may experience more exposure to second hand smoke. Anytime someone is smoking in the house, everyone else is exposed to second hand smoke. Second hand smoked is linked to several illnesses in children. 3. The parent indicates they have support from family members. 4. The parent signing up the child to receive breakfast and lunch at school is ensuring their child will receive adequate nutrition. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: Patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of famiN lyUaRnSdINfrGieTnBd.Cs;OaMnd transition and continuity. | AACN Essentials Competencies: 1.1: Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
12) The nurse is assessing a patient that has type I diabetes mellitus who lives in a rural area of the state. Which should the nurse recognize is a primary factor that may impact the patient's ability to obtain healthcare? 1. Location. 2. Finances. 3. Work schedule. 4. Level of education. Answer: 1 Explanation: 1. The geographical location can have a significant impact on the health of vulnerable populations. Residing in a rural area presents geographical challenges for some individuals seeking healthcare. 2. Not every person that lives in a rural area experiences financial constraints that will impact their access to healthcare. The challenge is primarily geographical. 3. A work schedule may not impact a patient's ability to obtain healthcare. A geographical challenge is the primary concern. 4. Patients living in rural areas do not necessarily have a lower level of education. Their geographical location remains the primary factor that may impact the patient's ability to obtain healthcare. Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: 1.5. ExNam URinSe INcGoTmBm .CoOnMbarriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: 1.5. Apply knowledge of social and cultural factors to the care of diverse populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.3: Recognize how geography, disability status, and socioeconomic status can influence health disparities in vulnerable populations.
13) The nurse is preparing to assess an adolescent in a community clinic. Which information should the nurse recognize is most important to obtain from the client? 1. Activity level. 2. Dietary intake. 3. Educational level. 4. Available transportation. Answer: 2 Explanation: 1. Activity level is important but adolescents tend to have unhealthy dietary habits. 2. It is important the nurse obtain the dietary intake of the adolescent. Adolescents have a high risk for unhealthy dietary behavior. 3. The educational level is not a significant concern for the nurse, unless there is reason to believe that chemical impairment, mental or physical illness, or socioeconomic factors have interfered with the patient's ability to participate in schooling. 4. Transportation is not a significant nursing concern for an adolescent patient. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: 1.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, andNreUfReSrIrN alGaTnBd.CfoOlM low-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
14) The manager is reviewing the risky behaviors of the adolescent population with the nursing staff. Which behaviors should the manager include in the discussion? Select all that apply. 1. Tobacco use. 2. Sexual risk. 3. Violence. 4. Alcohol use. 5. Drug abuse. Answer: 1, 2, 4, 5 Explanation: 1. Tobacco, alcohol, and drug use as well as sexual risky behavior should be of concern when caring for the adolescent population. Violence is not an identified risky behavior in the adolescent population. 2. Tobacco, alcohol, and drug use as well as sexual risky behavior should be of concern when caring for the adolescent population. Violence is not an identified risky behavior in the adolescent. 3. Tobacco, alcohol, and drug use as well as sexual risky behavior should be of concern when caring for the adolescent population. Violence is not an identified risky behavior in the adolescent. 4. Tobacco, alcohol, and drug use as well as sexual risky behavior should be of concern when caring for the adolescent population. Violence is not an identified risky behavior in the adolescent. 5. Tobacco, alcohol, and drug use as well as sexual risky behavior should be of concern when caring for the adolescent population. VioNlUenRcSeINisGnTB ot.CaOnMidentified risky behavior in the adolescent. Page Ref: 36 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; High Risk Behaviors Standards: QSEN Competencies: 1.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
15) The nurse is reviewing the risk factors for vulnerable populations. Which should the nurse take into consideration when caring for older adults? 1. Older adults are predisposed to the need for medical care. 2. Older adults are at the greatest risk for nutritional deficiency. 3. Older adults are identified as having a risk for alcohol abuse. 4. Older adults are the most vulnerable population. Answer: 1 Explanation: 1. Older adults often face unique healthcare challenges that predispose them to the need for medical care. 2. Older adults do not have the greatest risk for nutritional deficiency. Infants and children are at a great risk for inadequate nutrition. 3. Adolescents have an increased risk for alcohol abuse. 4. Older adults are not the most vulnerable population. Patients with disabilities are considered a vulnerable population and are at a higher risk for experiencing healthcare barriers than any other members of the population. Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: I.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, andNreUfReSrIrN alGaTnBd.CfoOlM low-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
16) The nurse is caring for an older adult. Which should the nurse recognize is a unique challenge for the older adult? 1. Neglect. 2. Transportation. 3. Substance abuse. 4. Homelessness. Answer: 2 Explanation: 1. Neglect is not unique to the older adult population. 2. Older adults often face unique healthcare challenges that predispose them to the need for medical care. The older adult may have transportation issues which interfere with accessing care. 3. The older adult is not at an increased risk for substance abuse. 4. The older adult is not at significant risk for homelessness. Page Ref: 37 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: 1.5: Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: Pl n.nCiO ngM G TaB Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
17) The nurse is integrating the use of Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) in the plan for the care of women in a community clinic. Which should the nurse plan on using the program for? 1. Provide prescription medication. 2. Provide insurance for women. 3. Provide nutritional counseling. 4. Provide counseling for domestic abuse. Answer: 3 Explanation: 1. The intention of WISEWOMAN is not to provide prescriptions for women. 2. The intention of WISEWOMAN is not to provide insurance for women. 3. Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) provides low-income, underinsured or uninsured women with the knowledge, skills, and opportunities to improve their diet, physical activity, and other lifestyle behaviors to prevent, delay, and control cardiovascular and other chronic diseases (CDC, 2017d). 4. The intention of WISEWOMAN is not to provide counseling for domestic abuse. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.B.3: Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-upNtUhRroSIuNgGhToBu.tCtOhM e lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Identify strategies to reduce and eliminate health disparities. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
18) The nurse is preparing to document the sexuality of a client. Which question should the nurse ask to ensure accuracy of the information obtained? 1. "How do you identify?" 2. "What is your sexuality?" 3. "Are you male or female?" 4. "Do you have a sexual preference?" Answer: 1 Explanation: 1. Asking the client how they identify and what they prefer to be called will enable the nurse to obtain accurate information regarding the client's gender identity and sexuality. 2. Asking specifically about sexuality may be interpreted as asking about gender. 3. Asking the client if they are male or female does not provide information beyond the gender of the client. 4. Asking about a client's sexual preference provides no information about their gender or sexual identity. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated CoNnUcReSpItNsG: N u.rCsO inMg Process: Assessment TB Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
19) The nurse is obtaining a history from a client that has identified themselves as bigender. Which should the nurse carefully assess the client for? 1. Employment. 2. Adequate housing. 3. Substance abuse. 4. Sexually transmitted diseases. Answer: 3 Explanation: 1. The LGBT population is not specifically at a risk for unemployment. 2. The LGBT population is not specifically at a risk for homelessness. 3. Lesbian, gay, bisexual, and transgender (LGBT) individuals experience health disparities associated with societal stigma, discrimination, and denial of their civil and human rights (ODPHP, Healthy People 2020, 2018). High rates of psychiatric disorders, substance abuse, and suicide are linked to discrimination against individuals in this group. 4. The LGBT population does not necessarily experience high rates of sexually transmitted diseases. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; High Risk Behaviors Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship CenterN edURCSaIrNeG : FTaBc.C toOrM s that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
20) The nurse is using The World Health Organization Disability Assessment Schedule (WHODAS 2.0) to evaluate a client. Which information should the nurse anticipate to obtain? 1. Substance abuse. 2. Cognition. 3. Socioeconomic status. 4. Medical history. Answer: 2 Explanation: 1. WHODAS 2.0 is not a screening tool for substance abuse. 2. WHODAS 2.0 is a short, simple tool that is applicable across all cultures and is used to assess cognition, mobility, self-care, getting along with others, life activities, and participation. 3. WHODAS 2.0 is not a screening tool for a client's socioeconomic status. 4. WHODAS 2.0 is not a screening tool for medical history. Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Knowledge and Science: Evidence and best practices for nursing | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3: Identify strategies to reduce and eliminate health disparities. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
21) The nurse is reviewing the socioeconomic status and the contributing factors to health disparity. Which should the nurse understand is one of the most common factors in determining a client's socioeconomic status? 1. Education. 2. Gender. 3. Sexual orientation. 4. Ethnicity .Answer: 1 Explanation: 1. Socioeconomic status (SES) is often a main contributor or compounding issue affecting health disparities in vulnerable populations. Education and income are two of the most common factors that determine the socioeconomic status of a client. 2. Gender is used to identify vulnerable populations. 3. Sexual orientation is used to identify vulnerable populations. 4. Ethnicity is used to identify vulnerable populations. Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaNteUnRhSIeNaGltThB. .|CN Ou Mrsing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.3: Recognize how geography, disability status, and socioeconomic status can influence health disparities in vulnerable populations.
22) The nurse is caring for a male prison population. Which ethnicity should the nurse understand has the greatest risk for poorer health outcomes? 1. Hispanic. 2. African American. 3. White. 4. Native American. Answer: 2 Explanation: 1. The Hispanic males do not have the greatest risk for poorer health outcomes. 2. The African American males are at the greatest risk for poorer health outcomes than the other ethnicities imprisoned. 3. The white males do not have the greatest risk for poorer health outcomes. 4. The Native Americans do not have the greatest risk for poorer health outcomes. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
23) The nurse is performing a health screening for a child from a mixed-status family. Which should be the nurse's most immediate concern? 1. Homelessness. 2. Deficient healthcare. 3. Inadequate education. 4. Lack of transportation. Answer: 2 Explanation: 1. Homelessness is not the most immediate concern for the child from a mixedstatus family. 2. The nurse should be most concerned with deficient healthcare of the child. A mixed-status family is a family in which one or more family members are undocumented immigrants and other family members are citizens, lawful permanent residents, or immigrants with another form of temporary legal immigration status. Illegal immigrants are wary of applying for public health benefits for their children because they fear doing so will alert the authorities to their illegal status. 3. Inadequate education is not the most immediate concern for the child from a mixed-status family. 4. Lack of transportation is not the most immediate concern for the child from a mixed-status family. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Diagnosis Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
24) The nurse is planning care for a vulnerable population. Which should the nurse take into consideration when planning the care? 1. Educating the population about the risk factors for disease. 2. Implementing health promotion in the community. 3. Increasing awareness of healthy lifestyle choices. 4. Eliminating access barriers to healthcare. Answer: 4 Explanation: 1. Vulnerable populations have many barriers to accessing healthcare. Educating the population about the risk factors for disease does not help them access healthcare. 2. Vulnerable populations have many barriers to accessing healthcare. Implementing health promotion in the community does not eliminate the barriers to accessing healthcare. 3. Vulnerable populations have many barriers to accessing healthcare. Increasing education on health lifestyle choices does not assist them in accessing healthcare. 4. Eliminating barriers to accessing healthcare should be taken into consideration when planning to care for a vulnerable population. Page Ref: 35 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN CoNm :O ReMlationship Centered Care: Factors that Up ReStIe Nn GcTie Bs.C contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.1: Consider the issues of health disparity in relation to vulnerable patient groups and its impact on the nurse's role in health assessment.
25) The nurse is planning to address the health disparity in the Native American population. Which should the nurse consider the primary reason for the health disparity? 1. Many Native Americans do not reside on reservations. 2. Many Native Americans do not trust the healthcare system. 3. Many Native Americans do not engage in western medicine. 4. Many Native Americans do not have health insurance. Answer: 1 Explanation: 1. Although the Indian Health Services (IHS) typically serves the needs of the Native American population, more than half of the people in this group do not reside on reservations and have limited or no access to IHS services. 2. A mistrust of the healthcare system is not the primary reason the Native American population experiences health disparity. 3. Not engaging in western medicine is not the primary reason the Native American population experiences health disparity. 4. Lack of health insurance is not the primary reason the Native American population experiences health disparity. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, includN inUgRgSeInNeGtTicBs.,Cw Oh Mich influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
26) The nurse is planning to address the healthcare needs for the fastest growing veteran population. Which subpopulation of veterans should the nurse prepare for? 1. Women. 2. Older veterans. 3. Younger men. 4. Minority men. Answer: 2 Explanation: 1. Women veterans do not make up the fastest growing veteran population. 2. Older veterans, especially those with cognitive impairment, increased fragility, and limited social support, make up the fastest growing segment of the VA's patients. 3. Younger men do not make up the fastest growing veteran population. 4. Minority men do not make up the fastest growing veteran population. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
27) The nurse is setting up a clinic to care for health needs of unaccompanied children entering the United States illegally. Which major vulnerability should the nurse prepare to address when caring for the children? 1. Existing illness. 2. Malnourishment. 3. Minimal education. 4. Language barrier. Answer: 4 Explanation: 1. Existing illness is not an identified major vulnerability. 2. Malnourishment is not an identified major vulnerability. 3. Minimal education is not an identified major vulnerability. 4. Unaccompanied children entering the United States remain vulnerable because of language barriers. No parental supervision is another main issue that makes the children vulnerable. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Advocacy Standards: QSEN Competencies: I.A.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.1: Explain health disparities in relation to vulnerable patient groups and their impact on the nurse's role in health assessment. MNL Learning Outcome: 4.4: Implement strategies to reduce and eliminate health disparities.
28) The nurse is caring for a homeless population of women in the clinic. Which increased risk factor should the nurse screen the women for? 1. Pregnancy. 2. Malnutrition. 3. Substance abuse. 4. Sexual abuse. Answer: 4 Explanation: 1. Women in a homeless situation do not have a higher incidence of pregnancy. 2. Malnutrition is not specifically identified as risk factor specific to homeless women. 3. Substance abuse is higher in the homeless population but not specifically for homeless women. 4. Homeless women are at an increased risk for sexual abuse or domestic abuse. Page Ref: 40 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.2: Recognize how age, race and ethnicity, gender, and sexual orientation and gender identity can influence health disparities in vulnerable populations.
29) The nurse is preparing to create a health program for the population with the highest risk for health disparity. Which population should the nurse focus upon? 1. Children. 2. Patients with disabilities. 3. Refugees. 4. Older veterans. Answer: 2 Explanation: 1. Children are a vulnerable population but do not experience the highest risk for barriers to healthcare. 2. Disabled persons are considered a vulnerable population and are at higher risk for experiencing barriers in healthcare than other members of the population. 3. Refugees are a vulnerable population but do not experience the highest risk for barriers to healthcare. 4. Older veterans are a vulnerable population but do not experience the highest risk for barriers to healthcare. Page Ref: pg. 37 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: 1.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and popuNlaUtRioSnINs.G|TBN.LCNOM Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2: Identify the factors that influence health disparities in vulnerable populations. MNL Learning Outcome: 4.3: Recognize how geography, disability status, and socioeconomic status can influence health disparities in vulnerable populations.
30) The nurse is assessing a client that is a new refugee in the country. Which should the nurse assist the client with to help them overcome a barrier unrelated to the healthcare system? 1. Insurance navigation. 2. Fear of the healthcare system. 3. Lack of transportation. 4. Healthcare literacy. Answer: 3 Explanation: 1. Some of the most common barriers for a refugee is navigating the insurance system. 2. Fear of the healthcare system is a barrier to obtaining healthcare. 3. Lack of transportation is a barrier not specific to the healthcare system. 4. Health literacy is a healthcare barrier. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Advocacy Standards: QSEN Competencies: 1.5. Examine common barriers to active involvement of patients in their own healthcare processes. | AACN Essentials Competencies: VII.1. Assess protective and predictive factors, including genetics, which influence the health of individuals, families, groups, communities, and populations. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3: Identify strategies to reduce and eliminate health disparities. MNL Learning Outcome: 4.4: Implement strategies to reduce and eliminate health disparities.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 5 Interviewing and Health History: Subjective Data 1) The student nurse is preparing to perform a health history interview. Which statements indicate that the student nurse requires further education regarding the purpose of the health history? Select all that apply. 1. "As the nurse, I will mainly focus on the course of the client's illness." 2. "The client's health history can be gathered during the initial interview." 3. "I realize that the client is sick but I also need to perform a wellness assessment." 4. "The healthcare provider's and nurse's assessments should be almost identical with the same focus." 5. "The nurse typically has a more holistic point of view regarding the client's health." Answer: 1, 4 Explanation: 1. The healthcare provider will typically focus on the client's illness, while thenurse will focus on the client. 2. The nurse can gather the health history during the initial interview. 3. The nurse should perform a wellness assessment as part of the health history. 4. The healthcare provider's focus and the nurse's focus regarding the client's health differ significantly. The nurse's health history may produce information about a medical diagnosis, but the focus is on the client's response to the health concern as a whole person. The healthcare provider focuses on specific body systems or body parts of the client. 5. The nurse does typically have a more holistic view of the client when compared to the healthcare provider's point of view. Page Ref: 45 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, andSupervision Standards: QSEN Competencies: II.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
2) The nurse is assessing the health patterns of a client. Which questions by the nurse are appropriate for this during this portion of the health history? Select all that apply. 1. "Do you have a family history of glaucoma?" 2. "Do you consume a healthy diet?" 3. "How many hours do you sleep at night?" 4. "How frequently do you exercise?" 5. "Do you take any routine medications?" Answer: 2, 3, 4 Explanation: 1. A medical history is not obtained during the assessment of health patterns. 2. Assessing health patterns includes diet and nutrition. 3. Assessing health patterns includes sleep patterns. 4. Assessing health patterns includes exercise. 5. Assessing for routine medications is not done during the assessment of health patterns. Page Ref: 58 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: II.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | Nursing/Integrated Concepts: OM Nursing Process: Planning Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
3) The nurse is performing a focused interview with the client. Which behaviors indicate that the client may be feeling threatened? Select all that apply. 1. The client begins to wiggle their foot back and forth. 2. The client frequently moves around in their chair. 3. The client crosses his arms and becomes very quiet. 4. The client leans forward in the chair making eye contact. 5. The client expresses anger when answering the questions. Answer: 1, 2, 3, 5 Explanation: 1. Restlessness, distraction, and anger are signs that the client perceives the interview as threatening. The client that begins wiggling their foot back and forth may be restless. 2. Restlessness, distraction, and anger are signs that the client perceives the interview as threatening. The client that frequently moves around in their chair may be restless. 3. Restlessness, distraction, and anger are signs that the client perceives the interview as threatening. The client who crosses his arms and becomes quiet may be distracted. 4. The client leaning forward making eye contact is displaying engaging behavior. 5. Restlessness, distraction, and anger are signs that the client perceives the interview as threatening. The client that expresses anger when answering the questions may feel threatened. Page Ref: 52 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Care: Communicate information effectively and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.2: Identify strategies that promote effective communication when conducting a health history interview. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
4) The nurse is preparing to gather the biographical data from a client. Which should be the nurse's priority immediately prior to obtaining the information? 1. Establish trust. 2. Exhibit positive regard. 3. Display genuineness. 4. Demonstrate empathy. Answer: 1 Explanation: 1. Establishing trust is a priority prior to obtaining information from a client. 2. Positive regard is a technique used to enhance the nurse-client interaction. 3. Genuineness is a technique used to enhance the nurse-client interaction. 4. Empathy is a technique to enhance the nurse-client interaction. Page Ref: 52 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Care: Communicate information effectively and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.2: Identify strategies that promote effective communication when conducting a health history interview. MNL Learning Outcome: 5.2: Recognize professional characteristics used in establishing a nurse—patient relationship and barriers to effective nurse—patient interaction.
5) The nurse is preparing to obtain a health history on a client. Which phase of the health history should the nurse recognize is occurring? 1. Preinteraction. 2. The initial interview. 3. The focused interview. 4. Closure of the interview. Answer: 2 Explanation: 1. Pre-interaction encompasses the nurse preparing to meet the client as well as the review of any available background information. 2. The initial interview is a planned meeting during which the nurse interviewer gathers a health history from a client. 3. The nurse uses a focused interview technique throughout the physical assessment, during treatment, and while caring for the client. 4. The phases of a health history do not include the closure of the interview. Page Ref: 52 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
6) The nurse is preparing to interview a client in their home. Which environmental factor should the nurse recognize will facilitate the client's comfort during the interview? 1. The nurse should remain approximately a foot away from the client. 2. After the client changes into a gown, provide a blanket for warmth. 3. The client can be interviewed in the backyard of their home. 4. The nurse should use a laptop to immediately record the client's information. Answer: 3 Explanation: 1. A distance of approximately 1.5 to 4 ft between the nurse and the client is most likely to make the client feel at ease. Moving closer than 1.5 ft may invade the client's intimate space, and some clients may consider this impingement on private space aggressive or seductive 2. The client should remain dressed until it is time for the physical examination. 3. In the home setting, a quiet room or even the backyard may be used as long as the client is comfortable and no distractions are present. 4. The nurse should sit facing the patient at a comfortable distance without using a table, a computer, a desk, or any other barrier that might make communication difficult. Page Ref: 51 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Care: Communicate information effectively and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.2: Identify strategies that promote effective communication when conducting a health history interview. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
7) The nurse is gathering information regarding the client's psychosocial history. Which question would be included in this assessment? 1. "How did your father die?" 2. "Have you had any major surgeries?" 3. "Have you noticed any change in your vision?" 4. "How long have you worked for your current employer?" Answer: 4 Explanation: 1. The nurse should gather information about the reasons for the father's death when creating the client's genogram and documenting the client's family history. 2. Surgical history is a part of medical history. 3. Information about vision changes would be included in the review of body systems. 4. Elements of the psychosocial history within the health history include gathering information about the client's occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. Page Ref: 61 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.6: Explain the importance of each component of the nursing health history for patients across the lifespan. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
8) The nurse is obtaining information about a client's past medical history. Which source should the nurse anticipate using to obtain this data? 1. Medication list. 2. Immunization records. 3. Biographic data. 4. Family information. Answer: 2 Explanation: 1. The client's medication list is related to current history. 2. Past history includes information about childhood diseases; immunizations; allergies; blood transfusions; major illnesses; hospitalizations; labor and deliveries; surgical procedures; mental, emotional, or psychiatric health problems; and the use of alcohol, tobacco, and other substances. 3. The biographic data includes the client's name and address, age and date of birth, birthplace, marital or relationship status, sex, gender identity, sexual orientation, race, religion, occupation, health insurance information, and the reliability of the source of information. 4. Information about the family is obtained in a psychosocial history. Page Ref: 60 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
9) The nurse is preparing to reassess a client admitted for congestive heart failure. Which part of the interview should the nurse use to update the diagnostic cues of the client? 1. Initial. 2. Focused. 3. Preinteraction. 4. Psychosocial .Answer: 2 Explanation: 1. The initial interview is a planned meeting during which the nurse interviewer gathers information from the client. In most cases, the nurse uses a health history form to collect the data to avoid overlooking any area of information. 2. Nurses use the focused interview continuously to update diagnostic cues because signs, symptoms, and patient health concerns often change from moment to moment or day to day. 3. The preinteraction phase is the period before first meeting with the client. 4. A psychosocial history is obtained information about the client's living situation, educational level, financial background, roles and relationships, ethnicity and culture, family, spirituality, and self-concept. Page Ref: 52 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Illness Management Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
10) The nurse is gathering patient data from secondary sources. Which sources would the nurse utilize to collect this data? Select all that apply. 1. Medical records. 2. Patient. 3. History and physical. 4. Physical therapist. 5. Spouse. Answer: 1, 3, 4, 5 Explanation: 1. The medical records are a secondary source of information. 2. The patient is a primary source of information. 3. The history and physical is a secondary source of information. 4. The patient's physical therapist is a secondary source of information. 5. The patient's spouse is a secondary source of information. Page Ref: 57 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: IV.6. Evaluate data from all relevant sources, including technology, to inform the delivery of care. | NLN Competencies: Context and Environment: Read and interpret data and apply health promotion/disease prevention strategies. | Nursing/IntegraNteUdRC epB.tCs:ON SIoNnGcT Mursing Process: Assessment Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
11) The nurse is reviewing ways to obtain data for a client's sexual history. Which method should the nurse recognize would provide the most sensitivity? 1. Paper. 2. In-person. 3. Telephone. 4. Online questionnaire. Answer: 2 Explanation: 1. Obtaining information on paper does not offer the client the most sensitivity. 2. Discussion of sensitive information, including that related to sexual health and practices, requires the nurse to first establish trust and rapport with the patient. As such, this information is best discussed in person, as opposed to collecting the data by way of paper, telephone, or online questionnaire. 3. Obtaining the information over the telephone does not offer the client the most sensitivity. 4. Obtaining the information using an online questionnaire does not offer the client the most sensitivity. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Confidentiality/Information Security Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: VI.B.1. Seek education about how information is managed in care settings before providing care | NLN Competencies: Quality and Safety: Carefully maintain anNdUuRsSeINeGleTcBt.rCoOnM ic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.3: Outline the professional characteristics used in establishing a nurse— patient relationship. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
12) A client tells the nurse they were born in a rural area of the state. Which question should the nurse ask based on the information? 1. "Were you exposed to pesticides?" 2. "How long did you live there?" 3. "Have you lived anywhere else?" 4. "Was the area you were born in a farming community?" Answer: 2 Explanation: 1. Exposure to pesticides does not exclusively occur in rural areas. It is also important that the nurse establish the length of time the client lived in the area that they were born. 2. Establishing the length of time the client lived in the area that they were born in is important. Cultural, environmental, and geographic characteristics of regions and nations influence the health and well-being of the inhabitants. 3. Asking about living in other areas is important after establishing the length of time the client lived in the geographical location they were born in. 4. It is important to establish the length of time the client lived in their place of birth prior to asking any further questions. Page Ref: 55 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.6: Explain the importance of each component of the nursing health history for patients across the lifespan. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
13) The nurse is preparing to review a client's current medications. Which question is the most important for the nurse to ask the client? 1. "Can you tell me how much the co-pay is for your medications?" 2. "Do you carry health insurance?" 3. "Can you tell me about any over-the-counter or prescription medications that you take?" 4. "Where do you store your medications in your home?" Answer: 3 Explanation: 1. When gathering the medication history, the nurse does not necessarily need to ask about the client's "co-pay." 2. When gathering the medication history, the nurse does not necessarily need to ask whether the client carries health insurance or not. 3. The nurse should gather information about medications that the client is currently using. The nurse should request information about all prescribed and over-the-counter medications that the client takes. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements, or other substances should also be listed. 4. The nurse does not necessarily need to ask where the client stores the medications within the home. Page Ref: 58 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Expected Actions/Outcomes Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
14) An incoherent client has been brought to the emergency department (ED) by a family member. Which resource should the nurse initially use to obtain information about the client's current state of health? 1. Call the client's healthcare provider. 2. Obtain the patient's records from the Medical Records department. 3. Discuss the situation with the family member who brought the client to the hospital. 4. Conduct a thorough physical assessment and document the health history as "unable to obtain." Answer: 3 Explanation: 1. Speaking with the client's healthcare provider may be helpful when attempting to gather information about the client's medical history. However, the family member may be able to provide more information regarding the client's current health status. 2. Obtaining the client's medical records will be helpful when gathering information about the client's health history. 3. The primary and best source of information for the health assessment interview is the client. In some situations, the client might be unwilling or unable to provide information. The nurse should use another source of information as indicated in the situation such as a family member. 4. The nurse should be able to gather information about the client's current health status from the family member. The nurse does not need to document that this information is unavailable. Page Ref: 57 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.2: Identify strategies that promote effective communication when conducting a health history interview. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
15) The nurse is assessing the client's pain using the acronym OLDCART & ICE. Rank thequestions asked by the nurse following the order of the acronym OLDCART & ICE. 1: "How long have you had this pain?" 2: "Would you please point to the location of your pain?" 3: "How would you describe your pain? Is it sharp, dull, stabbing?" 4: "Can you tell me when your pain first began?" Answer: 4, 2, 1, and 3 Explanation: 1: The third step is to determine the duration of the client's pain. 2: The second step is to identify the location of the client's pain. 3: The nurse would then assess the characteristics of the client's pain. 4: Using OLDCART & ICE, the nurse would first assess onset of the client's pain. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; and facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
16) The nurse is creating a genogram for a client. Which information should the nurse consider as critical in forming a plan of care for the client? Select all that apply. 1. Known genetic conditions. 2. Multiple family members with the same disease. 3. Late age of disease onset. 4. Death from chronic illness. 5. Multiple pregnancy losses. Answer: 1, 2, 5 Explanation: 1. Known genetic conditions is a critical finding. 2. Multiple family members with the same disease is a critical finding. 3. Early age of disease onset is a critical finding. 4. Sudden death from an illness is a critical finding. 5. Multiple pregnancy losses is a critical finding. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct popuNlUati baTsBe.CdOtrManscultural health assessments and RSoInN-G interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
17) The nurse is assessing a client's religious beliefs and practices. Which segments of the health history should the nurse recognize can provide opportunities to obtain information about the role of religion? Select all that apply. 1. Health practices. 2. Family history. 3. Past medical history. 4. History of present illness. 5. Psychosocial information. Answer: 1, 2, 4, 5 Explanation: 1. Information about the religious beliefs and practices can be obtained when asking about health practices. 2. Information about the religious beliefs and practices can be obtained when asking about family history. 3. The past medical history does not provide opportunities to obtain information about the role of religion. The past medical history includes gathering information about childhood diseases; immunizations; allergies; blood transfusions; major illnesses; injuries; hospitalizations; pregnancy; labor and childbirth; surgical procedures; mental, emotional, or psychiatric health problems; and the use of alcohol, tobacco, and other substances. 4. The history of present illness includes the focusing on religious health beliefs and practices as well as health patterns. 5. Information about the religious beliefs and practices can be obtained when assessing psychosocial information. Page Ref: 56 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Religious and Spiritual Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.6: Explain the importance of each component of the nursing health history for patients across the lifespan. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
18) A patient tells the nurse a maternal grandparent had type I diabetes. Which part of the client's record should the nurse document the information in? 1. Genogram. 2. Health practices. 3. Past medical history. 4. Present health/illness. Answer: 1 Explanation: 1. A genogram is used for the documentation of family history usually in the form of a diagram. 2. Health practices are health patterns that are documented in a general assessment. 3. Past medical history includes any major illness, injuries, hospitalizations, allergies, immunizations, and childhood diseases. 4. Present health/illness includes information about all of the client's current health-related issues, concerns, and problems as well as the reason for seeking care. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardizNeUdRsSyIm bol anOdMterminology. | NLN Competencies: NG T Bs.C Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.6: Explain the importance of each component of the nursing health history for patients across the lifespan. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
19) A client tells the nurse that they do not need any information about skin cancer screening because they obtained the information on the internet. Which should the nurse do to ensure the client receives accurate information? 1. Provide additional education to the client. 2. Evaluate the accuracy of the information. 3. Instruct the client to discuss the information with the healthcare provider. 4. Encourage the patient to avoid seeking healthcare information on the internet. Answer: 2 Explanation: 1. Prior to providing additional information, the nurse should evaluate the accuracy of the information the client has obtained. 2. The risks associated with the use of the internet for healthcare information are based on a client's ability to judge the validity, currency, and scientific basis of the sources. The nurse's role includes evaluating the client's health-related knowledge base and the accuracy of the information. 3. The nurse should be able to provide the appropriate education and obtaining online health information. 4. The nurse should encourage the client to use authoritative, evidence-based online resources when seeking healthcare information online. Page Ref: 57 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.2. DNeUsRcrSiIbNeGhToBw verse cultural, ethnic, and social .Cd OiM backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
20) The nurse is obtaining a health history for a client admitted to the unit. Which should the nurse understand is the purpose for obtaining the health history? 1. Documenting the client's response to health concerns. 2. Documenting the client's medication history. 3. Documenting the client's physical activity level. 4. Documenting the client's educational level. Answer: 1 Explanation: 1. The purpose of the health history is to document the responses of the client regarding actual and potential health concerns. 2. Information about the client's medications is part of a health history but is not the purpose of the health history. 3. The client's physical activity is an assessment of a health pattern. 4. The client's educational level is part of the psychosocial assessment. Page Ref: 45 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
21) The nurse is obtaining the subjective data for a health history. Which components should the nurse include? Select all that apply. 1. General survey. 2. Family medical history. 3. Description of ambulation. 4. History of present illness. 5. Review of body systems. Answer: 2, 4, 5 Explanation: 1. A general survey is an objective assessment of the patient that is performed by the nurse. 2. Subjective data in a health history includes the family medical history. 3. A description of ambulation is an objective assessment made by the nurse. 4. Subjective data in a health history includes the history of present illness. 5. Subjective data in a health history includes the review of body systems. Page Ref: 54 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5: Identify the purpose of each phase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
22) The nurse is assessing a client's past medical history. Which information should the nurse obtain during the assessment? 1. Allergies. 2. Marital status. 3. Health beliefs and practices. 4. Reason for seeking care. Answer: 1 Explanation: 1. Allergies are assessed when obtaining the past medical history. 2. Marital status is obtained during the assessment of biographical information. 3. Health beliefs and practices are obtained during the history of present illness. 4. The reason for seeking care is obtained during the history of present illness. Page Ref: 54 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.5: Identify the purNpU ose RSIoNfGeTaBc.hCp Oh Mase of the nursing health history interview. MNL Learning Outcome: 5.4: Incorporate the components of a health history to a patient interview.
23) The nurse is conducting a review of systems assessment during a health history. Which question should the nurse ask the client? 1. "Have you ever had a surgical procedure?" 2. "What is your level of education?" 3. "Are you currently taking any medication?" 4. "Do you have a history of respiratory issues?" Answer: 4 Explanation: 1. Questions regarding a history of surgical procedures are appropriate when assessing the past medical history. 2. Questions regarding level of education are appropriate when assessing a psychosocial history. 3. Questions regarding current medications are appropriate when assessing the history of the present illness. 4. While all of these questions are appropriate to include in a health history, the only question that is appropriate while conducting a review of systems is the item that asks about a history of respiratory issues. Page Ref: 54 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Analyze personal bias and other barriers to effective nurse—patient interaction. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
24) The nurse is obtaining a health history from a client. Which should the nurse recognize is the most efficient and low-cost method of providing individualized care? 1. Obtaining a family history. 2. Obtaining a psychosocial history. 3. Obtaining a past medical history. 4. Obtaining a history of present illness. Answer: 1 Explanation: 1. An accurate family history is critical to providing the highest quality of personalized healthcare. Even with all the advancements in genomic science and improved diagnostic precision, the family history still provides the most efficient and low-cost method of providing an individualized plan of care. 2. Obtaining an accurate psychosocial history is not the most efficient and low-cost method of providing individualized care. 3. Obtaining a past medical history is not the most efficient and low-cost method of providing individualized care. 4. Obtaining a history of present illness is not the most efficient and low-cost method of providing individualized care. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenRcSiIeNsG: TIXB.2.C.ORM ecognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
25) The nurse is obtaining the psychosocial history of a client. Which component of the history should the nurse recognize is most important to determine prior to discussing health problems with the client? 1. Income. 2. Living situation. 3. Education. 4. Self-concept. Answer: 3 Explanation: 1. Income will not interfere with the client's ability to be able to understand the discussion of health problems. 2. The client's living situation will not interfere with the patient's ability to be able to understand the discussion of health problems. 3. Determining the client's level of education establishes expectations related to the ability to comprehend verbal and written language. These abilities are significant during the assessment process, in discussion of health problems or needs, and in education of the client. 4. The client's self-concept will not interfere with the client's ability to be able to understand the discussion of health problems. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementaNtiUoRnSoIN f cGaTrBe.CpO laM n, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.4: Analyze personal bias and other barriers to effective nurse—patient interaction. MNL Learning Outcome: 5.3: Differentiate the different phases of the health history.
26) The nurse is obtaining a health history interview. Which question should the nurse ask that will set the direction for the rest of the health history interview? 1. "Have you ever had any surgeries?" 2. "Are you currently taking any medications?" 3. "Do you have any medical problems?" 4. "Can you tell me why you are seeking care today?" Answer: 4 Explanation: 1. A history of surgeries will not set the direction for the rest of the health history interview. 2. Current medications will not set the direction for the rest of the health history interview. 3. A history of medical problems will not set the direction for the rest of the health history interview. 4. The nurse explores the reason for seeking care because it provides the first clues to choosing possible nursing diagnoses and sets the direction of the rest of the health history interview. Page Ref: 57 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.2: Identify strategies that promote effective communication when conducting a health history interview. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
27) A client tells the nurse they are worried that they have cancer. Which response should the nurse provide the client that demonstrates reflection? 1. "Everything will be all right." 2. "You may be over reacting." 3. "It sounds like you are worried about having cancer." 4. "You must be angry that this is happening to you." Answer: 4 Explanation: 1. Telling a client that everything will be all right is a barrier to effective communication. It is a false reassurance for which the nurse has no basis for knowledge of the outcome. 2. Telling the client that they are over reacting does not demonstrate empathy for the patient and is a barrier to effective communication. 3. Paraphrasing is a technique to make sure the nurse has understood the client. 4. Reflecting is the repeating of the client's verbal message for the client's benefit. It is a way of showing the patient that the nurse empathizes or is in tune with the client's thoughts, feelings, and experiences. Page Ref: 48 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.4: Analyze personal bias and other barriers to effective nurse—patient interaction. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
28) The nurse is summarizing the information obtained after a health history with a client. Which should the nurse recognize is a benefit of summary? Select all that apply. 1. Encourages open communication. 2. Shows the nurse has listened. 3. Indicates the nurse has understood the concerns. 4. Allows time for the patient to process information. 5. Signals closure of the interview. Answer: 2, 3, 5 Explanation: 1. The use of leading skills encourages open communication. 2. The benefit of summary shows the nurse has listened. 3. The benefit of summary indicates the nurse has understood the concerns. 4. Silence allows time for the client to process the information. 5. The benefit of summary signals the closure of the interview. Page Ref: 48 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Centered Care: CommuNnUicRaStIeNG inTfB or.CmOaMtion effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.1: Examine the purpose of a nursing health history in the health assessment. MNL Learning Outcome: 5.2: Recognize professional characteristics used in establishing a nurse—patient relationship and barriers to effective nurse—patient interaction.
29) The nurse is using several interactional skills during a health history assessment. Which should the nurse recognize reflects the skill of attending? 1. Tell the client what you want to discuss. 2. Slightly lean toward the client. 3. Ask questions to help the client gain insight. 4. Listen for the client's basic message. Answer: 2 Explanation: 1. Telling the client what the nurse wants to discuss is a technique used for the interaction skill of direct leading. 2. Slightly leaning toward the client is a technique used for the interaction skill of attending. 3. Asking questions to help the client gain insight is a technique for the interaction skill of questioning. 4. Listening for the client's basic message is a technique for the interaction skill of paraphrasing/clarification. Page Ref: 47 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Relationship and Centered Care: Communicate information effectively and listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3: Outline the professional characteristics used in establishing a nurse— patient relationship. MNL Learning Outcome: 5.2: Recognize professional characteristics used in establishing a nurse—patient relationship and barriers to effective nurse—patient interaction.
30) The nurse is preparing to use a direct leading technique for a client that is experiencing pain. Which question should the nurse ask the client? 1. "Can you go over what you said about nothing relieving the pain? 2. "Do you think you know what caused the pain? 3. "Can you describe your pain?" 4. "When did your symptoms begin?" Answer: 4 Explanation: 1. Asking the client if they said nothing had relieved their pain is the use of the technique of focusing. 2. Asking the client if they knew what caused their pain is a form of open-ended questioning. 3. The nurse is using the skill of focusing when asking the client for a description of the pain. 4. Leading skills are helpful in getting clients to explore their feelings or to elaborate on areas already introduced into the discussion. Asking a client when their symptoms began is a direct leading technique. Page Ref: 47 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and CentereNdUCRaSrIN e:GPTrBo.m oM te and accept the CO patient's emotions; accept and respond to distress in patient and self; and facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3: Outline the professional characteristics used in establishing a nurse— patient relationship. MNL Learning Outcome: 5.1: Utilize strategies that promote effective communication when conducting a health history interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 6 Documentation 1) The nurse is documenting a client's family medical history in a genogram. Which standardized symbol should the nurse use to identify the patient's biological mother? 1. Square. 2. Circle. 3. Diamond. 4. Rectangle. Answer: 2 Explanation: 1. In a genogram, each family member is represented by a symbol, using a circle for females and a square for males. 2. In a genogram, each family member is represented by a symbol, using a circle for females and a square for males. 3. A diamond is used to denote an unaffected male. 4. A rectangle is not a standardized symbol used in a genogram. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screNeUnRinSgIN, G diTaBg.nCoOsM tics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
2) The nurse is using the acronym SOAP to record information obtained from a client assessment. Which should the nurse recognize should be recorded in the "S" category? 1. Blood pressure of 177/93 mmHg. 2. Inability to afford prescriptions. 3. Client states they lost their insurance. 4. Social service referral. Answer: 3 Explanation: 1. The category of "O" is objective data. A blood pressure is an objective finding. 2. The category of "A" refers to assessment findings that are conclusions drawn from the subjective and objective data that has been obtained. 3. This category of "S" is subjective data. The patient telling the nurse they have lost their insurance is a subjective finding. 4. The category of "P" is planning. A referral to social services is a plan.Page Ref: 76 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: VI.A.2. Identify essential information that must be available in a common database to support patient care. | AACN Essentials Competencies: I.4. Use written,verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
3) The nurse is using the SBAR tool to notify a healthcare provider about a client that is physically declining. Which statement should the nurse include when communicating the situation? 1. "I think an increase in furosemide will help the patient." 2. "The patient was admitted yesterday with congestive heart failure." 3. "The patient's O2 saturation is 89%." 4. "The patient is experiencing dyspnea." Answer: 4 Explanation: 1. Suggesting the client needs an increase in the dosage of furosemide is a recommendation. 2. The client's admission diagnosis is part of the background. 3. The oxygen saturation is part of the assessment. 4. The client's symptoms of dyspnea reflect the situation. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated CoNnUcReSpItNsG: N u.rCsO inM g Process: Implementation TB Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
4) The nurse is preparing to create a pedigree for the client using the client's family history information. Which should the nurse recognize are benefits to using a genogram? Select all that apply. 1. Easy to fill in the family history. 2. Contains standardized symbols. 3. Allows for a visualization of disease incidence. 4. Provides a visual representation of a family's health patterns. 5. Can predict which generations are more susceptible to family illness. Answer: 1, 2, 3, 4 Explanation: 1. A genogram makes it easy to fill in the family history. 2. A genogram contains standardized symbols. 3. A genogram allows for visualization of disease incidence. 4. A genogram provides a visual representation of a family's health patterns. 5. A genogram cannot predict which generations are more susceptible to illness. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardizNeUdRsSyIm bol anOdMterminology. | NLN Competencies: NG T Bs.C Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the purpose of nursing documentation. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
5) The nurse is constructing a pedigree for a client. Which symbol should the nurse use to represent the client's biological father? 1. Circle. 2. Square. 3. Diamond. 4. Rectangle. Answer: 2 Explanation: 1. A circle represents a female. 2. A square connected to a circle represents the biological father and mother. The father is represented by the shape of a square. 3. A diamond is used to represent an unaffected or unknown person on the genogram. 4. A rectangle is not used to represent any family member in the genogram. Page Ref: 74 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated ConN ceUpRtSsI:NNGuTrB si.nCgOPMrocess: Assessment Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
6) The nurse is using the SBAR communication tool to communicate with a healthcare provider. Which statement should the nurse use to communicate the background? 1. "I think that the client's medication has caused the confusion." 2. "The client's mental status is confused." 3. "I am calling about Mr. X's blood pressure." 4. "I would suggest decreasing the dosage of the medication." Answer: 2 Explanation: 1. Suggesting that the confusion has resulted from the medication is an assessment. 2. Describing the client's mental status is an example of the background. 3. Identifying the client and the reason the call that is being made are examples of the situation. 4. Suggesting the reduction in the dosage of the medication is a recommendation. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
7) The preceptor is reviewing the use of the SBAR tool with a new nurse. Which statement made by the nurse indicates an understanding of the tool? 1. "The SBAR tool will help me organize my client's problems." 2. "The SBAR tool will help me organize the assessment on my client." 3. "The SBAR tool will help me organize my shift report." 4. "The SBAR tool will help me organize my documentation." Answer: 4 Explanation: 1. The SBAR tool is not intended to organize a client's problems. 2. The SBAR tool is not intended to organize an assessment on a client. 3. The SBAR tool is not intended to organize a routine shift report. 4. The SBAR can be useful in organizing the nurse's documentation because it prompts the nurse about which areas to include and presents a logical order or sequence to follow. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the purpose of nursing documentation. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
8) The nurse is using the principles of documentation. Which principle should the nurse anticipate to incorporate? 1. Ethics. 2. Accountability. 3. Professionalism. 4. Communication. Answer: 3 Explanation: 1. Ethics is not one of the principles of documentation but is a characteristic of professionalism. 2. Accountability is not a principle of documentation. 3. The purpose of documentation is communication across providers in the healthcare setting. Professionalism is one of the four basic principles of documentation. 4. Communication is the purpose of the documentation not an actual principle of documentation. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
9) The preceptor is discussing the principles of documentation with a new nurse. Which principles should the preceptor include? Select all that apply. 1. Completeness. 2. Professionalism. 3. Accuracy. 4. Timeliness. 5. Confidentiality . Answer: 1, 2, 3, 5 Explanation: 1. Completeness is one of the four basic principles of documentation. 2. Professionalism is one of the four basic principles of documentation. 3. Accuracy is one of the four basic principles of documentation. 4. Timeliness is not specifically identified as one of the four principles of documentation. Timeliness is a component of the completeness of the documentation. 5. Confidentiality is one of the four basic principles of documentation. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
10) The nurse has incorporated the principles of documentation into written communication. Which should the nurse recognize reflects the accuracy of the documentation? 1. Documentation that is limited to factualness. 2. Uniform language used throughout the documentation. 3. Limited sharing of the information. 4. Documentation that is completed promptly and is easily readable. Answer: 1 Explanation: 1. The most important aspect of documentation is accuracy, which means that documentation is limited to facts or factual accounts of observations rather than opinions or interpretations of observations. Documentation that is limited to factualness is an example of accuracy. 2. Uniform use of language used in documentation is an example of professional documentation. 3. Limiting the sharing of the information reflects the principle of confidentiality. 4. Documentation that is completed promptly and easily readable reflects completeness. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN CompetNeU ncRiSeIsN: GQTuBa.lCitOyMand Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
11) The nurse manager is discussing the principles of documentation with the nursing staff. Which statement made by a nurse indicates an understanding of the principle of professionalism? 1. "I will maintain the privacy of the information that I document." 2. "I will use uniform language so my documentation can be understood." 3. "I will use quotation marks when I record my subjective data." 4. "I will make sure I immediately document all of my assessments." Answer: 2 Explanation: 1. Maintaining the privacy of the information that is documented reflects the documentation principle of confidentiality. 2. Nursing documentation as a communication tool among healthcare professionals requires the nurse to use language that is commonly accepted and understood. The use of uniform language reflects the documentation principle of professionalism. 3. Using quotation marks when recording subjective data reflects the documentation principle of accuracy. 4. Timely documentation reflects the documentation principle of completeness. Page Ref: 68 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, NnU onR-SvIeNrGbTaBl,.C anOdMemerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
12) A client tells the nurse that they have pain in their lower abdomen. Which should the nurse record to reflect accuracy in the documentation of the information? 1. The client told me they have "pain" in their lower abdomen. 2. The client states, "I have pain in my lower abdomen." 3. The client complains they have pain in their lower abdomen. 4. The client states they are having pain in their abdomen. Answer: 2 Explanation: 1. This does not use quotation marks that include the exact words of the client. 2. Accuracy of the recording of subjective data is dependent on what the client says. When recording subjective data, it is important to use quotation marks to record a patient's exact words rather than interpreting the statement by putting it in nursing or medical terms. The documentation reading the client states, "I have pain in my lower abdomen," is correct. 3. When recording subjective data, it is important to use quotation marks to record a client's exact words rather than interpreting the statement by putting it in nursing or medical terms. 4. When recording subjective data, it is important to use quotation marks to record a client's exact words rather than interpreting the statement by putting it in nursing or medical terms. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, NnU onR-SvIeNrGbTaBl,.C anOdMemerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
13) The nurse is documenting an assessment. Which terms should the nurse be mindful of when recording information to ensure the documentation is accurate and complete? Select all that apply. 1. Precise. 2. Comprehensive. 3. Professional. 4. Succinct. 5. Concise. Answer: 1, 3, 4, 5 Explanation: 1. Precise is a term that defines the requirement for ensuring accurate and complete documentation. 2. Information documented should be comprehensive but also brief. These are descriptors of the term concise. 3. Professional is a term that defines the requirement for ensuring accurate and complete documentation. 4. Succinct is a term that defines the requirement for ensuring accurate and complete documentation. 5. Concise is a term that defines the requirement for ensuring accurate and complete documentation. Page Ref: 66 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
14) The nurse manager is reviewing tips for appropriate documentation with the nursing staff. Which statement made by the nursing staff indicates further education is required? 1. "I will document the exact time the events occurred." 2. "I will document why the client refused their medication." 3. "I will document for my colleague during an emergency." 4. "I will document client statements using quotations." Answer: 3 Explanation: 1. Accurate documentation of the times of a sequence of events is appropriate. 2. It is appropriate to document the reason why the client refused their medication. 3. The nurse's documentation is a legal record of individual nursing care. The nurse should not document anything for a colleague unless they are a designated recorder in an emergency. The colleague can document the events at the first opportunity they have. 4. Subjective statements should by encased by quotation marks to record the client's exact words. Page Ref: 68 Cognitive Level: Evaluation Client Need & Sub: Management of Care; Ethical Practice Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team memberNsU, oRtShINerGcTaBr.eCOproviders, patients, families, etc.) so as to M minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
15) A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort? 1. Distal to the elbow. 2. Proximal to the elbow. 3. Anterior to the elbow. 4. Inferior to the elbow. Answer: 2 Explanation: 1. Distal implies below the elbow. 2. Professional nursing documentation requires use of specific terms to describe assessment and physical examination findings. A client's description of discomfort above the elbow is professionally described as proximal to the elbow. The word proximal means above the elbow. 3. Anterior implies toward the front of the elbow. 4. Inferior implies below the elbow. Page Ref: 68 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffsNaU mRoSnIN g GpTroBv.CidOeM rs and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
16) The nurse is preparing to describe a location in the body in the documentation of an assessment. Which terminology should the nurse anticipate using? 1. Anatomic definition. 2. Anatomic plane. 3. Anatomic alignment. 4. Anatomic pathology. Answer: 2 Explanation: 1. Anatomic definition is not used to describe a location in the body. 2. The body is separated into anatomic planes; therefore, the appropriate terminology should be used to describe the location of the assessment findings. 3. Anatomic alignment is not used to describe a location in the body. 4. Anatomic pathology is not used to describe a location in the body. Page Ref: 68 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: Pl n.nCiO ngM G TaB Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
17) The nurse is avoiding the use of a client's personally identifiable information. Which information should the nurse recognize should not be used? Select all that apply. 1. Diagnosis. 2. Gender. 3. X-rays. 4. Age. 5. Religion. Answer: 1, 2, 3, 4 Explanation: 1. Diagnosis is personally identifiable information. 2. Gender is personally identifiable information. 3. X-Rays are personally identifiable information. 4. Age is personally identifiable information. 5. Religion is not personally identifiable information. Page Ref: 69 Cognitive Level: Applying Client Need & Sub: Management of Care; Confidentiality/Information Security Standards: QSEN Competencies: VI.B.1. Seek education about how information is managed in care settings before providing care. | AACN Essentials Competencies: IV.8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
18) A client tells the nurse that their pain is okay now. Which question should the nurse ask the patient to obtain more accurate information? 1. "Do you feel better?" 2. "Can you explain what okay means?" 3. "Are you pain free?" 4. "Is feeling okay a tolerable condition for you?" Answer: 2 Explanation: 1. Asking the client if they feel better does not elicit much detail about the client's pain. 2. Asking the client to explain what "okay" means provides the opportunity for the nurse to elicit more information from the client. 3. The nurse should use an objective scale to obtain a baseline of the client's pain in order to elicit more accurate information, should the client's condition change. 4. Asking the client if the feeling okay is tolerable does not elicit much detail about the client's pain. Page Ref: 69 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks and to identify current and future health problems. | NLN Competencies: RNeUlaRtSioINnGshTiBp.CCOenMtered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
19) The nurse is assessing the family history of a client that has children. Which should the nurse plan to do when creating a genogram? 1. Obtain information for at least two generations. 2. Depict members of each generation along a vertical line. 3. Begin the genogram with a proband. 4. At the top of the genogram indicate the gender of the patient. Answer: 3 Explanation: 1. When documenting a history, at least three generations are included. 2. Members of each generation should be depicted along a horizontal line. 3. It is useful to begin the genogram with the proband and then "build" the genogram by adding the most closely related family members. 4. The ancestry or country of origin of the individuals originating generation should be depicted at the top of the genogram. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct popuNlUati on-based transcultural health assessments and RSIN GT B.COM interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting. MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
20) The nurse is preparing to document a narrative note. Which format should the nurse use? 1. Paragraph. 2. Acronyms. 3. Bullet points. 4. Short sentences. Answer: 1 Explanation: 1. When using narrative notes, the documentation is written in a paragraph style or format as if it is being "narrated" or told to a listener. 2. An acronym is not a format; it is an abbreviation that forms a word, not a narrative note. 3. Bullet points are not used to write a narrative note. 4. Short sentences are not used to write a narrative note. Page Ref: 75 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
21) The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception? 1. Allows for a focused documentation of symptoms. 2. The documentation is formatted for a specific purpose. 3. Focuses on problem-oriented documentation. 4. Repetition is eliminated from the documentation. Answer: 4 Explanation: 1. Symptom assessment documentation is intended to allow for a focused documentation. 2. Whether in paper or electronic form, the methods of documentation for flow sheets are usually formatted for a specific purpose. 3. Problem-oriented documentation includes the SOAP and APIE methods. 4. Much of the repetition is eliminated when using the documentation charting by exception. Page Ref: 77 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffsNaU mRoSnIN g GpTroBv.CidOeM rs and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1: Describe the purpose of nursing documentation. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
22) The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart? 1. "Encouraged the client to ask questions." 2. "Discussed the plan of care with the parents." 3. "The client is demanding and tired." 4. "The client is observed to be crying." Answer: 4 Explanation: 1. Documenting that the client is encouraged to ask questions does not indicate what the client is encouraged to ask about. 2. The statement does not identify what plan of care was discussed with the parents or their response to the plan of care. 3. Stating that the patient is demanding and tired is not a professional, objective statement. 4. Documenting that the client is observed to be crying is an appropriate objective statement. Page Ref: 79 Cognitive Level: Analyzing Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffsNaU mRoSnIN g GpTroBv.CidOeM rs and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
23) A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with? 1. Identify genetic risk factors. 2. Predict genetic illness. 3. Promote healthy behavior. 4. Prevent future illness. Answer: 1 Explanation: 1. A genogram can identify genetic risk factors. 2. A genogram does not predict genetic illness. 3. A genogram is not intended to promote health behavior. 4. A genogram does not prevent future illness. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1: Describe the purpose of nursing documentation. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
24) The nurse is creating a genogram for a client. Which standard symbol should the nurse use to identify a male carrier? 1. Square half shaded. 2. Diamond shaded. 3. Fully shaded square. 4. Fully shaded circle. Answer: 1 Explanation: 1. The half shaded square represents a male carrier. 2. The diamond is not shaded and represents an unaffected person, for which the sex is unknown. 3. A fully shaded square represents an affected male. 4. A fully shaded circle represents an affected female. Page Ref: 74 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated ConN ceUpRtSsI:NNGuTrB si.nCgOPMrocess: Assessment Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
25) The nurse is preparing to record a narrative health history. Which assessments should the nurse include in the health history? Select all that apply. 1. Spirituality. 2. Biographic data. 3. Family history. 4. Sexuality. 5. Medications. Answer: 1, 2, 3, 5 Explanation: 1. Spirituality is included in the narrative health history. 2. Biographical data is included in the narrative health history. 3. Family history is included in the narrative health history. 4. Sexuality is objective information that is included in the review of systems. 5. Medications are included in the narrative health history. Page Ref: 70 Cognitive Level: Applying Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffsNaU mRoSnIN g GpTroBv.CidOeM rs and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
26) The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply. 1. "I will only need to chart by exception with this method." 2. "Only subjective data are included in the assessment portion." 3. "The 'P' refers to the chief problem of the client." 4. "The activities implemented to manage the client's needs will be documented in the 'I' section." 5. "The 'E' refers to the evaluation that occurs after an intervention is implemented." Answer: 3, 4, 5 Explanation: 1. APIE is not the same as charting by exception. 2. The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. The assessment includes both the objective and subjective data. 3. The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. The "P" refers to the chief problem. 4. The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. "I" includes the interventions implemented to manage the client. 5. The APIE method of charting uses the letters to refer to the assessment, problem, intervention, and evaluation. "E" includes evaluation of the interventions that have been implemented. Page Ref: 76 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6.2: List the key principles of nursing documentation. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
27) The nurses have requested a documentation system that will reduce the time spent writing out routine tasks but will still allow for documentation of exceptions. Which type of documentation should the nurse manager consider implementing in the healthcare organization? 1. Focus documentation. 2. Flow sheets. 3. SOAP charting. 4. APIE charting. Answer: 2 Explanation: 1. Focused documentation records client problems and strengths. 2. Flow sheets use columns or categories to document assessment findings and note interventions that have been performed. Flow sheets also reduce repetition of documentation and are time efficient. 3. SOAP charting is detailed and includes subjective and objective data, assessment findings, and planning information. 4. APIE charting includes assessment, planning, intervention, and evaluation. Page Ref: 76 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, NnU onR-SvIeNrGbTaBl,.C anOdMemerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
28) The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation? 1. Supine. 2. Anterior. 3. Prone. 4. Lateral. Answer: 1 Explanation: 1. The client laying on their back facing the ceiling is in a supine position. 2. An anterior position implies towards the front. 3. The client laying on their stomach is in a prone position. 4. Lateral describes a side lying position. Page Ref: 68 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: Ev on G TaBlu .CaOtiM Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
29) A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram? 1. The current geographical residence. 2. The medications her mother takes. 3. The current age of her mother. 4. The age of onset of the type II diabetes. Answer: 4 Explanation: 1. The current geographical residence of her mother is not included in the genogram. 2. The current medications her mother is on are not included in the genogram. 3. It is not necessary to include the age of her mother in the genogram. 4. It is important to include the age of the family member or the age at death and the age at diagnosis of chronic conditions. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct popuNlUati baTsBe.CdOtrManscultural health assessments and RSoInN-G interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
30) The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation? 1. S: The client states, "I am so nauseated." 2. O: The client reports feeling fatigued. 3. A: Bowel sounds are high-pitched in all abdominal quadrants. 4. P: The client will remain NPO.Answer: 2 Explanation: 1. S refers to subjective data. Client reports are examples of subjective information. 2. O refers to objective data. Client reports are examples of subjective information. 3. A refers to assessment. The characteristics of the client's bowel sounds are reflective of an assessment. 4. P refers to planning. Planning indicates actions taken to resolve or address the client's needs. Page Ref: 76 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team memberNsU, oRtShINerGcTaBr.eCOproviders, patients, families, etc.) so as to M minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment. MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 7 Physical Assessment Techniques and Equipment 1) The nurse is preparing to lightly palpate a client's abdomen. Which part of the hand should the nurse use? 1. Finger pads. 2. Palmer surface of the fingers. 3. Palmer surface of the hand. 4. Finger pads and palmer surface of the fingers. Answer: 1 Explanation: 1. Light palpation of the abdomen is performed using the finger pads. 2. The palmer surface of the fingers is used for deep palpation. 3. The palmer surface of the hand is not a technique used for any type of palpation. 4. The finger pads and the palmer surface of the fingers together is not a technique used for any type of palpation. Page Ref: 84 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
2) The nurse is preparing to assess the sinuses of an adult client using direct percussion. Which technique is the most appropriate for this assessment? 1. Using the hyperextended middle finger of the nondominant hand. 2. Using the closed fist of dominant hand. 3. Using the palm of the nondominant hand. 4. Using the fingertips of the dominant hand. Answer: 4 Explanation: 1. Indirect percussion is the technique most commonly used and performed by placing the hyperextended middle finger of the nondominant hand firmly over the area to be examined and striking it with a plexor. 2. Blunt percussion is used for assessing pain and tenderness in the gallbladder, liver, and kidneys and involves placing the palm of the nondominant hand flat against the body surface and striking the nondominant hand with the closed fist of the dominant hand. 3. The palm of the nondominant hand is used to assess pain and tenderness of the gallbladder, liver, and kidneys in blunt percussion. 4. Direct percussion is the technique of tapping the body with the fingertips of the dominant hand. It is used to assess the thorax of an infant and also to assess the sinuses of an adult client. Page Ref: 85 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N.GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
3) During auscultation of the breath sounds of an adult male client, the nurse hears crackling sounds over most of the chest. Which action by the nurse is the most appropriate? 1. Document this as abnormal. 2. Avoid moving the stethoscope while listening. 3. Place the diaphragm on top of the client's shirt. 4. Switch from the diaphragm to the bell. Answer: 2 Explanation: 1. The crackling sounds may or may not be an abnormal finding; the cause of the sounds should be fully investigated before the nurse documents the finding as abnormal. 2. Friction on either the bell or the diaphragm from coarse body hair may cause a crackling sound easily confused with abnormal breath sounds. To avoid artifact caused from friction, the nurse should avoid moving the stethoscope while listening. 3. Auscultating lung sounds over the client's clothing will increase rather than decrease friction sounds. 4. Lung sounds are high-pitched sounds, best heard with the diaphragm of the stethoscope. Friction from hair will cause abnormal crackling sounds using either the diaphragm or the bell, so switching them won't make a difference. Page Ref: 86 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
4) The nurse is planning to perform light abdominal palpation on an adult client. Moving the hand slowly in circles, which technique should the nurse use? 1. Using the finger pads, apply a downward pressure of 2 cm. 2. Using the finger pads, apply light pressure at a depth of 1 cm. 3. Using the finger pads, apply a downward pressure of 1/2 cm. 4. Using the finger pads, apply a light pressure of 3 cm. Answer: 2 Explanation: 1. A pressure of 2 cm is too deep for light abdominal palpation. 2. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. For light palpation, the finger pads of the dominant hand are placed on the surface of the area to be examined. The hand is moved slowly and the finger pads, at a depth of 1 cm (0.39 in.), form circles on the skin during assessment. 3. A pressure of 1/2 cm is not deep enough for light abdominal palpation. 4. A pressure of 3 cm is too deep for light abdominal palpation. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
5) The nurse is preparing to assess a client's abdomen. Place the sequence for an abdominal assessment is the correct order. 1: Percussion. 2: Palpation. 3: Auscultation. 4: Inspection. Answer: 4, 3, 1, and 2 Explanation: 1: Percussion is the third step taken during an abdominal assessment. 2: Palpation is the last step taken during an abdominal assessment. 3: Auscultation is the second step taken during an abdominal assessment. 4: Inspection is the first step taken during an abdominal assessment. Page Ref: 83 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
6) The nurse is inspecting a client's chest and upper extremities. Which would be the appropriate method for the nurse to assess these body areas? 1. Examine the right arm, the chest, and then the left arm. 2. Examine the left arm, the chest, and then the right arm. 3. Examine the left arm, the right arm, and then the chest. 4. Examine the chest and then examine the right and left arms. Answer: 3 Explanation: 1. The nurse should compare the left and right arms before moving to the chest. 2. The nurse should compare the left and right arms before moving to the chest. 3. Inspection begins with a survey of the client's appearance and a comparison of the right and left sides of the body, which should be nearly symmetrical. The nurse should compare the left and right arms before moving to the chest. 4. The nurse should compare the left and right arms before moving to the chest. Page Ref: 83 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
7) A client has a reddened area on the left forearm. Which assessment technique should the nurse use to assess this area? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation. Answer: 2 Explanation: 1. Percussion is used to determine the size and shape of organs and masses, and whether underlying tissue is solid or filled with air or fluid. 2. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. 3. Moderate palpation is used to assess most of the other structures of the body. 4. Deep palpation is used to assess an organ that lies deep within a body cavity. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
8) While auscultating a client's lungs, the nurse identifies more than one sound. Which action by the nurse is the most appropriate? 1. Obtain a stethoscope with longer tubing. 2. Ask another nurse to listen to the lung sounds. 3. Hold the stethoscope tubing while listening to the lung sounds. 4. Close the eyes and focus on one sound at a time. Answer: 4 Explanation: 1. Long tubing on a stethoscope can distort sounds; this would not help the nurse identify chest sounds. 2. Asking another nurse to listen to the lung sounds would not help the nurse discern the tones being heard. 3. Touching the stethoscope tubing can cause additional sounds and should be avoided. 4. Closing the eyes and concentrating on each sound may help the nurse focus on the sound. Page Ref: 87 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
9) The nurse is assessing a client's right lower extremity and notes an area of redness. Which part of the hand will the nurse use to further assess the client's skin? 1. Fingertips. 2. Metacarpophalangeal joints. 3. Dorsal surface. 4. Ulnar surface. Answer: 3 Explanation: 1. The fingertips are used for identifying underlying skin structures and functions such as pulses, superficial lymph nodes, or crepitus. 2. The metacarpophalangeal joint area of the hand is used to assess for vibration or fremitus. 3. The skin on the dorsal surface of the fingers and the hand is thinner; therefore, it is the best area to assess skin temperature. 4. The ulnar surface of the hand is also used to assess for fremitus. Page Ref: 84 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
10) The nurse is preparing to percuss the lower lobes of a client's lungs. Which percussion technique is the most appropriate for the nurse to use during this assessment? 1. Direct percussion. 2. Blunt percussion. 3. Indirect percussion. 4. Tapping percussion. Answer: 3 Explanation: 1. Direct percussion is used to examine the thorax of an infant and to assess the sinuses of an adult. 2. Blunt percussion is used to assess for pain and tenderness in the gallbladder, liver, and kidneys. 3. Percussion of the lungs is done using indirect percussion, as it produces sounds that are clearer and more easily interpreted. Of all the percussion techniques, indirect is the most commonly used. 4. Tapping is a technique used during percussion; it is not a type of percussion. Page Ref: 85 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
11) The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session? Select all that apply. 1. The stethoscope works by blocking out environmental sounds. 2. Short tubing provides the listener with the most accurate sounds. 3. The bell of the stethoscope is used for high-pitched sounds, such as lung sounds. 4. The diaphragm of the stethoscope is used for low pitched sounds. 5. The binaurals should fit snugly in the ears. Answer: 1, 2, 5 Explanation: 1. The stethoscope works by blocking out environmental sounds; it does not amplify sounds in the body. 2. Short tubing provides the listener with the most accurate sounds; longer tubing may distort sound. 3. The bell of the stethoscope is used for low-pitched sounds, such as the sounds of a heart murmur. 4. The diaphragm is used for high-pitched sounds, such as normal heart sounds and lung sounds. 5. The binaurals should fit snugly yet comfortably in the ears. Page Ref: 89 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
12) The nurse is preparing to assess a client with an otoscope. Which should the nurse use the otoscope to assess? Select all that apply. 1. Inspecting the nose. 2. Funneling light into the ear canal. 3. Inspecting the internal structures of the eye. 4. Assessing pulses that are not palpable. 5. Detecting fungal infections of the skin. Answer: 1, 2 Explanation: 1. The otoscope can be used to inspect the nose, by inserting a wide speculum into the client's naris. 2. The otoscope funnels light into the ear canal to allow the examiner to inspect the tympanic membrane (eardrum) as well as the ear canal itself. 3. The ophthalmoscope is used to inspect the internal structure of the eye. 4. The Doppler uses ultrasonic waves to detect pulses that are difficult to palpate. 5. A Wood's lamp produces a black light that emits a yellow-green fluorescence on skin in the presence of a fungal infection. Page Ref: 91 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
13) The nurse is preparing to assess the size and location of an optical lesion. Which light source should the nurse use on the ophthalmoscope? 1. Grid. 2. Slit. 3. Small aperture. 4. Red-free filter. Answer: 1 Explanation: 1. The grid allows the examiner to assess the size, location, and pattern of any lesions. 2. The slit allows for examination of the anterior eye and aids in assessing the elevation or depression of lesions. 3. The small aperture is used for undilated pupils. 4. The red-free filter shines a green beam used to examine the optic disc for pallor or hemorrhaging, which appears black with this filter. Page Ref: 90 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
14) The preceptor has reviewed the correct technique to assess heart murmurs with a new nurse. Which statement made by the nurse indicates an understanding? 1. "I will listen for murmurs with the bell of the stethoscope." 2. "A stethoscope with long tubing will produce a better heart sound." 3. "A Doppler is the best instrument to use to listen for murmurs." 4. "The diaphragm of the stethoscope should be used to listen for murmurs." Answer: 1 Explanation: 1. The bell of the stethoscope is used to assess murmurs. 2. Long tubing length can distort sound. 3. A Doppler is not used to auscultate heart sounds. 4. The diaphragm of the stethoscope is used to assess normal heart sounds. Page Ref: 89 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
15) The nurse is planning to perform a physical assessment on an adult client. Prior to the assessment, which should be the nurse's first action? 1. Provide a gown for the client to change into. 2. Explain to the client what will happen during the examination. 3. Obtain a written consent. 4. Wash hands in the presence of the client. Answer: 2 Explanation: 1. The client may need to change into a gown in order for the nurse to perform the assessment; however, the nurse should first explain what will be happening before asking the client to change clothing. 2. The first thing the nurse should do prior to beginning the physical assessment of a client is explain to the client what is about to happen. This helps to relieve a client's anxiety and enlists the client's cooperation with the assessment. 3. Obtaining a written consent is not necessary, unless an invasive procedure will be performed. 4. Handwashing should be performed just before the nurse begins to touch the client and after a full explanation of the process is given and again at the completion of the physical assessment. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safeNtyUR anSdINqGuTaBli.tCyO. M | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
16) The nurse is preparing to assess the abdomen of a client experiencing pain. Which technique should the nurse use? 1. Palpating known painful areas first. 2. Touching each area lightly before applying deeper palpation. 3. Performing the exam as quickly as possible. 4. Refraining from conversation during the assessment. Answer: 2 Explanation: 1. Known painful areas are usually the last area to be palpated as pain and tenderness cause the client to tense. 2. Touch informs the client that the examination of the area is about to begin and may prevent a startled reaction. 3. Rushing through the exam may result in a poor assessment. 4. The client will be more relaxed if the nurse talks during the assessment, explaining each movement in advance. The nurse often needs to ask the client questions during the assessment to gain a broader knowledge of the client's health. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
17) The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority? 1. Give the client a short break and then resume the assessment. 2. Document what was done and what was refused. 3. Summon another nurse to the room to serve as a witness. 4. Enlist the assistance of the client's family to encourage the rest of the assessment. Answer: 2 Explanation: 1. The nurse must never attempt to influence or coerce the client to agree to a procedure; giving the client a break and then resuming the assessment could be viewed as a form of coercion. 2. The client has the right to refuse care. It is important to document what has been done and what, if anything, has been refused. 3. It is not necessary for another nurse to witness a client's refusal of care. The nurse should document what was done and what the client refused. 4. Allowing a family member to be present during the assessment may be helpful, but the client's wishes (refusal) must be respected. Page Ref: 93 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Client Rights Standards: QSEN Competencies: I.B.11. Recognize the boundaries of therapeutic relationships | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, NanUdRSeInNvGirToBn.m ntal assessments of health and COeM illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship and Centered Care: Respect the patient's dignity, uniqueness, integrity, and self-determination and the patient's power and self-healing processes | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
18) The nurse is preparing to perform a complete health assessment on a client. Which actions by the nurse are appropriate just prior to the examination? Select all that apply. 1. Putting on nonsterile gloves. 2. Providing an opportunity for the client to void. 3. Washing hands in the presence of the client. 4. Turning on soft music to relax the client. 5. Ensuring adequate light in the room. Answer: 2, 3, 5 Explanation: 1. Gloves are needed only if the nurse may come into contact with the client's blood or body fluids, such as during the assessment of the genitalia or anus. 2. The client should be given an opportunity to void prior to physical assessment. This helps the client feel more comfortable and facilitates the assessment of the abdomen and reproductive organs. 3. The nurse should always perform handwashing in the presence of the client prior to physical contact. This demonstrates that the nurse is providing for the client's safety and also protects the nurse. 4. The assessment should take place in a quiet environment in order for the nurse to correctly identify sounds and their characteristics. 5. The room should be brightly lit to facilitate good visibility. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: V.B.1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
19) The nurse is assessing a client's abdomen. Which sound is expected when percussion is used during the assessment? 1. Resonance. 2. Dullness. 3. Tympany. 4. Hyperresonance. Answer: 3 Explanation: 1. Resonance is a loud, low-pitched tone of normal findings over the lungs. 2. Dullness is a soft, high-pitched tone of short duration, usually heard over solid organs such as the liver. 3. Tympany is a loud, high-pitched, drum-like tone that is heard over air-filled organs such as the intestines. 4. Hyperresonance is an abnormally loud, low tone of longer duration heard when air is trapped in the lungs. Page Ref: 86 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : KGnToBw .Cle OdMge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
20) The nurse is using a Wood's lamp to assess a client's skin. Which should the nurse expect to see if a fungal infection is present? 1. Yellow-green appearance. 2. Reddened appearance. 3. Blue-green appearance. 4. Violet appearance. Answer: 1 Explanation: 1. A yellow-green experience is characteristic of a fungal infection. 2. A reddened appearance is not associated with a fungal infection. 3. A blue-green appearance is not associated with a fungal infection. 4. A violet appearance is not associated with a fungal infection. Page Ref: 88 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
21) The nurse has completed auscultating the abdomen of a client. Which assessment technique should the nurse expect perform next? 1. Percussion. 2. Palpation. 3. Transillumination. 4. Auscultation. Answer: 1 Explanation: 1. After auscultating the client's abdomen, the nurse would begin percussion. 2. Palpation is the last step of the abdominal assessment. 3. Transillumination of the abdomen is not part of the abdominal assessment. 4. Auscultation is the second step of the abdominal assessment. Page Ref: 83 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
22) The nurse is using a Doppler ultrasonic stethoscope to assess a client's pulse in the lower extremity and is unable to locate the pulse. Which action by the nurse is appropriate in this situation? 1. Check the pressure applied to the probe. 2. Add more gel to the end of the probe. 3. Palpate the pulse then reapply the probe. 4. Replace the probe of the Doppler. Answer: 1 Explanation: 1. Heavy pressure to the probe should be avoided because it may impede blood flow. The probe should be placed gently against the client's skin, over the artery to be auscultated. 2. A small amount of gel is applied to the end of the Doppler probe to eliminate interference. 3. The intention of the Doppler is to identify the pulse. 4. The nurse does not replace the probe of the Doppler. The technique being used should be reevaluated. Page Ref: 90 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
23) A client has a visible pulsation in the middle of his abdomen. Which assessment technique is appropriate for the nurse to use to assess this pulsation? 1. Percussion. 2. Light palpation. 3. Moderate palpation. 4. Deep palpation. Answer: 3 Explanation: 1. Percussion is used to determine the size and shape of organs and masses and whether underlying tissue is solid or filled with air or fluid. 2. Light palpation is used to assess surface characteristics, such as skin texture, pulse, or a tender, inflamed area near the surface of the skin. 3. With moderate palpation, the nurse uses the palmar surface of the fingers to determine the depth, size, shape, consistency, and mobility of organs, as well as any pain, tenderness, or pulsations that might be present. 4. Deep palpation is used to assess an organ that lies deep within a body cavity. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.1: Differentiate between the four basic techniques used by the professional nurse when performing physical assessment. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
24) The nurse is assessing a client with right lower quadrant abdominal pain. Which technique should the nurse use when palpating the abdomen? 1. Assessing the painful area first using moderate palpation. 2. Assessing the painful area last using deep palpation. 3. Assessing the painful area last using light palpation. 4. Assessing the painful area first using deep palpation. Answer: 2 Explanation: 1. Painful areas are not palpated first. 2. Known painful areas of the body are usually the last area to be palpated. The assessment of structures of the abdomen requires moderate to deep palpation. 3. Light palpation is used to evaluate surface characteristics, not the structures of the abdomen. 4. While deep palpation is the appropriate technique, the painful area is examined last. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3: Discuss professiNoUnRalSrIN esGpToBn.sCiO bilities related to critical thinking, patient M safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.2: Recognize the proper equipment, techniques, and safety/comfort considerations when performing palpation during a physical assessment.
25) While percussing a client's lung area the nurse notes a resonance. Which should the nurse recognize the tone indicates? 1. The tone indicates the nurse is percussing over bone. 2. The tone is an expected finding. 3. The tone indicates the lungs contain solid matter. 4. The tone indicates air is trapped in the lungs. Answer: 2 Explanation: 1. Flat tones are high-pitched and soft tones of short duration and are the result of percussion over solid tissue such as muscle or bone. 2. Percussion over normal lung tissue should elicit a loud, low-pitched, hollow tone of long duration known as resonance. 3. Solidified areas of the lung will produce dullness on percussion and a high-pitched soft tone of short duration. 4. Percussion over the lung where air has become trapped produces an abnormally loud, low tone of longer duration than resonance. Page Ref: 85 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.C enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
26) The nurse is unable to palpate a client's pedal pulses. Which item will the nurse use to assess this client's pedal pulses? 1. Stethoscope. 2. Doppler. 3. Transilluminator. 4. Goniometer. Answer: 2 Explanation: 1. A stethoscope is used to auscultate body sounds such as blood pressure and heart, lung, and abdominal sounds. 2. The Doppler uses ultrasonic waves to detect sounds that are difficult to hear with a regular stethoscope, such as peripheral pulses. 3. A transilluminator detects blood, fluid, or masses in body cavities. 4. A Goniometer is used to measure the degree of joint flexion and extension. Page Ref: 90 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2: Compare and contrast the purpose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
27) The nurse auscultating heart sounds suspects the client has a murmur. Which action should the nurse take? 1. Inform the client of "the abnormality." 2. Stop the assessment and refer the client to the healthcare provider. 3. Request another examiner to assess the finding. 4. Document the finding with a plan to reassess the patient on the next visit. Answer: 3 Explanation: 1. Informing the client of "the abnormality" may cause the client undue anxiety, as the finding may be a normal variant. 2. When the nurse identifies an unfamiliar finding, it is appropriate to complete the assessment before referral to a healthcare provider. 3. The nurse should complete the assessment, which includes having a colleague assess the finding prior to referring the patient to the healthcare provider. 4. The finding should be investigated during the current visit, initially by requesting another examiner to assess the finding. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VI.2. Use inter-and intraprofessional communication and collaborative skills to deliver evidence-bNasUeRdS,IpNaGtTieBn.Ct-OceMntered care. | NLN Competencies: Teamwork: Adapt communication to the team and situation to share information or solicit input and initiate requests for help when appropriate. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.4: Recognize the proper equipment, techniques, and safety/comfort considerations when performing auscultation during a physical assessment.
28) The nurse is preparing to examine several clients in the clinic setting. Which client should the nurse recognize requires special consideration during the physical examination? 1. An adult client with flu symptoms. 2. A preschool-age client in for a well check-up. 3. An adolescent client who complains of fatigue. 4. An older adult client with chronic lung disease. Answer: 4 Explanation: 1. A client ill with an acute condition such as a flu-like illness is not the same riskcategory as the older client with a chronic disease. 2. Assessment approaches and techniques may vary for children, but a 3-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. 3. Fatigue in a teenager may indicate anemia or it may be caused by lack of sleep, but in general, the position changes required during the complete health assessment should not be taxing on a teen. 4. Clients who are frail, weak, debilitated, or suffering from a chronic illness may become extremely fatigued during the physical examination due to frequent position changes. The nurse should make every effort to minimize the number of position changes for the client and should complete the exam in a timely fashion. Page Ref: 93 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
29) The nurse is preparing to perform percussion over the lung fields of a client. Which technique should the nurse use to ensure an accurate assessment is obtained? 1. Release the plexor immediately after the first strike. 2. Initiate the motion from the plexor finger. 3. Use the pad of the flexor finger to deliver the blow. 4. Make contact with only the pleximeter. Answer: 4 Explanation: 1. The plexor finger should be released immediately after the delivery of two sharp strikes, as this action will allow for the clearest, most accurate sound to be produced. 2. Ensure that motion is from the wrist, not the forearm or plexor finger. 3. Use the tip of the plexor finger, not the finger pad, to deliver the blow as this will help produce the clearest sound. 4. The plexor is the fingertip of the flexed middle finger of the dominant hand. Only the pleximeter makes contact with the body. Page Ref: 86 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : KGnToBw edMge and Science: .ClO Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.3: Discuss professional responsibilities related to critical thinking, patient safety and comfort, and principles of standard precautions in nursing practice. MNL Learning Outcome: 7.3: Recognize the proper equipment, techniques, and safety/comfort considerations when performing percussion during a physical assessment.
30) The nurse is preparing equipment to be used in an exam. Which principle should the nurse include when preparing the medial equipment? 1. Sterile instruments should be placed on a sterile cloth. 2. All instruments should be placed on a sterile cloth. 3. Clean instruments should be placed on a sterile cloth. 4. A sterile cloth should be placed over the instruments. Answer: 4 Explanation: 1. It is not necessary to place the sterile instruments on a sterile cloth. The sterile instruments should be placed on a clean surface. 2. It is not necessary to place all instruments on a sterile cloth. All instruments can be placed on a clean surface. 3. Clean instruments do not need to be placed on a sterile cloth. Clean instruments can be placed on a clean surface. 4. The clean area should be draped with a sterile cloth or paper liner. Page Ref: 94 Cognitive Level: Applying Client Need & Sub: Safety and Infection Control; Safe Use of Equipment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Knowledge and Science: Evidence and best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2: Compare and coNnUtRraSsIN t tGhTeBp.CuOrpMose of equipment required to perform a complete physical assessment MNL Learning Outcome: 7.1: Recognize the proper equipment, techniques, and safety/comfort considerations when performing inspection during a physical assessment.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 8 General Survey and Physical Exam: Objective Data 1) The nurse is preparing to conduct a general survey. Which should the nurse recognize is the purpose of performing the general survey prior to the physical assessment?
1. Allows for vital signs prior to starting exam. 2. Provides an opportunity for the client to relax before the exam. 3. Yields information to guide the physical assessment. 4. Provides the information necessary for the diagnosis. Answer: 3 Explanation: 1. Vital signs are not part of the general survey. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior. 2. The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax. 3. The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment. 4. The general survey does not provide the necessary information to identify client problems or nursing diagnoses but rather serves as a guide for a more detailed assessment. Page Ref: 97 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentiaels:CIXo.m comprehensive and focused 1.pCeotnenduc ct physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Identify the components of the general survey. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
2) The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity to obtain data related to which item?
1. Mobility. 2. Balance. 3. Activity tolerance. 4. Strength of upper and lower extremities. Answer: 1 Explanation: 1. During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the client's mobility. These data will then be incorporated into the remainder of exam and history. 2. Balance is a descriptor for mobility. 3. Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior. 4. Watching the client walk and sit provides the nurse information about the strength of a client's lower extremities but does not provide information about the client's upper extremity strength. Page Ref: 97 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pTmBe.C ntOaM lly and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Identify the components of the general survey. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
3) The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client? Select all that apply.
1. Blood pressure 112/68, pulse 68, 98.6°F, and respiratory rate 16. 2. Thin, well-nourished male client appears younger than stated age. 3. Client ambulatory without difficulty. 4. Abdomen flat, nondistended, bowel sounds present, and nontender on palpation. 5. Pain rating of 3 on a 0 to 10 scale. Answer: 2, 3 Explanation: 1. The vital signs are objective information but not part of the actual general survey. 2. The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well- nourished male client appears younger than stated age reflects the client's physical appearance, one of the components of the general survey. 3. The documentation client ambulatory without difficulty describes the client's overall mobility, another component of the general survey. 4. The documentation abdomen flat, nondistended, bowel sounds present, and nontender on palpation is specific to the abdominal assessment and not part of the general survey. 5. A pain assessment is not included in the general survey of the client. Page Ref: 97 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5.NEUxR plSaIiNnGtThBe.C roOleMof evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Identify the components of the general survey. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
4) The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?
1. Observation of the client ambulating. 2. Asking the client to describe elements of his health history. 3. Observation of the client's clothing selections. 4. Observation of eye contact during the examination. Answer: 2 Explanation: 1. Observation of the client ambulating is an assessment for mobility. 2. The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history is part of the mental status assessment. 3. Observation of the client's clothing selections is part of the assessment of physical appearance. 4. Observation of eye contact during the examination is helpful in assessing behavior. Page Ref: 97 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Identify the components of the general survey. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
5) A client is unable to identify the correct date and time during a health interview. Which indicator should the nurse document the finding as?
1. Affect and mood. 2. Orientation. 3. Cooperation. 4. Level of anxiety. Answer: 2 Explanation: 1. The client's affect and mood are revealed through speech, body language, and facial expression. 2. The client's inability to state the date and time indicates the client is not fully oriented. 3. There is no indication the client is uncooperative. 4. The client's level of anxiety is revealed through speech, body language, and facial expression. Page Ref: 97 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.4: Interpret nurseN -pUaRtiSeInNtGeTnBc.oCuOnMter findings accurately. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
6) The nurse is preparing to obtain initial vital signs on a client with seizure activity of unknown etiology. Which method should the nurse use to obtain the temperature?
1. Axillary. 2. Oral. 3. Rectal. 4. Tympanic .Answer: 3 Explanation: 1. Although axillary is the safest, it is also the least accurate. 2. Measuring the temperature orally requires the client's cooperation, which is not possible during seizure activity. 3. A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth. 4. Measuring the temperature tympanically requires the client's cooperation, which is not possible during seizure activity. Page Ref: 102 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Accident/Error/Injury Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
7) The nurse is assessing a client's left brachial pulse. Which area will the nurse palpate to?
1. Wrist. 2. Behind the knee. 3. Cubital fossa. 4. Neck. Answer: 3 Explanation: 1. The radial pulse is located in the wrist area. 2. The popliteal pulse is located behind the knee. 3. The brachial pulse is located in the cubital fossa. 4. The carotid pulse is located in the area of the neck. Page Ref: 104 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
8) The nurse is obtaining vital signs for a newborn client. Which route and sequence will the nurse use to obtain vital signs?
1. Rectal temperature, respirations, and pulse rate. 2. Respirations, pulse rate, blood pressure, and rectal temperature. 3. Respirations, apical pulse rate, and axillary temperature. 4. Oral temperature, respirations, pulse rate, and blood pressure. Answer: 3 Explanation: 1. The temperature should be taken last as it may cause the infant to cry, altering the rate of respirations and pulse. 2. A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of two. 3. Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the temperature. The rectal temperature is the most accurate; however, an axillary temperature is appropriate since the rectal route can lead to perforation. 4. Oral temperatures are not used to measure the temperature in children under the age of five. Page Ref: 108 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused GT B .COM physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm ic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
9) The nurse is preparing to assess the temperature of a child post oral surgery suspected of having an infection. Which route should the nurse use?
1. Oral. 2. Tympanic. 3. Rectal. 4. Axillar y. Answer: 2 Explanation: 1. The oral route should not be used since the client has had oral surgery. 2. The nurse should take the client's temperature using a tympanic thermometer. Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using the ear for temperature assessment is quick, noninvasive, and reliable. 3. A rectal temperature is invasive and unnecessary in the assessment of this client's temperature. 4. The axillary route is sometimes used in the temperature assessment of infants and children. It is considered the least accurate method of measurement. Page Ref: 102 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
10) The nurse is assessing an adult client's pulse. Which method should the nurse initially use?
1. Monitoring for a full 2 minutes. 2. Monitoring for 1 complete minute. 3. Monitoring for 30 seconds and multiply by 2. 4. Monitoring for 15 seconds and multiply by 4. Answer: 3 Explanation: 1. It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute. 2. The pulse rate should be counted for one full minute if the pulse is irregular. 3. If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2. 4. Counting for 15 seconds and multiplying by 4 may not yield an accurate result and therefore should not be used in assessing the rate. Page Ref: 104 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
11) The new nurse asks the educator, "What is the most important part of a pain assessment?" Which response should the nurse educator provide?
1. "Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment." 2. "A client's response to pain is always based on the underlying cause, so the client's admitting diagnosis is important." 3. "Vital signs are not reliable indicators of acute pain because only some clients are able to elicit a change in blood pressure or pulse rate." 4. "The response to pain is unique and based on numerous factors, which need to be assessed." Answer: 4 Explanation: 1. Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience. A patient's level of pain is not determined by physiologic response. 2. Pain is unique to each person and may be experienced differently by clients with the same diagnosis. 3. Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates. 4. Pain is a subjective experience and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. Page Ref: 101 Cognitive Level: Applying Client Need & Sub: Physiological IntegriNtyU;RBSaIsNicGTCB ar.CeOaM nd Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
12) During the assessment of an adult client's blood pressure, the nurse notes the following on the sphygmomanometer: first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. Which should the nurse document the client's blood pressure in this way? . Record your answer as a fraction.
Answer: 136/76 Explanation: The sounds above are the five phases of Korotkoff's sounds. The first sound heard (Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is marked by the period in which the sounds change from tapping to swishing; blood flows turbulently through the artery. Phase 3 is when blood flows through the artery during systole but collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the beginning of silence (Phase 5). This is when the cuff no longer collapses the artery and blood is free flowing through the artery. Page Ref: 108 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
13) The nurse is assessing a 15-month-old client. Which arterial site should the nurse use to assessing the pulse?
1. Radial artery. 2. Brachial artery. 3. Apical site. 4. Carotid artery. Answer: 3 Explanation: 1. In older children and adults, the radial artery is used to assess the pulse. 2. In preschool children, the brachial artery is used to assess the pulse. 3. The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age. 4. The carotid pulse is assessed in adult clients as part of the cardiovascular assessment. Page Ref: 108 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine whicNhUtReScIhNnGiqTuBe.CsOwMill ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
14) The nurse educator is observing the student nurse take a blood pressure on an older adult client. In which instances should the educator intervene? Select all that apply.
1. The student nurse ushers the client into the exam room and immediately assesses the client's blood pressure. 2. The student nurse places the blood pressure cuff on the client's arm over a lightweight, longsleeved sweater. 3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. 4. The student nurse has the client sit in a chair and supports the client's arm on a table at the level of the heart. 5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery. Answer: 1, 2, 3 Explanation: 1. The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading. 2. The client's blood pressure should be assessed on a bare arm. If the client is wearing a longsleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise, the arm should be removed from the sleeve. 3. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 15-30 seconds before inflating the cuff again. 4. In order to obtain an accurate blood pressure, the client should be seated with the arm B. COM slightly flexed, supported at the level ofNthUeRShIeNaGrtTw ith palm facing up. 5. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery. Page Ref: 107 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, andSupervision Standards: QSEN Competencies: II.B.9. Explain how authority gradients influence teamwork and patient safety. | AACN Essentials Competencies: IX.14. Demonstrate clinical judgment and accountability for patient outcomes when delegating to and supervising other members of the healthcare team. | NLN Competencies: Teamwork: Choose communication styles that diminish the risks associated with authority gradients among team members to accomplish care, assert one's own views, and minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
15) A mother brings her child into the clinic and states, "My child has had a fever the past few days because the skin has felt warm." Which response should the nurse provide the mother?
1. "When the skin feels warm, it means our blood vessels are constricted." 2. "The only way to reliably assess the temperature with your hand is by feeling the forehead." 3. "The skin temperature changes when the temperature in our surroundings changes." 4. "The temperature of the skin is not related to what is occurring inside the body." Answer: 3 Explanation: 1. Fever causes vasodilation, not vasoconstriction. 2. When fever is present, the skin covering the entire body may feel warm. Touching the forehead is not a reliable method of measuring the body's temperature. 3. The surface temperature of the body is constantly changing in response to environmental influences and, as a result, is not a reliable indicator of the body's temperature. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed. 4. The temperature of the skin is reflective of physiological changes in the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch. Page Ref: 101 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research prN ocUeRsSsIN anGdTBm.CoO deMls for applying evidence to clinical practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.
16) The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which physiological changes should the nurse recognize are associated with the blood pressure finding? Select all that apply.
1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood. 2. Arteriosclerosis increases blood vessel elasticity. 3. Arteriosclerosis decreases blood vessel compliance. 4. Age decreases blood vessel elasticity. 5. Arteriosclerosis does not affect the blood pressure in older clients. Answer: 3, 4 Explanation: 1. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure. 2. Arteriosclerosis decreases the elasticity of the arteries. 3. Arteriosclerosis results in hardened and rigid arteries, which are less compliant. 4. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. 5. Arteriosclerosis has a direct effect on blood pressure; decreased elasticity and compliance are directly related to the increase in blood pressure. Page Ref: 106 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeUteRrSsIN inGpTaBt.iCeO ntMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships betweenknowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
17) The nurse is preparing to obtain a pulse oximeter reading. Which should the nurse understand may provide a false reading? Select all that apply.
1. Long nails. 2. Artificial nails. 3. Pierced earlobe. 4. Polished nails. 5. Cool extremities. Answer: 2, 4, 5 Explanation: 1. Long nails do not influence the accuracy of a pulse oximeter reading. 2. Pulse oximeter readings from the hand can be inaccurate if the client has artificial nails. 3. A pierced earlobe does not interfere with a pulse oximeter reading. 4. Pulse oximeter readings from the hand can be inaccurate if the client has polished nails. 5. Pulse oximeter readings from the hand can be inaccurate if the client has cool extremities. Page Ref: p.105 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
18) The nurse is preparing to assess the blood pressure of a client with a history of a left breast mastectomy. Which anatomical location should the nurse use to place the blood pressure cuff on?
1. Right arm. 2. Left thigh. 3. Left arm. 4. Right thigh. Answer: 1 Explanation: 1. The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. 2. A blood pressure reading taken from the left thigh is not necessary. 3. The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. 4. A blood pressure reading taken from the right thigh is not necessary. Page Ref: 107 Cognitive Level: Applying Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships betweenknowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
19) The nurse is preparing to weigh a client on a digital scale. Which intervention should the nurse implement to obtain an accurate weight?
1. Calibrate the scale. 2. Ensure the scale has a capacity to hold greater than 159 kg. 3. Ask the client to remove their shoes. 4. Have the client stand on the scale facing backward. Answer: 3 Explanation: 1. It is not necessary to calibrate a digital scale prior to weighing the client. 2. A scale that can hold weight of greater than 159 kg is used to weigh an obese client. There is no indication the client is obese. 3. To obtain the most accurate weight, the client should remove their shoes. 4. It is not necessary to have a client step on a scale backwards to obtain a weight. Page Ref: 99 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2: Identify the necNeUssRaSrIyNsGtTeBp.sCaOnMd equipment for measuring height and weight. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
20) The nurse is preparing to measure the head circumference of an infant. Which technique should the nurse use?
1. Measure the head directly circumferentially around the forehead. 2. Measure the head around the occiput and above the eyebrows. 3. Measure around the most prominent part of the occiput and above the eyebrows. 4. Measure the crown of the head circumferentially. Answer: 3 Explanation: 1. The infant or toddler's head circumference should be measured at the widest point, usually around the most prominent part of the occiput and above the eyebrows. 2. The infant or toddler's head circumference should be measured at the widest point, usually around the most prominent part of the occiput and above the eyebrows. 3. The infant or toddler's head circumference should be measured at the widest point, usually around the most prominent part of the occiput and above the eyebrows. 4. The infant or toddler's head circumference should be measured at the widest point, usually around the most prominent part of the occiput and above the eyebrows. Page Ref: 100 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally .C OM appropriate approaches. | NLN CompetN enUcRieSsIN : KGnToBw ledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.2: Identify the necessary steps and equipment for measuring height and weight. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
21) The nurse observes that an adolescent client is wearing dirty clothes. Which initial risk factor should the nurse further assess the client for?
1. Substance abuse. 2. Lack of hygiene knowledge. 3. Neglect. 4. Low self-esteem. Answer: 2 Explanation: 1. Further assessment is required to make the determination the adolescent is at risk for substance abuse. 2. The appearance of an adolescent provides information about self-care. An adolescent that is wearing dirty clothes may lack knowledge about hygiene. 3. Further assessment is required to make the determination the adolescent is at risk for neglect. 4. Further assessment is required to make the determination that the adolescent is at risk for low self-esteem. Page Ref: 98 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Personal Hygiene Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally .C OM appropriate approaches. | NLN CompeteNnUcRieSsIN : KGnToBw ledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
22) The nurse notes the client's oral temperature at 6 a.m. was 98.0°F and 99.2°F at 5:00 pm. Which should the nurse recognize is the reason for the variation?
1. Improper assessment. 2. Infection. 3. Stress. 4. Diurnal pattern. Answer: 4 Explanation: 1. There is no evidence to suggest the temperatures were incorrectly assessed. 2. One elevated temperature of 99.2°F does not indicate the client has an infection. 3. There is no indication the client is experiencing stress. 4. The difference in body temperature is evidence of diurnal pattern. Core body temperature is lowest during the early morning and rises slightly higher during the course of the day. Page Ref: 102 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships betweenknowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 8.4: Interpret nurseN -pUaRtiSeInNtGeTnBc.oCuOnMter findings accurately. MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.
23) The nurse is providing education about blood pressure for a group of clients. Which information should the nurse include?
1. Females tend to have higher blood pressure readings than males of the same age. 2. Stress can result in an increase in blood pressure. 3. Blood pressure readings tend to be lowest in the evening. 4. During physical activity, blood pressure can slightly decrease. Answer: 2 Explanation: 1. After puberty, females tend to have lower blood pressure readings than males of the same age. 2. Stress increases cardiac output and arterial vasoconstriction, resulting in increased blood pressure. 3. Blood pressure is sensitive to diurnal variations; blood pressure is lower in the morning and peaks in the late afternoon. 4. During physical activity, blood pressure increases due to the increase in cardiac output. Page Ref: 106 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.2: Explain the body's regulation of temperature, pulse, respirations, and blood pressure.
24) The educator has observed the nurse taking the blood pressure with the client's arm above the level of the heart. Which assessment finding does the educator anticipate?
1. False low reading. 2. False high reading. 3. High systolic, low diastolic reading. 4. Low systolic, high diastolic reading. Answer: 1 Explanation: 1. Holding the arm above the level of the heart will result in a false low reading. 2. False high readings result from a bladder cuff that is too narrow, an unsupported arm, insufficient rest in between readings, cuff wrapped too loosely or unevenly, or assessing a client after a meal or smoking. 3. A high systolic or low diastolic readings can occur if the assessments are repeated too quickly. 4. A low diastolic or high systolic readings can occur if the assessments are repeated too quickly. Page Ref: 107 Cognitive Level: Applying Client Need & Sub: Health Promotion/Disease Prevention; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally .C OM appropriate approaches. | NLN CompeteNnUcRieSsIN : KGnToBw ledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
25) The nurse is preparing to obtain an adult client's temperature with a tympanic thermometer. Which technique should the nurse use to obtain an accurate reading?
1. Pull the client's pinna up and back. 2. Pull the client's pinna down and back. 3. Place the covered probe at the opening of the ear. 4. Tilt the client's head to the opposite side. Answer: 3 Explanation: 1. Pulling the pinna up and back is a technique used to inspect an adult client's inner ear with an otoscope. 2. Pulling the pinna down and back is a technique used to inspect a child's inner ear with an otoscope. 3. To obtain an accurate temperature using a tympanic thermometer, the covered tip of the probe is placed at the opening of the ear canal, being careful not to force the probe into the canal or cover the opening. 4. It is not necessary to have the client tilt their head to the opposite side. Page Ref: 103 Cognitive Level: Applying Client Need & Sub: Health Promotion/Disease Prevention; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally .C OM appropriate approaches. | NLN CompeteNnUcRieSsIN : KGnToBw ledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
26) An unlicensed assistive personnel (UAP) reports an older adult's vital signs to nurse as follows: Temperature 97.4°F (oral), BP 165/70, pulse rate 84/min., and respirations 28. Which action should the nurse take?
1. Maintain routine vital signs. 2. Instruct the UAP to recheck the temperature. 3. Request a prescription for an antihypertensive. 4. Request oxygen therapy. Answer: 1 Explanation: 1. Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time. 2. The temperature is within a normal range for this client; there is no need to recheck the temperature. 3. While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this client's blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated. 4. The client's vital signs are within a normal range; there is no indication for oxygen therapy. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3: Determine which techniques will ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
27) An older client asks why their height has decreased by 1/4 of inch over past two years. Which response should the nurse provide?
1. "Your bones are weaker and are shrinking." 2. "Maybe you are mistaken about your actual height." 3. "Your height decreases with age due to musculoskeletal changes." 4. "Stand up straighter this time and we will measure again." Answer: 3 Explanation: 1. During the older adult years, the bones may lose density but they do not shrink. 2. Responding to the client stating they may be mistaken does not properly address their concern. 3. The height of older adults may decrease as a result of thinning of the intervertebral discs. Flexion of the hips and knees may also occur affecting their ability to stand erect. 4. Flexion of the hips and knees may affect the ability of the client to stand erect. Page Ref: 101 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
28) The nurse is reviewing the prescription for a client with pneumonia. The client's vital signs are: Temperature 101.2°F (oral), BP 100/70, pulse rate 110/min., respirations 22, and oxygen saturation 96%. Based on these findings, which order should the nurse seek clarification for?
1. Administer acetaminophen (Tylenol) 650 mg every 4 hours as needed for a temperature greater than 100.5°F. 2. Administer intravenous (IV) fluids: 0.9% Normal Saline Solution at 125 ml/hour. 3. Start oxygen therapy at 3L/minute via nasal cannula. 4. Schedule client for a chest x-ray. Answer: 3 Explanation: 1. The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. 2. The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss as a result of the fever and increased respiratory rate. 3. The nurse should clarify the oxygen therapy order. Although the client's respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The client's oxygen saturation level of 96% is within normal limits; therefore, the client does not need oxygen therapy. 4. A chest film is indicated to determine the extent of pulmonary involvement. Page Ref: 105 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team Standards: QSEN Competencies: III.B.3.NBUaR seSIiNnG diTvBid.CuOalM ized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.4: Apply the principles of assessing vital signs in patient care.
29) The nurse is preparing to assess the respiratory system of an infant. Which physiological differences between the infant and a child should the nurse consider?
1. Infants have thicker muscular chest walls. 2. Breath sounds may be more subtle. 3. Thoracic breathing is common. 4. Referred sounds from the upper airways are common. Answer: 4 Explanation: 1. Infants have thinner, less muscular chest walls with a more noticeable xyphoid process than children. 2. Breath sounds are louder and harsher. 3. Abdominal breathing is common in children up to 6 years of age. 4. Referred sounds from the upper airways in an infant are more common. Page Ref: 106 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships betweenknowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3: Determine whicNhUtReScIhNnGiqTuBe.CsOwMill ensure accurate measurement of vital signs. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
30) While interviewing a client, the nurse observes that the client is changing position frequently, wringing hands, and laughing at inappropriate times. Which assessment should the nurse perform?
1. Anxiety assessment. 2. Mental status testing. 3. Attention deficit testing. 4. Nutritional assessment. Answer: 1 Explanation: 1. Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview, it may be a reflection of anxiety related to the situation or a need for further assessment. 2. Mental status testing would be indicated if the client demonstrates confusion. 3. The nurse does not conduct attention deficit testing. This is beyond the nurse's scope of practice. 4. The observations by the nurse do not provide clues to the client's nutritional state. Page Ref: 97 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1: Identify the components of the general survey. MNL Learning Outcome: 8.1: Recognize the components of the general survey, including the functional assessment.
31) A client asks what the numbers in the blood pressure mean. Which statements should the nurse include in the response to the client? Select all that apply.
1. "Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest." 2. "Diastolic pressure is the arterial pressure between ventricular contractions." 3. "Systolic pressure, indicated by the top number, is the result of the heart rate." 4. "Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation." 5. "Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts." Answer: 1, 4 Explanation: 1. The nurse should use terms the client can understand to respond to this question about blood pressure. "Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest" is a statement the client should understand. 2. While the statement "Diastolic pressure is the arterial pressure between ventricular contractions" is correct; this is not an explanation the client is likely to understand. 3. The systolic pressure is not a direct result of the heart rate. 4. The nurse should use terms the client can understand to respond to this question about blood pressure. "Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation" is a statement that a client can understand. 5. The statement "Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts," while a true statemNeUnRt,SiIsNnGoTtBo.CnO eM that a client will understand. Page Ref: 106 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships betweenknowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.4: Interpret nurse-patient encounter findings accurately. MNL Learning Outcome: 8.3: Examine the factors that influence the measured results of vital signs.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 9 Pain Assessment 1) An adolescent states to the nurse during a pain assessment, "I don't know how to describe my pain,it just hurts and I don't understand why I just cannot have something for it." Which action should the nurse take?
1. Leave the room and come back later. 2. Provide questions that require yes or no answers related to pain. 3. Ask the client what they would like to have for pain. 4. Continue with the assessment. Answer: 2 Explanation: 1. Leaving the room will not provide effective pain management. 2. Client's that are experiencing pain may have difficulty with open-ended questions, such as "Describe." The nurse may be better able to obtain a description of the client's pain by having them respond to descriptive words. 3. Asking the client what they would like for pain is not appropriate without a complete assessment. 4. Continuing to assess the client without acknowledging their statement will not yield any additional information and is not appropriate communication. Page Ref: 119 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. ANsUseRsSsINpG reTsBe.nCcOeMand extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
2) The nurse is working at a pain clinic and is preparing an orientation for new staff nurses. Which definition of pain should the nurse include in the orientation?
1. Pain is validated after determining the cause. 2. Pain is an unpleasant sensation, typically experienced upon movement. 3. Pain is whatever the experiencing person says it is. 4. Pain is very subjective, so observation must be used to assess the characteristics. Answer: 3 Explanation: 1. The cause of the pain may not always be determined at the time the client reports it. The nurse's role is not to validate the client's report but to assess and assist in alleviating or managing the pain. 2. Pain involves unpleasant sensations, though not always limited to movement. 3. The most widely accepted definition of pain is the one offered by McCaffery: "whatever the experiencing person says it is, existing whenever he or she says it does" (McCaffery & Pasero, 1999, p. 5). 4. Pain is a subjective experience and the client's report of pain must be acknowledged in orderto effectively manage it. Page Ref: 114 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: KNnUoRwSlIeNdGgTeBa.C ndOM Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.1: Define pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
3) A patient tells the nurse they are experiencing jaw, chest, and arm pain. Which type of pain should the nurse suspect is occurring?
1. Phantom pain. 2. Radiating pain. 3. Intractable pain. 4. Cutaneous pain. Answer: 2 Explanation: 1. Phantom pain is a painful sensation perceived in an absent body part or a body part that is paralyzed. 2. The client is describing radiating pain, which has an origin in one part of the body and then spreads to other adjacent body parts. 3. Intractable pain does not respond to relief measures. 4. Cutaneous pain is pain experienced in the cutaneous tissues. Page Ref: 117 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.3: Discuss the natuNrUeRoSfINpG aiTnB, .iCnOclM uding types and other concepts related to pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
4) The nurse is caring for two postoperative clients that had the same procedure, but one client reports greater pain than the other. Which pain theory should the nurse recognize is useful in explaining this phenomenon?
1. Pattern. 2. Specificity. 3. Stress. 4. Gate control. Answer: 4 Explanation: 1. Pattern theory implies that the pattern of the stimulus is more important than the specific stimulus. It does not address the psychosocial component of pain. 2. Specificity theory holds that pain neurons are specific and unique, and the specific pain neurons transport the sensations directly to the brain. 3. Stress does influence a client's perception of pain but is not a specific theory. 4. Gate control theory attempts to explain the involvement of the brain as well as nerve fibers in the pain experience. The involvement of the brain helps explain why painful stimuli are interpreted differently by people experiencing pain. Page Ref: 114 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: KNnUoRwSlIeNdGgTeBa.C ndOM Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.1: Define pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
5) A client asks the nurse why they are feeling pain in the area with edema. Which response should the nurse provide?
1. The edema damages the tissue. 2. The edema puts pressure on the pain receptors. 3. The edema irritates the tissue. 4. The edema causes the cells of the tissue to die. Answer: 2 Explanation: 1. The pain does not occur from the edema damaging the tissue. 2. Pain experienced in the area of edema results from pressure on the pain receptors. 3. The pain does not directly occur from the edema irritating the tissue. 4. The edema causes the cells of the tissue to die. Page Ref: 115 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.1: Explain thN e UpRhSyIsNioGloTgBi.cCpOrMocess involved in the perception of pain.
6) A cooperative, well-dressed, postoperative client that grimaces when sitting down rates their pain 2 out of 10. The nurse suspects which of the following?
1. The client should increase their activity to build up tolerance. 2. The client that does not identify pain as severe does not require treatment. 3. The client's recovery is going well based on the pain rating. 4. The client has adapted to the pain and is able to control behaviors. Answer: 4 Explanation: 1. A pain rating and grimacing are not the major determinants for increased activity levels. 2. A pain rating of 2 out of 10 is not a determinant of treatment. 3. A pain rating is not a major determinate factor of recovery. 4. People with chronic pain develop their individual coping styles to deal with pain, discomfort, or suffering. Also, physiologic responses may be marked in acute pain but because of central nervous system adaptation, physiologic responses are likely to be absent. Therefore, behavioral and physiologic responses are not good indicators of pain. Page Ref: 118 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
7) A patient that appears to be moving around easily and smiling rates their pain at 7 out of 10 and requests pain medication. Which action should the nurse take?
1. Wait 30 minutes and see if the client is still requesting the pain medicine. 2. Administer half the ordered dose of pain medication. 3. Administer the pain medication as prescribed. 4. Inform the healthcare provider that the client is exaggerating their pain. Answer: 3 Explanation: 1. Waiting to administer the medication is inappropriate and is an action that negates the client's report. 2. Administration of only a portion of the ordered medication places the nurse in a position of prescribing medications and is outside the nurse's scope of practice. 3. Since pain occurs whenever the experiencing person says it does and is whatever the experiencing person says it is, the nurse should accurately assess and treat the pain based on the prescribed treatment. 4. Informing the healthcare provider that the client is exaggerating their pain is not professional or ethical. Page Ref: 114 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: KNnUoRwSlIeNdGgTeBa.C ndOM Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
8) A client with a coronary artery blockage is experiencing pain. Which should the nurse recognize is the physiological basis for the pain?
1. Tissue ischemia. 2. Trauma to the tissues. 3. Muscle spasm. 4. Blockage of a duct. Answer: 1 Explanation: 1. A chemical stimulus occurs with tissue ischemia resulting in the stimulation of pain receptors because of accumulated lactic acid and other chemicals in the tissues. 2. Trauma to the tissue occurs due to mechanical stimuli which cause tissue damage, direct irritation of the pain receptors, and inflammation. 3. Muscle spasms occur as a result of mechanical stimuli which stimulate the pain receptors. Tissue ischemia is secondary to the mechanical insult resulting in muscle spasms. 4. A blockage of a duct occurs from a mechanical stimulus which causes distention of the lumen of the duct. Page Ref: 115 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Diagnosis Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.
9) The nurse is assessing a client admitted with severe abdominal pain. Which essential components of a pain assessment should the nurse include? Select all that apply.
1. Description of the pain. 2. Temperature, pulse, respirations, and blood pressure. 3. Pain intensity rating. 4. Family medical history. 5. Previous pain experience. Answer: 1, 2, 3, 5 Explanation: 1. The nurse assessing the client will need to determine characteristics of the pain. These characteristics, expressed by the client, will aid in the management of the condition. 2. The vital signs of the client reporting acute pain will likely provide supportive information concerning the pain being experienced. 3. An integral part of the definition of pain is that it is what the individual reports it to be. The degree of intensity will be needed to determine the level of pain being experienced. The degreeof pain intensity assessment will be a key component in the interventions being used to manage the pain. 4. While the family medical history is a component of a generalized health assessment, it is not specific to the assessment of pain. 5. An individual's past experience with pain is a determining factor in the ability to manage pain. Past experience will also impact reports of pain by the client. Page Ref: 122 Cognitive Level: Applying Client Need & Sub: Physiological IntegriNtyU; RBSaIsNicGTCB ar.CeOaM nd Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
10) A client asks the nurse how ibuprofen will relieve their back pain. Prior to answering the question, which phase of nociception should the nurse recognize ibuprofen has an effect on?
1. Transduction. 2. Transmission. 3. Perception. 4. Modulation. Answer: 1 Explanation: 1. Since ibuprofen blocks the production of prostaglandin, it acts during the transduction phase. 2. In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord to the brain stem and thalamus, and, ultimately, to the somatic sensory cortex. 3. Perception occurs when the client becomes aware of the pain. 4. Modulation is the process by which neurons in the brain stem send signals back down stimulating the release of neurotransmitters that can inhibit the ascending pain impulses. Page Ref: 115 Cognitive Level: Remembering Client Need & Sub: Pharmacological and Parenteral Therapies; Expected Actions/Outcomes Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
11) The nurse is assessing the impact a client's migraine pain has on their daily functioning. Which assessment tool should the nurse use?
1. Psychological well-being inventory. 2. Body diagram tool. 3. Intensity rating scale. 4. Brief pain inventory. Answer: 4 Explanation: 1. A psychological well-being inventory may yield information about the impact of pain on the client's sense of well-being but is not designed to specifically assess the elements of pain. 2. A unidimensional tool such as the body diagram is useful for assessing pain severity at the time the client is experiencing pain. 3. A unidimensional tool such as the intensity rating scale is useful for assessing pain severity at the time the client is experiencing pain. 4. Migraine pain is chronic in nature and, therefore, a multidimensional tool such as the brief pain inventory is the most useful for assessing two or more elements of the pain and the impact of pain on daily living. Page Ref: 125 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, COM behavioral, psychological, spiritual, socioeconomic, NanUdRSeInNvGirToBn.m ental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
12) Which term describes the amount of pain stimulation that is needed for an individual to feel pain?
1. Pain threshold. 2. Pain tolerance. 3. Somatic interval. 4. Cephalgia reporting. Answer: 1 Explanation: 1. The pain threshold is the amount of pain stimulation a person requires in orderto feel pain. 2. Pain tolerance refers to the ability of an individual to manage differing levels of discomfort. 3. Somatic interval is not legitimate pain terminology. 4. Cephalgia reporting is not legitimate pain terminology. Page Ref: 118 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.
13) A client with a right above-the-knee amputation tells the nurse their right foot hurts. Which type of pain should the nurse understand the client may be experiencing?
1. Phantom pain. 2. Radiating pain. 3. Intractable pain. 4. Cutaneous pain. Answer: 1 Explanation: 1. The client is describing phantom pain, which is a painful sensation perceived in an absent body part or a body part that is paralyzed. 2. Radiating pain has an origin in one part of the body and then spreads to other adjacent body parts. 3. Intractable pain does not respond to relief measures. 4. Cutaneous pain is pain experienced in the cutaneous tissues. Page Ref: 117 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
14) The nurse is assessing a client admitted with chronic back pain. Which assessment findings related to the pain should the nurse anticipate? Select all that apply.
1. Sudden onset of pain. 2. Pain that interferes with daily activities. 3. Pain described as being low intensity. 4. Prolonged pain duration. 5. Pain causing a sharp elevation in body temperature. Answer: 2, 4 Explanation: 1. Chronic pain is recurring and persists for a period of 6 months or longer. 2. Chronic pain invades the life of a client. The daily activities of the client with chronic pain are impacted. 3. The level of intensity experienced by the client with chronic pain will vary. It is not necessarily low in intensity. 4. By definition, chronic pain lasts for a period of 6 months or longer. 5. Sharp elevations in vital signs are not associated with chronic pain. Page Ref: 116 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain. MNL Learning Outcome: 9.2: Recognize the nature of pain, including types and other concepts related to pain.
15) A client asks the nurse why they were prescribed a tricyclic antidepressant for pain. Which should the nurse understand prior to providing a response to the client?
1. The action of the prescription decreases the perception of pain. 2. The action of the prescription interferes with the transduction of pain. 3. The action of the prescription increases the modulation phase of pain. 4. The action of the prescription blocks the transmission of pain. Answer: 3 Explanation: 1. Tricyclic antidepressants do not directly decrease the perception of pain. Nonpharmacological interventions are used to help alter the perception of the client's pain. 2. Tricyclic antidepressants do not interfere with the transduction of pain. Pain medications or analgesics are used to interfere with the transduction of pain. 3. The action of tricyclic antidepressants increases the modulation phase that helps inhibit painful ascending stimuli. 4. Tricyclic antidepressants do not directly decrease the transmission of pain. Opioids are used to inhibit the release of neurotransmitters blocking the pain at the spinal level. Page Ref: 115 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safeNpUaRtiSeInNtGcTaBre.C. O|MNursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
16) The new nurse states to the preceptor, "My client keeps saying he is in pain. I don't believe him because I had the same surgery last year and didn't feel nearly as bad as he claims." Which response should the preceptor provide?
1. "It sounds as if your client is a drug seeker." 2. "You should contact the healthcare provider." 3. "I would call the nursing supervisor for this one." 4. "Pain differs from person to person." Answer: 4 Explanation: 1. There is no evidence that this client is drug seeking. 2. Contact with the healthcare provider is premature at this time. 3. Contact with the nursing supervisor is premature at this time. 4. Pain has been defined as "whatever the experiencing person says it is, existing whenever he or she says it does." Pain reports will vary between people. Page Ref: 114 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.4: Examine factorsNtUhRaStIiNnGflTuBe.nCcOeMperception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
17) The nurse is performing an assessment on a client experiencing chronic back pain. Which findings should the nurse anticipate? Select all that apply.
1. Increased pulse rate. 2. Increased respiratory rate. 3. Normal pulse rate. 4. Normal blood pressure. 5. Diaphoresis. Answer: 3, 4 Explanation: 1. The heart rate of the client in chronic pain will be within normal limits. The heart rate will more likely be increased in the client with acute pain. 2. The respiratory rate of the client experiencing chronic pain will most likely be within normal levels. The respiratory rate will most likely increase in the client with acute pain. 3. The pulse rate of the client experiencing chronic pain will likely be within normal limits. Elevations in pulse rate are seen in clients experiencing acute pain. 4. The blood pressure findings in the client experiencing chronic pain will most likely be within normal limits. Elevations are most often seen in clients experiencing acute pain. 5. Diaphoresis is seen most likely in the client in acute pain, not chronic pain. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate tNhU eoRrSiIeNsGaTnBd.CcO onMcepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain. MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.
18) The nurse is planning to implement nonpharmacological pain interventions for a preschool age client. Which interventions should the nurse implement? Select all that apply
1. Offer a glucose-coated pacifier. 2. Sit with the child and allow the child to "blow bubbles." 3. Explain to the child the cause of the pain. 4. Teach the child how to use of guided imagery. 5. Hold the child. Answer: 2, 5 Explanation: 1. The use of a glucose-coated pacifier is most effective with an infant in the management of pain. 2. Blowing bubbles is an age-appropriate activity for the preschool-age child. The child can be encouraged to "blow the pain" away. 3. A preschool age client is too young to grasp a discussion of the causes of the pain being experienced. 4. Age-appropriate guided imagery is not a successful nonpharmacological means to manage pain in a preschool-age child. This may be helpful for the school-age child. 5. The preschool-age child will find comfort in being held during the pain. Page Ref: 119 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, COM behavioral, psychological, spiritual, socioeconomic, NanUdRSeInNvGirToBn.m ental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
19) The nurse is preparing to assess a client with chronic pain. Which objective finding should the nurse anticipate?
1. Restlessness. 2. Rubbing painful area. 3. Related tissue injury. 4. Warm, dry skin. Answer: 4 Explanation: 1. Restlessness is an objective finding for a client experiencing acute pain. 2. Rubbing a painful area is an objective finding for a client experiencing acute pain. 3. Related tissue injury is an objective finding for a client experiencing acute pain. 4. Warm, dry skin is a finding for a client experiencing chronic pain. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
20) A child tells the nurse their throat is sore. Which assessment finding should the nurse anticipate to be associated with the child's statement?
1. Dehydration. 2. Headache. 3. Stomachache. 4. Decreased food intake. Answer: 4 Explanation: 1. Children with sore throats often present with a history of normal fluid intake. 2. Children with a headache may be frightened or experiencing anxiety. 3. Children with a stomachache may be frightened or experiencing anxiety. 4. Children with sore throats often present with a history of decreased food intake. Page Ref: 119 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.3: Discuss the nature of pain, including types and other concepts related to pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
21) The nurse is reviewing the environmental factors that influence a client's pain. Which internal environmental factor should the nurse anticipate will influence the client's pain?
1. Noise. 2. Support systems. 3. Previous experiences. 4. Family role. Answer: 3 Explanation: 1. Noise is an external factor that can be associated with the increase or decrease of pain. 2. Support systems are an external factor that can be associated with the increase or decrease of pain. 3. Previous experiences related to pain are considered an internal factor that is associated with the increase or decrease of pain. 4. The role in the family is an external factor that can be associated with the increase or decrease of pain. Page Ref: 120 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNtU : CRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
22) A spouse of a postoperative client tells the nurse that they do not understand why no pain medication has been given. Which response should the nurse provide the spouse?
1. "Some clients do not require analgesics." 2. "I am monitoring your spouse for nonverbal pain cues." 3. "I am going to talk to your spouse about refusing the pain prescription." 4. "Some clients are too sedated to realize they need something for pain control." Answer: 2 Explanation: 1. At this time, the client may not require a pain prescription but may need something at a later time. 2. The nurse will integrate the plan to monitor the client for nonverbal pain cues. Some clients are stoic or afraid to use pain prescriptions. 3. There is no indication the client refused a pain prescription. The nurse's role in pain assessment and management includes educating the client about pharmacological and nonpharmacological options for pain control. 4. Telling the spouse that some clients are too sedated to realize they need something for pain is inappropriate. Page Ref: 121 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, NaU ndRSeInNvGirToBn.CO meM ntal assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
23) The nurse is performing a pain assessment on a client who is unable to communicate verbally. Which vital sign data should the nurse understand is associated with acute pain? Select all that apply.
1. Temperature of 100.6 degrees. 2. Pulse rate 94. 3. Respiratory rate 32. 4. Blood pressure 158/92 mmHg. 5. Facial grimacing. Answer: 2, 3, 4, 5 Explanation: 1. The client may be diaphoretic with acute pain but not directly as a result of a low-grade temperature. 2. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. 3. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. 4. When in acute pain, a client will typically have sympathetic nervous system responses that are exhibited in an increased pulse, respiratory rate, and blood pressure. 5. Facial grimacing may be noted in the expressions of the client experiencing acute pain. Page Ref: 117 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the Oo Mdels of pain and comfort. | AACN concepts of pain and suffering, includingNpUhRySsIiNoGloTgBic.Cm Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
24) The nurse is preparing to conduct a focused interview for a pain assessment. Which components should the nurse include in the interview? Select all that apply
1. Pain history. 2. Socioeconomic status. 3. Direct observation. 4. Medication history. 5. Psychosocial assessment. Answer: 1, 3 Explanation: 1. A focused interview for pain assessments consist of two major components, or phases: (a) a pain history to obtain facts from the patient and (b) direct observation of behavioral and physiologic responses to pain by the patient. 2. A client's socioeconomic status is not assessed during a focused assessment for pain. 3. A focused interview for pain assessments consist of two major components, or phases: (a) a pain history to obtain facts from the patient and (b) direct observation of behavioral and physiologic responses to pain by the patient. 4. A medication history is not included in the pain assessment. 5. A psychosocial assessment is not included in the pain assessment. Page Ref: 121 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN RSINGTB.C OM Essentials Competencies: IX.1. Conduct N coUm prehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
25) The nurse is assessing the history of treatment for a client with pain. Which question should the nurse include in the assessment?
1. "What have you done to relieve the pain?" 2. "Do you rest when you have pain?" 3. "What were you doing just before the pain started?" 4. "Does your pain move or is it in just one place?" Answer: 2 Explanation: 1. Asking the client about relief measures is a question that focuses on relieving factors. 2. Asking a client if they rest when experiencing pain is an assessment for treatment. 3. Assessing the client's activity prior to the start of the pain is an assessment question to identify aggravating factors. 4. Assessing the movement or placement of pain is an assessment question to help identify the location of the pain. Page Ref: 123 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science:NRUeRlaStIiN onGsThBip.CsObMetween knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
26) The nurse is completing an admission assessment for a client with severe pain. Which order of action should the nurse take?
1: Contact the healthcare provider. 2: Discuss the unit routine with the client and family. 3: Ask the client when the pain first began. 4: Ask the client what helps to relieve the pain. 5: Assess the client's past coping methods for pain throughout their life. Answer: 3, 4, 5, 2, and 1 Explanation: 1: The healthcare provider will need to be contacted about the current condition of the client but this cannot be completed until the client has been assessed. The assessment information will allow the nurse to provide information to the healthcare provider. 2: The client and family need to have information provided concerning unit policies but this is not an immediate task. Management of the client's admission data collection takes precedence. 3: Determining the duration of the pain is the most important step that must be taken by the nurse. This information will provide a guide for the remaining information that will be sought from the client. 4: The client in pain has likely been employing methods to manage the discomfort at home. Determining the measures being taken away from the acute care facility will help lead the healthcare team in managing the current pain. This information can also be used to help indicate the severity of pain being experienced. 5: An individual's methods of coping with pain will help determine their tolerance and ability to manage current pain. This information is needed but does not take priority over assessing the duration of the pain being experienced oNrUtRhSeINmGeTtBh.oCdOsMbeing used to manage the current pain. Page Ref: 121 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
27) The nurse is assessing a client who is recovering from open-heart surgery. Which assessment data is most reflective of a client's pain response?
1. Family report of pain. 2. Response from the client based on use of a pain tool. 3. Observations of the client's behaviors while asleep. 4. Measurement of vital signs. Answer: 2 Explanation: 1. The family may perceive the client to be in pain when the client is not. 2. The use of a standardized pain tool that has been discussed with the client preoperatively will provide the most useful data. 3. Observations of behavior while the client is asleep may indicate pain, but use of a tool while the client is awake would be more accurate. 4. Vital sign changes may be a result of the body's response to surgery and not just specifically to pain. Page Ref: 124 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU/IRnSteINgG raTtBe.dCO CoMncepts: Nursing Process: Assessment Learning Outcome: 9.5: Demonstrate techniques and tools used for assessment of pain. MNL Learning Outcome: 9.4: Apply the techniques and tools used for assessment of pain for a patient reporting pain.
28) An older client tells the nurse they have had joint pain for years. Which should the nurse recognize is a common finding in the older client experiencing pain?
1. Clients start to complain of many types of pain as they age. 2. The joint pain is probably not the real reason the client is in the office. 3. The client is most likely depressed. 4. Older adults frequently avoid seeking treatment for their pain. Answer: 4 Explanation: 1. Older clients typically do not complain of pain. They may fear that the treatment prescribed may limit their independence. 2. There is no other information given to suggest that the client has another cause for the visit. 3. There is no other information given to suggest that the client is depressed. 4. The older adult may perceive pain as part of the aging process. They may fear that the treatment prescribed may limit their independence. Page Ref: 119 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 9.2: Outline the physiologic process involved in the perception of pain. MNL Learning Outcome: 9.1: Explain the physiologic process involved in the perception of pain.
29) A young adult male client of Arab descent is admitted to the medical-surgical unit for a ruptured appendix. The client's parents are at the bedside for most of the day. The nurse who is providing care notes that the client denies pain while on day shift but request medication every four hours during the night. Which explanation for this client behavior is the most probable?
1. The night nurse had more time to spend with the client. 2. The client must be afraid or lonely at night and is trying to get attention. 3. The client may not report pain in the presence of parents based on their influence or cultural beliefs. 4. The client was asking for medication at night to facilitate sleep. Answer: 3 Explanation: 1. There is no information provided to indicate the night nurse spent more time with the client than the day/evening shifts. 2. There is no indication the client is afraid or lonely. 3. A client may have ethnic or cultural beliefs that influence the response to pain. Some clients may be verbal and open, while some clients may choose to be quiet and suffer with the pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may have not wanted to contradict the perceived parental expectations of how an adult Arab male was to respond to pain. 4. There is no indication the client is experiencing difficulty sleeping. Page Ref: 177-178 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. DNeUmRoSInNsG trTaBte.CcOoM mprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.4: Examine factors that influence perception and expression of pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
30) A client with terminal cancer tells the nurse that nothing helps relieve their pain. Which type of pain should the nurse recognize the client is experiencing?
1. Referred pain. 2. Intractable pain. 3. Retractable pain. 4. Radiating pain. Answer: 2 Explanation: 1. Referred pain refers to pain that is felt in an area that is physically distant to the affected area. 2. Intractable pain refers to pain that is not controllable. It is often associated with an advanced malignancy. 3. Retractable pain is not a classification of pain. 4. Radiating pain refers to pain that extends to surrounding areas of the body. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.3: Discuss the natN urUeRoSfINpG aiTnB, .iCnOclM uding types and other concepts related to pain. MNL Learning Outcome: 9.3: Examine factors that influence perception and expression of pain.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 10 Nutritional Assessment 1) The nurse is reviewing the BMI (body mass index) of an adult client. Which should the nurse recognize a BMI of 23 indicates? 1. Mild malnutrition. 2. Normal. 3. Overweight. 4. Obese class 1. Answer: 2 Explanation: 1. Mild malnutrition is considered a BMI of 17-18.49. 2. Normal BMI ranges between 18.5 and 24.9. 3. Overweight BMIs are between 25 and 29.9. 4. Obese class 1 BMIs are between 30 and 34.9. Page Ref: 135 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A G ss T Be.sCsOm Ment Learning Outcome: 10.4: Describe the components and tools of a physical assessment as they pertain to nutrition. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
2) The nurse is using a dietary recall tool to obtain a nutritional history from a client. Which should the nurse recognize is the greatest limitation of the tool? 1. Clients do not remember liquid intake from day to day. 2. The tool does not reflect food preferences of the client. 3. Clients do not provide reliable nutritional information. 4. The tool does not reflect occasional food habits. Answer: 4 Explanation: 1. The diet recall does not reflect all fluids and liquids taken in during the previous 24 hours or longer. 2. The diet recall is not intended to assess food preferences. 3. The accuracy of the recall relies heavily on the memory of the patient and the good interviewing skills of the nurse. 4. Patients may have significant food habits that occur occasionally but not on the day recalled. Page Ref: 131-132 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
3) The nurse is obtaining tricep skinfold measurement on a client. Which anatomical locations should the nurse use to obtain the measurement? 1. Midpoint of the arm between the scapula and the elbow. 2. Two inches and centered below the scapula. 3. One inch around the umbilicus. 4. Lateral aspect of thigh. Answer: 1 Explanation: 1. Tricep skinfold measurements are obtained at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. 2. Tricep skinfold measurements are obtained at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not 2 inches and centered below the scapula. 3. Tricep skinfold measurements are obtained at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not at the umbilical region. 4. Tricep skinfold measurements are obtained at the midpoint of the arm, equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow, not in the lateral aspect of thigh. Page Ref: 138 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
4) The nurse is calculating the body mass index (BMI) to assess a client's weight. Which should the nurse recognize is a limitation of the calculation? 1. There is lack of correlation of the values in the BMI table with those in height-weight tables. 2. Assumption that all individuals have equal body composition at each given weight. 3. BMI is difficult to accurately calculate. 4. The BMI's use to determine the risk for obesity is reduced in individuals who are on reduced calorie diets. Answer: 2 Explanation: 1. The BMI is easily calculated using the standard formula and has a relationship with height and weight. 2. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences. 3. The BMI is easily calculated using the standard formula and has a relationship with height and weight. 4. The BMI is not used to determine the risk for obesity. The use of the tool is not limited by an individual's current caloric intake. Page Ref: 135 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.3: Describe the components and tools used to obtain a nutritional history. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
5) The nurse is caring for a client with undernutrition. Which should the nurse recognize is a clinical condition associated with undernutrition? 1. Renal failure. 2. Hypertension. 3. Delayed wound healing. 4. Delayed menopause. Answer: 3 Explanation: 1. Multiple factors that are not related to nutrition can cause renal failure. 2. Hypertension often accompanies overnutrition. 3. Undernutrition can lead to delayed growth, compromised immune status, poor wound healing, muscle loss, physical and functional decline, and lack of proper development. 4. Delayed menopause is not correlated with undernutrition. Page Ref: 129 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 10.1: Define nutritional health. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
6) The nurse is preparing to assess a client experiencing obesity paradox. Which information should the nurse recognize contributes to this condition? 1. The client has a binge eating disorder. 2. The client does not have access to nutritious food. 3. The client gains and loses large amounts of weight. 4. The client has a metabolic disorder. Answer: 2 Explanation: 1. Obesity paradox does not result from a binge eating disorder. 2. Obesity paradox is a term that denotes the joint presence of obesity and nutritional deficiency. Food deserts contribute to the condition. Food deserts are low-income, urban or rural areas that lack access to healthy, affordable food, and the food available is high calorie food of poor nutritional quality. 3. Obesity paradox does not result from large amounts of weight gained and lost. 4. Obesity paradox does not result from a metabolic disorder. Page Ref: 128 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
7) The nurse is assessing a client with overnutrition. Which question should the nurse ask the client? 1. "Do you have access to adequate amounts of food?" 2. "Do you take multiple medications?" 3. "Are you taking dietary supplements?" 4. "Are you allergic to any foods?" Answer: 3 Explanation: 1. Access to adequate amounts of food is for a client that is experiencing undernutrition. 2. Multiple medications are mostly associated with undernutrition. 3. A client may excessively intake dietary supplements which can result in overnutrition. 4. Food allergies can result in the undernutrition of a client. Page Ref: 128 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease managemenNt;UhReSaIlNthGcTaBr.eCO syMstems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Nursing Assessment Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
8) The nurse is obtaining nutritional history data from a client. Which question should the nurse ask that specifically assesses the beliefs and practices of the client? 1. "What type of diet do you prefer?" 2. "Can you describe the portion size of the cereal you eat for breakfast?" 3. "Do you take any vitamin supplements?" 4. "Can you describe your activity level?"Answer: 1 Explanation: 1. The type of diet the client prefers is associated with dietary beliefs and practices. 2. Asking a client to describe portion sizes is associated with the assessment of food. 3. Vitamin supplements are assessed when specifically asking about supplements and medication use. 4. The client's activity level is assessed during the socioeconomic and educational influences. Page Ref: 131 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., tranNsUmRiSsIsNioGnToBf.CdOisMease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Nursing Assessment Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
9) The nurse is reviewing the procedure for taking a skinfold measurement with the educator. Which statement made by the nurse should the educator recognize requires further education? 1. Two measurements should be taken at each site and then compared. 2. Skinfold measurements should be taken on the left and right side of the body. 3. Plastic calipers should be used for the comfort of the client. 4. Both the skinfold layer and muscle are pinched and held gently. Answer: 4 Explanation: 1. Three measurements should be taken at each site and then compared. 2. Skinfold measurements should only be taken on right side of the body. 3. Plastic calipers should not be used because they become bent or warped with use and then measurements are inaccurate. 4. Both skinfold layers and subcutaneous fat are pinched and then held gently between the thumb and forefinger with care taken not to grasp underlying muscle. Page Ref: 138 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Assessment Learning Outcome: 10.3: Describe the components and tools used to obtain a nutritional history. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
10) The nurse is preparing to assess an infant with a riboflavin deficiency. Which assessment finding should the nurse anticipate? 1. Mottled tooth enamel. 2. Dull, sparse, and brittle hair. 3. Lips cracked at the corners. 4. Muscle wasting. Answer: 3 Explanation: 1. Mottled tooth enamel occurs with a vitamin D deficiency. 2. Dull, sparse, and brittle hair is a reflection of a protein deficiency. 3. Lips cracked at the corners are characteristic of a riboflavin deficiency. 4. Muscle wasting is associated with a protein, calorie, and vitamin D deficiency. Page Ref: 142 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
11) The nurse is using waist circumference to assess overnutrition in an adult female. Which is the correct placement for the measurement tape? 1. At the umbilicus. 2. Below the umbilicus. 3. Upper lateral border of the ilium midaxillary line 4. Lower lateral border of the ilium midaxillary line Answer: 3 Explanation: 1. Measuring the waste circumference at the umbilical area is unreliable. 2. Measuring a waste circumference below the umbilical area is unreliable. 3. The correct placement of the measuring tape is the upper lateral border of the ilium midaxillary line. 4. The lower lateral border of the ilium midaxillary is incorrect. Page Ref: 136 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches, | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4: Describe the components and tools of a physical assessment as they pertain to nutrition. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
12) A Bioelectrical Impedance Analysis (BIA) is being performed on a client. Which interventions will the nurse implement for this client? Select all that apply. 1. Instruct the client to be NPO for 6 to 8 hours prior to the assessment. 2. Instruct the client to discontinue all vitamin and mineral supplementation for 24 hours prior to the assessment. 3. Instruct the client to lie in a supine position during the assessment. 4. Place electrodes on the dorsal surface of the client's foot. 5. Place electrodes on the dorsal surface of the client's hand. Answer: 3, 4, 5 Explanation: 1. Altered hydration and altered skin temperature will cause measurement error by altering electrical current flow. Clients should be well hydrated when employing BIA technology or dehydration will slow conductivity and give a falsely high body fat measurement. 2. Calculations are based on the knowledge that muscle and fluids have a higher electrolyte and water content than does fat and thus conduct electrical current differently. Discontinuation of vitamin and mineral supplementation does not impact test findings. 3. During the assessment, the client will be instructed to lie in a supine position. 4. Electrodes are placed on the dorsal surface of the client's foot for the test. 5. Electrodes are placed on the dorsal surface of the client's hand for the test. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | NLN Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.3: Describe the components and tools used to obtain a nutritional history. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
13) A client tells the nurse they are frustrated because their BMI places them in an overweight category. Which response should the nurse provide the client? 1. "The BMI is a reflection of your nutritional intake." 2. "The BMI used alone does not indicate that you are overweight." 3. "The BMI should be used with a height and weight-table to establish your category of weight. 4. "The BMI can help you set new goals to modify your nutritional intake." Answer: 2 Explanation: 1. The BMI is not a reflection of nutritional intake. 2. Exclusive use of the BMI as an indicator of weight status makes the assumption that all individuals have equal body composition at each given weight. This generalization has not been found to be true and, therefore, represents a clinical limitation to the use of BMI alone. 3. The height and weight table has the same limitation as the BMI. The BMI is based on the client's weight and height. 4. The BMI should not be used exclusively as an indicator of weight status. Page Ref: 135 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 10.1: Define nutritional health. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
14) A client asks the nurse how anthropometric measurement is obtained. Which information should the nurse provide to the client? 1. The assessment is obtained by subtracting the height in centimeters from the weight in pounds and multiplying by two. 2. The assessment includes any scientific measurement of the body for nutritional analysis. 3. The measurements include the use of growth chart evaluations using height and weight. 4. The measurement estimates skinfold thicknesses. Answer: 2 Explanation: 1. Anthropometric measurements are specific body measurements such as height, weight, and measurement of body fat. It does not utilize the calculation of weight and height in this manner. 2. Anthropometric measurements are any scientific measurements of the body. 3. Anthropometric measurements are any scientific measurements of the body. They are not growth chart evaluations. 4. Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. They may include measurements of skinfold thickness, not estimations. Page Ref: 133 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUeR nci 1..CInOtMegrate theories and concepts S Ie NsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4: Describe the components and tools of a physical assessment as they pertain to nutrition. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
15) A client weighed 156 pounds one month prior currently weighs 140 pounds. Which percent of weight change should the nurse document in the client's record? 1. 5%. 2. 10%. 3. 12%. 4. 14.3%. Answer: 2 Explanation: 1. A 5% weight loss would result in a weight of approximately 146 lbs. 2. A weight loss of 10% would result in a weight of approximately 141 lbs. 3. A weight loss of 12% would result in a weight of approximately 137 lbs. 4. A weight loss of 14.3% would result in a weight of approximately 134 lbs. Page Ref: 135 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4: Describe the components and tools of a physical assessment as they pertain to nutrition. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
16) The nurse is educating a client about the risk factors for poor nutritional health. Which should the nurse include when discussing overnutrition? Select all that apply. 1. Alcohol abuse. 2. Sedentary lifestyle. 3. Excess intake of fat, sugar, calories, or nutrients. 4. Lack of knowledge about food preparation. 5. Lack of knowledge about portion sizes. Answer: 2, 3, 4, 5 Explanation: 1. Alcohol abuse is statistically linked to undernutrition. 2. The lack of calorie burning activity of a sedentary lifestyle is associated with overnutrition and weight gain. 3. Excess intake of fat, sugar, calories, or other nutrients is commonly linked to overnutrition and weight gain. 4. Food preparation may result in overnutrition, as "unhealthy" techniques may be employed. 5. Portion control is key in the management of weight gain and loss. Lack of knowledge about portion control may result in over eating. Page Ref: 129 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehenNsUivReSIaNnGdTfBo.cCuOseMd physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
17) A postoperative client asks the nurse why a registered dietician is evaluating their nutritional intake. Which information should the nurse provide the client? Select all that apply. 1. Meet a regulatory agency requirement. 2. Determine nutritional needs. 3. Asses for cultural dietary considerations. 4. Asses for potential food-drug interactions. 5. Review religious practices Answer: 2, 3, 4, 5 Explanation: 1. Although the collection of dietary information may be needed to meet the requirements of a regulatory agency, it is not the priority action in this situation. 2. The assessment of a client's nutritional health requires a collaborative approach. Postoperative clients may have different nutritional requirements to promote healing. 3. The client's cultural dietary practices should be evaluated when assessing nutritional needs. 4. Prescriptions may have changed in the postoperative period so the assessment for food-drug interactions is required. 5. Religious practices may include altered dietary intake or restriction of certain foods. Page Ref: 131 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementaNtiUoRnSoIN f cGaTrBe.CpO laM n, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.1: Define nutritional health. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
18) The nurse is preparing to assess the nutritional status of several clients. Which client should the nurse expect is most likely to underreport their nutritional intake? 1. Client with depression. 2. Client that smokes. 3. Client that is an older adult. 4. Client that has diabetes. Answer: 2 Explanation: 1. A client that is experiencing depression is not the client most likely to underreport their nutritional intake. 2. Underreporting occurs for all ages and is seen more often in smokers, the obese, and individuals with lower educational and socioeconomic levels. 3. An older adult is not the client most likely to underreport their nutritional intake. 4. A client with diabetes is not the client most likely to underreport their nutritional intake. Page Ref: 132 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
19) The nurse is reviewing the food record of a client. Which factor should the nurse consider when reviewing the record? 1. The client changes their eating patterns. 2. The client does not measure the food correctly. 3. The client changes the type of foods they eat. 4. The client omits any alcohol that was consumed. Answer: 3 Explanation: 1. The client's eating patterns may not be altered. 2. The client is not instructed to measure their food. 3. Maintaining a food record can directly influence a person's consumption. This phenomenon is attributed to the patient's concern that consumption habits may be met with judgment by the healthcare practitioner, causing the patient to alter food selections during the recording period. 4. Alcohol may be omitted but the greater concern is the client altering their consumption habits. Page Ref: 133 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
20) A nurse is teaching a client how to estimate portion sizes of food. Which technique should the nurse use during the client's teaching? 1. Measuring cups. 2. Food scale. 3. Analogies. 4. Plastic containers. Answer: 3 Explanation: 1. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home but not realistic when estimating portion sizes at restaurants. 2. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home but not realistic when estimating portion sizes at restaurants. 3. When teaching a client using analogies associated with everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, the client will be able to visually estimate appropriate portions. Using analogies is a useful and easy approach for teaching clients. 4. Having a client use measuring cups, food scales, and plastic containers can be helpful when preparing foods at home but not realistic when estimating portion sizes at restaurants. Page Ref: 132 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
21) The nurse is preparing to assess an older client that has experienced undernutrition. Which assessment findings should the nurse anticipate? Select all that apply. 1. Muscle loss. 2. Memory loss. 3. Functional decline. 4. Physical decline. 5. Poor concentration. Answer: 1, 3, 4, 5 Explanation: 1. Muscle loss results from undernutrition. 2. Memory loss is a neurological condition not associated with undernutrition. 3. Functional decline can occur as a result of undernutrition. 4. Physical decline can occur as a result of undernutrition. 5. Poor concentration can result from undernutrition as a result of fatigue and functional and physical decline. Page Ref: 128 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.3: Apply the principles of physical assessment to the nutritional assessment of a patient.
22) The nurse is evaluating a list of clients that may require a detailed nutritional assessment. Which client should the nurse recognize would most benefit from a detailed nutritional assessment? 1. A 21-year-old female who has just begun college and has lost 5 pounds in the first semester. 2. A 2-year-old whose mother stated that he seems to be growing faster than she can buy him clothes. 3. A 50-year-old male who reported that he lost 10 pounds in 6 weeks without even trying. 4. A 35-year-old female who has gained 10 pounds in a year after the birth of her first child. Answer: 3 Explanation: 1. The female that just began college has experienced activity and nutritional changes. 2. Toddlers experience growth spurts that are normal physiological processes. 3. Unintentional weight loss is considered clinically significant and requires further assessment. 4. During the first year after the birth of a child, a woman may increase body weight as a result of diet, activity, and hormonal changes. Page Ref: 135 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
23) The nurse is evaluating the nutritional intake of college athletes. Which tool should the nurse use? 1. BMI. 2. Height-weight table. 3. Food record. 4. Skinfold measurements. Answer: 3 Explanation: 1. Calculating a BMI is a measurement not a tool to evaluate the nutritional intake. 2. The height-weight table is a measurement tool not the evaluation of nutritional intake. 3. A food record can be used to evaluate the nutritional status of college athletes. 4. Skinfold measurement is a tool not an evaluation of nutritional intake. Page Ref: 133 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
24) An older adult asks the nurse why skinfold measurements are not done during the assessment. Which response should the nurse provide? 1. "Skinfold measurements are no longer included in the assessment of a BMI." 2. "As a person ages, the skinfold measurement test is not as accurate." 3. "Calculating the BMI (body mass index) is more efficient." 4. "A detailed dietary history will provide the information that we need." Answer: 2 Explanation: 1. Skinfold measurements are not included in the assessment of a BMI. 2. The subcutaneous fat distribution and total body fat composition change as an adult ages. The reference values for older adults and suggested locations of skinfold measurements require further investigation and data collection to be accurate. 3. The efficiency of calculating a BMI is not the reason skinfold measurements are not obtained on an older adult. 4. A diet history is an important part of a nutritional assessment but does not provide body composition values. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
25) The nurse is collecting nutritional intake information from a client. The nurse does not feel the client is being forthcoming and honest with the intake self-reports. Which factor may be associated with inaccurate reporting of dietary intake? 1. Female gender. 2. Male gender. 3. Higher socioeconomic levels. 4. Lower educational levels. Answer: 4 Explanation: 1. Gender is not correlated with inaccurate reporting of dietary intake. 2. Gender is not correlated with inaccurate reporting of dietary intake. 3. High socioeconomic levels are not correlated with inaccurate reporting of dietary intake. 4. Clients seeking the social approval of the nurse or wanting to avoid disapproval for their habits may underreport. Underreporting occurs for all ages and is seen more often in smokers, obese clients, and individuals that are undereducated and are at a socioeconomic disadvantage. Page Ref: 132 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
26) The nurse is preparing a community education program to address obesity. Which subpopulation should the nurse focus upon? 1. Native American males. 2. Hispanic females. 3. African American females. 4. White males. Answer: 3 Explanation: 1. The prevalence for obesity is not the highest among Native American males. 2. The prevalence for obesity is not the highest among Hispanic females. 3. The prevalence for obesity is the highest among African American females. 4. The prevalence for obesity is not the highest among White males. Page Ref: 129 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.1: Recognize health promotion activities and risk factors that affect nutritional health.
27) A client asks the nurse about the use of height and weight tables to determine ideal weight. Which response should the nurse provide the client? 1. "It is important for you to adhere to the recommendations of height and weight tables to avoid weight-related complications." 2. "Height and weight tables are highly subjective." 3. "Using height and weight tables can be problematic because they are often inaccurate." 4. "Height and weight tables have significant limitations for predicting weight status of an individual." Answer: 4 Explanation: 1. Height-weight tables have been used in the past to assess body weight in adults but are no longer the standard to determine ideal weight. 2. Height-weight tables are not subjective but they are no longer the standard to determine ideal weight. 3. The height-weight tables are not inaccurate. However, they are no longer the standard for determining ideal weight. 4. Height and weight tables have significant limitations for predicting weight status of an individual. The use of these tables is no longer standard to determine the ideal weight. Page Ref: 136 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RI.S1I.NInGtTeBg.rCaOteMtheories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
28) The nurse is reviewing the records for the obstetrical client's in the clinic. Which client should the nurse recognize is at the greatest risk for insufficient gestational weight gain? 1. 33-year-old African American female. 2. 18-year-old White female. 3. 24-year-old Hispanic female. 4. 28-year-old Asian female. Answer: 1 Explanation: 1. Black women and adolescents under age 15 are more likely to have insufficient gestational weight gain and are more likely to deliver low birth weight babies than other populations. 2. The 18-year-old White female does not have the highest risk for insufficient gestational weight gain. 3. The 24-year-old Hispanic female does not have the highest risk for insufficient gestational weight gain. 4. The 28-year-old Asian female does not have the highest risk for insufficient gestational weight gain. Page Ref: 129 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN CNoU mRpSeItNeGnTcBie.sC:OKMnowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
29) The nurse is preparing to assess a client's tricep skinfold measurement. Which location is appropriate for the nurse to use during this assessment? 1. Olecranon process. 2. Midpoint of the arm. 3. Upper most arm. 4. Acromion process. Answer: 1 Explanation: 1. Triceps measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. 2. Triceps measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. 3. Triceps measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. 4. Triceps measurements are done at the midpoint of the arm equidistant from the uppermost posterior edge of the acromion process of the scapula and the olecranon process of the elbow. Page Ref: 138 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN CNoU mRpSeItNeGnTcBie.sC:OKMnowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6: Identify the most commonly used nutritional screening and assessment tools. MNL Learning Outcome: 10.4: Recognize laboratory tests and results, screening methods, and tools when conducting a nutritional assessment.
30) The nurse is preparing to conduct a focused interview on a client who reports a recent weight gain. Which inquiry by the nurse is the most appropriate for this client? 1. "Have you increased your carbohydrate intake?" 2. "Are you eating your meals late in the day?" 3. "Please tell me about what foods and beverages you have consumed for the past 24 hours." 4. "Have you noticed your energy level has decreased with your recent weight gain? Answer: 3 Explanation: 1. The client may not understand which foods are sources of carbohydrates and increased dietary carbohydrates may not directly be associated with weight gain. 2. Eating at specific time of the day does not provide the nurse with information regarding nutritional intake. 3. The focused interview of the client's nutritional concerns will include asking the client to recall dietary intake for the past 24 hours. The 24-hour period will provide insight into the dietary intake of the client by providing a snapshot of food selections and eating patterns. 4. Energy levels may change with weight gain. The initial purpose of the focused interview is to obtain information to guide the physical assessment in relation to nutrition and weight gain. Page Ref: 132 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2: Identify factors that affect or influence a nutritional assessment of an adult. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
31) Which nitrogen laboratory finding should the nurse anticipate for a client experiencing catabolism? 1. Loss of nitrogen exceeds the intake. 2. Intake of protein exceeds the nitrogen loss. 3. Caloric intake exceeds the nitrogen loss. 4. The level of nitrogen in the body is balanced. Answer: 1 Explanation: 1. Catabolism occurs when the loss of nitrogen exceeds the intake. 2. Anabolism occurs when the intake of protein and calories exceeds the nitrogen loss. 3. Anabolism occurs when the intake of protein and calories exceeds the nitrogen loss. 4. A nitrogen balance is evident when the nitrogen in the body is balanced. Page Ref: 143 Cognitive Level: Applying Client Need & Sub: Reduction of Risk Potential; Laboratory Tests Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, and epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5: Identify the laboratory parameters used in a nutritional assessment. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
32) Which laboratory finding should the nurse anticipate for a client experiencing mild malnutrition? 1. Prealbumin of 115 mg/L. 2. Prealbumin of 75 mg/L. 3. Prealbumin of 40 mg/L. 4. Prealbumin of 175 mg/L. Answer: 1 Explanation: 1. A prealbumin of 115 mg/L is found in a client experiencing mild malnutrition. 2. A prealbumin of 75 mg/L is found in a client experiencing moderate malnutrition. 3. A prealbumin of 40 mg/L is found in a client experiencing severe malnutrition. 4. A prealbumin of 175 mg/L is an expected finding. Page Ref: 143 Cognitive Level: Applying Client Need & Sub: Reduction of Risk Potential; Laboratory Tests Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systemNsU; RtrSaInNsGcTuBlt.uCrOaM l approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5: Identify the laboratory parameters used in a nutritional assessment. MNL Learning Outcome: 10.2: Consider the assessment factors utilized when performing a nutritional history.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 11 Psychosocial Health, Substance Abuse, and Intimate Partner Violence 1) The educator is reviewing the symptoms associated with emotional stress with the staff nurses. Which symptoms should the educator include? Select all that apply. 1. Chest pain. 2. Vomiting. 3. Difficulty breathing. 4. Back pain. 5. Diaphoresis. Answer: 1, 3, 4 Explanation: 1. Physical symptoms that indicate a problem related to emotional stress includes chest pain. 2. Vomiting is not a physical symptom related to emotional stress. 3. Physical symptoms that indicate a problem related to emotional stress includes difficulty breathing. 4. Physical symptoms that indicate a problem related to emotional stress includes back pain. 5. Diaphoresis is not a physical symptom related to emotional stress. Page Ref: 150 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Stress Management Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
2) A client being seen in the clinic for abdominal discomfort and a decreased energy level tells the nurse they just lost their job. Which factor should the nurse suspect could be attributed to the client's abdominal discomfort? 1. Income. 2. Stress. 3. Ethnicity. 4. Occupation. Answer: 2 Explanation: 1. Income may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. 2. Stress is most likely having the greatest impact with the symptoms being reported. Emotional stress affects the immune system and typically causes individuals to be less attentive to their personal health. Individuals under stress may also use mood-altering substances to "feel better." 3. Ethnicity may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. 4. Occupation may influence physical and emotional health in some way, but stress is most likely having the greatest impact with the symptoms being reported. Page Ref: 154 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Stress Management Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
3) The nurse interviewing an adolescent suspects problem with self-concept. Which should the nurse recognize is a main contributing factor to a limited self-concept? 1. Inability to form lasting relationships. 2. Decreased ability to form attachments with other people. 3. Inability to maintain stable employment. 4. Feelings of worthlessness, anxiety, and/or depression. Answer: 4 Explanation: 1. The increased desire to form lasting relationships may be seen in individuals with both healthy and unhealthy self-concepts. 2. Decreased ability to form attachments to other people can result in other psychosocial issues and is not limited to poor self-concept. 3. Decreased ability to maintain stable employment can result in other psychosocial issues and is not limited to poor self-concept. 4. Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Page Ref: 152 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Mental Health Concepts Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, N anUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
4) A client's mother is distraught over her child's recent leukemic relapse and states, "What did I do wrong? Why does he deserve this? Why can't it be me?" Which should the nurse recognize the statements are associated with? 1. Ineffective coping. 2. Emotional emptiness. 3. Spiritual distress. 4. Psychologic anxiety. Answer: 3 Explanation: 1. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping. 2. Emotional emptiness is not an acceptable term to describe behaviors indicating distress. 3. Questions such as "What did I do wrong?" and "Why does he deserve this?" are reflective of spiritual distress. 4. Further evidence would be required before determining psychologic anxiety. Page Ref: 155 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Relationship Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; and facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
5) A client tells the nurse that they have been experiencing emotional distress over the past few weeks. Which physical assessment finding should the nurse anticipate? 1. Hyperactive bowel sounds. 2. Elevated blood pressure. 3. Pinpoint pupils. 4. Elevated temperature. Answer: 2 Explanation: 1. A client experiencing emotional distress experiences constipation. The bowel sounds are not hyperactive in a patient that is constipated. 2. A client experiencing emotional distress may experience elevated blood pressure. 3. The client's pupil size does not decrease during emotional distress. 4. The client's temperatures should not be affected by the emotional distress. Page Ref: 150 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise, and patient/family values. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Nursing DiagNnUoRsiSsINGTB.COM Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
6) The nurse educator is reviewing the components of a psychosocial assessment with a group of students. Which definition of psychosocial health is appropriate for the educator to include in the review session? 1. Being emotionally balanced and socially astute. 2. Being mentally stable, physically fit, and psychologically well. 3. Being spiritually and psychologically mature. 4. Being mentally, emotionally, socially, and spiritually well. Answer: 4 Explanation: 1. Emotionally balanced is another way of referring to emotionally well, though the term is not often used. Being socially astute is a characteristic that one may develop but is not necessary for social wellness. 2. Mental stability is a component of psychosocial health and includes psychologic health. Being physically fit may influence psychosocial health, but individuals may be not physically fit but still in good psychosocial health. 3. Many would argue that children are not spiritually and psychologically mature yet may exhibit psychosocial health, so being spiritually and psychologically mature are not criteria for psychosocial health. 4. Psychosocial health is defined as being mentally, emotionally, socially, and spiritually well. Page Ref: 149 Cognitive Level: Remembering Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
7) The nurse is preparing to give an injection to a young child. Which technique should the nurse use? 1. Place the child in the parent's lap. 2. Request the parent to leave the room. 3. Allow the parent to remain with the child. 4. Have the parent restrain the child. Answer: 3 Explanation: 1. The child should not be seating in the parents lap during an injection. Children need to know they are safe when a parent is holding them. 2. Requesting the parents to leave the room during an injection may increase the anxiety of the child and the parents. 3. It is appropriate to allow the parent to remain with the child during a painful procedure. 4. The child should not be restrained by a parent. Children need to know they are safe when a parent is holding them. Page Ref: 150 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. SynthesizeNtU heRoSIrNieGsTaBn.dCOcoMncepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
8) The nurse is assessing a client that lives in a rural area for stressors. Which should the nurse assess the client for? 1. Unhealthy living conditions. 2. High crime rates. 3. Limited resources. 4. Access to healthy food. Answer: 3 Explanation: 1. There is no indication the client is exposed to unhealthy living conditions. 2. The rural population does not experience high rates of crime. 3. A stressor for a client that lives in a rural area includes limited resources. 4. Lack of access to healthy food is not a significant problem in the rural community. Page Ref: 151 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Stress Management Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
9) The educator is discussing the impact of self-concept on health with the nursing staff. Which factor should the educator include in the discussion? 1. Self-concept develops in early childhood. 2. Self-concept develops over time. 3. Self-concept is a component of self-esteem. 4. Self-concept is a component of body image. Answer: 2 Explanation: 1. Self-concept develops over time as a person reacts to and learns from interactions. 2. Self-concept refers to the beliefs and feelings one holds about oneself. Self-concept develops over time as a person reacts to and learns from interactions with others. As an individual develops across the lifespan, the interactions move from the immediacy of contact as children with caregivers to contact with individuals in the greater environment. Self-esteem and body image are components of self-concept. 3. Body image and self-esteem are components of self-concept. 4. Body image and self-esteem are components of self-concept. Page Ref: 152 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, commuNnUicRaStIion dOeM ducation; physical comfort and NG,TaBn.C emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Diagnosis: Nursing Diagnosis Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
10) The nurse is caring for a client with anorexia. Which subjective findings should the nurse anticipate? Select all that apply. 1. Constipation. 2. Abdominal pain. 3. Obsession with physical appearance. 4. Periods of excessive food consumption followed by purging. 5. Perception of being overweight. Answer: 1, 2, 5 Explanation: 1. Anorexia nervosa is a complex psychosocial problem characterized by a severely restricted intake of nutrients and a low body weight. Subjective findings associated with anorexia nervosa include constipation. 2. Anorexia nervosa is a complex psychosocial problem characterized by a severely restricted intake of nutrients and a low body weight. Subjective findings associated with anorexia nervosa include abdominal pain. 3. The obsession with physical appearance is a subjective finding for a patient with bulimia nervosa. 4. Periods of excessive food consumption followed by purging is a subjective finding for a patient with bulimia nervosa. 5. Anorexia nervosa is a complex psychosocial problem characterized by a severely restricted intake of nutrients and a low body weight. Subjective findings associated with anorexia nervosa include a perception of being overweight. Page Ref: 152 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. |Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
11) The nurse is preparing to assess a client with bulimia nervosa. Which assessment findings should the nurse anticipate? 1. Irregular or absent menses. 2. Damage to teeth enamel. 3. Refusal to consume nutritional supplements. 4. Extreme weight loss. Answer: 2 Explanation: 1. Irregular or absent menses occurs in clients with anorexia nervosa. 2. Bulimia nervosa is an eating disorder characterized by binge eating and purging or another compensatory mechanism to prevent weight gain. Damage to teeth enamel occurs due to over exposure to gastric acid if purging behaviors include vomiting. 3. Refusal to consume nutritional supplements is an objective finding for a client with anorexia nervosa. 4. Extreme weight loss occurs in clients with anorexia nervosa. Page Ref: 152 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screeNnUinRgS,INoG utTrBe.aCcOhM , disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
12) The educator is reviewing the objective findings for binge eating disorder with the nurses. Which statement made by a nurse indicates further teaching is required? 1. "A client with a binge eating disorder experiences marked distress." 2. "A client with a binge eating disorder will eat faster than normal." 3. "A client with a binge eating disorder may abuse laxatives." 4. "A client with a binge eating disorder will eat alone out of embarrassment." Answer: 3 Explanation: 1. A client with a binge eating disorder has marked distress related to their eating habits. 2. Eating faster than normal is a characteristic associated with binge eating episodes. 3. A client with a binge eating disorder does not abuse laxatives. 4. Eating alone out of embarrassment is a characteristic associated with binge eating episodes. Page Ref: 153 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN CompeteNnUcR ieSsI:NCGoTnBt.eCxOt M and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
13) The nurse is caring for an adult client with a history of sexual abuse. Which behavioral and phycological affect should the nurse be aware of that increases the client's vulnerability to health problems? 1. Interdependence. 2. Helplessness. 3. Selflessness. 4. Powerlessness. Answer: 4 Explanation: 1. Interdependence is the dependence of two or more people on each other and is not identified as a behavioral or psychological effect of sexual abuse. 2. Helplessness is the inability to help oneself and is not identified as a behavioral or psychological effect of sexual abuse. 3. Selflessness is the concern for others needs over their own and is not identified as a behavioral or psychological effect of sexual abuse. 4. Powerlessness is a behavioral and psychological effect that increases the client's vulnerability to health problems. Page Ref: 154 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, commuNnUicRaStIiN onG,TaBn.CdOeM ducation; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: I.2. Synthesize theories and concepts from liberal education to build an understanding of the human experience. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Diagnosis: Assessment Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.
14) The nurse is preparing to assess the physiological signs of stress in a client. Which findings does the nurse anticipate? Select all that apply. 1. Elevated blood glucose. 2. Increased red blood cells. 3. Decreased blood clotting time. 4. Decreased T lymphocytes. 5. Decreased white blood cells. Answer: 1, 3, 4 Explanation: 1. An elevated blood glucose is associated with stress. 2. Red blood cells do not increase during stress. 3. A decreased clotting time is associated with stress. 4. Decreased T lymphocytes are associated with stress. 5. White blood cells do not decrease during stress. Page Ref: 155 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, diseaseNaUnRdSoINuGtbTrBe.aCkOiM nvestigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
15) The nurse is preparing to assess a client suspected of synthetic cannabinoid (SCB) toxicity. Which assessment findings should the nurse anticipate? Select all that apply. 1. Respiratory depression. 2. Chest pain. 3. Bradycardia. 4. Tachycardia. 5. Lethargy. Answer: 2, 4, 5 Explanation: 1. Respiratory depression is not a clinical finding in a client that is experiencing SBC toxicity. 2. Chest pain is a clinical finding in a client that is experiencing SBC toxicity. 3. Bradycardia is not a clinical finding in a client that is experiencing SBC toxicity. 4. Tachycardia is a clinical finding in a client that is experiencing SBC toxicity. 5. Lethargy is a clinical finding in a client that is experiencing SBC toxicity. Page Ref: 155 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct cNoUmRpSIrNehGeTnBs.C ivOeMand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.2: Analyze the health and other impacts of substance abuse and substance use disorder. MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.
16) The nurse is assessing a client for substance abuse using the CAGE tool. Which question should the nurse ask the client? Select all that apply. 1. "Have people asked you about your drinking or drug use in the past?" 2. "Have people annoyed you by criticizing your drinking or drug use?" 3. "Have you ever felt bad or guilty about your drinking or drug use?" 4. "Have you ever been found guilty for drinking or drug charges?" 5. "Have you ever felt you should cut down on your drinking or drug use?" Answer: 2, 3, 5 Explanation: 1. "Have people asked you about your drinking or drug use in the past" is not a question used for a CAGE screening. 2. "Have people annoyed you by criticizing your drinking or drug use" is a question used for a CAGE screening. 3. "Have you ever felt bad or guilty about your drinking or drug use" is a question used for a CAGE screening. 4. "Have you ever been found guilty for drinking or drug charges" is not a question used for a CAGE screening. 5. "Have you ever felt you should cut down on your drinking or drug use" is a question used for a CAGE screening. Page Ref: 157 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2: Analyze the health and other impacts of substance abuse and substance use disorder. MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.
17) The educator is discussing with the nursing staff the reasons why women stay in abusive relationships. Which statement made by a nurse indicates further education is required? 1. "Women may be financially dependent on their abusers." 2. "Fear of losing custody of their children keeps a woman from leaving an abusive relationship." 3. "Women are not educated on how to get out of abusive relationships." 4. "Women who stay in an abusive relationship hope that the behavior may change." Answer: 3 Explanation: 1. Women may be financially dependent on their abusers. 2. Fear of losing custody of their children may keep a woman from leaving an abusive relationship. 3. Lack of education about how to leave an abusive relationship is not one of the reasons women stay in an abusive relationship. 4. Women who stay in an abusive relationship hope that the behavior may change. Page Ref: 158 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Abuse and Neglect Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct cNoUmRpSIrNehGeTnBs.C ivOeMand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care. MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.
18) The nurse is assessing a client that begins using a collection of conglomeration words that have no meaning. Which should the nurse document the finding as? 1. Echolalia. 2. Circumlocution. 3. Neologisms. 4. Word salad. Answer: 4 Explanation: 1. Echolalia is a constant repetition of words or phrases that client's hear others say. 2. Circumlocution is an inability to communicate an idea due to numerous digressions. 3. Neologisms are coining new words that have symbolic meaning to the client. 4. Word salad is a collection of a conglomeration of words that have no meaning. Page Ref: 161 Cognitive Level: Understanding Client Need & Sub: Psychosocial Integrity; Mental Health Concepts Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
19) The nurse is preparing to assess a client. Which should the nurse recognize is a risk factor for suicide? Select all that apply. 1. Gender. 2. Sexual orientation. 3. Occupation. 4. Limited education. 5. History of mental illness. Answer: 2, 4, 5 Explanation: 1. Gender is not a factor that increases an individual's risk for attempting suicide. 2. A factor that increases the risk of an individual attempting suicide includes sexual orientation. 3. A specific occupation is not a factor that increases an individual's risk for attempting suicide. 4. A factor that increases the risk of an individual attempting suicide includes limited education. 5. A factor that increases the risk of an individual attempting suicide includes a history of mental illness. Page Ref: 164 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Crisis Intervention Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of famiN lyUaRnSdINfrGieTnBd.Cs;OaMnd transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.
20) The nurse is assessing a client for potential warning signs of an impending suicide attempt. Which statement should the nurse be concerned with? 1. "I called my counselor three times this week." 2. "I have lost some weight over the past month." 3. "I feel like crying sometimes." 4. "I feel like such a burden to my family." Answer: 4 Explanation: 1. A client that is reaching out for help is not exhibiting warning signs of an impending suicide. 2. The weight loss should be further assessed and cannot be assumed to be associated with an impending attempt of suicide. 3. The statement "I feel like crying sometimes" is not an indication of an impending suicide. 4. The statement, "I feel like such a burden to my family" is a potential warning sign of an impending suicide attempt. Page Ref: 165 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Crisis Intervention Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct cNoUmRpSIrNehGeTnBs.C ivOeMand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.
21) The educator is teaching the nursing staff about the potential warnings of an impending suicide. Which should the educator include? Select all that apply. 1. Sudden change in mood. 2. Altered mental status. 3. Increased incidence of alcohol abuse. 4. Purchasing a weapon. 5. Reckless behavior. Answer: 1, 3, 4, 5 Explanation: 1. A sudden change in mood is a potential warning sign of an impending suicide. 2. Altered mental status is not a sign of an impending suicide. 3. Increased incidence of alcohol abuse is a potential warning sign of an impending suicide. 4. Purchasing a weapon is a potential warning sign of an impending suicide. 5. Reckless behavior is a potential warning sign of an impending suicide. Page Ref: 165 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Crisis Intervention Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences and values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, N anUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.3: Identify risk factors and assessment tools for substance abuse.
22) The nurse is preparing to assess a client with an exacerbated anxiety disorder that has a history of asthma and arthritis. Which initial assessment should the nurse perform? 1. Respiratory assessment. 2. Musculoskeletal. 3. Medication history. 4. Psychosocial assessment. Answer: 4 Explanation: 1. There is no indication the client is currently experiencing respiratory compromise, so the assessment of this system is not an immediate concern. 2. Although the patient has a history of arthritis, there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. 3. Although the patient has a history of arthritis, there is no indication that the client is experiencing immediate concerns related to the musculoskeletal system. Review of the client's current medications will be included in the admission assessment but is not an immediate concern. 4. The psychosocial assessment is a priority assessment. The client is presenting with concerns related to the anxiety disorder. Page Ref: 160 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Stress Management Standards: QSEN Competencies: I.A.I. Integrate understanding of multiple dimensions of patient centered care: patient/family/coNmUm tyTpBr.C efOeM rences and values; coordination and RSuInNiG integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
23) The nurse is concerned that a client is having a problem with self-concept. Which statement should the nurse recognize support client's concern? 1. "I never have any fun." 2. "I am the oldest in the family." 3. "I think I'm pretty much outgoing." 4. "At times I like to be alone."Answer: 1 Explanation: 1. There are a variety of questions that can be asked to assess a client's selfconcept. The client's response provides information to the nurse about problems or concerns with this characteristic. Clients who are unable or do not find pleasure in life may be experiencing a negative self-concept. 2. Birth order in the family is not associated with a negative self-concept. 3. A client that views themselves as outgoing is not experiencing a problem with self-concept. 4. Occasional desire to be alone does not indicate a problem with self-concept. Page Ref: 92-93 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and cultNuUraRlSlyINaGpTpBro.CpOriM ate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
24) The nurse suspects a client is having difficulty coping. Which assessment question should the nurse ask when assessing the client's ability to cope? 1. Who is your closest friend? 2. What social groups do you belong to? 3. What is your birth order in your family? 4. Who do you call when you need help? Answer: 4 Explanation: 1. Questions about friends assess the client's roles and relationships. 2. Questions about social groups assess the client's roles and relationships. 3. Questions about birth order focus on the client's family history. 4. Questions that are helpful to gather additional information about a client's stress and coping mechanisms include: What do you do for relaxation and recreation? What is your greatest source of comfort when you are feeling upset? Who do you call for help? What is your current level of stress? Page Ref: 164 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
25) The nurse is assessing a client self-concept. Which question should the nurse include in the assessment? 1. "Do you have trouble making decisions?" 2. "Can you describe your social life?" 3. "Do you hear voices or see objects?" 4. "Can you describe how you were raised?" Answer: 2 Explanation: 1. A client's ability to make decisions is associated with cognition. 2. Asking about a client's social life will assist in gathering data about the client's self-concept. 3. Hearing voices or seeing objects is an assessment of the client's perception. 4. The description of how the client was raised will provide information about family history. Page Ref: 163 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship Centered Care: The role of family, culture, and community in a person's development. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.1: Understand the major components of psychosocial health and apply to overall health and wellness. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
26) A client with a family history of schizophrenia expresses concern about having a child with the disorder. Which response should the nurse provide the client? 1. "Schizophrenia is a genetic disorder so you are right to be very concerned." 2. "Your family history does increase the risk factors but there are other variables to be considered." 3. "Schizophrenia should not be a significant concern for you." 4. "You should consider being tested before becoming pregnant." Answer: 2 Explanation: 1. Informing the client that they should be concerned about having a child with schizophrenia does not provide the client with any information. 2. Individuals with a family history of schizophrenia have a genetic predisposition of having a child with the disorder. There are, however, other variables such as environmental factors that are linked to the disorders. 3. Advising the client that it should not be a significant concern minimized the client's concern and provides inaccurate information. 4. There is currently no testing available to predict the disorder. Page Ref: 149 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Mental Health Concepts Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: V.II.2. ConductNaUhReSIaNltGhThBis.CtoOrMy, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
27) The nurse is using a HITS screening tool to assess the client for domestic violence. Which type of abuse should the nurse understand the client is being screened for? Select all thatapply. 1. Emotional. 2. Financial. 3. Physical. 4. Psychological. 5. Sexual. Answer: 1, 3, 4 Explanation: 1. The HITS tool is a screening tool for domestic violence that focuses on emotional, physical, and psychological abuse. 2. The HITS tool does not screen for financial abuse. 3. The HITS tool is a screening tool for domestic violence that focuses on emotional, physical, and psychological abuse. 4. The HITS tool is a screening tool for domestic violence that focuses on emotional, physical, and psychological abuse. 5. The HITS tool does not screen for sexual abuse. Page Ref: 159 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Abuse and Neglect Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences and expressed needs as part of clinical interview, implementatioNnUoRf ScIaNrGeTpBla.CnOaMnd evaluation of care. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care. MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.
28) The nurse is reviewing phase II of the cycle of abuse with a client. Which information should the nurse discuss? 1. The perpetrator is threatening. 2. The perpetrator becomes loving and kind. 3. The abusive incidence occurs. 4. The tension prior to the abuse is building. Answer: 3 Explanation: 1. During the first phase of the abuse cycle, the tension builds and the perpetrator can be threatening. 2. During the third phase of the abuse cycle, the perpetrator becomes calm, loving, and may be remorseful. 3. During the second phase of the abuse cycle, the abusive incident occurs. 4. During the first phase of the abuse cycle, the tension builds. Page Ref: 158 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Abuse and Neglect Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., tranNsUmRiSsIsNioGnToBf.CdOisM ease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care. MNL Learning Outcome: 11.4: Recognize the importance of intimate-partner screening and violence identification in holistic patient care.
29) The nurse is reviewing the traits of a perpetrator of violence with a community group. Which traits should the nurse include? Select all that apply. 1. Low self-esteem. 2. Social withdrawal. 3. Limited ability to cope. 4. Reckless behavior. 5. Possessive behavior. Answer: 1, 3, 5 Explanation: 1. Traits of a perpetrator of violence include a low self-esteem. 2. Social withdrawal is not a trait of a perpetrator of violence. 3. Traits of a perpetrator of violence include a limited ability to cope. 4. Reckless behavior is not a trait of a perpetrator of violence. 5. Traits of a perpetrator of violence include a display of possessive behavior. Page Ref: 158 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Abuse and Neglect Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: V.II.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic diseNasUeRm nt; healthcare systems; transcultural SIa NnGaTgBe.m COeM approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 11.3: Synthesize the importance of intimate partner violence (IPV) screening and violence identification in holistic patient care. MNL Learning Outcome: 11.2: Recognize factors that relate to the assessment of a patient for substance abuse or exposure to violence.
30) The nurse caring for a client experiencing back pain, nausea, and fatigue inquiries about current stressors. The client states, "I am sick. Why are you asking me about all of this stress stuff?" Which information should the nurse provide the client? 1. "Stress can impact our body by producing a variety of symptoms." 2. "Your nausea and fatigue are most often related to increase of stress in life." 3. "Screening for stress is required for every client." 4. "I am assessing your ability to cope with additional stressors." Answer: 1 Explanation: 1. Stress is associated with a variety of physical ailments, including back pain, nausea, and fatigue. The nurse will provide education to the client concerning the reasons behind the questions being asked. 2. It is premature in the assessment period for the nurse to assume increased life stressors are the causative factor of the client's physical symptoms. 3. A stress assessment may be indicated during the period of data collection but this does not provide an adequate explanation to the client. 4. Assessing the stressors in a client's life is not an assessment for the client's ability to cope. Page Ref: 154-155 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity; Coping Mechanisms Standards: QSEN Competencies: I.B.3 Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal educN atUioRnSIiN ntGoTnBu.CrO siM ng practice. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4: Describe application of the nursing process in the assessment of psychosocial health for patients across the lifespan. MNL Learning Outcome: 11.1: Consider the internal and external factors that affect a patient's psychosocial health and overall health and wellness when performing a patient assessment.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 12 Skin, Hair, and Nails 1) The educator has reviewed the layers of skin with a nurse. Which statement indicates further teaching is required? 1. "The cutaneous glands help protect against bacteria on the skin." 2. "The subcutaneous tissue contains half of the body's fat cells." 3. "The dermis contains collagen and elastin fibers." 4. "The epidermis produces melanin." Answer: 4 Explanation: 1. Cutaneous glands help protect against bacteria on the skin 2. The subcutaneous tissue contains half of the body's fat cells 3. The dermis contains collagen and elastin fibers. 4. Melanin is produced in the stratum basale. Page Ref: 171 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G ImTpBl.eCm entation OM Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails. MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.
2) Which structure of the nail protects the root of the nail? 1. Lunula. 2. Cuticle. 3. Posterior nail fold. 4. Nail matrix. Answer: 2 Explanation: 1. The lunula does not protect the root of the nail. 2. The cuticle protects the root and sides of each nail. 3. The posterior nail fold does not protect the root of the nail. 4. The nail matrix does not protect the root of the nail. Page Ref: 172 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails. MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.
3) The nurse is conducting a focused interview on the client's integumentary system. Which questions should the nurse ask to identify risk factors for the development of integumentary disorders? Select all that apply. 1. "How much time do you spend outdoors?" 2. "How do you care for your skin?" 3. "Do you have any tattoos or body piercings?" 4. "Have you noticed any drainage from your skin?" 5. "Do you take any medications on a regular basis?" Answer: 1, 2, 3, 5 Explanation: 1. The nurse should ask the client about the amount of time spent outdoors Spending time outside in the sun is a risk factor for the development of skin disorders, such as squamous cell carcinoma. 2. The nurse should ask the client about routine skin care. The client may be performing a specific care that places them at risk for the development of an integumentary disorder. 3. Tattoos and body piercings can increase the client's risk for developing an integumentary disorder. 4. Inquiring about drainage is an assumption that there is an existing integumentary disorder. 5. Certain medications, if taken on a regular basis, can increase the client's risk for developing skin disorders. Page Ref: 173 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview. MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.
4) A client asks the nurse what the risk factors are for piercing the naval area. Which information should the nurse recognize is most important? 1. "You are at risk for scar tissue at the site." 2. "The piercing may get caught on clothing." 3. "You may not want the piercing in a few years." 4. "You are at risk for hepatitis A." Answer: 1 Explanation: 1. The client is at risk for scar tissue at the site of the piercing which may result in keloid formation. 2. The piercing may get caught on clothing but that is not the most important risk factor. 3. The client may change their mind about the piercing and they can simply choose not to put any rings or jewelry into the piercing site. 4. Hepatitis C is a risk factor when obtaining a piercing. Page Ref: 176 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
5) The nurse is preparing to assess the client's skin, hair, and nails. Which technique will the nurse use initially during this assessment? 1. Percussion. 2. Palpation. 3. Auscultation. 4. Inspection. Answer: 4 Explanation: 1. Percussion is not used to assess the client's skin, hair, and nails. 2. The nurse inspects then palpates during the assessment of the client's skin, hair, and nails. 3. Auscultation is not used to assess the client's skin, hair, and nails. 4. Inspection is the nurse's first step when assessing the client's skin, hair, and nails. Page Ref: 180 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails. MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.
6) The nurse observes that a client's skin is pale. Which assessment data should the nurse anticipate is associated with the observation? Select all that apply. 1. Blood pressure is 96/62. 2. The client states, "I just smoked a cigarette before I came in the office." 3. Oxygen saturation level is 86% on room air. 4. The client states, "I have been diagnosed with osteoporosis." 5. The client states, "It is snowing again outside with a wind chill factor of -11 degrees Fahrenheit." Answer: 1, 2, 3, 5 Explanation: 1. Pallor may be seen in the client with hypotension. 2. Smoking cigarettes causes a vasoconstrictive response which may result in pallor. 3. The client with a decreased oxygen saturation level may exhibit pallor. 4. Pallor is not normally associated with osteoporosis. 5. A cold environment can produce vasoconstriction resulting in pallor. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.
7) The nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in color. Which term is most appropriate for the nurse to use to describe this condition when documenting in the medical record? 1. Uremia. 2. Cyanosis. 3. Jaundice. 4. Carotenemia. Answer: 3 Explanation: 1. Uremic skin is pale and yellow and is associated with renal disease. The yellowtinge seen in the patient with uremic skin is very pale and does not affect conjunctivae or mucous membranes. 2. Cyanotic skin is bluish in color. 3. The nurse's findings indicate jaundice, which is due to increased levels of bilirubin in the blood. Jaundice is visible in the sclerae, oral mucosa, junction of hard and soft palate, palms of the hands, and soles of the feet. 4. Carotenemic skin has a yellow-orange tinge. The yellow-orange tinge seen in the client with carotenemia is most visible in palms of the hands and soles of the feet. This client would not exhibit yellowing of sclerae or mucous membranes. Page Ref: 180 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
8) The nurse is performing a skin assessment on a client and notes a round, elevated, fluidfilled mass approximately 0.4 cm in size. Which term should the nurse use when documenting the finding? 1. Vesicle. 2. Macule. 3. Papule. 4. Tumor. Answer: 1 Explanation: 1. The area described is a vesicle and may be caused by herpetic lesions, poison ivy, or small burn blisters. 2. A macule is a flat, nonpalpable change in skin color. 3. A papule is an elevated, solid, palpable mass. 4. Tumors are elevated but solid, hard, or soft palpable and extend deeper into the dermis. Page Ref: 191 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | Nursing/Integrated OM Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
9) The nurse is assessing a client's nails for clubbing. Which technique should the nurse use? 1. Place two thumbs touching side-by-side. 2. Place two of the same fingers from each hand together. 3. Place two index fingers together tip-to-tip. 4. Place the hands out straight with the palm sides down. Answer: 2 Explanation: 1. Placing the thumbs together side-by-side is not an appropriate way to determine the presence of clubbing. 2. To assess for clubbing, the nurse can use the Schamroth technique, in which the nurse asks the client to bring the dorsal aspect of corresponding fingers together, and if there is clubbing, a diamond is not formed and the distance increases at the fingertip. 3. Placing the index finger tip-to-tip is not an appropriate way to determine the presence of clubbing. 4. Placing the hands straight out with the palms facing downward is not an appropriate way to determine the presence of clubbing. Page Ref: 189 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails. MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.
10) A client asks the nurse why they are growing facial hair. Which statement should the nurse provide the patient? 1. "Your diet is not nutritionally balanced." 2. "You may have some hormone imbalances." 3. "Usually, there is not a known cause for this condition." 4. "You may be lacking particular vitamins." Answer: 2 Explanation: 1. Hirsutism is not typically linked to nutrition. 2. Hirsutism is the occurrence of excess body hair in females on the face, chest, abdomen, arms, and legs, following the male pattern. It is typically due to endocrine or metabolic dysfunction but may be idiopathic in nature. 3. Hirsutism is typically due to endocrine or metabolic dysfunction. 4. Hirsutism is not related to vitamin deficiency. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
11) The nurse is inspecting the fingernails of a client who is diagnosed with polycythemia. Which assessment data would be expected for this client? 1. Dark red nails. 2. Horizontal white bands. 3. Pale nail beds. 4. Spoon-shaped nails. Answer: 1 Explanation: 1. The client with polycythemia has nails that appear dark red due to a pathological increase in red blood cells. 2. Horizontal white bands in the nails are seen with the client who has been diagnosed with chronic hepatitis. 3. Pale nail beds are associated with anemia or peripheral circulatory disorders. 4. Spoon-shaped nails may be related to iron deficiency. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
12) An adolescent client tells the nurse that they shower daily but still have a skin odor. Which action should the nurse take? 1. Reassure the adolescent that this is normal. 2. Notify the client's healthcare provider. 3. Recommend a strong body wash product. 4. Educate the client regarding the importance of increased water intake. Answer: 1 Explanation: 1. The apocrine glands are dormant until the onset of puberty; when they become active, they produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in auxiliary and anogenital areas and when mixed with bacteria on skin surface produces a musky odor. This is a normal part of normal growth and development. 2. The teenage client's healthcare provider does not need to be notified because this odor is associated with normal growth and development. 3. The nurse should not recommend body wash products to the client. 4. Increasing fluid intake will not help prevent the occurrence of this odor. It is a normal part of normal growth and development. Page Ref: 174 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUsRCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails. MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.
13) The nurse is providing education to a postpartum client. Which should the nurse include in the teaching about the client's hair? 1. "You may notice an increase in the dryness of your hair." 2. "Due to the hormonal changes, the thickness of your hair may increase." 3. "You may notice that your hair will shed for up to several months." 4. "Hormones may alter melanocyte production slightly altering your hair color." Answer: 3 Explanation: 1. Dryness of the hair does not occur during pregnancy or the postpartum period. 2. Thinning or shedding may occur on the scalp during pregnancy and continue for up to 15 months after childbirth. 3. Thinning or shedding may occur on the scalp during pregnancy and continue for up to 15 months after childbirth. 4. Hormones do not alter the melanocyte production. Page Ref: 177 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails. MNL Learning Outcome: 12.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails.
14) The nurse notes an oval-shaped, elevated, fluid-filled mass that is approximately 1.5 centimeters in size on the client's skin. Which term should the nurse use to document the finding? 1. Vesicle. 2. Bulla. 3. Papule. 4. Tumor. Answer: 2 Explanation: 1. Vesicles are smaller than 0.5 centimeters but are also described as elevated, fluid-filled, round or oval-shaped, palpable mass with thin, translucent walls and circumscribed borders. 2. The area described is a bulla and may be caused by contact dermatitis, friction blisters, or large burn blisters. 3. A papule is an elevated, solid palpable mass with a circumscribed border. Papules are smaller than 0.5 centimeters. 4. Tumors are elevated, solid, hard, or soft palpable and extend deeper into the dermis. Page Ref: 191 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
15) The nurse notes the presence of crusted lesions on the lips and inside the client's mouth along the cheek during an assessment. Which condition should the nurse suspect the client is experiencing? 1. Chickenpox. 2. Contact dermatitis. 3. Herpes simplex. 4. Psoriasis .Answer: 3 Explanation: 1. Chickenpox is a mild infectious disease caused by the herpes zoster virus. It begins as groups of small, red, fluid-filled vesicles usually on the trunk and progresses to the face, arms, and legs. Vesicles erupt over several days, forming pustules and then crusts. The condition may cause intense itching. It occurs mostly in children. 2. Contact dermatitis is inflammation of the skin due to an allergy to a substance that comes into contact with the skin, such as clothing, jewelry, plants, chemicals, or cosmetics. The location of the lesions may help identify the allergen. It may progress from redness to hives, vesicles, or scales and is usually accompanied by intense itching. 3. The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. 4. Psoriasis is thickening of the skin in dry, silvery, scaly patches. It occurs with overproduction of skin cells resulting in buildup of cells faster than they can be shed. It may be triggered by emotional stress or generally poor health. It may be located on scalp, elbows and knees, lower back, and perianal area. Page Ref: 199 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
16) The nurse notes that the client's skin, nails, and mucous membranes are very light in color. Which description should the nurse use to document the findings? 1. Cyanosis. 2. Pallor. 3. Erythema. 4. Jaundice. Answer: 2 Explanation: 1. Cyanotic skin is bluish in color. 2. Pallor is pale skin. It may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. 3. Erythema indicates that the skin is reddened. 4. Jaundice is used to describe yellowish skin. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
17) The nurse notes a client has several abdominal lesions that appear in distinct clusters. Which terminology should the nurse use when documenting the pattern of the lesions? 1. Grouped. 2. Annular. 3. Discrete. 4. Confluent. Answer: 1 Explanation: 1. The lesions described are grouped lesions because they appear in clusters. 2. Annular lesions are lesions with a circular shape. 3. Discrete lesions are lesions that are separate and distinct. 4. Confluent lesions run together. Page Ref: 197 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
18) The nurse is preparing to document herpetic lesions noted on a client. Which terms should the nurse use to document the finding? Select all that apply. 1. Vesicular. 2. Pustular. 3. Pruritic. 4. Ulcerated. 5. Crusty. Answer: 1, 2, 5 Explanation: 1. Herpes simplex lesions may be described as vesicular. 2. Herpes simplex lesions may be described as pustular. 3. Herpes simplex lesions are not associated with pruritis. 4. Herpes simplex lesions are not typically ulcerated. 5. Herpes simplex lesions may be described as crusty. Page Ref: 199 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
19) The nurse reviewing a client record notes a documented finding of "+1 edema right lower leg." Which assessment finding should the nurse expect? 1. The presence of slight pitting, no obvious distortion. 2. Deep pitting, obvious distortion. 3. Pitting is obvious and extremities are swollen. 4. Moderate amount of edema. Answer: 1 Explanation: 1. Edema, or accumulation of fluid in the body's tissues, is recorded as +1, +2, +3, or +4. The designation +1 means the client has slight pitting in the right lower leg with no obvious distortion. 2. Deep pitting with obvious distortion may be documented as +4 edema. 3. Obvious pitting with swollen extremities may be described as +3 edema. 4. A moderate amount of edema may be described as +2 to +3 edema. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
20) The nurse reviewing a client record notes a documented finding of "vitiligo present bilateral hands." Which assessment finding should the nurse anticipate? 1. Nodules with ulcerations. 2. Dark, asymmetrical colored patches. 3. Grouped vesicles. 4. Abnormal loss of melanin in patches. Answer: 4 Explanation: 1. The term vitiligo does not indicate the presence of nodules with ulcerations. 2. The term vitiligo does not indicate the presence of dark, asymmetrical colored patches. 3. The term vitiligo does not indicate the presence of grouped vesicles. 4. Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. Page Ref: 182 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
21) The nurse is preparing to assess a client suspected of having a fungal nail infection. Which question should the nurse include in the assessment? 1. "Have you recently been ill?" 2. "Do you submerge your hands in water for long periods of time?" 3. "Have you recently changed anything in your dietary intake?" 4. "Do you take any over-the-counter medications or prescriptions?" Answer: 2 Explanation: 1. Illnesses can cause various changes in the nails such as grooves, ridges, or discoloration. 2. Submerging hands in water for long periods of time is associated with a fungal nail infection. 3. Changing a dietary intake is not associated with fungal nail infections. 4. Over-the-counter medications or prescriptions can cause nail changes but are not related to fungal infections. Page Ref: 178 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview. MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.
22) A mother of a newborn infant calls the clinic and states, "I think my baby has jaundice." Which question should the nurse ask the mother? 1. "Does your baby have tiny, white facial bumps?" 2. "Does your baby's skin and mucous membranes have a yellowish color?" 3. "Does your baby have irregular red patches on the back of the neck?" 4. "Does your baby have dark spots on the area above the buttock?" Answer: 2 Explanation: 1. Milia are tiny, white facial papules due to sebum and will resolve within a few weeks of birth. 2. Yellowing of skin and mucous membranes in an infant who is 3-4 days old is a temporary form of jaundice called physiological jaundice which may require treatment with fluids andphototherapy. 3. Vascular markings are also called stork bites and may be located on the back of the neck. 4. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3: Determine which questions about the skin, hair, and nails to ask for the focused interview. MNL Learning Outcome: 12.2: Plan questions about the skin, hair, and nails for the focused interview.
23) The nurse is preparing to assess a client with darker skin for jaundice. Which assessment technique should the nurse use? 1. Use a bright lamp and a magnifying glass. 2. Press the client's skin and observe for blanching. 3. Assess the skin the same way you would inspect a client with lighter skin. 4. Inspect the lips, oral mucosa, sclera, conjunctivae, and palms. Answer: 4 Explanation: 1. A bright light may assist the nurse but the nurse should inspect the client's lips, oral mucosa, sclera, conjunctivae, and palms when assessing for jaundice. 2. Pressing the client's skin to observe for blanching is not an appropriate skin assessment for jaundice. 3. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae for a client with darker skin. 4. Changes in skin color may be difficult to observe in darker skinned clients. The nurse should inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the skin, hair, and nails. MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.
24) The nurse is assessing the skin of a client with hypothyroidism. Which findings should the nurse anticipate? 1. Excessively smooth skin. 2. Thin, shiny skin. 3. Rough, scaly skin. 4. Diaphoretic skin. Answer: 3 Explanation: 1. Excessively smooth skin is associated with hyperthyroidism. 2. Thin, shiny skin is associated with impaired circulation. 3. A patient with hyperthyroidism may have rough, scaly skin. 4. Diaphoretic skin can be associated with many factors other than hypothyroidism. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
25) The nurse notes an elevated irregular darkened area of excess scar tissue on a client. Which term should the nurse use to document the finding? 1. Ulcer. 2. Keloid. 3. Fissure. 4. Scar. Answer: 2 Explanation: 1. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. This tissue is best described as a keloid. 2. This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. 3. A fissure is a crack in the skin extending to the dermis. This tissue is best described as a keloid. 4. A scar is connective tissue left after healing but is flat and usually linear. This is most likely a keloid, which is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. There is higher incidence in people of African descent. Page Ref: 192 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.5: Generate the appropriate documentation to describe the assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
26) A client that has had abdominal surgery one month prior expresses concern that the scar is "purplish." Which response should the nurse provide? 1. "Having a scar is unavoidable." 2. "The color is normal and will fade with time." 3. "You can have plastic surgery to remove the scar later." 4. "Everyone's skin heals a little bit differently." Answer: 2 Explanation: 1. The client is expressing concern regarding the appearance of the scar and should be reassured the scar will fade over time. 2. New scars may be red or purple in color and will fade to silvery or white over time. 3. Plastic surgery is not performed to remove new scar formation. 4. Everyone does heal a bit differently, but the findings are normal when new scar tissue is forming. Page Ref: 193 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.1: Describe the anatomy and physiology of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
27) The nurse is preparing to assess a client with a stage pressure III ulcer. Which findings should the nurse anticipate? 1. Ulcer involving muscle and bone. 2. Ulcer that extends into the subcutaneous tissue. 3. Involvement of the epidermal skin layer that may extend into the dermis. 4. A reddened area with skin intact and no involvement of the tissues Answer: 2 Explanation: 1. An ulcer involving muscle and bone is descriptive of a stage IV pressure ulcer. 2. An ulcer extended into the subcutaneous tissue is descriptive of a stage III pressure ulcer. 3. An ulcer that involves the epidermal skin layer that may extend into the dermis is descriptive of a stage II pressure ulcer. 4. A reddened area with skin intact and no involvement of the tissues is descriptive of a stage I pressure ulcer. Page Ref: 185 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
28) The nurse is preparing to asses a client with polycythemia. Which assessment finding in the client's nails should the nurse anticipate? 1. Pale. 2. Horizontal white bands. 3. Dark red. 4. A single nail with a darkly pigmented band. Answer: 3 Explanation: 1. Pale and colorless nails are found in clients with peripheral arteriosclerosis or anemia. 2. Horizontal white bands may occur in clients with chronic hepatitis or renal disease. 3. Dark red nails occur in clients with polycythemia. 4. A single nail with a darkly pigmented band may indicate the presence of melanoma. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
29) A client tells the nurse they have been stung by a bee. Which skin assessment findings should the nurse anticipate? 1. Bullae. 2. Plaque. 3. Wheal. 4. Vesicle . Answer: 3 Explanation: 1. Bullae are larger than 0.5 cm and are an elevated, fluid-filled, round or oval shaped, palpable masses with thin, translucent walls and circumscribed borders. Bullae result from friction blisters, contact dermatitis, and large burns. 2. A plaque is an elevated, solid palpable mass with a circumscribed border. Elevated warts, moles, and lichens are plaques. 3. A wheal is an elevated, often reddish area with an irregular border caused by diffuse fluid in tissues and is of varying sizes. Insect bites and hives can form wheals. 4. A vesicle is smaller than 0.5 cm and is an elevated, fluid-filled, round- or oval-shaped, palpable masses with thin, translucent walls and circumscribed borders. Herpes simplex/zoster, early chickenpox, poison ivy, and small burn blisters result in a vesicle. Page Ref: 191 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUsRCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
30) The nurse observes flat bright red dots with tiny radiating blood vessels of various sizes during a skin assessment of an adult client. Which should the nurse document the findings as in the client's record? 1. Spider angioma. 2. Purpura. 3. Hemangioma. 4. Hematoma. Answer: 1 Explanation: 1. A spider angioma is characterized as flat bright red dots with tiny radiating blood vessels of various sizes. 2. Purpura can be described as flat, reddish-blue, irregularly shaped extensive patches of varying sizes. 3. A hemangioma is a bright red raised lesion about 2 to 10 cm in diameter that does not blanch with pressure and is usually present at birth or within a few months of birth. 4. A hematoma is a raised irregularly shaped lesion similar to an ecchymosis except that it elevates the skin and looks like a swelling. Page Ref: 194 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.6: Identify abnormal findings in the physical assessment of the skin, hair, and nails. MNL Learning Outcome: 12.4: Differentiate normal and abnormal variations of the skin, hair, and nails observed during physical assessment.
31) The nurse is preparing a client for a detailed assessment of the integumentary system. Which instruction should the nurse provide the client? Select all that apply. 1. "Please remove all jewelry so that I can conduct a full assessment." 2. "I will turn the temperature down in the exam room before we begin." 3. "Use this blanket to cover up until we are ready to begin." 4. "I will be touching your skin as part of the process." 5. "I will need you to take off your head dress for the entire examination." Answer: 1, 3, 4 Explanation: 1. Jewelry can often hinder the nurse's ability to conduct a complete skin assessment. This statement is appropriate to prepare the client for the exam. 2. The temperature of the room should be warm, yet comfortable. Turning down the temperature without first asking the client's input is not appropriate. 3. It is often necessary to expose certain areas of the skin during the assessment process. A drape should be provided to the client to cover all areas that are not being assessed. This action is appropriate prior to beginning the exam. 4. Palpating the skin is part of an integumentary assessment. It is important to state this to the client before the examination. This statement is appropriate to prepare the client for the exam. 5. While it may be necessary for the client's head dress to be removed during certain portions of the exam, it is not necessary for the entire examination process. This statement does not take the client's cultural background into consideration and is not appropriate. Page Ref: 179 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.4: Outline the techniques for assessment of the skin, hair, and nails. MNL Learning Outcome: 12.3: Utilize the appropriate techniques and tools for physical assessment of the skin, hair, and nails.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 13 Head, Neck, and Related Lymphatics 1) The nurse is preparing to assess a client that is experiencing TMJ discomfort. Which should the nurse be concerned with? Select all that apply. 1. Difficulty swallowing. 2. Difficulty speaking. 3. Difficulty chewing. 4. Decreased tongue motion. 5. Impaired ability to slide the upper jaw. Answer: 2, 3 Explanation: 1. The TMJ is not associated with difficulty swallowing. 2. The TMJ allows a person to open and close the mouth, protract and retract the chin, and slide the lower jaw from side to side. These actions are used for chewing and speaking. 3. The TMJ allows a person to open and close the mouth, protract and retract the chin, and slide the lower jaw from side to side. These actions are used for chewing and speaking. 4. The TMJ is not associated with the movement of the tongue. 5. The upper jaw does not slide. Page Ref: 211 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
2) Which best describes the function of the axis? 1. Carries the skull. 2. Denotes the first cervical vertebrae. 3. Allows for movement of the skull. 4. Connects the skull to the vertebrae. Answer: 3 Explanation: 1. The atlas carries the skull. 2. The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head. 3. The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head. 4. The neck is formed by the seven cervical vertebrae, ligaments, and muscles, which support the cranium. The second cervical vertebra is commonly referred to as the axis. The axis allows for movement of the head. Page Ref: 212 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. |NNULRNSICNoGm pe.CtO enMcies: Knowledge and TB Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics. MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.
3) A client asks the nurse why their lymph node is enlarged. Which response should the nurse provide the client? 1. "Sometimes, enlarged lymph nodes indicate an infection." 2. "All of your lymph nodes should be easily palpable." 3. "The lymph system is making antibiotics to fight infection." 4. "An enlarged lymph node is an abnormal finding." Answer: 1 Explanation: 1. The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes, this indicates that the client has developed an infection. 2. Lymph nodes should not be palpable. 3. The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection. 4. An enlarged lymph node is not necessarily an abnormal finding. Page Ref: 214 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A G ss T Be.sCsOm Ment Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.
4) A client has a history of palpable submental lymph nodes. Which anatomical area should the nurse assess? 1. At the base of the skull. 2. Behind the ear over the outer surface of the mastoid bone. 3. At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw. 4. Behind the tip of the mandible at the midline. Answer: 4 Explanation: 1. The occipital lymph nodes are located at the base of the skull. 2. The posterior auricular lymph nodes are located behind the ear over the outer surface of the mastoid bone. 3. The retropharyngeal lymph nodes are located at the junction of the posterior and lateral walls of the pharynx at the angle of the jaw. 4. The submental lymph nodes are located behind the tip of the mandible at the midline. Page Ref: 214 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics. MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.
5) The client has an enlarged lymph node in front of the right ear. Which should the nurse document the finding as? 1. Right-sided occipital lymph node enlarged. 2. Right-sided submaxillary lymph node enlarged. 3. Right-sided deep cervical lymph node enlarged. 4. Right-sided preauricular lymph node enlarged. Answer: 4 Explanation: 1. The occipital lymph nodes are located at the base of the skull. 2. The submaxillary lymph nodes are located in the medial border of the mandible. 3. The deep cervical lymph nodes are located behind and inferior to the sternocleidomastoid muscle. 4. The preauricular lymph node is located in front of the ear. Page Ref: 215 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.5: Generate the appropriate documentation to describe the assessment of the head, neck, and related lymphaticNsU. RSINGTB.COM MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.
6) The nurse auscultates a bruit in the left temporal artery. Which should the nurse understand is the initial contributing factor to the assessment finding? 1. Increased blood flow. 2. Narrowing of the vessel. 3. Decreased blood flow. 4. Dilated arterial vessel. Answer: 2 Explanation: 1. A bruit is indicative of a narrowing (stenosis) of the arterial vessel. 2. A bruit is indicative of a narrowing (stenosis) of the arterial vessel. 3. A bruit is indicative of a narrowing (stenosis) of the arterial vessel. 4. A bruit is indicative of a narrowing (stenosis) of the arterial vessel. Page Ref: 222 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
7) A client tells the nurse they do not understand how they got Bell's Palsy. Which information should the nurse include in the response? Select all that apply. 1. "One of your cranial nerves has been affected." 2. "This is usually caused by a virus." 3. "This is a temporary disorder." 4. "This is related to a possible stroke." 5. "This condition is related to an autoimmune disorder." Answer: 1, 2, 3 Explanation: 1. Bell's Palsy is a temporary disorder affecting cranial nerve VII (facial) thatproduces unilateral facial paralysis. 2. Bell's Palsy is a temporary disorder affecting cranial nerve VII (facial) that produces unilateral facial paralysis. 3. Bell's Palsy is a temporary disorder affecting cranial nerve VII (facial) that produces unilateral facial paralysis. 4. Bell's Palsy is not related to a stroke. 5. Bell's Palsy is not related to an autoimmune disorder. Page Ref: 228 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. |NNULRNSICNoGm pe.CtO enMcies: Knowledge and TB Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
8) The nurse is teaching a client with a history of migraines about avoiding foods that are rich in tyramine. Which foods should the nurse include in the teaching? Select all that apply. 1. Nuts. 2. Avocados. 3. Corn. 4. Eggs. 5. Onions. Answer: 1, 2, 5 Explanation: 1. Foods rich in tyramine include nuts. 2. Foods rich in tyramine include avocados. 3. Corn does not contain tyramine in it. 4. Eggs does not contain tyramine. 5. Foods rich in tyramine include onions. Page Ref: 288 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
9) A client asks why the nurse is looking at their jugular veins and arteries. Which response should the nurse provide? Select all that apply. 1. I am looking for pulsation. 2. I am looking for distension. 3. I am evaluating placement. 4. I am evaluating the pulse rate. Answer: 2 Explanation: 1. The primary reason for the observation of the carotid arteries and veins is not to observe for pulsation but for distension. 2. Observation of the carotid arteries and veins is important to assess for any distension or prominence, both of which may indicate a vascular disorder. 3. The primary reason for the observation of the carotid arteries and veins is not to evaluate the placement. 4. The primary reason for the observation of the carotid arteries and veins is not to evaluate the pulse rate. Page Ref: 223 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcUeRaSnIdNGqTuaBl.iCtyOM and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
10) The nurse observes involuntary facial muscle movement on a client. Which cranial nerve should the nurse evaluate? 1. Cranial nerve III. 2. Cranial nerve VI. 3. Cranial nerve VII. 4. Cranial nerve IV. Answer: 3 Explanation: 1. Cranial nerve III controls ocular motor movement. 2. Cranial nerve VI controls ocular motor movement 3. Cranial nerve VII controls facial movement. 4. Cranial nerve IV controls ocular motor movement Page Ref: 222 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
11) The nurse is obtaining a focused head and neck interview on a client. Which should the nurse ask the client to assess their internal environment? 1. "Do you use any home remedies?" 2. "Have you ever had irradiation to your neck?" 3. "Have you been exposed to chemicals in the work place?" 4. "Does anyone smoke in the home environment?" Answer: 1 Explanation: 1. Home remedies are reflective of the client's internal environment. 2. Irradiation is an environmental factor. 3. Chemicals in the work place are an environmental factor. 4. Exposure to smoke in home is an environmental factor. Page Ref: 220 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/InNtUeRgSraINteGdTC epts: Nursing Process: Assessment Bo .CnOcM Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview. MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.
12) A client tells the nurse they are experiencing headaches. Which question should the nurse ask the client that best encourages a detailed description? 1. "How long does a typical headache last?" 2. "Do you experience any nausea or vomiting with the headache?" 3. "What seems to relieve the symptoms?" 4. "Do you feel that the headache is triggered by a specific event?" Answer: 1 Explanation: 1. A detailed description of a headache includes the frequency, onset, and duration. Asking how long the headache lasts is part of the information needed to obtain a detailed description of the headache. 2. Nausea and vomiting are symptoms are associated with the headache not a detailed description. 3. Interventions that relieve the symptoms is an assessment for treatment not a detailed description of the headache. 4. Triggering events is an assessment of precipitating factors not a detailed description of the headache. Page Ref: 219 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview. MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.
13) A client tells the nurse that they experience daily headaches. Which should the nurse include in the assessment? Select all that apply. 1. "Rate your pain on a scale from 0 to 10, with 0 being no pain and 10 the worst." 2. "Daily headaches are not of any concern." 3. "Is there anything that relieves the pain, like resting or medication?" 4. "Is the pain sharp, dull, steady, or throbbing?" 5. "Have you had a recent cold or infection?" Answer: 1, 3, 4, 5 Explanation: 1. The nurse should gather as much information about the client's pain as possible. The nurse should gather information about the pain's intensity. 2. Daily headaches can be an indication of a problem. This statement is not appropriate. 3. The nurse should determine if there is anything that helps alleviate the client's pain, such as resting, medication, or exercise. 4. It is important to assess the character of the pain. 5. Sometimes headaches can be associated with recent colds or infections. Page Ref: 231 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.
14) Reviewing a client's record, the nurse notes that the client has a goiter. Which priority question should the nurse include in the focused interview? 1. "Where do you purchase your medication?" 2. "What type of salt do you use in your diet?" 3. "Do you work around chemicals?" 4. "How long have you had this problem?" Answer: 2 Explanation: 1. Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client's past history and present symptomatology. 2. Thyroid disease is common where iodine is limited and deficient amounts of iodine can cause a goiter to develop. Use of iodized salt in the United States has generally eliminated iodine deficiencies. 3. Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client's past history and present symptomatology. 4. Although this question is important to gain general information, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client's past history and present symptomatology. Page Ref: 231-232 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Physiological Adaptation Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3: Determine which questions about the head, neck, and related lymphatics to use for the focused interview. MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.
15) A client asks why they are being asked about tobacco products during a head and neck assessment. Which response should the nurse recognize the primary reason for the question? 1. The use of tobacco results in enlarged lymph nodes. 2. The use of tobacco may cause headaches. 3. The use of tobacco contributes to decreased sense of taste. 4. The use of tobacco may cause a loss of the sense of smell. Answer: 2 Explanation: 1. Enlarged lymph nodes are the result of infection or disease. This is not the primary reason the client is asked about tobacco use. 2. The use of tobacco can affect neurological and neurovascular function and increase headaches. 3. Tobacco does interfere with the sense of taste but this is assessed during a neurological exam. 4. Tobacco can interfere with the sense of smell but this is assessed during a neurological exam. Page Ref: 219 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qTuaBl.iCtyOM and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.2: Plan questions about the head, neck, and related lymphatics for the focused interview.
16) The nurse is preparing to instruct a client to take a drink of water during a head and neck assessment. Which statement should the nurse provide the client? 1. "I am preparing to assess your temporomandibular joint." 2. "I am preparing to assess your lymph nodes." 3. "I am preparing to assess your temporal artery." 4. "I am preparing to assess your trachea." Answer: 4 Explanation: 1. The temporomandibular joint should be inspected and palpated. 2. The lymph nodes are inspected and palpated. 3. The temporal artery can be inspected and palpated. 4. The nurse will ask the client to drink from the glass of water when the nurse is ready to assess the hyoid bone, tracheal cartilage, and thyroid as the client swallows. Page Ref: 224 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
17) The nurse is assessing the client's neck. Which should the nurse recognize is an abnormal finding? 1. The client's carotid arteries are visibly pulsating. 2. The neck is symmetrical. 3. The tracheal cartilage does not move when the client swallows. 4. The thyroid has no palpable nodules. Answer: 3 Explanation: 1. It is normal to note that a client's carotid arteries visibly pulse during inspection of the neck. 2. The neck should be smooth and symmetrical. 3. The tracheal cartilage should move when the client swallows. 4. The thyroid should be free of any nodules and this would be noted during palpation. Page Ref: 223 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
18) The nurse suspects a client has a concussion. Which findings should the nurse expect to support the suspicion? 1. Enlarged lymph nodes. 2. Headache. 3. Blurred vision. 4. Temporal bruits. Answer: 3 Explanation: 1. Enlarged lymph nodes are associated with infection. 2. A headache is associated with many different factors. 3. Blurred vision may be associated with a concussion. 4. A temporal bruit is indicative of the narrowing of a vessel. Page Ref: 218 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
19) The nurse is auscultating the temporal artery and hears a soft blowing sound. Which term should the nurse use to document the findings? 1. Bruit. 2. Murmur. 3. Stenosis. 4. Occlusion .Answer: 1 Explanation: 1. A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. This is an abnormal sound. 2. The sound described is not a murmur, which is heard when auscultating the heart. 3. Stenosis is a medical diagnosis and the nurse should not document any conclusive diagnoses from assessment findings. 4. When a vessel is occluded, there is no associated sound because blood is not flowing through the vessel. Page Ref: 222 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 13.5: Generate the appropriate documentation to describe the assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
20) The nurse is preparing to perform a head and neck assessment on a client with Parkinson's disease. Which finding should the nurse anticipate? 1. Exophthalmos. 2. Facial paralysis. 3. Enlargement of the head. 4. Mask-like expression. Answer: 4 Explanation: 1. Exophthalmos is associated with hyperthyroidism. 2. Facial paralysis is associated with a cerebrovascular accident or Bell's Palsy. 3. An enlargement of the head is associated with hydrocephalus. 4. A mask-like expression occurs with Parkinson's disease. The disease is the result of a decrease in the production of the neurotransmitter dopamine. Page Ref: 230 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
21) The nurse is examining a client's neck. Which techniques should the nurse use to palpate the trachea? Select all that apply. 1. Palpate while the client is swallowing. 2. Slide the thumb and index finger upward on each side of the trachea. 3. Palpate the midline of the neck to feel the cricoid cartilage. 4. Ask the client to open and close their mouth. 5. Stand behind the client and ask them to turn their head slightly to the right. Answer: 1, 2, 3 Explanation: 1. The nurse should confirm that the hyoid bone and tracheal cartilages move up when the client swallows. 2. The nurse should use their thumb and index finger to identify the thyroid cartilage as they slide these fingers up the client's neck. 3. The trachea should be midline. The C rings are also called cricoid cartilage. 4. The client should be asked to open and close their mouth during inspection and palpation of the temporomandibular joint. 5. This position causes the client's neck muscles to relax and is done when palpating the thyroid not the trachea. Page Ref: 223 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenRci 1..CInOtMegrate theories and concepts S IeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
22) The nurse is preparing to palpate the submental lymph node. Which anatomical location should the nurse palpate? 1. Under the chin. 2. At the base of the skull. 3. Behind the tip at the mandible midline. 4. At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw. Answer: 3 Explanation: 1. The submental lymph nodes are behind the tip at the mandible midline. 2. The occipital lymph nodes are at the base of the skull. 3. The submental lymph nodes are behind the tip at the mandible midline. 4. The retropharyngeal (tonsillar) lymph nodes are at the junction of the posterior and lateral walls of the pharynx at the angle of the jaw. Page Ref: 214 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1: Describe the anatomy and physiology of the head, neck, and related lymphatics. MNL Learning Outcome: 13.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics.
23) The nurse is planning care for a client with hypothyroidism. Which should the nurse recognize is a priority nursing diagnosis? 1. Risk for constipation related to metabolic imbalance. 2. Activity intolerance related to fatigue. 3. Risk for injury related to confusion and lethargy. 4. Altered nutrition, less than body requirements. Answer: 2 Explanation: 1. While confusion, lethargy, and constipation are commonly associated with hypothyroidism, the nursing diagnosis statement identifies this as a risk not an actual condition that is actually present. 2. The nursing diagnosis indicates the presence of activity intolerance. Feeling tired, exhausted, and not having enough energy to perform even small tasks is a common finding for clients with hypothyroidism. 3. While confusion, lethargy, and constipation are commonly associated with hypothyroidism, the nursing diagnosis statement identifies this as a risk not an actual condition that is actually present. 4. The client with hypothyroidism typically experiences weight gain. Page Ref: 231 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
24) The nurse is preparing to assess a client with cluster headaches. Which statement made by the client should the nurse recognize supports the diagnosis? 1. "I see flashing lights before my headache starts." 2. "Before I get my headaches, I experience mood changes." 3. "I wake up at night with pain in the side of my face." 4. "My headaches start gradually and the pain is steady." Answer: 3 Explanation: 1. Some client's that have migraines experience neurological symptoms such as flashing lights. 2. Some client's that have migraines experience mood changes. 3. Cluster headaches often begin suddenly at night with an excruciating pain on one side of the face. The pain spreads upward behind one eye. 4. Tension headaches begin with a gradual pain that remains steady. Page Ref: 231 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
25) A client with hypothyroidism tells the nurse they have forgotten to take their medication for the past several days. Which should the nurse assess the client for? 1. Headache. 2. Constipation. 3. Exophthalmos. 4. Cardiac dysrhythmias. Answer: 2 Explanation: 1. A headache is not associated with hypothyroidism, 2. Constipation is associated with hypothyroidism, 3. Exophthalmos is a condition that occurs with hyperthyroidism. 4. Cardiac dysrhythmias are associated with hyperthyroidism. Page Ref: 231 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
26) The nurse is preparing to assess a client's lymph nodes. Which technique should the nurse use? 1. Assessing each side separately. 2. Applying gentle, circular pressure. 3. Applying strong, deep pressure. 4. Attempting to push the nodes into the muscle. Answer: 2 Explanation: 1. Nodes should be palpated on both sides simultaneously for comparison. 2. Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the finger pads of both hands. 3. Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. 4. It is not appropriate to exhibit enough pressure to push the lymph nodes into the client's neck muscles because it makes it more difficult to find the lymph nodes. Page Ref: 225 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A G ss T Be.sCsOm Ment Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
27) A client tells the nurse they are experiencing sudden intermittent headaches after seeing "flashes of light" and experiencing nausea. Which should the nurse suspect the client is experiencing? 1. Migraine headaches. 2. Cluster headaches. 3. Tension headaches. 4. Increased intracranial pressure. Answer: 1 Explanation: 1. Migraine headaches are often preceded by an aura during which the client may feel depressed, restless, or irritable; see spots or flashes of light; and feel nausea. 2. Cluster headaches come in waves over a period of time and then disappear and reappear. 3. Tension headaches occur gradually. 4. The headache associated with increased intracranial pressure is usually sudden and severe and is not intermittent. Page Ref: 231 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
28) A client tells the nurse they have been experiencing "severe headaches intermittently over the past 3 days" that are accompanied with unilateral pain over the right side of their face and nasal congestion. Which should the nurse suspect the client is experiencing? 1. Cluster headache. 2. Classic migraine. 3. Tension headache. 4. Hydrocephalus. Answer: 1 Explanation: 1. Cluster headaches can occur over time. They have no associated aura, are often unilateral, and can be excruciating. Nasal congestion is commonly associated with this type of headache. 2. Migraine headaches are associated with an aura, nausea, tremors, and vertigo. 3. Tension headaches are also known as a muscle contraction headache. The onset for tension headaches is gradual and the pain is steady. 4. Hydrocephalus is not a type of headache. Page Ref: 231 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
29) The nurse assessing a newborn notes an enlarged head with visible prominent scalp veins. Which should the nurse suspect the newborn is experiencing? 1. Craniosynostosis. 2. Hydrocephalus. 3. Acromegaly. 4. Fetal alcohol syndrome. Answer: 2 Explanation: 1. Craniosynostosis is early closure of the sutures, which causes head elongation. 2. Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid. 3. Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant. Acromegaly is usually found in adult clients. 4. Fetal alcohol syndrome causes specific types of facial deformities such as a small head circumference, small widely spaced eyes, and a flat mid-facial area. Page Ref: 230 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMDiagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
30) The nurse is preparing to assess an adult client suspected of having hyperthyroidism. Which assessment findings does the nurse anticipate? Select all that apply. 1. Blood pressure: 162/92 mmHg. 2. Apical pulse: 120 bpm. 3. Respiratory rate of 14 breaths per minute. 4. Constricted pupils. 5. Temperature of 100.1°F Answer: 1, 2, 5 Explanation: 1. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client's blood pressure increases. The normal blood pressure range for an adult is 120/80 mmHg to 140/90 mmHg. 2. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client's heart rate will increase. A normal heart rate for an adult client is 60-100 beats per minute. 3. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 12-20 breaths per minute. This client has a normal respiratory rate which is not associated with symptomatic hyperthyroidism. 4. The client with hyperthyroidism will present with dilated pupils. 5. When the sympathetic nervous system is stimulated due to hyperthyroidism, the client's body temperature will increase. A normal temperature range is from 97°F to 99°F. Page Ref: 231 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 13.6: Identify abnormal findings in the physical assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.4: Differentiate normal and abnormal variations of the head, neck, and related lymphatics observed during physical assessment.
31) The nurse is preparing to assess a client's thyroid. Which information should the nurse provide the client prior to the assessment? 1. "Please lie down while I assess your thyroid gland." 2. "When I assess your thyroid gland, you can expect to feel strong pressure." 3. "I will stand behind you while palpating your thyroid gland." 4. "Please chew this mint so that I can assess your thyroid gland." Answer: 3 Explanation: 1. The client is either asked to sit on the exam table or stand up during a thyroid gland assessment. Lying down will not allow the nurse to complete an accurate assessment of the thyroid gland. 2. The nurse will apply light pressure, not strong pressure, during thyroid gland palpation. 3. The nurse will stand behind the client while palpating the thyroid gland. 4. The nurse would ask the client to swallow water to distinguish the thyroid from other structures. Chewing a mint would be appropriate to assess certain cranial nerves. Page Ref: 224 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G NTuBrs.C inOgMAssessment Learning Outcome: 13.4: Outline the techniques for assessment of the head, neck, and related lymphatics. MNL Learning Outcome: 13.3: Utilize the appropriate techniques and tools for physical assessment of the head, neck, and related lymphatics.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 14 Eyes 1) A client asks the nurse why it is important to protect their eyes from the sun. Which response should the nurse provide to the client? 1. Excessive sun exposure places you at risk for cataracts. 2. Excessive sun exposure places you at risk for night blindness. 3. Excessive sun exposure places you at risk for increased intraocular pressure. 4. Excessive sun exposure places you at risk for excessive corneal dryness. Answer: 1 Explanation: 1. Excessive sun exposure places the client at risk for cataract formation. 2. A dietary deficiency of vitamin A can cause night blindness. 3. Some medication can increase intraocular pressure. 4. Some medication can cause excessive corneal dryness. Page Ref: 242 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Context and Environment: Environmental health; heaNltUhRpSrIN om disease prevention (e.g., transmission of GToBti.o Cn O/M disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
2) The nurse notes that a client is unable to control the amount of light that enters the eye. Which structure's dysfunction is the most likely cause of this problem? 1. Cornea. 2. Sclera. 3. Conjunctiva. 4. Iris. Answer: 4 Explanation: 1. The cornea is the window of the eye. It is the clear, transparent part of the sclera and forms the anterior one-sixth of the eye. 2. The sclera supports and protects the structures of the eye. 3. The conjunctiva protects the eye and produces a lubricating fluid that prevents the eye from becoming too dry. 4. The iris responds to the light coming through the cornea by making the pupil larger or smaller, thereby controlling the amount of light that enters the eye. Page Ref: 237 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: Ev on G TaBlu .CaOtiM Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
3) The nurse has elicited a blink reflex in a client. Which structure of the eye is responsible for the reflex? 1. Lens. 2. Macula. 3. Cornea. 4. Iris. Answer: 3 Explanation: 1. The lens is located directly behind the pupil and is used to refract light through the eye. 2. The macula is located within the retina and does not assist with light refraction. 3. The cornea is a transparent part of the eye and is located anteriorly. The extensive nerve endings in the cornea are responsible for the blink reflex. 4. The iris controls the amount of light that enters the eye but is not associated with refraction. Page Ref: 237 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
4) The nurse taught the client how to self-administer eye drops. During the return demonstration, the client inadvertently touched the applicator to their cornea, which caused the client to blink and produce tears. Which term should the nurse describe the reflex elicited by the client? 1. Abnormal and should be reported to the healthcare provider. 2. Hyperactive. 3. A medication side effect. 4. A normal response. Answer: 4 Explanation: 1. When the cornea is touched, the eyelids blink and tears are produced. The cornea contains many nerve endings and this action would produce a painful sensation for the client. This is not an abnormal response. 2. This would not be noted as a hyperactive response. 3. This is not due to a medication side effect. 4. This is a normal response because the cornea is very sensitive. Page Ref: 237 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5: Generate the appropriate documentation to describe the assessment of the eyes. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
5) A client asks the nurse what is the name of the structure of the eye that is colored. 1. Optic disc. 2. Iris. 3. Cornea. 4. Sclera. Answer: 2 Explanation: 1. The optic disc is an internal structure in the eye. 2. The iris is the circular colored, muscular aspect of the eye and is located in the anterior portion of the eye. 3. The cornea is the clear transparent part of the sclera. 4. Sclera is the white fibrous part of the eye. Page Ref: 237 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
6) The nurse is preparing to review the secondary sources of data for a patient with glaucoma. Which diagnostic testing should the nurse anticipate to be included? 1. Tonometry. 2. Ultrasonography. 3. Fluorescein angiography. 4. Refraction test. Answer: 1 Explanation: 1. Glaucoma is caused by increased ocular pressure. Tonometry measures intraocular pressure. 2. Ultrasonography does not measure the pressure in the eye. Ultrasound is used for imaging. 3. Fluorescein angiography is used to assess the blood flow throughout the eye. 4. A refraction test is a visual test that allows the healthcare provider to identify the prescription needed for correct vision. Page Ref: 242 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Assess adaptation of a client to health alteration, illness, and/or disease. Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care: patient/family/community preferences, values; coordination and integration of care; information, communication, and education; physical comfort and emotional support; involvement of family and friends; and transition and continuity. | AACN Essentials Competencies: IX.1. Conduct cNoUmRpSIrNehGeTnBs.C ivOeMand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview. MNL Learning Outcome: 14.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes.
7) The nurse is preparing to perform the cover and uncover test on a client. Which explanation will the nurse provide the client prior to performing the exam? 1. This will test the muscles that control your eye movement. 2. This will test the ability of your pupil size to change. 3. This will test the balance mechanism that keeps your eyes parallel. 4. This will test the ability of your eyes to focus on distant objects. Answer: 3 Explanation: 1. The cover and uncover test does not test the ability of the pupil size to change. 2. The cover and uncover test does not test the ability of the pupil size to change. 3. The cover and uncover test determines the balance mechanism (fusion reflex) that keeps the eyes parallel. 4. The cover and uncover test does not assess a client's ability to focus on distant objects. Page Ref: 252 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of diseaseN, UdR isSeIaNsGeTpBa.tCtO erMns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4: Outline the techniques for assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
8) The nurse is assessing the eyes of an older adult client. Which finding is expected by the nurse based on the client's age? 1. The client has difficulty reading from a paper held at far range without corrective glasses. 2. There is a noticeable increase in fat within the orbit of the eye. 3. The client states that they feel that their tear production has increased over the years. 4. The client is unable to clearly read from a paper held at close range. Answer: 4 Explanation: 1. Myopia is the inability to see things clearly unless they are close to the eyes and is a common condition for clients under 40 years of age. 2. There is a decrease in the amount of fat in the orbit of the eye, which produces a drooping appearance of the eye. 3. Older adults experience a decrease in lacrimal secretions. 4. Presbyopia is the inability to accommodate for near vision and is common in clients over 45 years of age. Page Ref: 249 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
9) The nurse is performing a visual examination on a client with complaints of black dots appearing in the visual field. Which statement by the nurse is most appropriate in this situation? 1. "The black dots are known as floaters and are usually normal." 2. "We need to refer you to an eye surgeon immediately." 3. "You may have glaucoma." 4. "You may have a cataract." Answer: 1 Explanation: 1. Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. 2. Floaters are considered normal unless they obstruct vision, so they should not be immediately referred to a healthcare provider. 3. Halos around lights are associated with glaucoma. 4. Floaters are not seen with cataracts. Page Ref: 244 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; and family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
10) A client tells the nurse they see halos around light. Which question should the nurse ask the client? 1. "Do you take any routine medications?" 2. "Do you wear corrective lenses?" 3. "Have you experienced any eye trauma?" 4. "When was your last eye examination?" Answer: 1 Explanation: 1. Seeing halos around lights are associated with digitalis toxicity. 2. While it is important to assess the client's need for corrective lenses, this is not directly related to the client's visual symptoms. 3. Eye trauma is not directly associated with seeing halos around lights. 4. It is important to evaluate the client's history of eye exams, but this is not helpful in directly determining the client's visual symptoms. Page Ref: 244 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
11) A client tells the nurse they are experiencing blurred vision. Which initial question should the nurse ask the client? 1. "Can you describe your vision?" 2. "Are you experiencing double vision?" 3. "Have you recently had any eye pain?" 4. "What kinds of activities do you perform at work?" Answer: 1 Explanation: 1. A focused interview should begin with open-ended questions that provide the client the opportunity to describe their own perception about their experience. 2. Asking about double vision is a closed-ended question. 3. Asking about eye pain is a closed-ended question. 4. Obtaining information about work activity is not a priority question. Page Ref: 242 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview. MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.
12) During an eye assessment, a young adult client reports difficulty seeing items within close range. This assessment data is consistent with which factor? 1. Aging. 2. Presbyopia. 3. Hyperopia. 4. Astigmatism . Answer: 3 Explanation: 1. Aging can produce changes in the eye but this client is 24 years old. 2. Presbyopia is an age-related condition. The lens loses its ability to accommodate viewing items at close range. 3. Younger clients who are unable to see items well at close range have a condition called hyperopia. This condition is also referred to as farsightedness. 4. Astigmatism occurs when light is refracted over a wide area rather than on a distinct area of the retina. Page Ref: 262 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
13) The nurse is reviewing the records of a client with astigmatism. Which visual changes should the nurse anticipate? 1. Double vision. 2. Presence of floaters. 3. Decreased field of vision. 4. Inability to see things at a close range. Answer: 1 Explanation: 1. With astigmatism, the refraction of light is spread over a wide area rather than on a distinct point on the retina. A client with astigmatism may experience blurred or double vision. 2. Floaters are considered normal unless they obstruct vision. 3. Changes in visual fields accompany damage to the retina, lesions in the optic nerve or chiasm, increased intraocular pressure, and retinal vascular damage. 4. The inability to see things at a close range is a common finding in clients over age 45. Page Ref: 262 Cognitive Level: Understanding Client Need & Sub: Physiological Integrity; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
14) During an eye examination, the nurse requests that the client read letters located on the Snellen E chart. The client's vision is determined to be 20/200. Which statements regarding this client's vision are accurate? Select all that apply. 1. The client is legally blind. 2. The client is unable to read from a paper at close range. 3. The client is found to be farsighted. 4. The client is myopic. 5. This is common in clients who are over 45 years old. Answer: 1, 4 Explanation: 1. When a client's vision is found to be 20/200, the client is legally blind. 2. The Snellen E chart assists with determining if the client is able to see items in the distance. 3. Clients who are farsighted are able to see things in the distance. This client is unable to see near objects. 4. Clients who are myopic are unable to see objects in the distance. 5. Presbyopia is the inability to see items at close range. This condition is more common in people who are over 45 years old. Page Ref: 248 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
15) The nurse is assessing a client's visual fields by confrontation. Which actions by the nurse indicate appropriate practice? Select all that apply. 1. The nurse asks the client to cover one of her eyes with a card. 2. The nurse uses a penlight to assist with performing the test. 3. The nurse asks the client to sit 20 feet away. 4. The client tells the nurse when she first sees the object. 5. The nurse asks the client to stand 4 feet away. Answer: 1, 2, 4 Explanation: 1. Confrontation to test visual fields is done by asking the client to cover one eye with a card while the nurse covers the eye opposite to the client. 2. The nurse and client sit 2-3 feet away from each other, at eye level. An object such as a pen or penlight is advanced from the periphery to the midline. Both the client and the nurse should be able to see the object at the same time. 3. The nurse and client should sit only 2-3 feet away from each other. 4. The client should tell the nurse when she first sees the object in her peripheral vision. 5. The nurse and client should sit only 2-3 feet away from each other. Page Ref: 249, 250 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.4: Outline the techniques for assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
16) A client tells the nurse they experience double vision. Which question should the nurse ask the client? 1. "Do you take any medications?" 2. "Do you have a history of hyperthyroidism?" 3. "Do you have a history of diabetes?" 4. "Do you have a history of renal disease?" Answer: 1 Explanation: 1. Some medications may cause double vision. 2. Hyperthyroidism is not associated with double vision. 3. Diabetes is not associated with double vision. 4. Renal disease is not associated with double vision. Page Ref: 244 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview. MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview. 17) The nurse reviewing the records of a client notes there is a diagnosis of nystagmus. Which should the nurse recognize is a causative factor of the condition? 1. Eye infection. 2. The development of cataracts. 3. Weakness in the extraocular muscles. 4. Inability of the lens of the eye to accommodate. Answer: 3 Explanation: 1. An eye infection does not directly cause nystagmus. 2. Cataracts do not cause nystagmus. 3. Nystagmus can result from a weakness of the extraocular muscles. 4. An inability of the lens of the eye to accommodate is a condition known as presbyopia. Page Ref: 251 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment. 18) The nurse is assessing the client's vision. Which information should the nurse provide the client? 1. "I am going to perform this test with you standing." 2. "You may leave your glasses on during the exam." 3. "I am going to have you close your covered eye." 4. "I will have you stand 20 feet from the chart." Answer: 4 Explanation: 1. The test can be performed with the client sitting or standing. 2. The client should be tested with their glasses on and then again with their glasses off. 3. The client should be instructed not to close or apply pressure to their covered eye. 4. The client will be tested 20 feet from the chart. Page Ref: 247 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G AsTsBe.sCsOmMent Learning Outcome: 14.4: Outline the techniques for assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
19) The nurse is assessing the fundus of the older adult client's eye with an ophthalmoscope. The nurse determines that there is a cyst within the macula. Which client symptom does the nurse anticipate? 1. Impaired central vision. 2. Impaired peripheral vision. 3. Consistently elevated serum glucose levels. 4. Uncontrolled hypertension. Answer: 1 Explanation: 1. Degeneration of the macula can be related to cysts located in this area. It is more common in older adults and results in impaired central vision. 2. Impaired peripheral vision can be related to problems with the rods that are located in the retina. 3. Elevated serum glucose levels may be associated with diabetic retinopathy. 4. Uncontrolled hypertension can be associated with hypertensive retinopathy. Page Ref: 259 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G DTiaBg.nCoOsM is Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
20) The nurse is preparing to visually inspect a client's eye. Which should the nurse anticipate to note? Select all that apply. 1. Clear lens. 2. Moist conjunctiva. 3. White Sclera. 4. Round irises. 5. Clear cornea. Answer: 1, 2, 3, 4 Explanation: 1. The lens should be clear. 2. The conjunctiva should be moist. 3. The sclera should be white. 4. The irises should be round. 5. The cornea cannot be visually inspected. The cornea is inspected by shining a penlight from across the cornea. Page Ref: 253 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: A G ss T Be.sCsOm Ment Learning Outcome: 14.1: Describe the anatomy and physiology of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
21) The nurse is assessing a client's eyes during a comprehensive health assessment. Which assessment finding would require immediate intervention? 1. Acute glaucoma. 2. Blepharitis. 3. Periorbital edema. 4. Anisocoria .Answer: 1 Explanation: 1. Acute glaucoma results from a sudden increase in intraocular pressure caused by a blockage in fluid flow around the anterior chamber. Acute glaucoma requires immediate interventions to prevent further eye damage. 2. Blepharitis is when the eyelid becomes inflamed. The eye burns, itches, and tears but does not require an immediate intervention. 3. Periorbital edema is when the eyelid becomes puffy and swollen. It can be related to crying, infection, or systemic problems. It does not require an immediate intervention. 4. Anisocoria refers to unequal pupil size, which may be a normal finding or it may indicate that the client has a central nervous system disease. Page Ref: 258 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. |NNULRNSICNoGm pe.CtO enMcies: Knowledge and TB Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
22) The nurse is performing the cover test and notes inward turning of the client's eye. Which term will the nurse use to document this finding? 1. Exophoria. 2. Strabismus. 3. Esophoria. 4. Mydriasis . Answer: 3 Explanation: 1. Exophoria is when the eye turns outward during the cover test. 2. Strabismus is when the axes of the eye cannot be directed at the same object. 3. Esophoria is when the eye turns inward during the cover test. 4. Mydriasis refers to fixed and dilated pupils. Page Ref: 264 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.5: Generate the appropriate documentation to describe the assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
23) After a comprehensive eye examination, it is determined that the client requires corrective lenses for myopia. Which explanation by the nurse to the client is the most appropriate? 1. "Your glasses will help you to see objects in the distance." 2. "Your glasses will help you to see objects that are very close to you." 3. "Your glasses will help you to improve your eyes' ability to focus and reduce your blurred vision." 4. "Your age has made it more difficult to read items that are at close range. Your new glasses will help." Answer: 1 Explanation: 1. Myopia is the inability to see objects in the distance. 2. Hyperopia is the inability to see objects at close range. 3. Astigmatism causes blurred or double vision when the eyes attempt to focus. 4. Presbyopia causes the client to experience difficulty focusing on items that are at close range. Presbyopia affects people who are over 45 years old. Page Ref: 262 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G ImTpBl.eCm entation OM Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
24) The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. Which conclusion by the nurse is the most appropriate? 1. Cranial nerve III may not be functioning appropriately. 2. This is a normal finding. 3. This is evidence of increased intracranial pressure. 4. This is evidence of optic nerve damage. Answer: 1 Explanation: 1. When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III. 2. This is not a normal finding. 3. Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped. 4. This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client's visual fields. Page Ref: 260 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
25) During the assessment of a client's eyes, the nurse suspects the client has entropion. Which assessment data caused the nurse to come to this conclusion? 1. Eversion of the lower eyelid. 2. Inversion of the lid and eyelashes. 3. Swollen, red hair follicles. 4. Firm, non-tender nodule on the eyelid. Answer: 2 Explanation: 1. Ectropion is eversion of the lower eyelid caused by muscle weakness. 2. Entropion is inversion of the lid and lashes caused by a muscle spasm of the eyelid. 3. A stye causes swelling and redness in the affected eye. A stye is a result of a staphylococcal infection of hair follicles on the margin of the lids. 4. A chalazion is a firm, non-tender nodule on the eyelid. Page Ref: 256 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: DifferentNiaUteRSnIoNrGmTaBl.C anOdMabnormal variations of the eyes observed during physical assessment. 26) During the assessment of a client's eyes, the nurse suspects that the client has ptosis. Which assessment data caused the nurse to come to this conclusion? 1. The palpebral conjunctiva is exposed. 2. The iris and cornea are reddened. 3. The eyelid is drooping. 4. The eyelids are swollen and puffy. Answer: 3 Explanation: 1. Ectropion is eversion of the lower eyelid caused by muscle weakness that produces exposure of the palpebral conjunctiva. 2. Iritis is characterized by redness of the iris and cornea. 3. Ptosis is drooping of the eyelid. 4. Periorbital edema refers to swollen, puffy eyelids. Page Ref: 256 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment. 27) The nurse notes a client has an absence of the lateral third of the eyebrow. Which question should the nurse ask the client? 1. "Do you have a history of cardiovascular disease?" 2. "Do you have a history of obsessive-compulsive disorder?" 3. "Do you have a history of thyroid disease?" 4. "Do you have a history of diabetes?" Answer: 3 Explanation: 1. Cardiovascular disease is not associated with the absence of the lateral third of the eyebrow. 2. Obsessive-compulsive disorder is not associated with the absence of the lateral third of the eyebrow. 3. Hyperthyroidism is associated with the absence of the lateral third of the eyebrow. 4. Diabetes is not associated with the absence of the lateral third of the eyebrow. Page Ref: 253 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN RSINGTB.C OM Essentials Competencies: IX.1. Conduct cNoUm prehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3: Determine which questions about the eyes to use for the focused interview. MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.
28) The nurse notes there is a lack of convergence when testing a client's accommodation. Which cranial nerves should the nurse recognize are potentially dysfunctional? Select all that apply. 1. II. 2. III. 3. VII. 4. IV. 5. VI. Answer: 2, 4, 5 Explanation: 1. Cranial nerve II is the optic nerve, which is not associated with convergence. 2. Cranial nerve III is the oculomotor nerve, which is associated with convergence. 3. Cranial nerve VII is the facial nerve, which is not associated with convergence. 4. Cranial nerve IV is the trochlear nerve, which is associated with convergence. 5. Cranial nerve VI is the abducens nerve, which is associated with convergence. Page Ref: 254 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
29) The nurse examining the eyes of a client notes bilateral subconjunctival hemorrhage. Which next action should the nurse take? 1. Obtain a culture. 2. Assess the client's blood pressure. 3. Inquire about allergies. 4. Assess the client's blood glucose. Answer: 2 Explanation: 1. Bilateral subconjunctival hemorrhage is not associated with infection. 2. Bilateral subconjunctival hemorrhage is caused by ruptured blood vessels and can be associated with hypertension. 3. Bilateral subconjunctival hemorrhage is not associated with allergies. 4. Bilateral subconjunctival hemorrhage is not directly associated with abnormal blood glucose that occurs in diabetes. The diabetes may damage the blood vessels resulting in hypertension which directly can cause bilateral subconjunctival hemorrhage. Page Ref: 257 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.2: Plan questions about the eyes to use for the focused interview.
30) The nurse is preparing to assess the vision of a 5-year-old child. Which Snellen chart is most appropriate for the nurse to use? 1. Chart with letters. 2. Chart with symbols. 3. Chart with numbers. 4. Chart with pictures. Answer: 4 Explanation: 1. The child may not recognize the letters. 2. The child may understand how to communicate using the symbols. 3. The child may not recognize the numbers. 4. The Snellen chart with pictures is most appropriate to use for a 5-year-old child. Page Ref: 248 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.4: Outline the techniques for assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
31) The nurse is performing a focused interview and eye assessment on a client. Which assessment findings indicate the client's is experiencing a vision problem? Select all that apply. 1. The client is frowning and squinting while she is reading the Snellen chart. 2. The client exhibits a symmetrical pupillary light reflex response. 3. As the nurse checks for accommodation, the pupils remain dilated. 4. The client's near vision acuity is 14/14 bilaterally. 5. When the cornea is lightly touched in the right eye, both eyelids close. Answer: 1, 3 Explanation: 1. If the client is frowning or squinting during the test of their ability to see distant objects, this is indicator that the client may be experiencing visual problems. 2. Symmetrical pupillary responses are normal. 3. When checking accommodation, the eyes should converge and the pupils should constrict as the eyes focus on the penlight. 4. The normal result for near vision is 14/14 in each eye. 5. When testing the corneal reflex, touch the eye gently and quickly with a wisp of cotton. The client will react by blinking both eyes. If one or both eyes fail to respond, there could be a problem. Page Ref: 242, 253 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
32) The nurse is preparing to test the near vision of a client. Which instructions should the nurse include? 1. Hold the chart 12 to 14 inches from the eyes. 2. Instruct the client to initially read the smallest line they can see. 3. Request the client to remove corrective lenses for reading prior to the exam. 4. Initially, have the client read the lines prior to covering a single eye at a time. Answer: 1 Explanation: 1. To test near vision, the client should be instructed to hold the Jaeger or Rosenbaum chart 12 to 14 inches from their eyes. 2. The client should be instructed to read the letters from the top of the card down to the smallest line they can see. 3. If the client uses corrective lenses for reading, they should be tested with them on. 4. The client should initially be asked to cover one eye with an opaque card or eye cover and then repeat the test with the other eye and then with both eyes uncovered. Page Ref: 248 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.4: Outline the techniques for assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
33) The nurse notes that a client's pupils are fixed and dilated. Which should the nurse suspect has occurred? 1. Damage to the pons. 2. Syphilis. 3. Glaucoma. 4. Monocular blindness. Answer: 3 Explanation: 1. Miosis occurs when the pons is damaged. Miosis is characterized by fixed and constricted pupils. 2. Small, irregular pupils that exist bilaterally and are nonreactive to light are associated with syphilis. This condition is known as Argyll Robertson pupils. 3. Mydriasis is characterized by pupils that are fixed and dilated. Glaucoma can cause this condition. Other conditions associated with mydriasis are sympathetic nerve stimulation, CNS damage, or deep anesthesia. 4. Monocular blindness is characterized by a direct consensual response to light directed in the normal eye and absence of response in either eye when the light is directed into the blind eye. Page Ref: 260 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14.6: Identify abnormal findings in the physical assessment of the eyes. MNL Learning Outcome: 14.4: Differentiate normal and abnormal variations of the eyes observed during physical assessment.
34) Prior to conducting an eye assessment, which statement by the nurse is appropriate to prepare the client for the examination process? 1. "You can choose which eye to cover during your assessment." 2. "Are you able to read English words?" 3. "Apply pressure to the eye while it is covered during the examination." 4. "You will need to stand 10 feet from the chart for an accurate assessment." Answer: 2 Explanation: 1. The nurse should instruct which eye to cover during the examination process. It is not always appropriate to allow the client to choose. 2. It is important to determine if the client is able to read prior to initiating an eye assessment. Clients who cannot read should have their vision assessed using a chart with pictures. 3. While covering the eye during the examination, the client should be discouraged from applying pressure to the eye. 4. When using the Snellen chart for an eye assessment, the client should stand 20 feet from the chart for an accurate assessment. Page Ref: 242 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.C enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the eyes. MNL Learning Outcome: 14.3: Utilize the appropriate techniques and tools for physical assessment of the eyes.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 15 Ears, Nose, Mouth, and Throat 1) A client asks the nurse what part of the ears becomes blocked with pressure when they travel on an airplane. Which structure of the ear should the nurse be prepared to discuss? 1. Tympanic membrane. 2. Ossicles. 3. Cochlea. 4. Eustachian tube. Answer: 2 Explanation: 1. Sound waves initially strike the tympanic membrane causing it to vibrate transferring the vibration to the ossicles. 2. The ossicles transfer vibration. 3. This is the cochlea in the inner ear that contains receptors for hearing. 4. The eustachian tube helps equalize air pressure on both sides of the tympanic membrane. The tubes can become blocked causing the client to have a sensation of increased pressure. Sound waves initially strike the tympanic membrane causing it to vibrate transferring the vibration to the ossicles. This is the cochlea in the inner ear that contains receptors for hearing. Page Ref: 268 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1: Describe the anatomy and physiology of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
2) A client with recent cerebrovascular accident (CVA) is no longer able to smell. Which cranialnerve assessment should the nurse anticipate to include in the documentation? 1. Cranial nerve I. 2. Cranial nerve XII. 3. Cranial nerve VIII. 4. Cranial nerve VII. Answer: 1 Explanation: 1. The sense of smell is controlled by cranial nerve I. 2. Tongue movement is controlled by cranial nerve XII. 3. Hearing and balance is controlled by cranial nerve VIII. 4. The sense of taste is controlled by cranial nerves VII and IX. Page Ref: 290 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.5: Generate the appropriate documentation to describe the assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. 3) The nurse is preparing to assess the ventral surface of the tongue. Which should the nurse anticipate to find? 1. Papillae. 2. Parotid salivary glands. 3. Smooth vascular tissue. 4. Frenulum. Answer: 3 Explanation: 1. The papillae are on the dorsal surface of the tongue. 2. The parotid salivary glands are situated anterior to the ear within the cheek. 3. Smooth vascular tissue is on the ventral surface of the tongue. 4. The frenulum attaches the anterior portion of the tongue to the floor. Page Ref: 271 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 15.1: Describe the anatomy and physiology of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. 4) The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract? 1. Olfactory cells. 2. Columella. 3. Turbinates. 4. Nares. Answer: 3 Explanation: 1. The olfactory cells assist the client to smell. 2. The columella is located at the base of the nose and helps form the nares. 3. The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs. 4. The nares are structures that lead into the internal vestibule and nasal cavity. Page Ref: 270 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1.NDUeRmSIN onGstTrBa.tCeOkM nowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1: Describe the anatomy and physiology of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
5) Which structure attaches the tongue to the floor of the mouth? 1. Hard palate. 2. Papillae. 3. Frenulum. 4. Alveoli sockets. Answer: 3 Explanation: 1. The hard palate is the anterior portion of the roof of the mouth. 2. The papillae contain the taste buds and assist with moving food within the mouth. The papillae are located on the dorsal surface of the tongue. 3. The frenulum connects the anterior portion of the tongue to the floor of the mouth. 4. The alveoli sockets contain the teeth within the mandible and maxilla. Page Ref: 271 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1: Describe the anatomy and physiology of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
6) The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client? Select all that apply. 1. Increasing risk of developing otitis externa. 2. Developing tophi along the outer rim of the ears. 3. Perforating the tympanic membrane. 4. Needing tympanostomy tubes. 5. Impacting cerumen. Answer: 3, 5 Explanation: 1. Otitis externa is an infection of the client's outer ear. This client does not have an increased risk of developing otitis externa. 2. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. 3. This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. 4. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes. 5. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Page Ref: 276 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
7) A client tells the nurse they are experiencing pain and noticed some drainage from their left ear. Which objective finding indicates the client may have developed acute otitis media? 1. Reddened ear canal. 2. Clear watery drainage. 3. Mucus-like drainage. 4. Yellowish-reddish drainage. Answer: 4 Explanation: 1. When the client complains that the ear canal is inflamed, painful, and with erythema, this indicates that the client may have developed otitis externa. 2. Clear drainage from the ear may indicate that the client has developed a cerebrospinal fluid leak following trauma. 3. Serous drainage can indicate that the client has developed drainage from the ears as a result of allergies. 4. The client with acute otitis media will state that he is experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent. Page Ref: 275 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
8) The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? Select all that apply. 1. Streptomycin. 2. Steroid inhalers. 3. Aspirin. 4. Neomycin. 5. Acetaminophen. Answer: 1, 3, 4 Explanation: 1. Streptomycin is an antibiotic that can cause hearing loss. 2. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa. 3. Aspirin can cause ringing in the ears. 4. Neomycin is an antibiotic that can cause hearing loss. 5. Acetaminophen is not associated with hearing loss. Page Ref: 276 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.2. Plan questions about the ears, nose, mouth, and throat for the focused interview.
9) The client has developed anosmia. The nurse educates the client about the possible causes of this condition. Which topics are appropriate for the nurse to include in the teaching session with the client? Select all that apply. 1. Commonly associated with gingivitis. 2. Possibly linked to heredity. 3. Related to a diet deficient in zinc. 4. An indicator of a neurological problem. 5. Caused by dental caries. Answer: 2, 3, 4 Explanation: 1. Anosmia is the inability to smell. It is unrelated to gingivitis. Clients with gingivitis often complain of a bad taste in their mouth. 2. Anosmia is the inability to smell. Anosmia may be related to genetic makeup. 3. Anosmia is the inability to smell. Anosmia may be related to a diet that is deficient in food containing zinc. 4. Anosmia is the inability to smell. Anosmia may be related to a neurological disorder. 5. Anosmia is the inability to smell. It is unrelated to dental caries. Anosmia is not related to dental caries. Page Ref: 277 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N.GCToBn.dCuOcMt comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
10) The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action? 1. Requesting information from the client regarding any chronic allergies. 2. Testing the drainage for glucose. 3. Asking the client if there have been recent middle ear infections. 4. Irrigating the ear with warm mineral oil or peroxide and flushing with warm water. Answer: 2 Explanation: 1. Chronic allergies would not result in clear fluid draining from the client's ear. However, an acute allergic reaction may result in serous fluid that drains from the client's ear. 2. When a client's ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid. 3. A recent middle ear infection may result in purulent or bloody drainage from the client's ear. 4. The ear should not be irrigated at this time. Irrigation with warm mineral oil, peroxide, and flushing with warm water is often used to remove cerumen. There is nothing to suggest that the client has impacted cerumen. Page Ref: 275 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
11) The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect? 1. Acute otitis media. 2. Recent trauma. 3. Blocked eustachian tubes. 4. History of frequent middle ear infections. Answer: 2 Explanation: 1. Acute otitis media is associated with a reddish or yellowish tinge on the tympanic membrane. 2. The presence of a darkened area on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent trauma. 3. A blocked Eustachian tube will cause the tympanic membrane to retract. 4. Previous middle ear infections will result in white patches noted on the tympanic membrane that indicate scarring. Page Ref: 293 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G DTiaBg.nCoOsM is Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
12) The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. Which action by the nurse is appropriate in this situation? 1. Pull the pinna up and back and then reinsert the otoscope. 2. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 4. Pull the pinna down and back and then reinsert the otoscope. Answer: 1 Explanation: 1. To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization. 2. The client should be instructed to state any feelings of discomfort or pain but not to pull away because this may result in injury during this examination. 3. The otoscope should not be inserted quickly and should not be pressed against either side of the inner auditory canal because it would be painful for the client. 4. Pulling down and back is recommended in children because of the shape of their auditory canal. Page Ref: 280 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.4: Outline the techniques for assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.3. Utilize the appropriate techniques and tools for physical assessment of the ears, nose, mouth, and throat.
13) The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Select all that apply. 1. Irrigating with warm mineral oil, peroxide, and flushing with warm water. 2. Inserting a sharp instrument to break up the ear wax. 3. Irrigating with a cold solution. 4. Inserting a cerumen spoon to remove the wax. 5. Irrigating with warm sudsy water. Answer: 1, 4 Explanation: 1. Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. 2. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. 3. Cold solutions may harden the ear wax, making it more difficult to remove. 4. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. 5. Warm, sudsy solutions may irritate the ear canal. Page Ref: 281 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.3. Utilize the appropriate techniques and tools for physical assessment of the ears, nose, mouth, and throat.
14) During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? Select all that apply. 1. The nurse notes that the nasal septum has perforated. 2. Temporomandibular joint pain when the client opens and closes the mouth. 3. The septum is noted to be very pale in color. 4. Yeast infection of nasal mucosa and in mouth. 5. Difficulty swallowing water. Answer: 1, 3 Explanation: 1. When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated. 2. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. 3. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color. 4. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use. 5. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion. Page Ref: 277 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Chemical and Other Dependencies/Substance UseDisorder Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
15) The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which interventions will the nurse implement? 1. Allow the client to walk independently. 2. Obtain an order for a catheter. 3. Limit fluid intake. 4. Obtain a bedside commode. Answer: 4 Explanation: 1. A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. 2. Catheter insertion is invasive and increases the client's risk of developing a urinary tract infection. 3. Restricting fluid intake is not indicated in this situation. 4. A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom. Page Ref: 284 Cognitive Level: Applying Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
16) A young mother brings an infant to the pediatric clinic. The infant has had a fever and is pulling at the left ear. Based on this data, which disorder does the nurse suspect? 1. Sinusitis. 2. Otitis media. 3. Tonsillitis. 4. Otitis externa. Answer: 2 Explanation: 1. Sinusitis is associated with facial pain, inflammation, and nasal discharge. 2. Fever and hearing loss are clinical manifestations associated with otitis media. The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears. 3. Tonsillitis is associated with reddened, inflamed tonsils and a fever. 4. Otitis externa is associated with a red, swollen auricle and ear canal. Clients with otitis externa also might have a fever. Page Ref: 276 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
17) The emergency department triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. Which interpretation of the assessment data by the nurse is the most appropriate? 1. Produced by severe nasal inflammation or obstruction. 2. Normal for a child. 3. A result of chronic allergies. 4. A result of sinusitis. Answer: 1 Explanation: 1. If the client cannot breathe through each naris, severe inflammation or an obstruction may be present. 2. This is not a normal finding in an adult or a child. 3. If nasal mucosa is pale and boggy or swollen, the client may have chronic allergies. Due to the client's history, this is an acute problem and not associated with chronic allergies. 4. The client with sinusitis will have tenderness over sinus cavities. Page Ref: 285 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
18) A client presents in the healthcare provider's office with complaints of headache and malaise. During the assessment, the nurse notes the client is experiencing severe pain when palpating behind the ears. Based on this data, which diagnosis does the nurse anticipate? 1. Sinusitis. 2. Mastoiditis. 3. Chronic allergies. 4. Anemia .Answer: 2 Explanation: 1. Pain is a common finding during palpation of the sinuses when an infection or inflammation is present in the sinuses. 2. Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the client's ears. 3. The client with chronic allergies may have pale, boggy, or swollen nasal mucosa. 4. Anemia would be associated with pale mucous membranes. Page Ref: 280 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
19) The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include? 1. Bleeding and inflamed gums. 2. Smooth and shiny tongue. 3. Red, swollen tonsils. 4. Ulcerations on the lip or under the tongue. Answer: 4 Explanation: 1. Bleeding and inflamed gums are associated with gingivitis. 2. A smooth, shiny tongue is associated with deficiencies of vitamin B and iron. 3. Red and swollen tonsils are associated with tonsillitis. 4. Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally. Page Ref: 290 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
20) A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Select all that apply. 1. Request information from the client regarding increased propensity for bruising or bleeding. 2. Assess the tonsils for redness or swelling. 3. Obtain a blood pressure. 4. Check for deviated septum. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose. Answer: 1, 3, 5 Explanation: 1. The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. 2. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. 3. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client's blood pressure to determine if it is elevated. 4. A deviated septum is not associated with epistaxis. 5. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Page Ref: 276, 277 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Hemodynamics Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
21) The nurse is examining a toddler client. The toddler has a fever and the nurse notes the ear canal is red and swollen and the presence of purulent drainage. Based on this assessment data, which diagnosis does the nurse anticipate? 1. Otitis media. 2. Otitis externa. 3. Hemotympanum. 4. Tophi. Answer: 2 Explanation: 1. The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears. 2. Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage. 3. Hemotympanum is a bluish tinge of the tympanic membrane indicating the presence of blood in the middle ear. It is usually associated with head trauma. 4. Tophi are small white nodules on the helix or antihelix. These nodules contain uric acid crystals and are a sign of gout. Page Ref: 275 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
22) The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen. 4. Provide a warm drink. Answer: 3 Explanation: 1. There is no indication the client has an electrolyte or fluid imbalance at this time, making the administration of IV fluids inappropriate at this time. 2. Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing oral hygiene is not an appropriate intervention because it will not increase the client's oxygenation levels. 3. Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client. 4. Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. Providing a warm drink will not correct the client's oxygenation problem. Page Ref: 289 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
23) The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. Based on this data, which does the nurse suspect? 1. Rhinitis. 2. Perforated septum. 3. Previous epistaxis. 4. Nasal polyps. Answer: 1 Explanation: 1. These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy. 2. A perforated septum is a hole in the septum caused by chronic infection, trauma, or sniffing cocaine. It can be detected by shining a penlight through the naris on the other side. 3. With a history of epistaxis, the nurse would note that there is old dried blood on the nasal mucosa. 4. Nasal polyps are pale, round, firm, non-painful overgrowth of nasal mucosa. Page Ref: 276 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.eCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
24) The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data? 1. "Have you recently been ill?" 2. "Do you chew tobacco?" 3. "Have you recently taken antibiotics?" 4. "Do you have a history of oral infections?" Answer: 3 Explanation: 1. This finding is directly unrelated to illness. 2. This finding is not related to chewing tobacco or oral cancer. 3. The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. 4. It may helpful for the nurse to determine if the client has a history of oral infections, but it is not the most important question. Page Ref: 296 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.3: Determine which questions about the ears, nose, mouth, and throat to use for the focused interview. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
25) An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client? 1. Presbycusis. 2. Mastoiditis. 3. Otitis media. 4. Otitis externa. Answer: 1 Explanation: 1. Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis. 2. Mastoiditis is a complication of either a middle ear infection or a throat infection. The client would complain of pain or tenderness behind the ear. 3. Otitis media is an infection of the middle ear producing a red, bulging eardrum, fever, and hearing loss. 4. Otitis externa is an infection of the outer ear, often called "swimmer's ear." Otitis externa causes redness and swelling of the auricle and ear canal. Page Ref: 275 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.C enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
26) The nurse notes there is no red glow when transilluminating the maxillary sinuses. Which initial question should the nurse ask the client? 1. "Have you experienced any nasal drainage?" 2. "Do you have any allergies?" 3. "Do you take any routine sinus medication?" 4. "Are you experiencing any sinus pain?" Answer: 2 Explanation: 1. Absence of a red glow when assessing the sinuses may indicate inflammation. Nasal drainage may be absent if the sinuses are filled with fluid or inflamed. 2. Allergies can cause sinus inflammation. The source of the inflammation must be determined in order for the appropriate treatment to be prescribed. 3. Sinus medication should unblock the sinuses. This is an important question but not an initial question to ask. 4. Pain can be associated with infection but not always inflammation. This question can be asked after it has been determined if the client has allergies. Page Ref: 288 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.3: Determine which questions about the ears, nose, mouth, and throat to use for the focused interview. MNL Learning Outcome: 15.2. Plan questions about the ears, nose, mouth, and throat for the focused interview.
27) The nurse observes that the Wharton's ducts are painful, reddened, and swollen. Which additional assessment finding should the nurse anticipate? 1. Bleeding gums. 2. Lesions. 3. Dry mouth. 4. Leukoplakia . Answer: 3 Explanation: 1. Bleeding gums are a result of poor dental hygiene or gum disease such as gingivitis. 2. Lesions are not clinical finding associated with infected or obstructed salivary glands. 3. The Wharton's ducts are the submandibular salivary glands. The assessment findings may indicate that the ducts are infected or obstructed which would interfere with the secretion of saliva resulting in a dry mouth. 4. Leukoplakia is characterized by white patches that form on the gums and cheeks resulting from chronic irritation, such as from smoking. Page Ref: 290 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
28) The nurse educator is teaching a group of students about cultural differences to consider when conducting an ear, nose, and throat assessment. Which statement by a nursing student indicates appropriate understanding of the information presented? 1. "Asians are more likely to experience greater difficulty with otitis media than people from other cultures." 2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark." 3. "Asians have a higher risk of having issues associated with cleft lips and cleft palates." 4. "Asians have a high incidence of tooth decay." Answer: 2 Explanation: 1. Asians do not have a tendency to develop otitis media more than other cultures. 2. Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color. 3. Cleft lip and palate occur with greatest frequency in Asians and least often in African Americans. 4. Caucasians have the highest incidence of tooth decay. Page Ref: 274 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUmRpSIrNehGeTnBs.C ivOeMand focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
29) The nurse is assessing several children in a pediatric clinic. Which child is experiencing adelay in the eruption of decidual teeth? 1. The 6-month-old infant that has one deciduous tooth. 2. The 18-month-old child that has 6 deciduous teeth. 3. The 4-month-old infant that has no deciduous teeth. 4. The 24-month-old child that does not have their second molars. Answer: 2 Explanation: 1. Eruption of permanent teeth begins at around age 6 and continues through adolescence. 2. Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. At 18 months of age, the child is expected to have their upper and lower lateral and central incisors, which accounts for a total of 8 teeth. 3. Deciduous teeth do not start erupting until 6 months of age. 4. The second set of molars is not expected to erupt until after 25 months of age. Page Ref: 272 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
30) The nurse is preparing to review the secondary sources of data for a client that has experienced a hearing loss. Which diagnostic testing should the nurse anticipate may have been performed? Select all that apply. 1. X-ray. 2. Computed tomography. 3. Electronystagmography. 4. Audiometric screening. 5. Auditory screening. Answer: 1, 3, 4, 5 Explanation: 1. Diagnostic testing for hearing loss may include an Xray,electronystagmography, audiometric screening, and auditory screening. 2. Computed tomography (CT) is used to diagnose conditions associated with the nose and sinuses. 3. Diagnostic testing for hearing loss may include an X-ray, electronystagmography, audiometric screening, and auditory screening. 4. Diagnostic testing for hearing loss may include an X-ray, electronystagmography, audiometric screening, and auditory screening. 5. Diagnostic testing for hearing loss may include an X-ray, electronystagmography, audiometric screening, and auditory screening. Page Ref: 274 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.6: Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.
31) The nurse conducting the Rinne test notes that the client hears the bone conduction sound longer than the air conduction sound. Which should the nurse anticipate documenting? 1. Possible conductive hearing loss. 2. No hearing loss. 3. Sensorineural hearing loss. 4. Mixed hearing loss. Answer: 3 Explanation: 1. The Rinne test compares air and bone conduction. A client that hears bone conduction sound longer than the air conduction sound may have conductive hearing loss. 2. The Rinne test compares air and bone conduction. A client that hears bone conduction sound longer than the air conduction sound may have conductive hearing loss. 3. The Rinne test compares air and bone conduction. A client that hears bone conduction sound longer than the air conduction sound may have conductive hearing loss. 4. The Rinne test compares air and bone conduction. A client that hears bone conduction sound longer than the air conduction sound may have conductive hearing loss. Page Ref: 283 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 15.5: Generate the appropriate documentation to describe the assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.4. Differentiate normal and abnormal variations of the ears, nose, mouth, and throat observed during physical assessment.
32) The educator is reviewing the Rinne test with a new nurse. Which statement by the nurse indicates an understanding of the test? 1. "This test requires the use of an otoscope." 2. "The test is performed by whispering statements a few feet away from the client." 3. "The test is used to determine if a client hears sound in one ear better than the other." 4. "This test compares air and bone conduction of sound using a tuning fork." Answer: 4 Explanation: 1. The Rinne test does not require the use of an otoscope. 2. The whisper test is administered by whispering statements a few feet away from the client. 3. The Weber test is performed to determine if during bone conduction, with the use of a tuning fork, the client hears the sound in one ear better than the other. If there is impaired conduction in one ear, the sound will lateralize to that ear during the Weber test. 4. The Rinne test compares air and bone conduction of sound with the use of a tuning fork. Page Ref: 283 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.4: Outline the techniques for assessment of the ears, nose, mouth, and throat. MNL Learning Outcome: 15.3. Utilize the appropriate techniques and tools for physical assessment of the ears, nose, mouth, and throat.
33) The nurse observes white patches on the tympanic membrane. Which question should the nurse ask the client that is most relevant to the finding? 1. "Do you have a history of ear infections?" 2. "Have you experienced any recent hearing loss?" 3. "Are you currently on any medication?" 4. "Are you experiencing any pain in your ears?" Answer: 1 Explanation: 1. White patches on the tympanic membrane indicate scars from prior infections. The client should be asked about a history of infections to help determine what has caused the scarring. 2. Recent hearing loss may result from scaring but does not cause the scaring. Hearing loss should be assessed after it is determined what has caused the scarring. 3. A medication history is important as some medications are associated with hearing loss but this is not the initial question the nurse should ask the client. 4. Pain is not associated with tympanic scarring. Page Ref: 342 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3: Determine which questions about the ears, nose, mouth, and throat to use for the focused interview. MNL Learning Outcome: 15.2. Plan questions about the ears, nose, mouth, and throat for the focused interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 16 Lungs and Thorax 1) The educator has reviewed the respiratory system for a nurse. Which statement made by the nurse indicates further teaching is required? 1. "The left main bronchus is shorter." 2. "The bronchi begin at the level of the sternal angle." 3. "The bronchi divide within each lobe of the lung." 4. "The bronchi warm and moisten air." Answer: 1 Explanation: 1. The right main bronchus is shorter. 2. The bronchi begin at the level of the sternal angle. 3. The bronchi divide within each lobe of the lung. 4. The bronchi warm and moisten air. Page Ref: 303 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: KnowNleUdRgSeINaGnTdBS.cCiO enMce: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1: Describe the anatomy and physiology of the lungs and thorax. MNL Learning Outcome: 16.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax.
2) The nurse reviewing a client's record notes that the client has a fractured floating rib. Which rib should the nurse identify has been fractured? 1. 1st. 2. 5th. 3. 9th. 4. 12th. Answer: 4 Explanation: 1. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. 2. Anteriorly, the first seven pairs of ribs articulate directly to the sternum. 3. The cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7. 4. The rib pairs of 11 and 12 are free floating and do not articulate anteriorly. Page Ref: 306 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Describe the anatomy and physiology of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
3) Which is the primary landmark used to identify and locate all of the other landmarks on the anterior chest? 1. Sternum. 2. Manubrium. 3. Suprasternal notch. 4. Angle of Louis. Answer: 3 Explanation: 1. The sternum is not the primary landmark used to identify and locate all of the other landmarks on the anterior chest. 2. The manubrium is not the primary landmark used to identify and locate all of the other landmarks on the anterior chest. 3. The suprasternal notch is the primary landmark used to identify and locate all of the other landmarks on the anterior chest. 4. The angle of Louis is not the primary landmark used to identify and locate all of the other landmarks on the anterior chest. Page Ref: 306 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Describe the anatomy and physiology of the lungs and thorax. MNL Learning Outcome: 16.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax.
4) The nurse is preparing to auscultate the apex of the client's right lung. Which anatomical location should the nurse place the stethoscope? 1. Intercostal space sixth rib near the sternum. 2. Intercostal space fourth rib near the axillary line. 3. Below the scapula. 4. Near the right clavicle. Answer: 4 Explanation: 1. The apex of each lung is slightly superior to the inner third of the clavicle. 2. The apex of each lung is slightly superior to the inner third of the clavicle. 3. The apex of each lung is slightly superior to the inner third of the clavicle. 4. The apex of each lung is slightly superior to the inner third of the clavicle. Page Ref: 306 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
5) The nurse is preparing to identify the angle of Louis prior to a thoracic assessment. Which landmark should the nurse use to identify this structure? 1. Clavicle. 2. Sternum. 3. First rib. 4. Vertebral column. Answer: 2 Explanation: 1. The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. 2. The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. 3. The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. 4. The angle of Louis is the horizontal ridge formed by the intersection of the manubrium and the body of the sternum. Page Ref: 306 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
6) The nurse is preparing to assess the spinous processes of a client. Which landmark should the nurse use to locate the spinous process? 1. T-1. 2. T-3. 3. C-7. 4. C-5. Answer: 3 Explanation: 1. When two spinous processes are equally prominent, they are C-7 and T-1. C-7 is the most visible at the base of the neck and is used as landmark to count and locate other spinous processes. 2. The seventh cervical vertebra is the most visible at the base of the neck and is used as landmark to count and locate other spinous processes. 3. The seventh cervical vertebra is the most visible at the base of the neck and is used as landmark to count and locate other spinous processes. 4. The seventh cervical vertebra is the most visible at the base of the neck and is used as landmark to count and locate other spinous processes. Page Ref: 306 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
7) The nurse is assessing the client's respiratory system. Which method will result in the most accurate assessment of the client's respiratory rate? 1. The nurse should place a hand on the client's chest to count respirations. 2. The nurse should inform the client that they are preparing to count the client's respirations. 3. The nurse should count when the respirations are audible. 4. The nurse should count the respirations in an unobtrusive manner without informing the client. Answer: 4 Explanation: 1. Though laying a hand on the client's chest allows the nurse to feel the rise and fall of the chest, this may be considered an intrusive and may increase the client's level of anxiety, altering their respiratory rate. 2. The nurse should not inform the client about this portion of the assessment. 3. Not all clients have audible respiratory cycles. 4. If a client is aware that their respirations are being counted, their normal breathing pattern may be altered. Page Ref: 321 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
8) The nurse is preparing to assess the client's respiratory system. Which order should the nurse conduct the assessment? 1: Auscultation. 2: Inspection. 3: Percussion. 4: Client survey. 5: Palpation. Answer: 4, 2, 5, 3, and 1 Explanation: 1: The fifth step in physical assessment of the respiratory system is auscultation. 2: The second step of respiratory assessment is inspection of the anterior and posterior thorax. 3: The fourth step in physical assessment of the respiratory system is percussion of the anterior and posterior thorax. 4: The first step in any physical assessment is the client survey. 5: The third step in respiratory assessment is palpation of the structures of the anterior and posterior thorax. Page Ref: 321 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
9) The nurse is preparing to auscultate the client's chest. Which anatomical location should the nurse place the stethoscope to auscultate tracheal breath sounds? 1. Below the xyphoid process. 2. Above the substernal notch. 3. Below the manubrium. 4. Between the substernal notch and manubrium. Answer: 2 Explanation: 1. Tracheal breath sounds are heard over the trachea which is located above the substernal notch. 2. Tracheal breath sounds are heard over the trachea which is located above the substernal notch. 3. Tracheal breath sounds are heard over the trachea which is located above the substernal notch. 4. Tracheal breath sounds are heard over the trachea which is located above the substernal notch. Page Ref: 304 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
10) The nurse is caring for a client that has been treated for asthma and is currently breathing shallow and trembling. Which action should the nurse take to help decrease the client's level of anxiety prior to assessing the client? 1. The nurse should explain all procedures in a calm and reassuring voice. 2. Request the immediate presence of the healthcare provider. 3. Provide oxygen for the client. 4. Delay the assessment until the client calms down. Answer: 1 Explanation: 1. Clients experiencing anxiety may demonstrate trembling hands and a shallow breathing pattern. Certain drugs, such as bronchodilators, are used in the treatment of respiratory conditions and may cause the hands to tremble visibly. The nurse should not confuse this sign with nervousness. Even mild respiratory distress is frightening for the client and family. Proceeding in a calm and reassuring manner helps reduce the client's fear. 2. At this time, there is no reason to request the presence of the healthcare provider. 3. There is not enough information to assume the client requires oxygen. 4. It is not necessary to postpone the assessment of the client. Page Ref: 312 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
11) The educator is observing the nurse's technique for a lung assessment. Which should the educator recognize demonstrates appropriate technique? 1. Auscultation begins from the base to apices of lungs. 2. Auscultation up one side of the thorax and then up the other. 3. Auscultation down one side of the thorax and then down the other. 4. Auscultation bilaterally from one side to the other. Answer: 4 Explanation: 1. Auscultation begins from apices to the bases. 2. Auscultation should follow the same pattern as for percussion, bilaterally from side to side, because comparison of sounds is an important step in respiratory assessment. 3. Auscultation should follow the same pattern as for percussion, bilaterally from side to side, because comparison of sounds is an important step in respiratory assessment. 4. Auscultation should follow the same pattern as for percussion, bilaterally from side to side, because comparison of sounds is an important step in respiratory assessment. Page Ref: 325 Cognitive Level: Understanding Client Need & Sub: Safe and Effective Care Environment; Assignment, Delegation, andSupervision Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
12) The nurse identifies abnormal breath sounds during an assessment. Which sounds should the nurse document as abnormal? Select all that apply. 1. Crackles. 2. Vesicular. 3. Bronchovesicular. 4. Wheezes. 5. Bronchial . Answer: 1, 4 Explanation: 1. Crackles are adventitious, or abnormal, lung sounds produced by collapsed or fluid-filled alveoli. 2. Vesicular sounds are normal and can be heard over the apices. 3. Bronchovesicular sounds are normal sounds that can be auscultated over the bronchi. 4. Wheezes are the result of blocked airflow as in asthma, infection, or due to a foreign body. 5. Bronchial sounds are normal and can be heard to the right and left of the trachea over the bronchi. Page Ref: 325 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
13) The nurse auscultating a client's lungs notes there is a low-pitched, continuous respiratory sounds that has a snoring quality. Which terminology should the nurse use to document the finding? 1. Rales. 2. Crackles. 3. Rhonchi. 4. Wheezes. Answer: 3 Explanation: 1. Rales are intermittent, non-musical brief sounds. 2. Coarser and louder rales are referred to as crackles. 3. Rhonchi are low-pitched and have a continuous respiratory sound that has a snoring quality. 4. There are two types of continuous respiratory sounds that may be heard during the respiratory cycle. Wheezes are high-pitched with a shrill quality. Page Ref: 325 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.5: Generate the appropriate documentation to describe the assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
14) The nurse notes movement on one side of the chest while palpating respiratory expansion. Which conditions should the nurse suspect is associated with this assessment finding? Select all that apply. 1. Atelectasis. 2. Chronic bronchitis. 3. Lobar pneumonia. 4. Pleural effusion. 5. Congestive heart failure. Answer: 1, 3, 4 Explanation: 1. Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client's affected side. 2. Chronic bronchitis results in chronic inflammation of the tracheobronchial tree, which leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. 3. Lobar pneumonia is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client's affected side. 4. Pleural effusion refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client's affected side. 5. Congestive heart failure is when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may causN e UeRdSeIm f .tChOeMbronchial mucosa. It does not result in Na GToB decreased lung expansion on one side. Page Ref: 327 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
15) The nurse is reviewing the records of a client with severe left pleural effusion. Which assessment finding should the nurse anticipate? Select all that apply. 1. Absent breath sounds on the left side. 2. Tracheal shift to the right. 3. Hyperresonance upon percussion. 4. Bronchial breath sounds on the right side. 5. Pleural friction rub. Answer: 1, 2, 5 Explanation: 1. In this condition, fluid accumulates in the pleural space and may result in absent breath sounds on the affected side. 2. In this condition, fluid accumulates in the pleural space. The trachea may shift to the unaffected side. 3. The trapping of air in the alveoli will produce a sound of hyperresonance upon percussion. This is not a typical finding in someone who has been diagnosed with a pleural effusion. 4. This is not a typical finding in someone who has been diagnosed with a pleural effusion. 5. In this condition, fluid accumulates in the pleural space and a pleural friction rub may be present during auscultation. Page Ref: 333 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
16) The nurse is assessing the client's respiratory pattern and notes periods of deep breathing alternating with periods of apnea. Which terminology should the nurse use to document the findings? 1. Tachypnea. 2. Obstructive breathing. 3. Hypoventilation. 4. CheyneStokes. Answer: 4 Explanation: 1. The client who has tachypnea exhibits rapid and shallow respirations. 2. Clients with obstructive breathing have prolonged expirations. 3. Hypoventilation is irregular and shallow breathing. 4. The breathing described is a Cheyne-Stokes pattern. Page Ref: 330 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.5: Generate the appropriate documentation to describe the assessment of the lungs and thorax MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
17) The nurse assessing the voice sounds of a client notes that the sounds are louder over the right lower lung lobe. Which should the nurse suspect the client is experiencing? 1. Atelectasis. 2. Lobar pneumonia. 3. Asthma. 4. Pleural effusion. Answer: 2 Explanation: 1. Voice sounds are decreased or absent over areas of atelectasis. 2. Voice sounds are increased and clearer over areas affected by lobar pneumonia. 3. Voice sounds are decreased or absent over areas of asthma. 4. Voice sounds are decreased or absent over areas of pleural effusion. Page Ref: 333 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
18) The nurse is preparing to assess a patient suspected of having orthopnea. Which question should the nurse include in the assessment? 1. "Are you able to carry out your routine activities without a change in breathing?" 2. "Do you prop yourself up on pillows when you sleep?" 3. "Do you breathe through your mouth or nose?" 4. "Can you describe your breathing during vigorous exercise?" Answer: 2 Explanation: 1. This provides the opportunity to elicit information about regular breathing patterns. 2. The norm is for a client to sleep fully reclined with a pillow. A client with orthopnea may have to prop themselves up on pillow to sleep to prevent dyspnea. 3. Nose breathing allows inhaled air, to be warmed, moistened, and filtered before entering the lungs and is considered the norm. Clients that identify themselves as mouth breathers require follow up. 4. A normal finding with breathing during exercise is the description of a patient describing breathing becoming more rapid or deeper during exercise but returning to normal when the activity is stopped. Page Ref: 313 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.3: Determine which questions about the lungs and thorax to use for the focused interview. MNL Learning Outcome: 16.2: Plan questions about the lungs and thorax for the focused interview.
19) A client asks the nurse why they are being evaluated for weight loss during a respiratory assessment. Which response should the nurse provide the client as the primary reason weight loss is assessed? 1. "Weight loss reflects poor nutrition which may affect the strength of respiratory muscles." 2. "Weight loss may have occurred as a result of lung or other diseases. 3. "Weight loss may be associated with poor nutrition which may interfere with the exchange of oxygen and carbon dioxide." 4. "Weight loss may be associated with nutritional deficiencies and places you at risk for respiratory infections." Answer: 2 Explanation: 1. Weight loss is not necessarily an indicator of poor nutrition. 2. Weight loss or gain may be associated with lung and other systemic diseases. 3. Weight loss is not necessarily an indicator of poor nutrition. 4. Weight loss is not necessarily an indicator of poor nutrition. Page Ref: 315 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax. MNL Learning Outcome: 16.2: Plan questions about the lungs and thorax for the focused interview.
20) The nurse is assessing the costal angle during the anterior inspection of the thorax. Which findings should the nurse anticipate? 1. 10°. 2. 30°. 3. 60°. 4. 90°. Answer: 4 Explanation: 1. The costal angle of a client should be 90°. An increase in the costal angle of a client may indicate the client has COPD. 2. The costal angle of a client should be 90°. An increase in the costal angle of a client may indicate the client has COPD. 3. The costal angle of a client should be 90°. An increase in the costal angle of a client may indicate the client has COPD. 4. The costal angle of a client should be 90°. An increase in the costal angle of a client may indicate the client has COPD. Page Ref: 319 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Describe the anatomy and physiology of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
21) The nurse notes the client's respiration rate is 14 per minute and the expiration phase is the same length as the end-inspiration phase. Which term should the nurse use to document the findings? 1. Obstructive breathing. 2. Bradypnea. 3. Respiratory distress. 4. Eupnea. Answer: 4 Explanation: 1. A client exhibiting obstructive breathing will have a prolonged expiration. 2. Bradypnea is a term used to describe slow, regular respirations that are less than 10 per minute. 3. These findings do not indicate that the client is experiencing respiratory distress. 4. The finding describes eupnea, which is a normal breathing pattern. Page Ref: 329 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5: Generate the appropriate documentation to describe the assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
22) The nurse notes a client has a barrel chest. Which question should the nurse ask the client? 1. "Do you have a history of pneumonia?" 2. "Do you have a history of emphysema?" 3. "Have you ever been exposed to tuberculosis?" 4. "Have you ever been diagnosed with scoliosis?" Answer: 2 Explanation: 1. Pneumonia is not associated with a barrel chest. 2. Clients with chronic obstructive pulmonary disease often have barrel chests. Aging can result in a barrel chest. 3. Tuberculosis is not associated with a barrel chest. 4. Scoliosis is a condition in which there is lateral curvature and rotation of the thoracic and lumbar spine and is not associated with a barrel chest. Page Ref: 320 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.3: Determine which questions about the lungs and thorax to use for the focused interview. MNL Learning Outcome: 16.2: Plan questions about the lungs and thorax for the focused interview.
23) The nurse is preparing to assess a client with scoliosis. Which assessment findings should the nurse anticipate? 1. An exaggerated posterior curvature of the thoracic spine. 2. A lateral curvature and rotation of the thoracic and lumbar spine. 3. Forward displacement of the sternum with depression of the adjacent costal cartilage. 4. Depression of the sternum and the adjacent costal cartilage. Answer: 2 Explanation: 1. An exaggerated posterior curvature of the thoracic spine is descriptive of kyphosis. 2. A lateral curvature and rotation of the thoracic and lumbar spine is descriptive of scoliosis. 3. An exaggerated posterior curvature of the thoracic spine is descriptive of pectus carinatum. 4. An exaggerated posterior curvature of the thoracic spine is descriptive of pectus excavatum. Page Ref: 320 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
24) The nurse is reviewing the records of a client with chronic bronchitis. Which assessment finding should the nurse anticipate? 1. Fever. 2. Decreased respiratory rate. 3. Use of accessory muscles. 4. Dry cough. Answer: 3 Explanation: 1. The client will not typically experience a fever. Fevers are associated with infections. 2. The respiratory rate may be elevated to compensate for the inability to breathe properly. 3. Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways, causing decreased air movement in and out of the alveoli, which in turn causes the client's respiratory rate to increase in order to compensate. The muscles of the chest wall work harder to try to pull more air into the alveoli, which causes increased chest wall expansion. The use of accessory muscles to breathe may be noted. 4. This client will most likely exhibit a chronic productive cough.Page Ref: 332 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
25) The nurse is preparing to assess for fremitus in a client. Which factor should the nurse recognize may result in absent fremitus? 1. Obesity. 2. Loud voice. 3. Sinus infection. 4. Cardiac arrhythmias. Answer: 1 Explanation: 1. Fremitus is a palpable vibration on the chest wall when the patient speaks. Absent fremitus may result from obesity. 2. A loud voice does not result in absent fremitus. 3. A sinus infection does not affect fremitus. 4. Cardiac arrhythmias do not affect fremitus. Page Ref: 322 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax. MNL Learning Outcome: 16.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax.
26) The nurse is auscultating tracheal breath sounds. Which should the nurse anticipate the normal findings to sound like? 1. Medium in loudness and pitch. 2. Soft and low pitched. 3. Harsh and high pitched. 4. Loud high pitched sounds. Answer: 3 Explanation: 1. Bronchovesicular sounds are medium in loudness and pitch. 2. Vesicular sounds are soft and low pitched. 3. Tracheal sounds are harsh and high pitched. 4. Bronchial sounds are loud and high pitched. Page Ref: 323 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1: Describe the anatomy and physiology of the lungs and thorax. MNL Learning Outcome: 16.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the lungs and thorax.
27) The nurse is preparing to auscultate the bronchovesicular sounds of a client. Which landmark should the nurse use to identify the correct placement of the stethoscope? 1. Anterior of the angle of Louis and lateral of the sternum in the second intercostal space. 2. Second and third intercostal spaces between scapulae. 3. Next to the trachea superior in each clavicle and in the first intercostal space. 4. Superiorly to the manubrium and anterior midclavicular. Answer: 2 Explanation: 1. The bronchovesicular sounds are not auscultated anteriorly of the angle of Louis and lateral of the sternum in the second intercostal space. 2. The correct placement of the stethoscope to auscultate bronchovesicular sounds is the second and third intercostal spaces between scapulae. 3. Bronchial sounds are heard next to the trachea superior in each clavicle and in the first intercostal space. 4. The bronchovesicular sounds are not auscultated superiorly to the manubrium and anterior midclavicular. Page Ref: 324 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.C enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4: Outline the techniques for assessment of the lungs and thorax. MNL Learning Outcome: 16.3: Utilize the appropriate techniques and tools for physical assessment of the lungs and thorax.
28) The nurse is preparing to auscultate the breath sounds of a client with asthma. Which breath sounds does the nurse anticipate to find upon assessment? 1. High pitch continuous sounds on inspiration and expiration. 2. Low pitch continuous rattling on inspiration and expiration. 3. High pitched short crackling. 4. Low pitched grating and rubbing on inhalation and exhalation. Answer: 1 Explanation: 1. High pitch continuous sounds on inspiration and expiration are breath sounds associated with asthma. 2. Low pitch continuous rattling on inspiration and expiration is caused by fluid blocked airways. 3. High pitched short crackling occurs at end inspiration and does not clear with a cough. This is associated with collapsed or fluid filled alveoli open. 4. Low pitched grating and rubbing on inhalation and exhalation are associated with pleural inflammation. Page Ref: 325 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
29) The nurse is caring for a client with increased cranial pressure. Which respiratory pattern should the nurse expect? 1. Cheyne-Stokes. 2. Hyperventilation. 3. Biot's respirations. 4. Bradypnea. Answer: 4 Explanation: 1. Cheyne-Stokes is characterized by periods of deep breathing alternating with periods of apnea and regular breathing and is associated with increased cranial pressure. 2. Hyperventilation is rapid deep respirations of greater than 24 breaths per minute not specifically associated with increased cranial pressure. 3. Biot's respirations are an irregular pattern of shallow deep respirations not specifically associated with increased cranial pressure. 4. Bradypnea is associated with increased cranial pressure. A client with bradypnea has a slow, regular respiratory rate of less than 10 per minute. Page Ref: 330 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Nursing Diagnosis Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
30) The nurse is preparing to assess a client with atelectasis. Which objective finding should the nurse anticipate? 1. Clubbing of the fingers. 2. Decreased or absent breath over the affected area. 3. No voice transmission. 4. Decreased chest wall expansion on the affected side. Answer: 1 Explanation: 1. Clubbing of the fingers is a finding in a client with emphysema. 2. Atelectasis occurs when there is a collapse or impaired inflation in one or more areas of the lung (NHLBI, 2013). Decreased or absent breath over the affected area is a finding in a client with atelectasis. 3. No voice transmission is a finding in a client with pleural effusion. 4. A decreased chest wall expansion on the affected side is a finding in a client with a pneumothorax. Page Ref: 331 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : CGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6: Identify abnormal findings in the physical assessment of the lungs and thorax. MNL Learning Outcome: 16.4: Differentiate normal and abnormal variations of the lungs and thorax observed during physical assessment.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 17 Breasts and Axillae 1) The nurse is conducting a breast health workshop for a group of women. Which would the nurse include in this workshop when outlining risk factors for breast cancer? Select all that apply. 1. Caucasian race. 2. Positive family history. 3. Low socioeconomic status. 4. Hormone replacement therapy. 5. Female age 35 to 40. Answer: 1, 2, 3, 4 Explanation: 1. Caucasian females, especially over the age of 40, have a higher risk of developing breast cancer than any other race or ethnic group. 2. A positive family history of breast cancer places an individual at a higher risk of developing breast cancer. The individual is at an even greater risk if the family member developed breast cancer prior to menopause. 3. Lower socioeconomic status places an individual at risk for breast cancer for a number of reasons, including lack of education on preventative measures and diagnostic recommendations; fear that breast cancer is not treatable and has a high mortality rate, thus they avoid diagnosis; and the mother of the family in lower socioeconomic groups often places her family's healthcare needs above herNs.URSINGTB.COM 4. Hormone replacement therapy is linked to higher incidence of breast cancer. 5. Females over the age of 40, not between the ages of 35 to 40, have been found to have a high incidence of breast cancer. Page Ref: 342 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
2) The nurse is reviewing the function of the breasts with a client. Which information should the nurse include? Select all that apply. 1. Release lactating hormones. 2. Mechanism for sexual arousal. 3. Produce milk. 4. Store milk. 5. Contain lymphatic tissue for immunity. Answer: 2, 3, 4 Explanation: 1. Lactating hormones are released by the pituitary and posterior pituitary gland. 2. Breasts in both females and males provide a mechanism for sexual arousal. 3. The main functions of the breast include producing, storing, and supplying milk for the process of lactation. 4. The main functions of the breast include producing, storing, and supplying milk for the process of lactation. 5. The lymphatic nodes drain lymph from the breast. Page Ref: 339 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
3) The nurse is preparing to palpate the lymph nodes of a client's breast. Which lymph nodes will the nurse palpate? Select all that apply. 1. Brachial nodes. 2. Subclavicular nodes. 3. Inguinal nodes. 4. Supraclavicular nodes. 5. Internal mammary nodes. Answer: 1, 2, 4, 5 Explanation: 1. Lymph nodes that will be palpated during a breast exam include brachial nodes, subclavicular nodes, supraclavicular nodes, and internal mammary nodes. 2. Lymph nodes that will be palpated during a breast exam include brachial nodes, subclavicular nodes, supraclavicular nodes, and internal mammary nodes. 3. Inguinal nodes are not included in the assessment of nodes during a breast exam. 4. Lymph nodes that will be palpated during a breast exam include brachial nodes, subclavicular nodes, supraclavicular nodes, and internal mammary nodes. 5. Lymph nodes that will be palpated during a breast exam include brachial nodes, subclavicular nodes, supraclavicular nodes, and internal mammary nodes. Page Ref: 424 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
4) The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting? 1. Symmetry. 2. Hard nodules. 3. Tenderness. 4. Skin consistency. Answer: 1 Explanation: 1. Symmetry of the breasts indicates that both breasts are nearly the same size and shape. This assessment is performed by the technique of inspection. 2. Hard nodules in the breast tissue cannot be assessed by inspection. Palpation would be necessary for this type of assessment. 3. Tenderness cannot be assessed by inspection. Palpation would be necessary for this type of assessment. 4. Skin thickening cannot be assessed by inspection. Palpation would be necessary for this type of assessment. Page Ref: 347 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5: Generate the appropriate documentation to describe the assessmentof the breasts and axillae. MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
5) The nurse is preparing to discuss the modifying risk factors for breast cancer with a community group. Which risk factors should the nurse include in the discussion? Select all that apply. 1. Smoking. 2. Physical activity. 3. Alcohol use. 4. Obesity. 5. Diet. Answer: 2, 3, 4, 5 Explanation: 1. Modifiable risk factors for breast cancer include physical activity, alcohol use, obesity, diet, and being overweight. Smoking is not an identified risk factor for breast cancer. 2. Modifiable risk factors for breast cancer include physical activity, alcohol use, obesity, diet, and being overweight. Smoking is not an identified risk factor for breast cancer. 3. Modifiable risk factors for breast cancer include physical activity, alcohol use, obesity, diet, and being overweight. Smoking is not an identified risk factor for breast cancer. 4. Modifiable risk factors for breast cancer include physical activity, alcohol use, obesity, diet, and being overweight. Smoking is not an identified risk factor for breast cancer. 5. Modifiable risk factors for breast cancer include physical activity, alcohol use, obesity, diet, and being overweight. Smoking is not an identified risk factor for breast cancer. Page Ref: 434 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
6) The nurse is asking a client questions regarding lifestyle patterns. Which statement by the client would alert the nurse to possible risk for breast cancer? 1. "I work in a chemical factory." 2. "I drink two glasses of wine each night." 3. "I have smoked two packs of cigarettes daily for four years." 4. "I occasionally have unprotected sexual contact with unknown partners." Answer: 2 Explanation: 1. Exposure to chemicals by working in a chemical factory would place the client at risk for developing lung-related cancers or other body system cancers or disease. 2. Research indicates that alcohol intake in excess of nine drinks per week may increase a woman's risk of developing breast cancer. Two glasses of wine each night totals 14 drinks per week. 3. Smoking two packs of cigarettes daily for four years would place the client at risk for developing lung-related cancers or disease. 4. Occasional unprotected sexual contact with unknown partners increases risk for STDs, HIV, as well as cervical cancer. Page Ref: 342 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.3: Determine which questions about the breasts and axillae to use for the focused interview. MNL Learning Outcome: 17.2: Plan questions about the breasts and axillae for the focused interview.
7) The nurse is discussing breast health with a 65-year-old client. Which screening recommendation should the nurse discuss? 1. Mammograms every 1 year. 2. Mammograms every 2 years. 3. There are no clear recommendations. 4. Recommended screening is based on the client's decision. Answer: 2 Explanation: 1. Mammograms annually are an option for a client not a recommendation. 2. For women over 55, the American Cancer Society recommends mammography screening every two years but leaves the option open for yearly screening. 3. For clients under 45 years of age, the consensus as to when to begin screening for a female of average risk for breast cancer is not uniform. 4. The client should always be a part of the decision-making process regarding any breast cancer screening; however, for women over 55, the American Cancer Society recommends mammography screening every two years but leaves the option open for yearly screening. Page Ref: 341 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
8) The nurse is assessing a client and confirms the presence of galactorrhea. Which conclusion by the nurse is the most appropriate? 1. It suggests an endocrine disorder. 2. It may indicate a malignancy. 3. It suggests a breast infection. 4. It is usually indicative of lactation. Answer: 1 Explanation: 1. Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressant and antihypertensive medications. 2. Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma, or it may indicate a malignancy. 3. Infections of the breast often cause enlargement and tenderness of the axillary lymph nodes. 4. Normal lactation is associated with childbearing and is not called galactorrhea. Page Ref: 353 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
9) The nurse is examining a client with a history of benign breast disease. Which findings does the nurse anticipate when assessing this client's breasts? Select all that apply. 1. Straw-colored discharge from the nipples. 2. Freely movable masses. 3. Hard, fixed nodules. 4. Thickened breast tissue. 5. Masses with well-defined boundaries. Answer: 1, 2, 4, 5 Explanation: 1. Straw-colored discharge from the nipples is common with benign breast disease. Discharge from the nipples may be clear, straw-colored, milky, or green. 2. Masses with benign breast disease are generally freely movable. 3. Hard, fixed nodules are more commonly associated with cancer of the breast. 4. The symptoms of benign breast disease are a result of fibrosis, which is a thickening of the normal breast tissue and may be accompanied by cyst formation. 5. The masses of benign breast disease are typically well demarcated (having defined boundaries). Page Ref: 356 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
10) The nurse is teaching a client with benign breast disease about symptom relief. Which topic would the nurse include in this session? 1. Avoiding all fat in the diet. 2. Heat application. 3. Limiting salt intake. 4. Drinking tea instead of coffee. Answer: 3 Explanation: 1. Avoiding all fat in the diet is not advisable for any client; limiting the amount of saturated fats may help alleviate pain associated with benign breast disease. 2. Applying heat to the area of discomfort is not an intervention to relieve the symptoms associated with benign breast disease. 3. Limiting salt intake has been found to help relieve symptoms associated with benign breast disease. 4. Limiting caffeine is advisable to help alleviate the pain associated with benign breast disease; however, drinking tea instead of coffee would not help since both contain caffeine. Page Ref: 356 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Non-Pharmacological Comfort Interventions Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communitieNsU, RaSnIdNpGoTpBu.ClaOtM ions. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
11) The nurse is reviewing the prescriptions for a client experiencing galactorrhea. Which prescription should the nurse understand is associated with galactorrhea? 1. Sertraline. 2. Glucophage. 3. Levothyroxine. 4. Amoxicilli n.Answer: 1 Explanation: 1. Sertraline is an SSRI used for depression. Galactorrhea can occur with the use of some antidepressants. 2. Glucophage is not associated with galactorrhea. 3. Levothyroxine is a thyroid hormone that is not associated with galactorrhea. 4. Amoxicillin is not associated with galactorrhea. Page Ref: 353 Cognitive Level: Analyzing Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
12) The nurse is preparing to review the characteristics of noncyclic mastalgia with a client. Which factors should the nurse discuss with the client? Select all that apply. 1. Often unilateral. 2. Most common in younger women. 3. Results from changes in breast structure. 4. Pain is often described as sharp and burning. 5. Typically disappears after menopause. Answer: 1, 2, 3, 4 Explanation: 1. Noncyclic mastalgia is often occurs in one breast. 2. Noncyclic mastalgia is most common in women aged 30 to 50. 3. Noncyclic mastalgia often results from changes in the breast structure. 4. Noncyclic mastalgia is often associated with pain described as a sharp or burning sensation that occurs in one region of the breast. 5. Cyclic mastalgia or breast pain is often associated with the menstrual cycle and typically disappears after menopause. Page Ref: 343 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
13) The nurse is interviewing a 37-year-old client for breast cancer risks. Which statement by the client indicates an appropriate understanding of the risks associated with breast cancer? 1. "I know my risk for breast cancer increases with age." 2. "A mammogram every three years is my goal." 3. "I will see my healthcare provider every two years for a breast examination." 4. "My family history is negative so I do not need to worry." Answer: 1 Explanation: 1. "I know my risk for breast cancer increases with age" is the correct statement since breast cancer risks increase significantly after the age of 35 to 40. 2. "A mammogram every three years is my goal" is not an accurate response. Mammography screening is dependent on several factors. Biennial screening is suggested between the ages of 50 and 74 years. Beginning biennial mammography before the age of 50 is based on cancer risk and values regarding the benefit and harm associated with mammography. 3. "I will see my healthcare provider every two years for a breast examination" is not an accurate response. Annual breast examination by a healthcare provider every 3 years for women from age 20 to 40 years, and annually thereafter, is suggested. 4. "My family history is negative so I do not need to worry" is not an accurate response. The client should be aware of current screening guidelines regardless of family history. Page Ref: 342 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3.NBUase ndGiTvBid.CuO alM ized care plan on patient values, RSIiN clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
14) The nurse is gathering statistics on breast cancer for a community presentation. Which facts about breast cancer should the nurse include? Select all that apply. 1. Breast cancer is one of the most common cancers in females. 2. Most often diagnosed in White women. 3. Geographical breast health disparities occur based on region. 4. More common in African American women under age 45. 5. White women are more likely to die from breast cancer. Answer: 1, 2, 3, 4 Explanation: 1. Breast cancer is one of the most common cancers in females. 2. Breast cancer is most often diagnosed in White women. 3. Geographical breast health disparities occur based on region. 4. Breast cancer is more common in African American women under age 45. 5. African American women are more likely to die from breast cancer. Page Ref: 342 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
15) The nurse performing a breast examination is palpating the tail of Spence. Why is it appropriate to palpate this area of the breast during an examination? 1. It does not contain any lymph nodes. 2. It can show the difference between fibrocystic disease and fibroadenomas. 3. Breast cancer occurs more frequently in this area. 4. Peau d'orange may occur in this area of the breast. Answer: 3 Explanation: 1. The area of the tail of Spence is in the upper outer quadrant of the breast into the axillary region, which does contain lymph nodes; therefore, this statement is not accurate. 2. It would be difficult to detect the difference between fibrocystic disease, breast cancer, and fibroadenomas by palpation alone–correlating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses. 3. Breast cancer does occur more frequently in this area. The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. 4. Peau d'orange and Paget's disease are changes in the breast skin and nipple area associated with forms of cancer; therefore, palpation in the tail of Spence area would not be a detection method for these abnormalities. Page Ref: 351 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae. MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
16) A menopausal woman comes to the clinic with complaints of thin, watery nipple discharge with blood present. Based on this data, which disorder does the nurse suspect? 1. Mammary duct ectasia. 2. Fibrocystic disease. 3. Breast malignancy. 4. Intraductal papillomas. Answer: 4 Explanation: 1. Discharge associated with mammary duct ectasia is thick and sticky, rather than thin and watery, as a result of inflammation of the lactiferous ducts. 2. Fibrocystic disease is first seen when women are in their twenties and discharge is typically straw-colored, clear, milky, or green. 3. Malignancy that affects the nipple must be correlated with other physical findings, mammogram, and biopsy. In addition, discharge is not typically thin and watery with breast malignancy. 4. Intraductal papillomas, which are small growths of epithelial cells that extend into the lumen of the lactiferous ducts, are the primary cause of thin, watery nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women. Page Ref: 356 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUsRCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
17) A client asks the nurse how milk is produced. When responding to the client, which structure will the nurse include as being responsible for milk production? 1. Montgomery's glands. 2. Areola. 3. Acini cells. 4. Mammary ridge. Answer: 3 Explanation: 1. Montgomery's glands are sebaceous glands; therefore, no milk production occurs from these glands. 2. The areola is circular wrinkled pigmented skin surrounding the nipple and is not responsible for milk production. 3. Each lobe in the breast contains approximately 20 to 40 lobules that contain the acini cells, which produce milk. 4. The mammary ridge is comprised of supernumerary nipples or breast tissue and extends from each axilla to the groin. No milk production occurs from this area. Page Ref: 338 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
18) During the breast examination on a client, the nurse palpates a small, subclavicular node on the right side of the client's chest. Which is the priority nursing action at this time? 1. Call the primary care provider. 2. Ask the client if they have a family history of breast cancer. 3. Continue with the exam. 4. Schedule a mammogram for the next available appointment. Answer: 3 Explanation: 1. Calling the primary care provider should not occur until the exam is complete. This will allow for all information, such as the size and location of any and all palpable masses, as well as subjective information from the client to be reported to the primary care provider. 2. Asking the client at this point in the examination if they have a family history of breast cancer would most likely alarm the client that there is something wrong. This question should be asked during the client interview. 3. Usually nodes are nonpalpable but subclavicular nodes must be assessed as part of the examination. It would be important for the nurse to complete the exam in order to document size and location of any and all palpable masses. Documentation of the client's report to corroborate findings is also important. Reporting these findings in completeness to the primary care provider would be the next step and any further follow-up would be determined by that provider, along with the client's input. 4. Scheduling a mammogram for the next available appointment would be inappropriate at this point. The examination should be completed and all information reported to the primary care provider, who will determine, with the inNpUuRtSoINf G thTeBc.CliOenMt, the necessity of scheduling a mammogram. Page Ref: 341 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
19) A client asks the nurse what is the purpose of the Montgomery's glands on the nipple of the breast. Which information should the nurse be prepared to discuss? 1. Secretion of oily secretions. 2. Secretion of milk. 3. Secretion of hormones. 4. Secretion of colostrum. Answer: 2 Explanation: 1. The Montgomery's glands secrete oily secretions to keep the areola and nipple lubricated. 2. The lactiferous ducts secrete milk. 3. Hormones are not secreted from breast tissue. 4. The lactiferous ducts secrete colostrum. Page Ref: 338 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae. MNL Learning Outcome: 17.1: ConsiderNthe icO, pMhysiologic, developmental, URSaInNaGto Tm B.C psychosocial, and cultural variations that guide assessment of the breasts and axillae.
20) The nurse is planning to perform a breast examination of a female client. Which techniques does the nurse anticipate documenting? Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.Answer: 1, 2, 5 Explanation: 1. Inspection involves looking at skin color, structures of the breast, and the appearance of the axillae. 2. Palpation involves feeling the breast tissue, nipples, and axillary regions for any abnormalities. 3. Percussion is a physical assessment technique that is not necessary for breast tissue. 4. Auscultation is a physical assessment technique that is not necessary for breast tissue. 5. The client interview is necessary in order to obtain subjective information regarding the client's state of breast health or illness. Page Ref: 342, 347 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5: Generate the appropriate documentation to describe the assessment of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
21) While the nurse is counseling a client about fibrocystic breast disease, the client asks if having this disorder will lead to cancer. Which response by the nurse is the most appropriate? 1. "There is no direct link between this disease and breast cancer." 2. "You will need to ask the primary healthcare provider that question." 3. "This disease is a form of cancer." 4. "Why are you so worried about this?" Answer: 1 Explanation: 1. This is the most appropriate response since research indicates that no direct link has been found between fibrocystic disease and breast cancer. However, the primary healthcare provider will want to monitor the client with fibrocystic breast disease because some clients with the disease develop ductal hyperplasia and dysplasia, which may eventually develop into noninvasive intraductal, lobular, or intraepithelial carcinoma. 2. "You will need to ask the primary care provider that question" is inappropriate because this statement does not address the client's question. 3. Fibrocystic breast disease is a thickening of the normal breast tissue, which may be accompanied by cyst formation. The statement "This disease is a form of cancer" is incorrect. 4. "Why are you so worried about this?" is not an appropriate statement as it disregards the client's feelings. Page Ref: 355 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
22) An adolescent client with a fibroadenoma asks the nurse what caused the tumor. Which answer should the nurse provide? 1. Inflammation of the breast tissue. 2. Growth of breast tissue. 3. Hormones associated with menstrual cycle. 4. A thickening of the breast tissue. Answer: 2 Explanation: 1. Fibroadenomas are benign glandular tumors not associated with inflammation of the breast tissue. 2. Fibroadenomas are benign glandular tumors most common in adolescent girls and are most commonly linked to breast hypertrophy which may occur during the growth spurt in puberty. 3. Fibroadenomas are benign glandular tumors that are not associated with the menstrual cycle. 4. Fibroadenomas are benign glandular tumors that are not associated with a thickening of the breast tissue. Page Ref: 356 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and EnvironNm uOctMpopulation-based transcultural health Ue RnStI:NC GoTnBd.C assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
23) A client asks the nurse why the breast has so many lymph nodes. Which response should the nurse provide? 1. Deliver fluid to the breast tissue and axillae. 2. Drain fluid away from the breast and axillae. 3. Protect the breast tissue from pathogens. 4. Transport hormones to the breast tissue. Answer: 2 Explanation: 1. The lymph nodes drain fluid from the breasts and axillae and return it to the circulatory system. 2. The lymph nodes drain fluid from the breasts and axillae and return it to the circulatory system. 3. The lymph nodes drain fluid from the breasts and axillae and return it to the circulatory system. 4. The lymph nodes drain fluid from the breasts and axillae and return it to the circulatory system. Page Ref: 340 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qTuaBl.iCtyOM and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1: Describe the anatomy and physiology of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
24) A parent of a newborn asks the nurse why their son's breast tissue is swollen. Which response should the nurse provide the parent? 1. "I have notified the healthcare provider of this finding." 2. "There must have been some slight trauma to the chest during birth." 3. "The maternal hormones can cause swollen breast tissue." 4. "This is an expected finding in all newborns." Answer: 3 Explanation: 1. This is a common assessment finding so there is no reason to notify the healthcare provider. The response does not answer the parent's question. 2. The swelling of the breast tissue is not due to trauma to the chest during birth. 3. The breast tissue of male newborns is sometimes swollen due to the maternal hormones of pregnancy. The swelling will subside as the infant's body eliminates maternal hormones. 4. This finding does not occur in all newborns; however, it is a normal finding. Page Ref: 357 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.CtO ioM ns. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
25) The nurse is providing teaching for a male client taking an estrogenic prescription for a prostate tumor. Which statements made by the client indicates an understanding of the information? Select all that apply. 1. "I may experience an enlargement in breast tissue." 2. "This prescription placed me at risk for breast cancer." 3. "I may experience discomfort in the lymph nodes around my breasts." 4. "I may experience some discharge from my nipples." 5. "I may experience pain and tenderness in my breasts." Answer: 1, 2, 4, 5 Explanation: 1. Estrogenic medications predispose a male client to gynecomastia. 2. Estrogenic medications predispose a male client to the risk of breast cancer. 3. Estrogenic medications does not cause discomfort in the lymph nodes around the breasts. 4. Estrogenic medication may cause some nipple discharge. 5. Estrogenic medications may cause pain and tenderness in the breast tissue which is associated with gynecomastia. Page Ref: 354, 357 Cognitive Level: Analyzing Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
26) The nurse assessing a client notes that the breasts do not fall freely from the chest. Which should the nurse suspect the finding is associated with? 1. Breast implants. 2. Breast cancer. 3. Pregnancy. 4. Lactation . Answer: 2 Explanation: 1. Breast implants allow the breasts to fall from the chest. 2. Breasts that do not fall freely from the chest are associated with breast cancer. 3. Breasts that do not fall freely from the chest are associated with breast cancer. 4. Breasts that do not fall freely from the chest are associated with breast cancer. Page Ref: 350 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.6: Identify abnorNmUaRl SfiInNdGinTgBs.CinOM the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
27) During a health assessment, a male client voices concern that he is at risk for breast cancer. The nurse is aware that further evaluation of the client's history should focus on predisposing factors that increase the chance for breast cancer in males. The interview should include questions related to which factors? Select all that apply. 1. Previous history of taking testosterone. 2. The client's mother having a history of breast cancer. 3. History of cirrhosis of the liver. 4. History of kidney disease. 5. History of radiation treatment for lung cancer. Answer: 2, 3, 5 Explanation: 1. Previously taking testosterone does not increase the risk of male breast cancer. Estrogen therapy in males does increase the risk for male breast cancer. 2. A family history of breast cancer in primary female relatives, such as a mother, does increase the risk for male breast cancer. 3. Cirrhosis of the liver has been found to increase the risk for male breast cancer. 4. A history of kidney disease is not a predisposing factor for male breast cancer. 5. Radiation exposure, such as radiation therapy for lung cancer, increases the risk for male breast cancer. Page Ref: 358 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.2: Plan questions about the breasts and axillae for the focused interview.
28) During a focused assessment, the female client reports breast tenderness, swelling, and lymph node enlargement around the time of her period. Which response by the nurse is the most appropriate? 1. "This sounds like a condition known as nodularity. It is a benign disorder so you will need to monitor your breasts monthly." 2. "Fluctuating hormone levels around the time of your period frequently causes these symptoms. I will note this in your chart and notify your primary care provider." 3. "As long as you have not detected any lumps, you have nothing to worry about." 4. "Do you have a history of fibrocystic breast disease? These symptoms are usually seen with this disease." Answer: 2 Explanation: 1. Nodularity is a benign physiologic condition of lumps in the breasts that occur just prior to the menstrual period through the end of the period. The client in this scenario does not report any lumps. 2. Fluctuating hormone levels frequently cause these symptoms, along with breast pain. Contraceptives can also cause these symptoms. The nurse is also correct in documenting the symptoms and informing the primary care provider so that further evaluation can occur. 3. "As long as you have not detected any lumps you have nothing to worry about," does not validate the information the client is reporting, nor does it help tell the client not to worry. In addition, this response may lead the client to believe that only lumps would be of significance to report. 4. While fibrocystic breast disease frequently coincides with fluctuating hormone levels of menstruation, its symptoms vary in that along with painful breasts, the client will have masses upon palpation that feel soft, well demarcated, and freely movable. These masses are usually found bilaterally. Clear, straw colored, milky, or green discharge from the nipples may also occur. Page Ref: 343 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
29) The nurse is preparing an educational session regarding the causes for male gynecomastia. Which items will the nurse include in the session? Select all that apply. 1. Breast cancer. 2. Infants following birth. 3. The onset of puberty. 4. Hormone therapy. 5. Breast infection. Answer: 2, 3, 4 Explanation: 1. Cancer of the breast in males typically manifests as a hard nodule fixed to the nipple and underlying tissue and nipple discharge may be present. Breast enlargement is not a typical symptom of breast cancer in males. 2. Gynecomastia is a temporary condition of breast enlargement in males and is commonly seen in infants following birth. 3. Gynecomastia is a temporary condition of breast enlargement in males that is sometimes seen at the onset of puberty and may occur in one or both breasts. 4. Gynecomastia is a temporary condition of breast enlargement in males that may be seen in older adult males, especially those that have received hormonal treatment for prostate cancer. 5. Infection of breast tissue is not generally associated with gynecomastia. Page Ref: 354 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3.NBUaR seSIiNnG diTvBid.CuO alM ized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breast and axillae MNL Learning Outcome: 17.4: Differentiate normal and abnormal variations of the breasts and axillae observed during physical assessment.
30) The nurse is educating a client about breast examination. Which area of the breast should the nurse inform the client that the majority of breast cancer occurs? Select all that apply. 1. Lower inner quadrant. 2. Axillary tail of Spence. 3. Lower outer quadrant. 4. Upper outer quadrant. 5. Areola and the nipple. Answer: 2, 4 Explanation: 1. The incidence of breast cancer is highest in the upper outer quadrant, including the tail of Spence. 2. The incidence of breast cancer is highest in the upper outer quadrant, including the tail of Spence. 3. The incidence of breast cancer is highest in the upper outer quadrant, including the tail of Spence. 4. The incidence of breast cancer is highest in the upper outer quadrant, including the tail of Spence. 5. The incidence of breast cancer is highest in the upper outer quadrant, including the tail of Spence. Page Ref: 351 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3.NBUase ndGiTvBid.CuO alM ized care plan on patient values, RSIiN clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.6: Identify abnormal findings in the physical assessment of the breasts and axillae. MNL Learning Outcome: 17.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the breasts and axillae.
31) The nurse is teaching self-breast examination to a client and demonstrates inspecting the breasts with arms over the head. The client asks the nurse why this is necessary. Which response by the nurse is the most appropriate? 1. "It allows any masses to bulge forward to be seen." 2. "This is the only position to detect Paget's disease." 3. "This is the best position to look for skin dimpling." 4. "It is the only way to look for nipple retraction." Answer: 3 Explanation: 1. Masses are rarely visible with inspection so stating that this position would allow for any masses to bulge forward to be seen is an inaccurate statement. 2. Paget's disease is a rare type of breast cancer typified by a red, scaly, eczema-like area over the nipple and, like nipple retraction, does not have to be visualized with the arms over the head. 3. This statement is accurate since recent dimpling of the skin over a mass is often a visible sign of breast cancer and it is accentuated with the client's arms over the head. 4. Nipple retraction is a possible sign of breast cancer but it does not require the arms over the head for visualization. Page Ref: 349 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.4: Outline the techniques for assessment of the breasts and axillae. MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
32) The nurse is performing a focused interview on breast health and is preparing to ask a client a question about internal environment. Which question should the nurse ask? 1. "Have you ever had a mammogram?" 2. "Do you have breast implants?" 3. "Have you been exposed to any environmental toxins?" 4. "Have you experienced any trauma to your breasts?" Answer: 2 Explanation: 1. A mammogram reflects health behavior. 2. Asking about breast implants is a question related to internal environment. 3. Environmental toxins are related to the external environment. 4. Trauma to the breasts is a question related to symptoms. Page Ref: 349 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.3: Determine which questions about the breasts and axillae to use for the focused interview. MNL Learning Outcome: 17.3: Utilize the appropriate techniques and tools for physical assessment of the breasts and axillae.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 18 Cardiovascular System 1) The nurse educator is teaching a group of nursing students to assess heart sounds. Which response by a student indicates appropriate understanding of how S2 heart sounds are produced? 1. "It results from the closure of the mitral valve." 2. "It is a result from the closure of the semilunar valves." 3. "It results from the closure of the tricuspid valve." 4. "It is caused by atrial contraction and ejection of blood into the ventricles in late diastole." Answer: 2 Explanation: 1. The S1 sounds result from the closure of the atrioventricular (AV) valves. The atrioventricular valves include the mitral and tricuspid valves. 2. The S2 sounds result from the closure of the semilunar valves. The semilunar valves include the aortic and pulmonic valves. A splitting of the S2 occurs toward the end of inspiration in some individuals. This results from a slight difference between the time the aortic and pulmonicvalves close. 3. The S1 sounds result from the closure of the atrioventricular (AV) valves. The atrioventricular valves include the mitral and tricuspid valves. 4. The S4 sound may be heard in children, well-conditioned athletes, and healthy elderly individuals without cardiac disease. It is caused by atrial contraction and ejection of blood into the ventricles in late diastole. Page Ref: 356 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.
2) The nurse is reviewing the function of the right side of the heart with a client. Which statement made by the client indicates further teaching is required? 1. "The right atrium receives blood that is deoxygenated." 2. "The mitral valve separates the right atrium from the right ventricle." 3. "The right atrium pumps blood to the right ventricle." 4. "The right atrium relaxes during diastole." Answer: 2 Explanation: 1. The right atrium receives deoxygenated blood. 2. The tricuspid valve separates the right atrium from the right ventricle. 3. The right atrium pumps blood to the right ventricle. 4. The right atrium is relaxed during diastole. Page Ref: 363, 364 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1: Describe the anatomy and physiology of the cardiovascular system. MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. 3) The client's stroke volume is 72 ml/beat. The client's heart rate is 82 beats per minute. What is the client's cardiac output? Record the response using a whole number. Answer: 5904 mL per minute. Explanation: Stroke volume describes the amount of blood that is ejected with every heartbeat. Normal stroke volume is 55 to 100 ml/beat. Cardiac output describes the amount of blood ejected from the left ventricle over 1 minute. Normal adult cardiac output is four to eight liters per minute. The formula for calculating cardiac output is: cardiac output = stroke volume multiplied by heart rate for 1 minute: 72 ml/ beat × 82 beats/ minute = 5904 mL/ minute. Page Ref: 376 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1: Describe the anatomy and physiology of the cardiovascular system. MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.
4) The nurse prepares to assess a client's point of maximal impulse (PMI). Which location should the nurse assess? 1. Second intercostal space, left sternal border. 2. Fifth intercostal space at the midclavicular line. 3. Second intercostal space, right sternal boarder. 4. Fourth intercostal space, left sternal boarder. Answer: 2 Explanation: 1. The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. 2. The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. 3. The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. 4. The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. Page Ref: 387 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.
5) The nurse is preparing to assess a client for heaves. Which location should the nurse palpate? 1. Fifth intercostal space, midaxillary line. 2. Second intercostal space, left sternal border. 3. Fourth intercostal space, left sternal border. 4. Second intercostal space, right sternal border. Answer: 4 Explanation: 1. Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension. 2. Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension. 3. Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension. 4. Pulsations or heaves palpated at the right sternal border in the second intercostal space are associated with systemic hypertension. Page Ref: 387 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. MNL Learning Outcome: 18.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system.
6) The nurse is obtaining a focused interview. Which statements made by the client suggest that the client has an increased risk of developing cardiovascular disease? Select all that apply. 1. "I have been stressed out since my divorce last year." 2. "I have cut back on my smoking." 3. "I have gained 25 pounds over the past year." 4. "I have cut back on fat and switched to a vegetarian diet." 5. "I have an occasional glass of wine." Answer: 1, 2, 3 Explanation: 1. Psychosocial problems and excessive stress can increase the client's risk for developing cardiovascular disease. 2. A client that smokes remains at risk for developing cardiovascular disease. 3. Obesity and a high percentage of body fat are risk factors for cardiovascular disease. Weight gain may accompany physical problems including systemic diseases such as diabetes, which increases this client's risk for developing cardiovascular disease. 4. A low-fat diet with vegetables and grains reduces the risk for cardiovascular disease. 5. An occasional glass of wine is not associated with cardiovascular disease. Page Ref: 377 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.
7) The nurse is assessing a client for risk factors of developing cardiovascular disease. Whichstatement made by the client places the client at risk? 1. "I was diagnosed with hypothyroidism about 5 years ago." 2. "My doctor always tells me when I come in that my blood pressure is low." 3. "I know my grandmother had diabetes, but every time it has been checked mine has been normal." 4. "My total cholesterol has been around 180." Answer: 1 Explanation: 1. Hypothyroidism may increase the client's risk for developing cardiovascular disease. 2. Hypertension, not hypotension, is associated with the development of cardiovascular disease. 3. Normal serum glucose levels indicate that the client does not currently have diabetes and so this client's risk is not necessarily increased. 4. Lower cholesterol levels do not place the client at risk for developing cardiovascular disease. The normal range for cholesterol is less than 200 mg/dl. Page Ref: 380 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.
8) The nurse is performing a focused interview with an adult male client who recently experienced a myocardial infarction. Which statement made by the client is generally unrelated to a myocardial infarction in males? 1. "I couldn't catch my breath." 2. "I did not feel any chest pain." 3. "I started sweating profusely." 4. "I got so sick to my stomach." Answer: 2 Explanation: 1. Typically, males who are experiencing a myocardial infarction will complain of dyspnea. 2. Typically, males who are experiencing a myocardial infarction will complain of chest pain that is prolonged, dull, and radiates to the shoulder or jaw. Females are more likely to experience nausea and vomiting, indigestion, shortness of breath, or extreme fatigue, without actual chest pain. 3. In males, the pain of MI is often accompanied by diaphoresis. 4. In males, the pain of MI is often accompanied by nausea. Page Ref: 380 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the cardiovascular system. MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.
9) The nurse is interviewing a client who has recently been diagnosed with atherosclerosis in the coronary arteries. Which question by the nurse is the priority when determining risk factors for this condition? 1. "Can you please tell me about the vitamins or supplements that you take?" 2. "Have you ever been diagnosed with rheumatic fever?" 3. "Do you smoke or are you exposed to secondhand smoke?" 4. "Have you ever had a diagnostic test, such as an electrocardiogram, stress test, or echocardiogram, or a surgical procedure for a cardiovascular problem?" Answer: 3 Explanation: 1. Information about vitamin and supplement use is important but is not specifically related to atherosclerosis and coronary artery disease. 2. A history of rheumatic fever can increase the client's risk for valvular problems but does not necessarily increase the client's risk for developing atherosclerosis and coronary artery disease. 3. The most important question regarding this client's history and recent diagnosis is about exposure to cigarette smoke. The chemical contained in the cigarette smoke injures the inner wall of arterial vessels and contributes to the subsequent development of a coronary artery plaque. 4. Diagnostic testing may help the nurse to determine if there was a previous suspicion that the client had developed a cardiovascular problem but is not specifically related to coronary artery disease and atherosclerosis. Page Ref: 378 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3: Determine which questions about the cardiovascular system to use for the focused interview. MNL Learning Outcome: 18.2. Plan questions about the cardiovascular system for the focused interview.
10) The nurse is preparing to assess the female client's cardiovascular system during a routine health assessment visit. Which items should the nurse have available in the room in order to complete the examination? Select all that apply. 1. Ruler (metric). 2. Stethoscope. 3. Reflex hammer. 4. Client gown and a drape. 5. An ultrasound machine. Answer: 1, 2, 4 Explanation: 1. The nurse will require a metric ruler to determine distention of blood vessels. 2. The nurse will require a stethoscope to auscultate the client's heart and arteries. 3. A reflex hammer is used during the assessment of the neuromuscular system. 4. Female clients should be provided with a gown and a drape for this examination in order to maintain privacy and avoid overexposure. 5. A Doppler stethoscope is needed to determine the presence of a pulse if the nurse is unable to adequately palpate the pulse. An ultrasound machine is not needed to conduct a thorough assessment. Page Ref: 383 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive and NG focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
11) The nurse is preparing to assess the client's cardiovascular system. Which client positions will the nurse use when conducting this assessment? Select all that apply. 1. Dorsal recumbent. 2. Leaning forward. 3. Right lateral position. 4. Left lateral position. 5. Sitting upright. Answer: 1, 2, 4, 5 Explanation: 1. The client will be asked to remain in a supine position or dorsal recumbent position for part of the examination. The nurse may be able to auscultate murmurs better while the client is in this position. 2. The client will be asked to lean forward during auscultation of the heart. The nurse should listen to the client's heart while the client is leaning forward. 3. Right lateral position is not a common position to place the client in during this type of examination. 4. The client will be asked to lie on the left side during part of this examination. In obese clients, heart sounds are best heard at the apical area with the client in the left lateral position. 5. The nurse will most likely begin this examination while the client is in this position. This is the position the nurse should ask the client to assume when beginning chest auscultation. Page Ref: 384-391 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
12) The nurse is preparing to auscultate heart sounds after repositioning the client on the left side. Which sounds should the nurse anticipate evaluating the client for? 1. S3 and S4 sounds. 2. S1 and S2 sounds. 3. Pulmonic valve murmurs. 4. Tricuspid valve murmurs. Answer: 1 Explanation: 1. A client is positioned left laterally to allow for the S3 and S4 sounds to be easily heard. 2. A client is positioned left laterally to allow for the S3 and S4 sounds to be easily heard. 3. A client is positioned left laterally to allow for the S3 and S4 sounds to be easily heard. 4. A client is positioned left laterally to allow for the S3 and S4 sounds to be easily heard. Page Ref: 391 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
13) The nurse is assessing the client's cardiovascular system. Which techniques are appropriate for the nurse to use during this assessment? Select all that apply. 1. Continuing the exam when the client complains of discomfort when lying flat. 2. Auscultating the apical impulse at the fifth intercostal space at the midclavicular line. 3. Examining the client's legs and noting the distribution pattern of the client's hair 4. Palpating the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate. 5. Examining the client's hands and fingers. Answer: 2, 3, 5 Explanation: 1. If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination. 2. This is normally where the point of maximal impulse can be palpated. 3. Examining the client's legs and noting the distribution pattern of the client's hair is an appropriate assessment for circulatory problems. 4. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole. 5. It is appropriate to examine the client's hands and fingers to determine the existence of peripheral circulatory problems. Page Ref: 384-387 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
14) The client has a history of rheumatic fever. Which layer of the heart is at the greatest risk for damage due to infection? 1. Epicardium. 2. Myocardium. 3. Endocardium. 4. Pericardium. Answer: 3 Explanation: 1. Strep infections can cause rheumatic fever. Rheumatic fever can damage the client's endocardium. The endocardium makes up the innermost layer of the heart and valve tissue. 2. Strep infections can cause rheumatic fever. Rheumatic fever can damage the client's endocardium. The endocardium makes up the innermost layer of the heart and valve tissue. 3. Strep infections can cause rheumatic fever. Rheumatic fever can damage the client's endocardium. The endocardium makes up the innermost layer of the heart and valve tissue. 4. Strep infections can cause rheumatic fever. Rheumatic fever can damage the client's endocardium. The endocardium makes up the innermost layer of the heart and valve tissue. Page Ref: 392 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
15) The nurse is preparing to assess the central venous pressure of a client with a ruler. Which techniques should the nurse include in the assessment? 1. Place the client in 45-degree angle. 2. Measure the distention on both sides. 3. Place the ruler horizontally at the angle of Lois and the second at a 45-degree angle. 4. Place the ruler at the substernal notch and the end of the juggler vein on the lateral aspect of the neck. Answer: 1 Explanation: 1. The client should be sitting at a 45-degree angle. 2. The distention only on one side needs to be measured. 3. The ruler should be placed vertically at the angle of Lois and the second at a horizontal 90degree angle. 4. One end of the ruler should be at the angle of Louis and the other end at the jugular area on the lateral aspect of the neck. Page Ref: 386 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : CGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
16) The nurse is performing a cardiac assessment on an older adult client admitted with hypertension. The nurse determines that the apical impulse can be palpated in an area 2 cm in diameter at the point of maximal impulse. Which conclusion by the nurse is appropriate based on this data? 1. Left ventricular hypertrophy. 2. Aortic stenosis. 3. Right ventricular volume overload. 4. Enlarged left atrium. Answer: 1 Explanation: 1. If the apical impulse can be palpated in an area greater than 1 cm in diameter or is laterally displaced, the conditions that may be present include left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation. 2. Clients with aortic stenosis often have heaves present at the right sternal border, second intercostal space. 3. The presence of heaves or thrills in the subxiphoid area suggests the presence of right ventricular volume overload. 4. Pulsations or heaves in the left sternal border, second intercostal space, are associated with an enlarged left atrium. Page Ref: 388 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
17) The nurse is assessing a client with a history of rheumatic fever. Subjective findings include fatigue and objective findings include a diastolic murmur in the apical area when the client is in the left lateral position. Which diagnosis should the nurse suspect? 1. Tricuspid regurgitation. 2. Mitral regurgitation. 3. Mitral stenosis. 4. Pulmonic stenosis. Answer: 3 Explanation: 1. The murmur associated with tricuspid regurgitation is often described as systolic, blowing, and high-pitched and may radiate. 2. Mitral regurgitation is a high-pitched, blowing, harsh, systolic murmur with radiation to the left axilla. 3. The murmur associated with mitral stenosis is best heard with the bell of the stethoscope at the apex while the client is placed in the left lateral position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection. 4. The murmur associated with pulmonic stenosis is often described as a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck. Page Ref: 393 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
18) During the cardiac assessment of a client, the nurse hears a loud rumbling at the left sternal border. Which diagnosis should the nurse suspect? 1. Aortic stenosis. 2. Tricuspid stenosis. 3. Mitral regurgitation. 4. Pulmonic stenosis. Answer: 2 Explanation: 1. The type of murmur heard with aortic stenosis occurs midsystole and is crescendo-decrescendo. 2. The sound heard in this scenario is most likely a murmur related to tricuspid stenosis. Tricuspid stenosis may produce a loud rumbling sound during diastole. The sound increases towards the end of the sound. 3. With mitral regurgitation, the sound is heard in systole and is continuous. 4. With pulmonary stenosis, the midsystolic sound is heard over the right sternal border in the second intercostal space. Page Ref: 394 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
19) The intensive care nurse is performing a cardiac assessment on a newly admitted older adult client and notes the following findings: peripheral edema, jugular venous distention of 5 cm above the sternal angle when the client is at a 45-degree angle, and an enlarged liver. Based on this data, which diagnosis does the nurse suspect? 1. Pulmonary edema. 2. Left-sided heart failure. 3. Myocardial infarction. 4. Right-sided heart failure. Answer: 4 Explanation: 1. Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. 2. Left-sided heart failure results in pulmonary congestion and pulmonary edema as blood backs up into the pulmonary system. 3. Heart failure may be caused by a myocardial infarction. However, the clinical manifestations associated with heart failure are not always the result of a myocardial infarction. 4. With right-sided heart failure, the right ventricle is ineffective as a pump, which leads to congestion as blood backs up into the systemic circulation. Right-sided heart failure results in increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Right-sided heart failure also results in peripheral edema and liver enlargement. Page Ref: 392 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
20) The nurse is assessing a client notes a loud, blowing sound over the right carotid artery. Based on this data, which diagnosis should the nurse anticipate? 1. Mitral stenosis. 2. Aortic regurgitation. 3. Atrial septal defect. 4. Stricture of the carotid. Answer: 4 Explanation: 1. Mitral stenosis is a narrowing of the left mitral valve. In a client with mitral stenosis, there is often a murmur heard at the apical area with the client in left lateral position. 2. Aortic regurgitation is the backflow of blood from the aorta into the left ventricle. With aortic regurgitation, a murmur may be heard when the client is leaning forward, at the second intercostal space. 3. With an atrial septal defect, there is an opening between the right and left atrium. Regurgitation occurs through this defect resulting in a harsh, loud, high-pitched murmur heard at the left sternal border at the second intercostal space. 4. A bruit, which is a loud swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. The most common cause for this is atherosclerosis. Page Ref: 390 Cognitive Level: Remembering Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
21) The nurse is preparing to listen to a client's mitral valve. Which landmark on the client's chest should the nurse place the bell of the stethoscope? 1. Left sternal boarder, third intercostal space. 2. Left sternal border, fourth intercostal space. 3. Right sternal boarder, second intercostal space. 4. The apex, fifth intercostal space, left midclavicular line. Answer: 4 Explanation: 1. The left sternal border third intercostal space is called Erb's point. 2. Closure of the tricuspid valve can be heard at the left sternal border fourth intercostal space. 3. The aortic valve can be auscultated at the right sternal boarder, second intercostal space. 4. The mitral valve can be auscultated at the apex, fifth intercostal space, left midclavicular line. Page Ref: 390 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 18.4: Outline the techniques for assessment of the cardiovascular system. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
22) The nurse notes that a client has xanthelasma during an assessment. Which cardiovascular condition should the nurse suspect? 1. Liver disease. 2. Diabetes. 3. Elevated cholesterol. 4. Premature atherosclerosis. Answer: 4 Explanation: 1. Liver disease is not directly associated with premature atherosclerosis. 2. Diabetes can contribute to premature atherosclerosis if the glucose is not kept under control. 3. Elevated cholesterol can contribute to premature atherosclerosis. 4. Premature atherosclerosis. Page Ref: 385 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
23) The nurse is preparing to care for a client with Paget's disease. Which assessment findings should the nurse monitor the client for? Select all that apply. 1. Dyspnea. 2. Fatigue. 3. Weakness. 4. Flushed skin. 5. Distended jugular veins. Answer: 1, 2, 3, 5 Explanation: 1. Paget's disease is characterized by a high cardiac output, which may lead to heart failure. Dyspnea is a symptom associated with heart failure. 2. Paget's disease is characterized by a high cardiac output, which may lead to heart failure. Fatigue is a symptom associated with heart failure. 3. Paget's disease is characterized by a high cardiac output, which may lead to heart failure. Weakness is a symptom associated with heart failure. 4. Flushed skin is not an expected finding associated with Paget's disease. 5. Paget's disease is characterized by a high cardiac output, which may lead to heart failure. Distended jugular veins are associated with heart failure. Page Ref: 385 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementaNtiUoRnSoIN f cGaTrBe.CpO laM n, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
24) The nurse observes splinter hemorrhages in a client's nailbeds. Which finding should the nurse suspect the findings are associated with? 1. Polycythemia. 2. Congestive heart failure. 3. Infective endocarditis. 4. Inadequate cardiac perfusion. Answer: 3 Explanation: 1. Polycythemia is not associated with splinter hemorrhages. 2. Congestive heart failure is not associated with splinter hemorrhages. 3. Splinter hemorrhages are associated with infective endocarditis. 4. Inadequate cardiac perfusion is not associated with splinter hemorrhages. Page Ref: 386 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnorNmUaRl SfiInNdGinTgBs.CinOM the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
25) The nurse is reviewing the symptoms of an MI with a female client. Which findings should the nurse include? 1. Extreme fatigue. 2. Prolonged dull chest pain. 3. Dyspnea. 4. Indigestion. 5. Nausea and vomiting. Answer: 1, 3, 4, 5 Explanation: 1. Extreme fatigue is associated with an MI in a female client. 2. Chest pain may be absent in a female client experiencing an MI. 3. Dyspnea is associated with an MI in a female client. 4. Indigestion is associated with an MI in a female client. 5. Nausea and vomiting are associated with an MI in a female client. Page Ref: 380 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
26) The nurse is reviewing the effects of smoking on the cardiovascular system with a client. Which information should the nurse include in the teaching? 1. Injury to the vessel walls. 2. Decreased workload of the heart. 3. Damage to the cardiac muscle. 4. Damage to cardiac valves. Answer: 1 Explanation: 1. Smoking has been linked to hypertension and is strongly suspected of contributing to injury in the walls of the arteries, thus accelerating the development of atherosclerotic plaques. 2. Smoking is not linked to a decreased workload of the heart. 3. Smoking is not linked to damage to the cardiac muscle. 4. Smoking does not damage the cardiac valves. Page Ref: 381 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
27) The nurse is caring for a client that is using cocaine. Which initial cardiovascular effect occurs due to the use of the drug? 1. Congestive heart failure. 2. Coronary artery spasms. 3. Vasodilation. 4. Atherosclerosis. Answer: 2 Explanation: 1. The client is at risk for congestive heart failure when the myocardial tissue is injured and can no longer function. 2. The use of cocaine is associated with coronary artery spasms and potential development of ischemia and injury to the myocardial tissue. 3. Cocaine use causes vasoconstriction. 4. Cocaine use is not associated with atherosclerosis. Page Ref: 381 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.6: Identify abnorNmUaRl SfiInNdGinTgBs.CinOM the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
28) The nurse observes that a client's skin is a ruddy color. Which condition should the nurse suspect? 1. Systemic Infection. 2. Polycythemia. 3. Coronary artery disease. 4. Rheumatic heart disease. Answer: 2 Explanation: 1. Ruddy skin is not specifically associated with a systemic infection; however, if there is a fever present, the client may have flushed skin. 2. A ruddy color may indicate polycythemia, a condition in which there is a significantly increased number of red blood cells, or Cushing syndrome, a hormonal disorder caused by prolonged exposure of the tissues of the body to cortisol, a product of the adrenal glands. 3. A client with coronary artery disease may have grayish undertones. 4. Flushed skin may be associated with a fever or rheumatic heart disease. Page Ref: 384 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU /IRnSteINgra e.dCC GTtB Oo Mncepts: Nursing Process: Diagnosis Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
29) The nurse is caring for a client suspected of having a myocardial infarction. Which assessment findings should the nurse recognize are associated with the condition? Select all that apply. 1. Mental confusion. 2. Vomiting. 3. Skin is flushed and warm. 4. Diaphoresis. 5. Jugular venous distension. Answer: 2, 4 Explanation: 1. Mental confusion is associated with right-sided heart failure not directly with a myocardial infarction. 2. Vomiting is associated with a myocardial infarction. 3. Warm, flushed skin is not necessarily associated with an acute cardiovascular problem. Cyanosis, blue or gray-tinged skin, and pallor are associated with an acute cardiovascular problem. 4. Diaphoresis is associated with a myocardial infarction. 5. Jugular venous distention is associated with right-sided heart failure, not directly with a myocardial infarction. Page Ref: 392 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
30) A client asks the nurse what pulmonary stenosis means. Which information should the nurse provide the client? 1. Narrowing between the pulmonary vein and left atrium. 2. Narrowing between the pulmonary artery and left ventricle. 3. Narrowing between the pulmonary vein and the right atrium. 4. Narrowing between the pulmonary artery and the right ventricle. Answer: 4 Explanation: 1. The pulmonary veins transfer oxygenated blood to the heart from the lungs and into the left atrium but this is not where the narrowing occurs. 2. The pulmonary artery does not drain into the left ventricle. 3. The pulmonary vein does not drain into the right atrium. 4. Pulmonary stenosis is a narrowing between the pulmonary artery and the right ventricle. Page Ref: 393 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.6: Identify abnormal findings in the physical assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
31) The nurse is conducting a cardiovascular focused assessment. Which question should the nurse ask that reflects behavior? 1. "Can you describe your diet?" 2. "Do you take any medications?" 3. "What is your present occupation?" 4. "Have you experienced a change in your weight?" Answer: 1 Explanation: 1. The client's diet is reflective of behavior. 2. Asking a client about medications is associated with the client's internal environment. 3. The client's occupation is reflective of the external environment. 4. Asking about a change in weight is a general question. Page Ref: 381 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.3: Determine which questions about the cardiovascular system to use for the focused interview. MNL Learning Outcome: 18.3. Utilize the appropriate techniques and tools for physical assessment of the cardiovascular system.
32) The nurse observes expected findings after assessing a client's conjunctiva. Which description should the nurse anticipate to document? 1. Red. 2. White. 3. Clear. 4. Pink. Answer: 3 Explanation: 1. Redness of the conjunctiva is an abnormal finding. 2. The sclera should be white in color. 3. Conjunctiva should be clear and the underlying tissue pink in color. 4. Conjunctiva should be clear and the underlying tissue pink in color. Page Ref: 385 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.5: Generate the appropriate documentation to describe the assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
33) The nurse is auscultating the fifth intercostal space left midclavicular line. Which should the nurse anticipate documenting? 1. Tricuspid sounds. 2. Apical pulse. 3. Pulmonic sounds. 4. Aortic sounds. Answer: 2 Explanation: 1. The tricuspid sounds are heard at the left sternal boarder fourth intercostal space. 2. The apical pulse is auscultated in the fifth intercostal space left midclavicular line. 3. The pulmonic sounds are heard at the left sternal border second intercostal space. 4. The aortic sounds are heard at the right sternal border second intercostal space. Page Ref: 387 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.5: Generate the appropriate documentation to describe the assessment of the cardiovascular system. MNL Learning Outcome: 18.4. Differentiate normal and abnormal variations of the cardiovascular system observed during physical assessment.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 19 Peripheral Vascular System 1) The nurse is preparing to assess the client's dorsalis pedis pulse. Which location will the nurse palpate to assess this pulse? 1. Behind the medial malleolus. 2. Lateral wrist. 3. Popliteal fossa. 4. Medial side of the dorsum of the foot. Answer: 4 Explanation: 1. The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot. 2. The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot. 3. The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot. 4. The dorsalis pedis pulses may be felt on the medial side of the dorsum of the foot. Page Ref: 399 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcUeRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1: Describe the anatomy and physiology of the peripheral vascular system. MNL Learning Outcome: 19.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system.
2) A client presents with an enlargement of several cervical lymph nodes and asks the nurse about the function of these structures. Which response by the nurse is the most appropriate? 1. "Your lymph nodes filter blood for your body." 2. "They are responsible for the breakdown of old red blood cells." 3. "They make lymphocytes for you." 4. "Your lymph nodes help to remove infectious organisms." Answer: 4 Explanation: 1. Lymph nodes actually filter lymph fluid before returning it to the client's blood. 2. The liver and the spleen are responsible for breaking down old red blood cells. 3. Lymphocytes are not made in lymph nodes. Lymph nodes filter lymph fluid before returning it the blood. 4. This statement is accurate. The lymph fluid is filtered in the lymph node to remove pathogens before returning it the bloodstream. Page Ref: 400, 401 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: G ImTpBl.eCm entation OM Learning Outcome: 19.5: Plan the patient education related to the assessment on the peripheral vascular system. MNL Learning Outcome: 19.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system.
3) The nurse is performing a focused interview with a client who was recently diagnosed with varicose veins. Which statements by the client will the nurse document as risk factors for varicose vein development? Select all that apply. 1. "My mother had big veins on her legs from the time I was little." 2. "My father is of Japanese descent." 3. "I'm a hair stylist." 4. "I was pregnant once and have a son." 5. "I know I weigh a lot more than I should." Answer: 1, 3, 4, 5 Explanation: 1. A client who has a family history of varicose veins has an increased risk fordeveloping them. 2. Risk factors for varicose veins include people who are of Irish or German descent. People of Japanese descent do not necessarily have an increased risk of developing varicose veins. 3. Hair stylists are more likely to be on their feet while they are working and this does result in an increase in their risk of developing varicose veins. 4. People who have been pregnant multiple times have an increased risk for developing varicose veins. 5. People who are obese have an increased risk for developing varicose veins. Page Ref: 402 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.6: Generate the appropriate documentation to describe the assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
4) While performing a focused interview with a healthy adult client, the nurse notes frequent position changes, wringing of hands, lack of eye contact, incomplete sentences, and rapid speech. The vital signs are BP 160/88 mmHg, apical pulse 102 beats per minute, and respiratory rate 26 per minute. Which responses by the nurse are appropriate in this situation? Select all that apply. 1. "I'm going to take your temperature now." 2. "Have you ever experienced chest pain?" 3. "Are you feeling any anxiety right now?" 4. "Are you experiencing any pain at this time?" 5. "Have you ever been diagnosed with hypothyroidism?" Answer: 2, 3, 4 Explanation: 1. It will be appropriate to assess the client's temperature, but the nurse should first determine whether the client is in pain or is experiencing anxiety. 2. The client's actions may indicate that the client is experiencing pain. Pain can result in increased blood pressure, pulse, and respiratory rate. The nurse should determine if the client is experiencing pain and seek to treat the pain prior to continuing with the focused interview. 3. The client's actions are consistent with anxiety. Anxiety stimulates the sympathetic nervous system, which can result in vasoconstriction, high blood pressure, increased heart rate, and respiratory rate. 4. The client may be experiencing chest pain. The nurse should determine whether the client is experiencing chest pain prior to continuing the focused interview. 5. The client's vital signs and actions are more likely associated with hyperthyroidism. Page Ref: 405 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
5) The nurse is preparing to assess a client newly diagnosed with hyperthyroidism. Which finding should the nurse anticipate? 1. Carotid bruit. 2. Pulse deficit. 3. Hypotension. 4. Delayed capillary refill. Answer: 1 Explanation: 1. An increased cardiac output such as that seen in hyperthyroidism will produce a bruit. 2. A pulse deficit is not an expected finding associated with hyperthyroidism. A pulse deficit can be associated with cardiac dysrhythmias. 3. Hypotension is not associated with hyperthyroidism. 4. Delayed capillary refill is not associated with hyperthyroidism. Page Ref: 409 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
6) The nurse is assessing a client's blood pressure. The client asks the nurse why it is important to feel for his pulse prior to taking his blood pressure. Which response by the nurse is the most appropriate? 1. "I can document this value if I am unable to measure your blood pressure the other way." 2. "I need to feel for your pulse to make sure it is regular." 3. "I am more likely to get an accurate reading if I do it this way." 4. "It is the best way to determine an arterial obstruction." Answer: 3 Explanation: 1. It is not appropriate to merely document the palpable systolic pressure. Efforts should be made to document the client's blood pressure. 2. Palpating the pulse prior to taking a blood pressure is not intended to evaluate the regularity of the pulse. Palpating the pulse is an assessment of the systolic pressure to help avoid inaccuracy in the blood pressure assessment. 3. Assessing the palpable systolic pressure helps avoid inaccuracy in blood pressure assessment that can occur with an auscultatory gap, or space in which beats are not heard, during this assessment. 4. This can be assessed by measuring the difference between the blood pressures in the arms. A difference of 10 mmHg or more between the arms may indicate an obstruction of arterial flow to one arm. Page Ref: 407 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.5: Plan the patient education related to the assessment on the peripheral vascular system. MNL Learning Outcome: 19.3. Utilize the appropriate techniques and tools for physical assessment of the peripheral vascular system.
7) The nurse educator is teaching a group of nursing students how to perform an assessment of the client's peripheral vascular system. Which student statements indicate an appropriate understanding of the peripheral vascular assessment? Select all that apply. 1. "I need to take a blood pressure only in the client's right arm." 2. "The best way to assess the carotid pulses is palpate one side and then the other." 3. "It will be difficult to assess the client's carotid pulses if the client is obese." 4. "I should inspect the arms to ensure that they are close to the same size." 5. "I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions." Answer: 2, 4, 5 Explanation: 1. A thorough peripheral vascular assessment includes blood pressure measurements taken in both arms and both legs. 2. The carotid pulses should not be palpated at the same time, otherwise it may cause the client to faint or pass out due to lack of blood flow to the brain. 3. It is much easier to assess the client's carotid pulses when the client has a long, thin neck. 4. The arms should be compared to each other to ensure that there is not a lymphatic problem that has developed that would result in edema. 5. The skin on the extremities should be clean, dry, and intact. The client's pattern of hair distribution should be evaluated to determine if there is adequate arterial circulation. Page Ref: 408, 409 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 19.4: Outline the techniques for assessment of the peripheral vascular system. MNL Learning Outcome: 19.3. Utilize the appropriate techniques and tools for physical assessment of the peripheral vascular system.
8) The nurse is teaching a client what they can expect during the peripheral vascular assessment of the lower extremities. Which statements by the nurse are appropriate to include in the teaching? Select all that apply. 1. "I am going to touch your legs and feet to see how warm they are." 2. "I will be assessing your legs for hair loss." 3. "I will be using a Doppler to find your pulses." 4. "I am going to test your ability to feel sensations." 5. "I will be looking for varicose veins." Answer: 1, 2, 4, 5 Explanation: 1. Warmth felt at the distal portions of the extremities indicate that the client is receiving an adequate amount of arterial blood flow to those areas. 2. Absence of hair on the legs may be related to peripheral vascular disease. 3. A Doppler is used if the pulses cannot be located through palpation. 4. The client's ability to feel sensation is associated with adequate blood flow to the extremities. 5. It is important to assess the client for varicosities. Page Ref: 404, 411 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.5: Plan the patient education related to the assessment on the peripheral vascular system. MNL Learning Outcome: 19.3. Utilize the appropriate techniques and tools for physical assessment of the peripheral vascular system.
9) The nurse is reviewing the history of a client. Which findings place the client at risk for damage to the peripheral circulation? Select all that apply. 1. Diabetes. 2. Varicose veins. 3. Blood clots. 4. Asthma. 5. Respiratory disease. Answer: 1, 2, 3, 5 Explanation: 1. Diabetes places a client at risk for damage to the peripheral circulation. 2. Varicose veins place a client at risk for damage to the peripheral circulation. 3. Blood clots place a client at risk for damage to the peripheral circulation. 4. Asthma does not place the client at risk for damage to the peripheral circulation. 5. Respiratory disease places a client at risk for damage to the peripheral circulation. Page Ref: 403 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
10) The nurse obtaining a blood pressure in both of the client's arms determines that there is a difference of 15 mmHg in the systolic readings between the arms and repeats the assessment with the same results. Based on this data, which does the nurse suspect? 1. Inaccurate technique. 2. Anxiety. 3. Unilateral arterial obstruction. 4. Shock. Answer: 3 Explanation: 1. After repeating the procedure and determining that the results were the same, the nurse would not necessarily assume that the technique was faulty. 2. Client anxiety may result in a higher blood pressure reading. It would not result in a difference between blood pressures assessed in each arm. 3. A difference of readings 10 mmHg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding. 4. If the client is developing clinical manifestations associated with shock, the nurse would most likely determine that the client's blood pressure is lower than normal. Shock would not result in a difference between blood pressures assessed in each arm. Page Ref: 407 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
11) Which question should the nurse ask the client that is associated with a diagnosis of chronic bronchitis? 1. "How long have your fingertips been this large?" 2. "How long have your fingernails been so hard?" 3. "How long have your nails been a bluish color?" 4. "How long have your nails had ridges in them?" Answer: 3 Explanation: 1. Many times, clients with a long-term history of chronic hypoxia such as chronicbronchitis will exhibit clubbing of their fingers. The fingertips will look large at the ends. 2. Clients with lung problems resulting in chronic hypoxia will more likely to complain that their nails are soft and spongy. 3. This is a likely statement from someone who has a long history of disorder resulting in chronic hypoxia. The nails may look blue or gray due to oxygen deprivation. 4. This is more likely the result of another disorder such as a nutritional deficiency. Page Ref: 416 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3: Determine which questions about the peripheral vascular system to use for the focused interview. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
12) The nurse is documenting an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding. Which other assessment data would be useful to determine the origin of this client's ulcer? 1. Skin turgor. 2. Calf measurements. 3. Homan's sign. 4. Peripheral pulses. Answer: 4 Explanation: 1. The nurse can use information about the client's skin turgor to help assess the client's fluid balance. 2. Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. 3. Homan's sign can be used to help determine if the client has developed a deep vein thrombosis. 4. Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. Page Ref: 419 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.4: Outline the techniques for assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
13) The nurse is assessing a client admitted to the hospital for congestive heart failure (CHF) and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client's ankles. The client's history indicates that the client has had a myocardial infarction and a left mastectomy. Which is the most probable cause of the edema in the client's left arm? 1. Impaired lymphatic drainage. 2. Noncompliance with medication regimen. 3. Right-sided heart failure. 4. Excessive intake of sodium. Answer: 1 Explanation: 1. This client most likely has developed lymphedema due to the removal of lymph nodes during the client's mastectomy. This type of surgery can inhibit the body's ability to drain lymph from the client's affected arm. 2. Noncompliance with medication may result in edema that affects the client's bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the client's extremity. 3. Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the client's arm. 4. Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema. Page Ref: 416 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
14) The nurse caring for a client post cardiac catheterization is unable to locate pulses in the right distal extremity with the Doppler. Which is the nurse's priority action? 1. Notify the healthcare provider immediately. 2. Assess for the client's right popliteal pulse. 3. Take the client's blood pressure. 4. Place the client in Trendelenburg position. Answer: 2 Explanation: 1. The nurse should attempt to palpate the client's popliteal pulse prior to notifying the healthcare provider to communicate the additional assessment. 2. This is the appropriate action at this time. This will help the nurse determine how much of this extremity is still receiving oxygenated blood. 3. After the nurse assesses the client's popliteal pulses, it may be appropriate to check the client's vital signs prior to notifying the healthcare provider. 4. Trendelenburg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
15) The nurse notes a client has a rusty discoloration over their tibial surface of the skin. Which should the nurse suspect is occurring? 1. Venous disease. 2. Bacterial infection. 3. Trauma to the tissue. 4. Arterial disease. Answer: 1 Explanation: 1. A rusty discoloration over the anterior tibial surface with the skin intact is associated with venous disease. The characteristic color stems from blood leaking out of a vessel with a decreased capacity for it to be reabsorbed. 2. The rusty discoloration over the tibial surface of the skin is not associated with a bacterial infection. 3. The rusty discoloration over the tibial surface of the skin is not associated with trauma to the tissue. 4. The rusty discoloration over the tibial surface of the skin is not associated with arterial disease. Page Ref: 411 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
16) The nurse is obtaining a history from an adult female client. Which statement made by the client should the nurse recognize places her at risk for a deep vein thrombosis? Select all that apply. 1. "I spend most of my time sitting at a desk." 2. "I have had a history of a mastectomy." 3. "I have quit smoking 6 months ago." 4. "I have taken oral contraceptives for the last 3 years." 5. "I have 2 glasses of wine every evening." Answer: 1, 4 Explanation: 1. Sedentary activities and prolonged periods of sitting or standing at work or in the home can promote peripheral vascular problems. 2. A client that has had a mastectomy is at risk for lymphedema not a deep vein thrombosis. 3. A client that is no longer smoking is at decreased risk for deep vein thrombosis. 4. Oral contraceptive use is linked to increased risk of blood clot formation. 5. Alcohol use is not associated with deep vein thrombosis. Page Ref: 405 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.iC enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
17) The nurse is preparing to assess the arteriovenous fistula of a client scheduled for dialysis. Which findings should the nurse anticipate? 1. Cool shiny skin. 2. Discoloration of the area. 3. Unilateral edema. 4. Bulging veins near the surface of the skin. Answer: 4 Explanation: 1. Cool shiny skin is not a finding associated with an arteriovenous fistula. 2. Discoloration of the arteriovenous fistula is not an expected finding. 3. Unilateral edema is not a finding associated with an arteriovenous fistula. 4. An arteriovenous fistula is characterized by bulging veins near the surface of the skin. Page Ref: 422 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
18) The nurse is assessing a client who may have arterial insufficiency in the left lower leg. Which assessment findings support the diagnosis of arterial insufficiency? Select all that apply. 1. Left dorsalis pedis pulse +1 and right dorsalis pedis pulse +3. 2. Skin is cool, tight, and shiny. 3. When left leg is dependent, erythema is present. 4. When left leg is elevated, pallor is present. 5. Client complains of increased pain during rest periods. Answer: 1, 2, 3, 4 Explanation: 1. The client with arterial insufficiency may have diminished pulses. The pulse in the left foot is difficult to palpate, while the pulse in the right foot is strong and easy to palpate. 2. This finding is consistent with arterial insufficiency. The affected limb will feel cool. The skin may look "tight" and appear shiny. These findings indicate that the limb is not receiving an adequate arterial supply of oxygenated blood. 3. This finding is consistent with arterial insufficiency. When in a dependent position, the affected limbs will become reddened. 4. This finding is consistent with arterial insufficiency. When elevated, affected limbs will become pale. 5. The client with arterial insufficiency is more likely to complain of pain during exercise of theleg. The pain decreases or is absent with rest. Page Ref: 419 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
19) The client was recently diagnosed with venous insufficiency. Which client statements support the client's diagnosis? Select all that apply. 1. "My legs are so cold that they feel like ice." 2. "My ankles and feet are always swollen." 3. "The skin on my leg looks so pale." 4. "When I walk around a lot, my legs just ache." 5. "I have an ulcer on my inner leg above my ankle that just bleeds and bleeds." Answer: 2, 5 Explanation: 1. Clients with arterial insufficiency may complain that their legs feel cool or cold. The nurse is more likely to determine that the legs of clients with venous insufficiency have temperatures that are within normal limits. 2. Edema in the lower extremities is associated with venous insufficiency. 3. Pale skin on the lower extremities is associated with arterial insufficiency. Venous insufficiency results in darkened skin on the lower extremities. 4. This statement is consistent with a client who has been diagnosed with arterial insufficiency. The type of discomfort associated with venous insufficiency is aggravated by prolonged standing or sitting and is relieved by several hours of rest. 5. This type of ulcer is consistent with a diagnosis of venous insufficiency. These ulcers are more likely to bleed and can be found in this area of the lower extremity. Arterial insufficiency ulcers are often described as dry, pale, with defined edges. Page Ref: 420 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
20) The client is visiting the healthcare provider's office with complaints of discoloration of her hands. The client states, "My fingertips turn whitish and then later they get really red." Which disorder does the nurse anticipate the client will be diagnosed with based on this data? 1. Lymphedema. 2. Raynaud disease. 3. Thrombosis. 4. Venous insufficiency. Answer: 2 Explanation: 1. Lymphedema is often described as edema that occurs in an affected extremity that is not draining lymph properly. 2. The findings described are consistent with Raynaud disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, and then redness. This condition is most commonly seen in young females. 3. These findings are not consistent with a venous clot in the client's arm. Clients with clots may have no symptoms at all or may experience pain. 4. Venous insufficiency results in discomfort that is aggravated by prolonged standing or sitting and is relieved by rest. The client's complaints are not consistent with venous insufficiency. Page Ref: 421 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
21) A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the left arm is normal in size. Which question by the nurse is the most appropriate based on this data? 1. "How much salt do you have in your diet?" 2. "Does the other arm swell also?" 3. "What surgical procedures have you had?" 4. "Do you ever feel self-conscious about your arm?" Answer: 3 Explanation: 1. This client most likely has lymphedema. If salt intake was excessive, the nurse would also determine swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity. 2. This is a good question but the nurse can see at this time that there is unilateral swelling. This is not the most important question to ask at this time. 3. This is the most important thing for the nurse to determine. This information will help the nurse to determine if the client has lymphedema due to a surgical procedure. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately. 4. This is important for the nurse to determine. However, this is not the most important question to ask at this time. The nurse should seek to determine how the lymphedema developed. Page Ref: 409 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3: Determine which questions about the peripheral vascular system to use for the focused interview. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
22) The nurse is preparing to assess the extremities of a client experiencing right-sided heart failure. Which findings should the nurse anticipate in the lower extremities? 1. Pallor. 2. Sensory loss. 3. Pitting edema. 4. Weak pedal pulses. Answer: 3 Explanation: 1. Pallor in the lower extremities may indicate arterial insufficiency. 2. Sensory loss occurs with arterial insufficiency. 3. Pitting edema can be related to failure of the right side of the heart. 4. Weak pedal pulses are associated with arterial insufficiency. Page Ref: 415 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
23) The nurse is preparing to document the findings associated with a client's peripheral pulses. Which should the nurse include in the documentation? Select all that apply. 1. Rate. 2. Symmetry. 3. Grade. 4. Rhythm. 5. Amplitude. Answer: 1, 2, 4, 5 Explanation: 1. The rate of the pulse should be documented. The rate is the number of beats per minute. 2. The symmetry of the pulse should be documented. Pulses on both sides of the body should be similar. 3. Pulses are not graded. The amplitude or the strength of the beat is assessed on a scale of 0 to 4. 4. The rhythm of the pulse should be documented. The rhythm of the pulse should be regular. 5. The amplitude of the pulse should be documented. Page Ref: 410 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.6: Generate the appropriate documentation to describe the assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
24) An older client tells the nurse they are experiencing impotence. Which should the nurse be concerned with? 1. Venous disease. 2. Hypertension. 3. Arterial disease. 4. Sexually transmitted infection. Answer: 3 Explanation: 1. Venous disease is not associated with impotence. 2. Hypertension is a result of peripheral arterial disease. 3. A diminished arterial flow to the pelvic arteries is associated with impotence. 4. A sexually transmitted infection is not associated with sexual impotence. Page Ref: 404 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.7: Identify abnorNmUaRl SfiInNdGinTgBs.CinOM the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
25) A client with peripheral arterial disease asks why they are experiencing so much pain in their lower extremities. Which information should the nurse be prepared to discuss with the client? 1. Varicose veins. 2. Increased fluid in the extremities. 3. Decreased oxygenation blood flow. 4. Arterial spasms. Answer: 3 Explanation: 1. Varicose veins occur in a client with venous insufficiency. 2. A client with venous insufficiency experiences edema in the lower extremities. 3. Peripheral arterial disease results in an inadequate oxygenated blood flow to the lower extremities. The decreased oxygenation blood results in pain. 4. Arterial spasms do not occur in peripheral arterial disease. Page Ref: 419 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions, | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.5: Plan the patient education related to the assessment on the peripheral vascular system. MNL Learning Outcome: 19.2. Plan questions about the peripheral vascular system for the focused interview.
26) The educator is reviewing the causes of orthostatic hypotension with the nurse. Which information should the educator include? Select all that apply. 1. Medications. 2. Dehydration. 3. Renal disease. 4. Cardiovascular disorder. 5. Endocrine disorder. Answer: 1, 2, 4, 5 Explanation: 1. Some medications can cause a temporary drop in blood pressure that occurs after standing up rapidly from a sitting or lying position. 2. Dehydration can cause a temporary drop in blood pressure that occurs after standing up rapidly from a sitting or lying position. 3. Renal disease is not associated with orthostatic hypotension. 4. Some cardiovascular disorders can cause a temporary drop in blood pressure that occurs after standing up rapidly from a sitting or lying position. 5. Endocrine disorders can cause a temporary drop in blood pressure that occurs after standing up rapidly from a sitting or lying position. Page Ref: 420 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUsRCSoIm te.CnOciM es: VII.3. Assess health/illness beliefs, NGpTeB values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system. MNL Learning Outcome: 19.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system.
27) The nurse has reviewed the functions of the peripheral vascular system with a client. Which statement made by the client indicates further teaching is needed? 1. "Deliver oxygen and nutrients to tissues of the body." 2. "Produces red blood cells that transport oxygen." 3. "Lymphatic system removes pathogens from the body fluid." 4. "Transports carbon dioxide and waste products from the tissues." Answer: 2 Explanation: 1. A function of the peripheral vascular system includes the delivery of oxygen and nutrients to the tissues of the body. 2. The peripheral vascular system does not produce red blood cells that transport oxygen. 3. A function of the peripheral vascular system includes the lymphatic system's ability to remove pathogens from the body fluid. 4. A function of the peripheral vascular system includes the transportation of carbon dioxide and waste products from the tissues. Page Ref: 401 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU /IRnSteINgra ed.CC GTtB Oo Mncepts: Nursing Process: Evaluation Learning Outcome: 19.1: Describe the anatomy and physiology of the peripheral vascular system. MNL Learning Outcome: 19.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system.
28) The nurse is preparing to take a client's blood pressure in a sitting and laying down position. Which results should the nurse anticipate? 1. The blood pressure to be lower when the client is sitting up. 2. The blood pressure to be the same in both positions. 3. The blood pressure to be higher when the client is in a supine position. 4. The blood pressure to be lower when the client is in a supine position. Answer: 4 Explanation: 1. The blood pressure should be higher when the client is sitting up. 2. The blood pressure should be higher when the client is in a supine position. 3. The blood pressure should be lower when the client is in a supine position. 4. The client's blood pressure should be lower when the client is laying down. Page Ref: 510 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.4: Outline the techniques for assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
29) An adult female client develops a pulmonary embolism and is admitted to the intensive care unit (ICU). While completing the client's health history interview, which statement made by the client is consistent with the diagnosis? Select all that apply. 1. "I am not a smoker." 2. "The nurse on the surgical unit really wanted me to sit on the side of the bed after surgery and to start walking with them later that evening, but I was so nauseated and in so much pain that I couldn't." 3. "I had an open appendectomy 4 days ago." A 4 cm incision noted to RLQ, staples intact and edges well-approximated. 4. "I have taken oral contraceptives for the last 7 years." 5. "I had some muscle cramping and tenderness in my left leg before they moved me to Intensive Care." Answer: 2, 3, 4, 5 Explanation: 1. A client that does not smoke is not at risk for a pulmonary embolism. 2. Ambulation following surgery is very important. Ambulation can reduce blood pooling in the calves and reduce the client's risk for clot formation. Immobility is a risk factor for blood clot formation. 3. The client's history of a recent abdominal surgery increases the client's risk of developing a blood clot. 4. Oral contraceptive use is linked to increases risk of blood clot formation because of the way the medication works within the client's body. 5. Muscle cramping and tenderness in the lower extremity are consistent with a deep vein thrombosis. Page Ref: 524-528 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.7: Identify abnormal findings in the physical assessment of the peripheral vascular system. MNL Learning Outcome: 19.4. Differentiate normal and abnormal variations of the peripheral vascular system observed during physical assessment.
30) The client developed a pulmonary embolism. In which area did the embolism most likely originate? 1. Calf. 2. Lungs. 3. Popliteal. 4. Ileum. Answer: 1 Explanation: 1. The client is more likely to have developed a blood clot within the calf. Blood clots can develop anywhere in the body but are most likely to occur within the calf. 2. The client is more likely to have developed a blood clot within the calf. Blood clots can develop anywhere in the body but are most likely to occur within the calf. 3. The client is more likely to have developed a blood clot within the calf. Blood clots can develop anywhere in the body but are most likely to occur within the calf. 4. The client is more likely to have developed a blood clot within the calf. Blood clots can develop anywhere in the body but are most likely to occur within the calf. Page Ref: 422 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 19.1: Describe the anatomy and physiology of the peripheral vascular system. MNL Learning Outcome: 19.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the peripheral vascular system.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 20 Abdomen 1) A client asks the nurse where their appendix is. Which response should the nurse provide? 1. "It is attached to the large intestine." 2. "It is attached to the sigmoid colon." 3. "It is attached to the large intestine at the cecum." 4. "It is attached to the small intestine at the cecum." Answer: 3 Explanation: 1. The vermiform appendix is attached to the large intestines at the cecum. 2. The vermiform appendix is attached to the large intestines at the cecum. 3. The vermiform appendix is attached to the large intestines at the cecum. 4. The vermiform appendix is attached to the large intestines at the cecum. Page Ref: 427 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
2) A client asks the nurse where their spleen is located. Which response should the nurse provide? 1. "Just above the umbilicus." 2. "Upper midline area of your abdomen." 3. "Right upper side of your abdomen." 4. "Left upper side of your abdomen." Answer: 4 Explanation: 1. The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm. 2. The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm. 3. The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm. 4. The spleen, the largest of the lymphoid organs, is located in the left upper portion of the abdomen directly inferior to the diaphragm. Page Ref: 427 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU e RaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
3) A client asks the nurse, "What's the purpose of the liver?" Which statements will the nurse include in the response to this client's question? Select all that apply. 1. "It helps you digest fats." 2. "It is an endocrine and exocrine gland." 3. "It filters waste from the blood and makes urine." 4. "It makes some blood-clotting substances." 5. "It can help you store certain vitamins." Answer: 1, 4, 5 Explanation: 1. The liver helps the body digest fats by producing bile. 2. The pancreas is an example of an exocrine and endocrine gland. 3. The kidneys filter nitrogen waste from the blood and make urine. 4. The liver makes blood-clotting substances. 5. The liver can store certain types of vitamins. Page Ref: 426 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
4) The nurse is palpating the right upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach. Answer: 1, 2 Explanation: 1. The liver is located in the right upper quadrant. 2. The gallbladder is located in the right upper quadrant. 3. The appendix is located in the right lower quadrant. 4. The spleen is located in the left upper quadrant. 5. The stomach is located in the left upper quadrant. Page Ref: 535 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.1: Describe the anatomy and physiology of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
5) A client asks the nurse, "What's the purpose of a gallbladder anyway? My mom lived for many years without her gallbladder." Which information would be beneficial for the nurse to share with this client? 1. "You are right. We still don't know the function of the gallbladder." 2. "It stores bile until it is needed for digestion of fats." 3. "It destroys old red blood cells." 4. "It helps you digest carbohydrates by producing enzymes." Answer: 2 Explanation: 1. The gallbladder does have an important function within the body. 2. The gallbladder is used to store bile that is produced in the liver, until the bile is needed to help digest fats. 3. The spleen destroys red blood cells. 4. The pancreas helps the body digest carbohydrates. Page Ref: 431 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
6) The nurse is palpating the left upper quadrant of a client's abdomen. Which organs may be assessed during this portion of the assessment? Select all that apply. 1. Liver. 2. Gallbladder. 3. Appendix. 4. Spleen. 5. Stomach. Answer: 4, 5 Explanation: 1. The liver is located in the right upper quadrant. 2. The gallbladder is located in the right upper quadrant. 3. The appendix is located in the right lower quadrant. 4. The spleen is located in the left upper quadrant. 5. The stomach is located in the left upper quadrant. Page Ref: 431 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
7) The nurse is mapping the client's abdomen into four quadrants. Which landmarks would the nurse use to perform this assessment? Select all that apply. 1. Umbilicus. 2. Midclavicular lines. 3. Xiphoid process. 4. Lower border of the right ribs. 5. Iliac crests. Answer: 1, 3 Explanation: 1. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone and then draw a horizontal line perpendicular to the first line. 2. The midclavicular lines are not used to map the client's abdomen into four quadrants. 3. To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone and then draw a horizontal line perpendicular to the first line. 4. The lower border of the right ribs is not used to map the client's abdomen into four quadrants. 5. The iliac crests are not used to map the client's abdomen into four quadrants. Page Ref: 429 and 430 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5.NEUxpRlSaIiNnGthTB e .rCoOleMof evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
8) The nurse is preparing to assess the abdomen of a client suspected of having an appendicitis. Which should the nurse include in the plan for the abdominal assessment? 1. Avoid palpation. 2. Palpate the area last. 3. Percuss the area first. 4. Auscultate the area first. Answer: 1 Explanation: 1. Palpation of the abdomen is contraindicated in a client suspected of having an appendicitis. 2. Palpation of the abdomen is contraindicated in a client suspected of having an appendicitis. 3. There is no indication the area of the abdomen should be percussed. Assessment of any painful area should be assessed last. 4. The abdomen is inspected prior to auscultation. Page Ref: 442 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
9) The nurse is preparing to examine a client who is complaining of right lower quadrant abdominal pain. Which actions by the nurse are appropriate in this situation? Select all that apply. 1. "It is a little cool in our examination room; may I turn up the thermostat?" 2. "I've been told you are experiencing some pain in the lower right area of your abdomen. I will examine that area first." 3. "I am going to stand on your left side so I can feel your liver better." 4. "I'm going to place this drape over you so you don't feel too exposed during this examination." 5. "I am going to place this pillow behind your head and this pillow under your knees." Answer: 1, 4, 5 Explanation: 1. The nurse should provide an environment that is warm and comfortable. 2. When a client is experiencing abdominal pain, the nurse should examine that area last. 3. Stand on the right side of the client because the liver and the right kidney are in the right side of the abdomen. 4. Maintain the dignity of the client through appropriate draping techniques. 5. The client should be in a supine position with a small pillow placed beneath the head and knees. Page Ref: 439 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3.NBUase ndGiTvBid.CuO alM ized care plan on patient values, RSIiN clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
10) The nurse is performing an abdominal assessment on a client. During the focused interview, the client tells the nurse about recently experiencing abdominal pain. As the nurse assesses the client, which behaviors indicate that the client may be experiencing pain or anxiety during the examination? Select all that apply. 1. The client is diaphoretic. 2. The client moves away from the nurse's hands. 3. The client grimaces. 4. The client pulls his knees toward his stomach. 5. The client coughs loudly. Answer: 1, 2, 3, 4 Explanation: 1. A client that is experiencing pain may be diaphoretic. 2. The client may move away from the nurse during the examination if the client is experiencing pain. 3. Grimacing is a facial expression that can indicate that the client is experiencing pain during the assessment. 4. The client who exhibits guarding behavior is most likely experiencing pain. 5. The client who coughs loudly is not necessarily experiencing pain. This is not a typical expression of pain or anxiety. Page Ref: 439 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Basic Care and Comfort Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
11) The client was recently admitted to the hospital with left lower quadrant pain. The client states, "It feels like my belly is cramping." During the focused interview, the client admitted to experiencing a significant amount of occupational stress. Guarding is noted during the abdominal examination. The nurse reviews the medical record (see chart below) and concludes that the client has developed a diverticulitis. Which client statement supports this conclusion by the nurse? Assessment or diagnostic test White blood cell count Red blood cell count Temperature Blood pressure
Results 25,000/mm3 4.2 × 1012/L 101.2 degrees Fahrenheit 152/84
1. "I get home so late at night, but I've got to stop lying down right after dinner." 2. "I drink a whole pot of coffee every day." 3. "I drink 9-12 beers after I get home from work, every day." 4. "We have been growing green beans in our garden and I think I ate too many the other day." Answer: 4 Explanation: 1. Lying down after meals is often associated with gastroesophageal reflux disorder. 2. Caffeine intake is associated with irritable bowel syndrome. TB 3. Drinking alcohol is associated with irriNtaUbRlSeIN boGw e.lCsOynMdrome and pancreatitis. 4. This client is most likely experiencing diverticulitis. The client's white blood cell count, temperature, and blood pressure are elevated as a result of the infection. High-fiber food intake can be a precipitating factor. Page Ref: 446 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
12) The nurse is performing an abdominal assessment on a client. While the nurse is palpating the lower border of the liver, the nurse asks the client to take a deep breath and hold it. The client complains of a sharp pain located in the right upper quadrant. How will the nurse document this finding in the medical record? 1. Positive Blumberg's sign. 2. Presence of pain at McBurney's point. 3. Positive Murphy sign. 4. Positive psoas sign. Answer: 3 Explanation: 1. Blumberg sign can be elicited when the nurse presses on an area of the abdomen. If the client complains of pain as the nurse pulls back and releases the compressed area, the client has a positive Blumberg sign which is present when the client has peritoneal irritation. 2. Pain at McBurney's point is associated with appendicitis. This area is located in the right lower quadrant of the client's abdomen. 3. Murphy sign can be elicited when the client takes a deep breath and holds it while the nurse presses into the right upper quadrant. The nurse is pressing against the gallbladder. Normally, the client will not complain of pain. 4. With the client in a supine position, the nurse places her left hand just above the level of the client's right knee. The client is requested to raise the leg to meet the nurse's hand. Flexion of the hip causes contraction of the psoas muscle and indicates that the client is experiencing peritoneal inflammation or appendicitis.N URSINGTB.COM Page Ref: 445 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.5: Generate the appropriate documentation to describe the assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
13) The nurse is assessing the client's abdomen and notes dullness when percussing over the left lower quadrant. Which question is most appropriate for the nurse to ask the client at this time? 1. "How much alcohol do you drink?" 2. "Do you have pain after eating?" 3. "When was your last bowel movement?" 4. "Have you ever had splenomegaly?" Answer: 3 Explanation: 1. Alcohol can place the client at risk for hepatomegaly and inflammation of the liver. 2. Pain after eating may indicate that some sort of upper gastrointestinal problem has developed. 3. Stool in the distal portion of the client's colon can produce dullness upon percussion of the left lower quadrant. 4. Splenomegaly would produce dullness while percussing the left upper quadrant. Page Ref: 443 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3: Determine which questions about the abdomen to use for the focused interview. MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.
14) The nurse is completing discharge instructions for a client admitted with esophagitis. Which client statements indicate the need for further education? Select all that apply. 1. "I'm going to talk to my doctor about a nicotine patch." 2. "I can do all of this stuff you're talking about as long as I don't have to give up my beer." 3. "I have been eating foods and drinks that were either too hot or too cold for my esophagus to handle." 4. "The root of this problem is that I just sleep too much." 5. "I told my wife to stop making serving me all of those vegetables." Answer: 2, 4, 5 Explanation: 1. Smoking cigarettes is associated with an increased risk for developing esophagitis. 2. Alcohol can increase the client's risk for developing esophagitis. 3. Eating foods that are either too hot or too cold can be irritating to the tissue and can result in esophagitis. 4. Sleeping "too much" is not associated with the development of esophagitis. 5. Eating vegetables is not associated with the development of esophagitis. Page Ref: 450 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
15) The nurse is assessing a client with reports of right upper quadrant pain that radiates toward the right upper portion of the back. The client states, "This has been happening more often after I eat rich, high-fat foods." Which question should the nurse include in the history? 1. "Do you have a history of cholecystitis?" 2. "Do you have a history of a duodenal ulcer?" 3. "Do you have a history of gastritis?" 4. "Do you have a history of pancreatitis?" Answer: 1 Explanation: 1. Right upper quadrant pain that radiates to the right scapula is characteristic of cholecystitis. The pain usually occurs after the client eats a fatty meal. 2. Duodenal ulcers cause aching, gnawing, epigastric pain. This is associated with stress and NSAID use. 3. Gastritis causes epigastric pain. It is associated with NSAID use, alcohol abuse, stress, infection, H. pylori infection, and/or autoimmune responses. 4. Pancreatitis produces upper abdominal, knife-like, deep epigastric or umbilical area pain. It is associated with alcohol abuse, use of acetaminophen, and infection. Page Ref: 436 and 446 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.3: Determine which questions about the abdomen to use for the focused interview. MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.
16) The nurse is performing reviewing the risk factors for colorectal cancer with a client. Which information should the nurse include? Select all that apply. 1. Stress. 2. Smoking. 3. Diabetes. 4. Obesity. 5. Diet high in red meat. Answer: 2, 3, 4, 5 Explanation: 1. Stress is not a risk factor for colorectal cancer. 2. Smoking is a risk factor for colorectal cancer. 3. Diabetes is a risk factor for colorectal cancer. 4. Obesity is a risk factor for colorectal cancer. 5. A diet high in red meat is a risk factor for colorectal cancer. Page Ref: 450 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
17) The nurse is preparing to percuss over the left upper portion of the client's abdomen. The client states, "I haven't had my breakfast, yet." Based on this statement, which does the nurse anticipate? 1. Dullness. 2. Flatness. 3. Tympany. 4. Hyperresonance. Answer: 3 Explanation: 1. Dullness suggests a mass within the stomach. It is a short high-pitched sound heard over solid organs, masses, or fluid-filled structures. 2. Flat sounds are short and abrupt. They are heard over bone or muscle. 3. Tympany is the normal sound that can be heard when an air-filled structure is percussed. 4. Hyperresonance is a hollow sound that is louder than tympany and is heard over air-filled or distended intestines. Page Ref: 447 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN CompeteNnUciReSsI:NCGoTnBte.CxO tM and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
18) The nurse documents "pain noted during palpation at McBurney's point." Which describes the techniques used during the assessment? 1. The nurse lightly palpated the around the client's umbilicus. 2. The nurse pressed into the client's abdomen and then pulled his hand back quickly. 3. The nurse palpated over the client's spleen. 4. The nurse palpated the area between the client's ileum and umbilicus in the client's right lower quadrant. Answer: 4 Explanation: 1. The nurse should be able to lightly palpate around the umbilicus without any complaints of pain by the client. 2. This procedure is used to elicit the Blumberg sign. 3. Palpation over the client's spleen may be used to determine if the client has splenomegaly. 4. McBurney's point is located 2.5 to 5.1 centimeters above the anterosuperior iliac spine, on a line between the ileum and the umbilicus. The nurse can palpate over McBurney's point to determine if the client has developed appendicitis. Page Ref: 444 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
19) The client states, "No one will let me eat or drink anything until after my test and it's been 9 hours since I last ate anything." While auscultating the client's abdomen, the nurse hears frequent bowel sounds. How will the nurse document this finding in the medical record? 1. Borborygmi present. 2. Hypoactive bowel sounds present. 3. Bruit present. 4. Friction rub present. Answer: 1 Explanation: 1. Borborygmi are hyperactive bowel sounds. 2. Hypoactive bowel sounds are not normally auscultated in clients who are merely hungry. They are more often auscultated in clients who have developed a bowel obstruction or who have had a major abdominal surgery. 3. Bruits can be auscultated over blood vessels. 4. Friction rubs are associated with the rubbing together of abdominal organs or organs thatmay be rubbing on the peritoneum. Page Ref: 441 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.5: Generate the appropriate documentation to describe the assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
20) The nurse is assessing a client in the emergency department (ED) who complains of right lower quadrant pain. The nurse determines that the client is exhibiting a positive psoas sign. Based on the client's assessment data, which conditions does the nurse suspect? Select all that apply. 1. Constipation. 2. Appendicitis. 3. Cholecystitis. 4. Small bowel obstruction. 5. Peritonitis. Answer: 2, 5 Explanation: 1. Constipation is not typically associated with a positive psoas sign. 2. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with appendicitis. 3. The client with cholecystitis may exhibit a positive Murphy's sign. 4. The client with a small bowel obstruction may exhibit abnormal bowel sounds. 5. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation. Page Ref: 445 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
21) The nurse is auscultating the abdomen of a client for vascular sounds. The nurse hears a soft, continuous humming sound. Based on this data, the nurse suspects dysfunction with which organ? 1. Stomach. 2. Spleen. 3. Pancreas. 4. Liver. Answer: 4 Explanation: 1. Dysfunction in the client's stomach did not result in this type of sound. 2. Dysfunction in the client's spleen most likely did not result in this type of sound. 3. Dysfunction in the client's pancreas did not result in this type of sound. 4. The nurse is hearing an abnormal abdominal sound called a venous hum, which is indicative of portal hypertension. Portal hypertension is the result of liver congestion. Page Ref: 446 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinINteGrTven ioM ns. | B.CtO Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
22) The nurse is performing an abdominal assessment on a client who had been previously diagnosed with cirrhosis. The nurse inspected the client's abdomen and notes ascites. Based on this data, which interventions will the nurse perform next? Select all that apply. 1. Obtain stool specimen for occult blood. 2. Measure the client's abdominal girth. 3. Obtain stool specimen for culture and sensitivity. 4. Bilateral leg measurements. 5. Percuss the abdomen at midline. Answer: 2, 5 Explanation: 1. The nurse would not necessarily suspect that the client had occult blood in the stool. 2. When ascites is suspected, the abdominal girth should be measured to obtain a baseline for further evaluation. 3. The nurse does not need to send a stool specimen for a culture and sensitivity. This would indicate that the nurse believed that the client had an infection within the gastrointestinal tract. 4. The nurse does not necessarily need to measure the circumferences of the client's legs for edema. 5. The nurse would need to assess the client's abdomen for tympany during percussion. This is a sign of ascites. Page Ref: 448 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches/ | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
23) The nurse is preparing to assess a client newly diagnosed with stomach cancer. Which assessment findings should the nurse anticipate? Select all that apply. 1. Diarrhea. 2. Vomiting. 3. Gastrointestinal bleeding. 4. Abdominal distention. 5. Dark-colored urine. Answer: 2, 3, 4 Explanation: 1. Diarrhea is not associated with stomach cancer. 2. Vomiting is an objective finding associated with stomach cancer. 3. Gastrointestinal bleeding is an objective finding associated with stomach cancer. 4. Abdominal distention is an objective finding associated with stomach cancer. 5. Dark colored urine is not associated with stomach cancer. Page Ref: 449 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinINteGrTveBn.CtO ioM ns. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
24) The nurse is performing an abdominal assessment on an infant. The nurse notes that the umbilicus is bulging and has been displaced slightly to the left of midline. Based on this data, which diagnosis does the nurse anticipate? 1. Infection. 2. Umbilical hernia. 3. Ventral hernia. 4. Hiatal hernia. Answer: 2 Explanation: 1. This is not a sign of an infection. 2. This is a normal finding in an infant. A protruding or displaced umbilicus is a normal variation in pregnant females. An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through the abdominis rectus muscle and come closer to the skin. 3. Ventral hernias occur in previous incisional sites. 4. A hiatal hernia is due to a weakening in the diaphragm that allows a portion of the stomach and the esophagus to move into the thoracic cavity. This type of hernia is more commonly found in adults than in children. Page Ref: 449 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementaNtiUoRnSoIN f cGaTrBe.CpO laM n, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
25) The nurse is performing an abdominal assessment on the client. Rank the assessment steps in the order in which they should occur. 1. Percuss the abdomen. 2. Visualize the quadrants of the abdomen. 3. Palpate the abdomen. 4. Auscultate the abdomen. 5. Encourage the client to void. Answer: 5, 2, 4, 1, and 3 Explanation: 1: The fourth step is for the nurse to percuss the abdomen. 2: The second step is for the nurse to visualize the quadrants of the client's abdomen. 3: The fifth step is for the nurse to palpate the abdomen. 4: The third step is for the nurse to auscultate the abdomen. 5: The first step is for the nurse to encourage the client to void prior to the abdominal assessment Page Ref: 439-445 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4: Outline the techniques for assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
26) The nurse is caring for a client diagnosed with the hepatitis A virus. The client requests information about how the virus is transmitted. Which statement by the nurse is appropriate? 1. "This virus is transmitted by sexual contact with someone who already has been infected with this virus." 2. "Most likely, you ate something that was contaminated with the virus." 3. "It is spread by blood transfusions." 4. "Have you ever injected an illegal drug?" Answer: 2 Explanation: 1. Sexual contact with someone who is infected with a specific virus resulting in hepatitis is most closely associated with developing hepatitis B or D. 2. Eating food that is contaminated with hepatitis A virus may result in the client developing clinical manifestations associated with hepatitis A virus. 3. Blood product transfusions can result in the transmission of hepatitis B, C, or D viruses. 4. Injecting illegal drugs can result in the transmission of hepatitis B, C, or D viruses. Page Ref: 450 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and EnvironNm uOctMpopulation-based transcultural health Ue RnStI:NC GoTnBd.C assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
27) The pediatric nurse is preparing an educational presentation for parents of school-aged children regarding hepatitis. Based on the pediatric risk, which type of hepatitis virus will the nurse focus on during the educational session? 1. Hepatitis A virus. 2. Hepatitis B virus. 3. Hepatitis C virus. 4. Hepatitis D virus. Answer: 1 Explanation: 1. Hepatitis A virus is the most common type of virus resulting in hepatitis that develops in children. 2. Hepatitis B virus is transmitted parenterally, sexually, or perinatally. 3. Hepatitis C virus is transmitted through blood and blood products, parenterally, and through unknown ways. 4. Hepatitis D virus is transmitted parenterally, sexually, and perinatally. Page Ref: 450 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU /IRnSteINgG raTtBe.dCO CoMncepts: Nursing Process: Planning Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen. MNL Learning Outcome: 20.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen.
28) The nurse has discussed the precipitating factors of pancreatitis with a client. Which statement made by the client indicates an understanding of the information? 1. "I will cut back on my drinking." 2. "I will no longer use acetaminophen." 3. "I am working with a dietician to reduce my weight." 4. "I am working to get my diabetes under control." Answer: 1 Explanation: 1. The client at risk for pancreatitis should abstain from alcohol. 2. Acetaminophen is a precipitator of pancreatitis. 3. Obesity and a poor diet place the client at risk for pancreatitis. 4. Uncontrolled diabetes places the client at risk for pancreatitis. Page Ref: 447 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.4. Differentiate normal and abnormal variations of the abdomen observed during physical assessment.
29) The nurse is interviewing an older adult Hispanic client who complains of recent weight loss, anorexia, and epigastric pain. The client reports recent use of "mints" for stomach upset. Based on this assessment data, which interventions are appropriate for this client? Select all that apply. 1. Schedule the client for an endoscopy as ordered. 2. Educate the client regarding the importance of taking antacids after meals and at bedtime as suggested by the healthcare provider. 3. Educate the client regarding Helicobacter pylori infections. 4. Discuss the importance of using over-the-counter aspirin for mild pain relief. 5. Educate the client about the importance of avoiding all spicy foods as this is the most likely cause of the peptic ulcer. Answer: 1, 2, 3 Explanation: 1. The client should be scheduled for an endoscopy as ordered by the healthcare provider. This is a common diagnostic test used for clients with suspected peptic ulcers. 2. The client should take antacids after meals and at bedtime. 3. The client should be educated about the most common cause of peptic ulcers, which is an infection due to Helicobacter pylori (H. pylori). H. pylori is a bacteria that results in an infection that causes more than 90% of peptic ulcers. It infects almost two thirds of the world's population and is more prevalent in the elderly, African Americans, Hispanics, and those in lower socioeconomic groups. 4. The client should avoid aspirin products because they can make the symptoms worse. 5. The client can avoid spicy foods but not because this is the most common cause of peptic ulcers. The spicy foods may aggravate the client's condition. In the past, it was believed that ulcers were caused by stress or eating too much acidic food. Now it is known that this is not true. Page Ref: 432 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.6: Identify abnormal findings in the physical assessment of the abdomen. MNL Learning Outcome: 20.3. Utilize the appropriate techniques and tools for physical assessment of the abdomen.
30) A client tells the nurse they are frequently under a great deal of stress. Which common gastrointestinal disorder should the nurse recognize the client is at risk for? Select all that apply. 1. Diverticulitis. 2. Duodenal ulcer. 3. Gastritis. 4. Gastroesophageal Reflux Disorder. 5. Irritable bowel syndrome. Answer: 2, 3, 5 Explanation: 1. Diverticulitis is not associated with stress. 2. A duodenal ulcer is related to stress. 3. Gastritis can occur in relation to stress. 4. Gastroesophageal reflux disorder is not related to stress. 5. Stress is related to irritable bowel syndrome. Page Ref: 446, 447 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 20.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the abdomen. MNL Learning Outcome: 20.2. Plan questions about the abdomen for the focused interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 21 Male Genitourinary System 1) During the examination of an older adult male client, the nurse notes thin, gray pubic hairs and a scrotal sac that hangs significantly lower than the penis. Which action by the nurse is the most appropriate? 1. Document the findings as normal. 2. Inform the client that he is no longer fertile. 3. Notify the healthcare provider of the findings. 4. Ask the client about his sexual practices. Answer: 1 Explanation: 1. The older adult male begins to demonstrate thinning and graying of the pubic hair. The penis and testicles begin to diminish in size and the scrotum hangs lower. 2. Sperm production in the middle aged and older man is reduced but there is still adequate sperm production to father children. 3. The findings are normal and do not warrant notification of the healthcare provider. 4. The sexual practices of the client are not impacted by the findings. Inquiry into them is not indicated at this time. Page Ref: 476 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
2) During the examination of a male client who has not been circumcised, the nurse attempts to retract the foreskin of the penis but the skin is very tight and cannot be pulled back. Based on this data, which condition does the nurse anticipate for this client? 1. Urethral stricture. 2. Paraphimosis. 3. Urethritis. 4. Phimosis .Answer: 4 Explanation: 1. Urethral strictures would be suspected in the event of voiding problems or if a pinpoint size meatus opening was noted, not an inability to retract the foreskin over the glans penis. 2. Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once it has been retracted. 3. Urethritis manifests with symptoms including redness and edema around the glans and foreskin, eversion of the urethral mucosa, and drainage. 4. Phimosis refers to a condition in which the foreskin cannot be moved back over the glans penis. Page Ref: 478 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUeR nci 1..CInOtMegrate theories and concepts S Ie NsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
3) The nurse is interviewing a male client who states "I feel like I have a bag of worms in my scrotum." Based on this data, which condition does the nurse suspect? 1. Orchitis. 2. Varicocele. 3. Epididymitis. 4. Inguinal Hernia. Answer: 2 Explanation: 1. Orchitis refers to a swelling and inflammation of the testicles. 2. A varicocele is a distention of the spermatic cord and may be described as a "bag of worms." 3. Epididymitis is an inflammatory condition of the epididymis. 4. An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
4) The nurse is caring for a client with chronic alcoholism. Which effect does this condition have on the client's genitourinary system? 1. Testicular cancer. 2. Impotence. 3. Prostate enlargement. 4. Sperm abnormalities. Answer: 2 Explanation: 1. Chronic alcoholism is not linked to testicular cancer. 2. Chronic alcoholism is linked to impotence. 3. Chronic alcoholism is not linked to prostate enlargement. 4. Chronic alcoholism is not linked to sperm abnormalities. Page Ref: 469 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
5) The nurse is preparing to assess a client that states they are experiencing painful tender testes. After noting the client's testes are swollen, which diagnosis should the nurse suspect? 1. Scrotal hernia. 2. Orchitis. 3. Hydrocele tumor. 4. Testicular tumor. Answer: 2 Explanation: 1. A scrotal hernia appears as a bulge in the testes. 2. Orchitis is characterized by swollen testes that are painful and tender. 3. A hydrocele tumor is characterized by a fluid filled nontender mass within the tunica vaginalis. 4. A testicular tumor is a painless tumor on the testes. Page Ref: 487 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
6) A client asks the nurse where the prostate gland is located. Which information should the nurse provide? 1. "The prostate gland is located by the rectum." 2. "The prostate gland is located above the testes." 3. "The prostate gland is located on each side of the urethra." 4. "The prostate gland is located by the bladder." Answer: 3 Explanation: 1. The lobes of the prostate gland are located on each side of the male urethra. 2. The lobes of the prostate gland are located on each side of the male urethra. 3. The lobes of the prostate gland are located on each side of the male urethra. 4. The lobes of the prostate gland are located on each side of the male urethra. Page Ref: 456 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.1: Describe the anatomy and physiology of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
7) The nurse is caring for a client who has hypospadias. When assessing this client, where does the nurse anticipate to find the urinary meatus? 1. Underside of the penis. 2. Lateral side of the penis. 3. Anterior side of the penis. 4. Dorsal side of the penis. Answer: 1 Explanation: 1. Hypospadias is a condition in which the urinary meatus opens on the underside of the penis. 2. Hypospadias is a condition in which the urinary meatus opens on the underside of the penis. 3. Hypospadias is a condition in which the urinary meatus opens on the underside of the penis. 4. Hypospadias is a condition in which the urinary meatus opens on the underside of the penis. Page Ref: 456 Cognitive Level: Remembering Client Need & Sub: Physiological Integrity; Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.4: Outline the techniques for assessment of the male genitourinary system. MNL Learning Outcome: 21.3. Utilize the appropriate techniques and tools for physical assessment of the male genitourinary system.
8) A couple seeking infertility treatments has just received the results of a semen analysis, which shows a diminished sperm count. Which question is most appropriate for the nurse to address to the male partner at this time? 1. "How often do you masturbate?" 2. "Do you smoke?" 3. "How old is your present house?" 4. "Do you still want to have children?" Answer: 3 Explanation: 1. Masturbation does not influence sperm count and the ability to father children. 2. Tobacco use does not impact sperm count and the ability to father children. 3. The age of the home may be influencing the sperm count. Lead paint may be present in older homes built before 1979. Lead exposure may result in reduced libido, diminished sperm count, and abnormal sperm motility. 4. The responsibility of the nurse is to assess for related causes, not to assess the desire to father children. Page Ref: 469 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3: Determine questions about the male genitourinary system to use for the focused interview. MNL Learning Outcome: 21.2. Plan questions about the male genitourinary system for the focused interview.
9) During the focused interview, a male client describes his erection and ejaculate in terms that are less than professional. Which action by the nurse is the most appropriate? 1. Ask the client to refrain from using the terms. 2. Ask the client to define the terms. 3. Document the client's responses in the terms used. 4. Find another nurse to complete the assessment. Answer: 3 Explanation: 1. Men may be embarrassed to discuss health problems or concerns involving their reproductive organs. During the interview, use words that the man can understand and do not be embarrassed or offended by the words he uses. 2. Asking the client to define terms may promote a sense of inferiority. Men may be embarrassed to discuss health problems or concerns involving their reproductive organs; it is important for the nurse to ask questions in a non-threatening, matter-of-fact manner. 3. The words and responses of the client will need to be documented. They provide the framework of the subjective data from the assessment. 4. Asking another nurse to complete the interview reduces the quality and continuity of care and is inappropriate. Page Ref: 483 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
10) The nurse has completed teaching a client about testicular self-examination. Which client statements indicate understanding of the content presented? Select all that apply. 1. "I will feel hardened areas where the testicles and epididymis are located." 2. "I should perform this exam monthly." 3. "I should be in a warm room or the shower to perform this exam." 4. "I should apply gentle pressure to each testicle to feel the area." 5. "It is normal to feel testicular pain during this exam." Answer: 2, 3, 4 Explanation: 1. The contour of the testicles should be firm and smooth. 2. The testicular self-examination should be performed monthly beginning in adolescence. 3. The most opportune time to perform the testicular self-examination is in the shower or bath. Heat and steam will warm the hands and will help their movement over the skin surface. 4. The correct technique utilizes a gentle pressure over the surface of the skin. 5. The client should not feel discomfort during the exam. If discomfort is experienced, the client is pressing too hard during the exam. Page Ref: 468 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
11) The nurse is preparing to examine the reproductive system for a male client recently admitted to the medical unit. Which techniques does the nurse plan to incorporate into this physical assessment? Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Aspiration .Answer: 1, 2 Explanation: 1. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. 2. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. 3. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Percussion is most often used to assess the gastrointestinal system and the respiratory system. 4. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Auscultation is used to assess the gastrointestinal, cardiovascular, and respiratory systems. 5. The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Aspiration may be used to obtain a specimen. Page Ref: 475, 480 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.4: Outline the techniques for assessment of the male genitourinary system. MNL Learning Outcome: 21.3. Utilize the appropriate techniques and tools for physical assessment of the male genitourinary system.
12) The nurse is preparing to examine a male client's reproductive organs. Which actions by the nurse are appropriate to prepare for this examination? Select all that apply. 1. Secure a private examination room. 2. Use clean hands for the examination. 3. Ask the client to lie down on the exam table. 4. Ask the client to empty his bladder. 5. Make sure the room's temperature is comfortable. Answer: 1, 2, 4, 5 Explanation: 1. A private room is indicated to perform a physical examination. 2. The examiner must have clean hands to perform the exam. This will reduce the transmission of infections. 3. The examination may be performed with the client sitting or standing. The client does not need to lie flat. 4. Emptying the bladder will reduce discomfort during palpation portions of the exam. In addition, a full bladder may impede the examination. 5. The examination room must be comfortable for the client. Page Ref: 475 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.4: Outline the techniques for assessment of the male genitourinary system. MNL Learning Outcome: 21.3. Utilize the appropriate techniques and tools for physical assessment of the male genitourinary system.
13) During the examination of a male client's scrotum, the nurse detects a hardened area in the right side of the scrotal sac. Which is the priority nursing action based on this finding? 1. Ask the client about voiding patterns. 2. Notify the healthcare provider of this finding. 3. Use a light to perform transillumination. 4. Ask the client about sexual practices. Answer: 3 Explanation: 1. Voiding patterns are not related to the findings of the examination. 2. Abnormalities noted on the assessment will need to be reported to the healthcare provider but first the nurse must obtain additional supporting information to include in the report. 3. Transillumination is indicated to obtain further information. Upon transillumination, light should shine through the scrotum with a red glow, with the testes showing up as oval structures. Abnormal areas, such as masses, will not show penetration of the light 4. The client's sexual practices do not have direct bearing on the findings. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.4: Outline the techniques for assessment of the male genitourinary system. MNL Learning Outcome: 21.3. Utilize the appropriate techniques and tools for physical assessment of the male genitourinary system.
14) The nurse is preparing to assess a client with internal hemorrhoids. Which finding should the nurse associate with the condition? 1. Redness. 2. Pain. 3. Swelling. 4. Bleeding without stool. Answer: 4 Explanation: 1. Internal hemorrhoids are rarely painful and identified by bright red bleeding that is not mixed with stool. 2. Internal hemorrhoids are rarely painful and identified by bright red bleeding that is not mixed with stool. 3. Internal hemorrhoids are rarely painful and identified by bright red bleeding that is not mixed with stool. 4. Internal hemorrhoids are rarely painful and identified by bright red bleeding that is not mixed with stool. Page Ref: 490 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
15) The nurse is examining a male client and notes small clusters of vesicular lesions on the glans penis. The client states that the areas are painful and often are reddened. Based on this data, which does the nurse anticipate? 1. Carcinoma. 2. Genital warts. 3. Syphilis. 4. Genital herpes. Answer: 4 Explanation: 1. Carcinoma lesions are nodular or ulcerative. 2. Genital warts present as soft fleshy growths. 3. Syphilis presents as non-painful ulcers called chancres. 4. Genital herpes presents as painful ulcerations. Page Ref: 486 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
16) The nurse is reviewing the records of a child diagnosed with cryptorchidism. Which assessment finding should the nurse anticipate? 1. Inflamed testicle. 2. Small testicle. 3. Absent testicle. 4. Herniated testicle. Answer: 3 Explanation: 1. Cryptorchidism is not a condition in which a testicle is inflamed. 2. Cryptorchidism is not a condition which a testicle is small. 3. Cryptorchidism is a condition where a testicle is undescended. 4. Cryptorchidism is a condition in which a testicle is not herniated. Page Ref: 488 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
17) During the examination of a male client, the nurse detects a bulge in the right inguinal area as the client is bearing down. Based on this data, which condition does the nurse suspect? 1. Varicocele. 2. Prostatitis. 3. Orchitis. 4. Inguinal Hernia. Answer: 4 Explanation: 1. The varicocele is a distention of the spermatic cord. It feels most like a "bag of worms" rather than a mass. 2. Examination of the prostate gland is performed via the rectum, rather than the inguinal area. 3. Orchitis refers to an inflammation in the testicular region. This would present as a pain and swelling in the scrotal region. 4. An inguinal hernia feels like a bulge or mass upon palpation of the inguinal canal, which indicates a protrusion of the intestine into the groin region. Page Ref: 476 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
18) The nurse is examining a male client's genitalia and notes that the scrotum is asymmetric. The left side hangs lower than the right side. Based on this data, which action by the nurse is the most appropriate? 1. Reassess after increasing the temperature in the room. 2. Report the finding to the healthcare provider. 3. Consider this a normal finding and proceed with palpation of the scrotum. 4. Ask if the client has noticed this before. Answer: 3 Explanation: 1. Elevation in temperatures will facilitate the scrotum's dropping away from the body. It will not correct symmetry issues. 2. The complete assessment findings will need to be shared with the healthcare provider but the nurse will need to have completed the assessment first to be able to provide adequate information. 3. This is a normal finding, but palpation of the scrotum is indicated to aid in determining any related abnormalities. 4. Asking the client for additional subjective information is not the priority action at this time. Page Ref: 479 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.1: Describe the anatomy and physiology of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
19) The nurse is preparing to review the signs of penile carcinoma with a client. Which information should the nurse include in the teaching? Select all that apply. 1. Usually occurs in the glans. 2. Rapidly growing popular lesions. 3. Reddened nodular growth. 4. May appear as an ulcer-like lesion. 5. Palpable hard plaques along the dorsum under the skin. Answer: 1, 3, 4 Explanation: 1. Symptoms associated with penile carcinoma usually occur in the glans. 2. Rapidly growing popular lesions are not associated with penile carcinoma. 3. Symptoms associated with penile carcinoma may appear as a reddened nodular growth. 4. Symptoms associated with penile carcinoma may appear as an ulcer-like lesion. 5. Palpable hard plaques along the dorsum under the skin are not associated with penile carcinoma. Page Ref: 486 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
20) During the examination of an adult male, the nurse notes thick, curly hair over the pubis area, a pear-shaped scrotum, and slightly darkened skin on the penis. Based on this data, which action is appropriate? 1. Ask the client about recent illnesses. 2. Ask the client about sexual practices. 3. Notify the healthcare provider the findings. 4. Document the findings as normal. Answer: 4 Explanation: 1. There is no need to explore medical health history relating to this normal physical appearance. 2. The sexual practices of the client have no bearing on the normal findings. 3. The assessment findings are normal and do not warrant notification of the healthcare provider. 4. The findings are normal for a healthy adult male. Page Ref: 476, 477 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.5: Generate the appropriate documentation to describe the assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
21) The nurse is preparing to assess the genitourinary system of a client with epispadias. Which assessment finding should the nurse anticipate? 1. Pinpoint appearance of the urinary meatus. 2. Urinary meatus located on the upper side of the glans. 3. Urinary meatus located on the underside of the glans. 4. Urinary meatus that is under a foreskin that cannot be retracted. Answer: 2 Explanation: 1. A client with a urinary meatus that is pinpoint in appearance is indicative of a urethral stricture. 2. A urinary meatus located on the upper side of the glans is termed epispadias. 3. A urinary meatus located on the underside of the glans is termed hypospadias. 4. A foreskin that cannot be retracted is known a phimosis. Page Ref: 478 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU /IRnSteINgra ed.CC GTtB Oo Mncepts: Nursing Process: Assessment Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
22) The nurse is preparing a presentation on testicular cancer to target the age group most frequently affected. Which settings would provide the nurse with audiences at an increased risk for this disease process? Select all that apply. 1. Elementary schools. 2. Colleges. 3. Cub Scout groups. 4. High schools. 5. Senior assisted living facilities. Answer: 2, 4 Explanation: 1. Children in elementary schools are too young to initiate the examination. Testicular cancer is the most common type of cancer in males between the ages of 20 and 34. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. 2. College-age males are in the target group and should be included. Testicular cancer is the most common type of cancer in males between the ages of 20 and 34. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. 3. Cub Scouts is a service group consisting primarily of elementary school-aged children. This group is too young to be considered in the target group. Testicular cancer is the most common type of cancer in males between the ages of 20 and 34. It is recommended that testicular selfexaminations be performed monthly beginning in adolescence and continue on through adulthood. 4. Testicular cancer is the most common type of cancer in males between the ages of 20 and 34. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. 5. Testicular cancer is the most common type of cancer in males between the ages of 20 and 34. It is recommended that testicular self-examinations be performed monthly beginning in adolescence and continue on through adulthood. Page Ref: 468 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
23) The nurse is interviewing a male client with an elevated prostate specific antigen level (PSA). In order to determine other risk factors for this client, which questions are appropriate for the nurse to include in the assessment process? Select all that apply. 1. "Do you have a positive family history for prostate cancer?" 2. "Do you masturbate?" 3. "How frequently do you have sexual intercourse?" 4. "Do you smoke?" 5. "Do you have a history of urinary tract infections?" Answer: 1, 4 Explanation: 1. Family history is a significant risk factor for the development of prostate cancer. 2. Masturbation is not considered a risk factor for the development of prostate cancer. 3. The frequency of sexual intercourse does not have a bearing on the occurrence of prostate cancer. 4. Smoking has been linked to the development of prostate cancer. 5. Urinary tract infections are not linked to the incidence of prostate cancer. Page Ref: 483 Cognitive Level: Analyzing Client Need & Sub: Reduction of Risk Potential; Laboratory Values Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and EnvironNm uOctMpopulation-based Ue RnStI:NC GoTnBd.C transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3: Determine questions about the male genitourinary system to use for the focused interview. MNL Learning Outcome: 21.2. Plan questions about the male genitourinary system for the focused interview.
24) A 45-year-old male client asks the nurse when they need to begin screening for prostate cancer. Which response should the nurse provide the client? 1. "You can start with either the prostate specific antigen screening or the digital rectal exam." 2. "PSA screening tests should be performed once you reach 50 years of age." 3. "When you turn 50, you can discuss this with the healthcare provider to determine a recommendation." 4. "Unless you are at an increased risk for the development of prostate cancer, no additional screening is indicated." Answer: 3 Explanation: 1. At age 50, both the PSA and DRE should be used for screening prior to the patient and healthcare provider deciding the future time frame for screening. 2. At age 50, both the PSA and DRE should be used for screening prior to the patient and healthcare provider deciding the future time frame for screening. 3. At age 50, both the PSA and DRE should be used for screening prior to the patient and healthcare provider deciding the future time frame for screening. 4. At age 50, both the PSA and DRE should be used for screening prior to the patient and healthcare provider deciding the future time frame for screening Page Ref: 483 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiNalUsRCSoIm te.CnOciM es: VII.3. Assess health/illness NGpTeB beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system. MNL Learning Outcome: 21.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the male genitourinary system.
25) A client expresses a feeling of pain during the palpation of the scrotum. The nurse notes that when the scrotum is lifted, the pain is relieved. Which condition should the nurse suspect? 1. Orchitis. 2. Testicular tumor. 3. Epididymitis. 4. Pilonidal cyst. Answer: 3 Explanation: 1. Orchitis is an inflammatory process that results in painful, tender, swollen testicles. The pain is not relieved when lifting the scrotum. 2. A testicular tumor is characterized by painless nodules on the testicles. 3. Epididymitis is an inflammation of the epididymis. If a client expresses pain during the assessment of the scrotum which is relieved when the scrotum is lifted, the client may have epididymitis. 4. A pilonidal cyst is almost always located at the sacrococcygeal area. Page Ref: 481 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
26) The nurse notes that a client has anal fissures. Which questions should the nurse ask the client that are causes of anal fissures? Select all that apply. 1. "Have you recently had diarrhea?" 2. "Do you have problems with constipation?" 3. "Do you have a history of hemorrhoids?" 4. "How often do you have a bowel movement?" 5. "Have you noticed any blood in your stool?" Answer: 1, 2 Explanation: 1. Tears or splits in the anal mucosa are usually seen in the posterior anal area and are most frequently associated with prolonged diarrhea or the passage of hard stools. 2. Tears or splits in the anal mucosa are usually seen in the posterior anal area and are most frequently associated with prolonged diarrhea or the passage of hard stools. 3. Hemorrhoids do not cause fissures. 4. The frequency of bowel movements is not directly related to fissures. 5. Blood in the stool does not cause anal fissures. Page Ref: 490 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3: Determine questions about the male genitourinary system to use for the focused interview. MNL Learning Outcome: 21.2. Plan questions about the male genitourinary system for the focused interview.
27) A couple is seeking infertility information from the nurse. Which statement made by the couple indicates the need for further intervention? 1. "We have been to two doctors already." 2. "We have intercourse at least three times a week." 3. "We are using temperature tracking for ovulation prediction." 4. "We have been trying to conceive for a year." Answer: 4 Explanation: 1. The number of healthcare providers being seen by the family is not relevant to the nurse's immediate actions. 2. The couple is engaging in sexual intercourse. This indicates that a lack of intercourse should not be of issue. 3. The use of the basal body temperature to assess for ovulation is recommended as an initial step in attempting to conceive. 4. Couples are not considered for infertility treatment until they have tried to conceive for at least one year. Page Ref: 466 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
28) The nurse is examining a male adolescent with suspected spermatic cord torsion. Which is the priority intervention for this client? 1. Medicate for pain with narcotics. 2. Prepare for surgery. 3. Elevate the scrotum. 4. Administer anti-inflammatory medications. Answer: 2 Explanation: 1. Medication for pain with narcotics may be ordered by the healthcare provider. It does not, however, present a higher priority than preparing the client for surgery. 2. Torsion of the spermatic cord requires immediate surgical intervention, making this the priority for the nurse in this situation. 3. The scrotum may be elevated after the procedure but elevation is not a priority in the preoperative period. 4. The administration of anti-inflammatory medications is not indicated for this client. Page Ref: 488 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Medical Emergency Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
29) An adult male presents to the urologist office with concerns relating to fertility. Which data in the client's medical history warrants further investigation? 1. Treated for gonorrhea 2 years prior. 2. Genital herpes simplex. 3. Past history of marijuana use. 4. Employment in a paint manufacturing company. Answer: 4 Explanation: 1. Gonorrhea in a male has not been linked to infertility. In addition, there are no factors provided to infer that damage has resulted from the disease. 2. Men with genital herpes simplex are not infertile. 3. A history of marijuana use is not associated with male-related infertility. 4. Chronic exposure to chemicals has been implicated in the development of male-caused infertility. Page Ref: 469 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.6: Identify abnormal findings in the physical assessment of the male genitourinary system. MNL Learning Outcome: 21.4. Differentiate normal and abnormal variations of the male genitourinary system observed during physical assessment.
30) The nurse is preparing to inspect a client's penis. Which information should the nurse include in the documentation? 1. Size. 2. Location of the dorsal vein. 3. Glans. 4. Pigmentation. 5. Hair distribution. Answer: 1, 2, 3, 4 Explanation: 1. The size of the penis is included in the assessment. 2. The location of the dorsal vein is included in the assessment. 3. The location of the glans is included in the assessment. 4. The skin pigmentation is included in the assessment. 5. The hair should be inspected prior to the inspecting the penis. Page Ref: 477 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.5: Generate the appropriate documentation to describe the assessment of the male genitourinary system. MNL Learning Outcome: 21.3. Utilize the appropriate techniques and tools for physical assessment of the male genitourinary system.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 22 Female Genitourinary System 1) A client asks the nurse what is the purpose of the Bartholin's gland. Which information should the nurse provide the client? 1. Secrete fluid to lubricate the vagina. 2. Secrete white blood cells. 3. Produce mucus to be released into the vagina. 4. Produce acid to protect against bacteria. Answer: 3 Explanation: 1. The Bartholin's glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule. 2. The Bartholin's glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule. 3. The Bartholin's glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule. 4. The Bartholin's glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule. Page Ref: 499 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1.NDUeRmSoINnGstTrBa.tCeOkM nowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1: Describe the anatomy and physiology of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
2) The nurse is discussing the segments of the uterus with a client. Which information should the nurse include? Select all that apply. 1. Ovaries. 2. Cervix. 3. Fundus. 4. Corpus. 5. Fallopian tubes. Answer: 2, 3, 4 Explanation: 1. The segments of the uterus include the cervix, fundus, and corpus. The ovaries and fallopian tubes are accessory structures. 2. The segments of the uterus include the cervix, fundus, and corpus. The ovaries and fallopian tubes are accessory structures. 3. The segments of the uterus include the cervix, fundus, and corpus. The ovaries and fallopian tubes are accessory structures. 4. The segments of the uterus include the cervix, fundus, and corpus. The ovaries and fallopian tubes are accessory structures. 5. The segments of the uterus include the cervix, fundus, and corpus. The ovaries and fallopian tubes are accessory structures. Page Ref: 500 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1.NDUeRmSoINnGstTrBa.tCeOkM nowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1: Describe the anatomy and physiology of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
3) The nurse is preparing to assess a female client's external genitalia. Which structures will the nurse anticipate including in the documentation? Select all that apply. 1. Vagina. 2. Cervix. 3. Clitoris. 4. Labia majora. 5. Labia minora. Answer: 3, 4, 5 Explanation: 1. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries. 2. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries. 3. Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area. 4. Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area. 5. Female external genitalia include the mons pubis, labia majora, labia minora, glands, clitoris, and perianal area. Page Ref: 498-500 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.5: Generate the appropriate documentation to describe the assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
4) The nurse is preparing to assess a client experiencing PMS. Which findings should the nurse anticipate? Select all that apply. 1. Cramping. 2. Spotting. 3. Headache. 4. Breast engorgement. 5. Irritability. Answer: 1, 3, 4, 5 Explanation: 1. Premenstrual syndrome (PMS) presents with a variety of signs and symptoms which includes cramping. 2. Spotting is not associated with PMS. 3. Premenstrual syndrome (PMS) presents with a variety of signs and symptoms which includes a headache. 4. Premenstrual syndrome (PMS) presents with a variety of signs and symptoms which includes breast engorgement. 5. Premenstrual syndrome (PMS) presents with a variety of signs and symptoms which includes irritability. Page Ref: 508 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
5) The nurse observes bulging over the femoral artery during an assessment. Which diagnosis should the nurse suspect? 1. Aneurysm. 2. Femoral hernia. 3. Swollen lymph node. 4. Hematomata. Answer: 2 Explanation: 1. An observable characteristic of a femoral aneurysm is pulsation. 2. A femoral hernia is characterized by bulging over the area of the femoral artery in the groin caused by a weakening or tear in the abdominal wall. 3. Swollen lymph nodes are characterized by palpable nodules. 4. A hematoma will appear discolored. Page Ref: 674 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
6) A 28-year-old female client asks the nurse how often she should have a Pap smear. Which information should the nurse provide? 1. "You should have a Pap test annually." 2. "You should have a Pap test every 3 years." 3. "You should have a Pap test and an HPV test annually." 4. "You should have a Pap test and an HPV test every 5 years." Answer: 2 Explanation: 1. Guidelines state that women of age 21-29 years at average risk should have Pap test once in every 3 years. 2. Guidelines state that women of age 21-29 years at average risk should have Pap test once in every 3 years. 3. Guidelines state that women of age 21-29 years at average risk should have Pap test once in every 3 years. 4. Guidelines state that women of age 21-29 years at average risk should have Pap test once in every 3 years. Page Ref: 502 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeUteRrSsIiNnGpTaBt.iCenOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
7) The nurse notes that a client's progesterone level is 15 ng/ml. Which should the nurse interpret the finding as in relation to the menstrual cycle? 1. Midcycle. 2. Preovulatory. 3. Menstruating. 4. Menopausal. Answer: 1 Explanation: 1. A progesterone level of 15 ng/ml indicates the client is midcycle. 2. A client that is preovulatory will have a progesterone of less the 1 ng/ml. 3. A client that is menstruating will have a progesterone of less the 1 ng/ml. 4. A client that is menopausal will have a progesterone of less the 1 ng/ml. Page Ref: 514 Cognitive Level: Analyzing Client Need & Sub: Reduction of Risk Potential; Laboratory Values Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.3. Utilize the appropriate techniques and tools for physical assessment of the female genitourinary system.
8) The nurse notes that the client's Bartholin's gland is reddened, inflamed, and tender and warm to palpation. Based on the findings, which additional infection should the nurse anticipate testing the client for? 1. Gonorrhea. 2. Candidiasis. 3. Herpes simplex virus. 4. Urinary tract infection. Answer: 1 Explanation: 1. Reddened and inflamed Bartholin's gland may be caused by gonorrhea. 2. Candidiasis is not associated with a reddened and inflamed Bartholin's gland. 3. Herpes simplex virus is not associated with a reddened and inflamed Bartholin's gland. 4. A urinary tract infection is not associated with a reddened and inflamed Bartholin's gland. Page Ref: 521 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.4: Outline the techniques for assessment of the female genitourinary system. MNL Learning Outcome: 22.3. Utilize the appropriate techniques and tools for physical assessment of the female genitourinary system.
9) The nurse is preparing to inspect the external genitalia of an obese female client. Which finding should the nurse be prepared to document? 1. Ecchymosis. 2. Edematous labia. 3. Reddened genitalia. 4. Excoriated labia majora. Answer: 2 Explanation: 1. Ecchymosis is not an expected finding. 2. Labia and other structures in the perineum may be edematous in obese clients as a result of pressure in the groin from the enlarged abdomen. 3. Reddened genitalia are not an expected finding associated with obesity. 4. Excoriated labia majora are not an expected finding associated with obesity. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.5: Generate the appropriate documentation to describe the assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
10) The nurse notes that a client's clitoris is elongated. Which hormonal imbalance should the nurse suspect is occurring? 1. Estrogen. 2. Progesterone. 3. Testosterone. 4. Luteinizing hormone. Answer: 3 Explanation: 1. Abnormal estrogen levels are not associated with an elongated clitoris. 2. Abnormal progesterone levels are not associated with an elongated clitoris. 3. An elongated clitoris may signal elevated testosterone levels and warrants further investigation and referral to the healthcare provider. 4. Abnormal luteinizing hormone is not associated with an elongated clitoris. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
11) The nurse is assessing the urethral opening of a female client. Which findings should the nurse recognize are associated with a urinary tract infection? Select all that apply. 1. Discharge. 2. Foul odor. 3. Redness. 4. Inflammation. 5. Leaking urine. Answer: 1, 3, 4 Explanation: 1. Urethral discharge is associated with a urinary tract infection. 2. A foul odor is not associated with a urinary tract infection but is most likely associated with a vaginal infection. 3. Redness of the urethra is associated with a urinary tract infection. 4. Urethral inflammation is associated with a urinary tract infection. 5. Leaking urine is a symptom of stress incontinence and weakening of the pelvic musculature. Page Ref: 522 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.4: Outline the techniques for assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
12) The nurse notes that a client's pubic area is excoriated. Which should the nurse further assess the client for? 1. Gonorrhea. 2. Genital warts. 3. Contact dermatitis. 4. Herpes simplex virus. Answer: 3 Explanation: 1. Gonorrhea is characterized by vaginal discharge or bleeding and abscesses in Bartholin's or Skene's glands. 2. Genital warts are raised, moist, cauliflower shaped papules. 3. Contact dermatitis appears as a red rash with associated lesions that are weepy and crusty. There are often scratches due to intense itching. 4. Herpes simplex virus is characterized by red, painful vesicles accompanies by localized swelling of the genitals and surrounding areas. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
13) The nurse is preparing to interview a client with uterine fibroids. Which question should the nurse initially ask the client? 1. "Are you experiencing any pelvic pressure?" 2. "Are you experiencing any vaginal itching?" 3. "Have you experienced an abnormal bleeding?" 4. "Have you experienced an abnormal vaginal discharge?" Answer: 3 Explanation: 1. Uterine fibroids are not associated with pelvic pressure. 2. Vaginal itching is not associated with uterine fibroids. 3. Uterine fibroids are associated with abnormal bleeding patterns. 4. Vaginal discharge is not associated with uterine fibroids. Page Ref: 511 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.3: Determine questions about the female genitourinary system to use for the focused interview. MNL Learning Outcome: 22.2. Plan questions about the female genitourinary system for the focused interview.
14) The nurse is reviewing the prescriptions of a client experiencing a decreased libido. Which medication should the nurse be concerned with? 1. Codeine. 2. Estradiol. 3. Levothyroxine. 4. Progesterone. Answer: 1 Explanation: 1. Codeine is an opiate. Opiates are associated with a decreased libido. 2. Estradiol is not associated with a decreased libido. 3. Levothyroxine does not decrease libido. 4. Progesterone is not associated with a decreased libido. Page Ref: 512 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
15) During the examination of a client's perineum, the nurse notes reddened areas on the labia and white curd-like vaginal discharge. Which condition should the nurse suspect? 1. Contact dermatitis. 2. Yeast infection. 3. Herpes infection. 4. Venereal warts. Answer: 2 Explanation: 1. Contact dermatitis is characterized by reddened lesions that weep and form crusts. 2. Yeast infections are the most common female genital infection and can produce redness, pruritis, and cheese-like discharge. 3. Herpes infection causes small, red, painful ulcerations. 4. Venereal warts appear as cauliflower-shaped, raised, moist papules. Page Ref: 528 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
16) The nurse is examining a female client and notes a greenish discharge with a foul odor. Which diagnosis does the nurse anticipate? 1. Trichomoniasis. 2. Herpes infection. 3. Gonorrhea. 4. Bacterial vaginosis. Answer: 3 Explanation: 1. Frothy yellow-green discharge is seen in trichomoniasis. 2. Herpes infection produces red, painful vesicles with localized swelling. 3. Green discharge that has a foul smell is associated with gonorrhea, which may spread to the abdominal cavity to cause pelvic inflammatory disease. 4. Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. Page Ref: 528 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
17) The nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules. Based on this data, which condition does the nurse suspect? 1. Genital warts. 2. Herpes infection. 3. Bartholin abscess. 4. Contact dermatitis. Answer: 1 Explanation: 1. Genital warts present as raised, cauliflower-shaped papules. 2. Herpes infection produces red, painful vesicles with localized swelling. 3. Bartholin's abscess produces inflammatory signs such as redness and warm skin. 4. Contact dermatitis produces red, weepy rashes. Page Ref: 526 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
18) The nurse reviewing a client's medical record notes documentation of a nontender protrusion into the anterior vaginal wall. Which condition does the nurse suspect based on this data? 1. Inflammation of the Skene gland. 2. Prolapsed uterus. 3. Rectocele. 4. Cystocele. Answer: 4 Explanation: 1. The Skene glands are examined by palpation on both sides of the urethra. 2. A prolapsed uterus may protrude from the vaginal wall and may occur with or without straining. 3. A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. 4. A cystocele is a hernia that is formed when the urinary bladder is pushed into the anterior vaginal wall. Page Ref: 523 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : CGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
19) The nurse reviewing a client's record notes there is a protrusion into the posterior vaginal wall. Based on this data, which condition does the nurse suspect? 1. Ovarian cyst. 2. Bartholin gland infection. 3. Cystocele. 4. Rectocele. Answer: 4 Explanation: 1. Ovarian cysts cause inflammation and tenderness upon examination. 2. The Bartholin glands are palpated by gently squeezing the posterior region of the labia majora. 3. A cystocele is a hernia that is formed when the urinary bladder is pushed into the anterior vaginal wall. 4. A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Page Ref: 523 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
20) The nurse is reviewing the symptoms of ovarian cancer with a client. Which symptoms should the nurse include? Select all that apply. 1. Ascites. 2. Abdominal bloating. 3. Abnormal vaginal bleeding. 4. Menstrual irregularities. 5. Increased urination. Answer: 1, 2, 3 Explanation: 1. Ascites is a symptom of ovarian cancer. 2. Abdominal bloating is a symptom of ovarian cancer. 3. Abnormal vaginal bleeding is a symptom of ovarian cancer. 4. Menstrual irregularities are not associated with ovarian cancer. 5. Increased urination is not associated with ovarian cancer. Page Ref: 531 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
21) The nurse is interviewing a female client who reports a frothy, yellow-green discharge. Based on this data, which condition does the nurse suspect? 1. Vaginitis. 2. Trichomoniasis. 3. Gonorrhea. 4. Chlamydia .Answer: 2 Explanation: 1. Vaginitis indicates a nonspecific inflammation of the vagina. 2. Frothy, yellow-green discharge is associated with trichomoniasis. 3. A green discharge that has a foul smell is associated with gonorrhea. 4. A yellow discharge is associated with a chlamydial infection. Page Ref: 528 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
22) The nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful. Based on this data, which condition does the nurse suspect? 1. Genital warts. 2. Herpes infection. 3. Bartholin abscess. 4. Contact dermatitis. Answer: 2 Explanation: 1. Genital warts produce cauliflower-like lesions. 2. Herpes infection produces red, painful vesicles with localized swelling. 3. Bartholin's abscess produces inflammatory signs, such as redness and warm skin. 4. Contact dermatitis produces red, weepy rashes. Page Ref: 525 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
23) The nurse is examining the external genitalia of a female client and notes draining papules. Based on this data, which condition does the nurse suspect? 1. Genital warts. 2. Herpes infection. 3. Syphilitic lesion. 4. Contact dermatitis. Answer: 3 Explanation: 1. Genital warts produce cauliflower-like lesions. 2. Herpes infection produces red, painful vesicles with localized swelling. 3. Syphilitic lesions are painless papules that may begin to produce drainage. 4. Contact dermatitis produces red, weepy rashes. Page Ref: 526 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
24) The nurse is reviewing the symptoms of an ovarian cyst with a client. Which should the nurse include? Select all that apply. 1. Lower back pain. 2. Loss of appetite. 3. Pelvic pain. 4. Pain during intercourse. 5. Change in bowel habits. Answer: 1, 3, 4 Explanation: 1. Lower back pain is a symptom of an ovarian cyst. 2. A loss of appetite is not associated with an ovarian cyst. 3. Pelvic pain is a symptom of an ovarian cyst. 4. Pain during intercourse is a symptom of an ovarian cyst. 5. A change in bowel habits is not associated with an ovarian cyst. Page Ref: 531 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
25) The nurse is reviewing the risk factors for uterine cancer with a client. Which should the nurse include in the teaching? 1. Smoking. 2. Obesity. 3. Multiple sexual partners. 4. Sexually transmitted infections. Answer: 2 Explanation: 1. Smoking does not increase the risk for uterine cancer. 2. Obesity is a risk factor for uterine cancer. 3. Multiple sex partners do not increase the risk for uterine cancer. 4. Sexually transmitted infections do not increase the risk for uterine cancer. Page Ref: 503 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.2: Identify anatoN mUicR,SpIhNyGsTioBl.oCgOicM, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
26) The nurse examining an adolescent female notes sparse pubic hair. Based on this data, which action by the nurse is appropriate? 1. Ask the client if she is menstruating. 2. Examine the client for breast buds. 3. Report the findings to the healthcare provider. 4. Document the findings as abnormal. Answer: 3 Explanation: 1. The presence or absence of menstrual history will aid in the determination of hormonal function. 2. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics. 3. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up. 4. A sparse hair pattern may be indicative of delayed puberty. Page Ref: 521 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
27) The nurse is examining an adult female and notes thick, coarse pubic hair covering the pubis and extending to the thighs. Which action by the nurse is the most appropriate based on this data? 1. Ask the client if she has started menstruation. 2. Report the findings to the healthcare provider. 3. Document the findings as normal. 4. Ask the client if she is sexually active. Answer: 3 Explanation: 1. The client's physical appearance indicates the correct level of maturation. Information concerning menstruation is not needed. 2. In the presence of normal findings, the healthcare provider does not need notification. 3. According to Tanner's Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. No further subjective information is required by the nurse. The nurse should document the findings. 4. Information concerning the client's level of sexual activity is not relevant in this scenario. Page Ref: 521 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, N anUdRSeInNvGirToBn.m ntal assessments of health and illness COeM parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
28) A parent of a 14-year-old female asks the nurse about the HPV vaccine. Which information should the nurse include in the teaching? 1. "Your daughter will need one dose of the vaccine." 2. "Your daughter will need three doses of the vaccine." 3. "Your daughter will need two doses of the vaccine." 4. "Your daughter will need to be vaccinated when she becomes sexually active." Answer: 3 Explanation: 1. CDC's Advisory Committee on Immunization Practices (ACIP) recommends routine two-dose vaccination of girls and boys ages 11 and 12. This two-dose vaccination series can be given any time between ages 9 and 14. 2. When vaccinating individuals 15 years or older, a three-dose series is recommended (CDC, 2016). 3. CDC's Advisory Committee on Immunization Practices (ACIP) recommends routine twodose vaccination of girls and boys ages 11 and 12. This two-dose vaccination series can be given anytime between ages 9 and 14. 4. CDC's Advisory Committee on Immunization Practices (ACIP) recommends routine twodose vaccination of girls and boys ages 11 and 12. This two-dose vaccination series can be given anytime between ages 9 and 14. Page Ref: 502 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Expected Actions/Outcomes Standards: QSEN Competencies: III.B.3.NBUase ndGiTvBid.CuO alM ized care plan on patient values, RSIiN clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.2: Identify anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system. MNL Learning Outcome: 22.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the female genitourinary system.
29) The nurse is examining a client with a gonorrheal infection. Which is the priority action by the nurse? 1. Counsel regarding safe sex practices. 2. Obtain history of sexual contacts. 3. Obtain a culture. 4. Document the findings. Answer: 3 Explanation: 1. The interaction between the nurse and client will include a discussion about safe sex practices. The discussion, however, of safe sexual practices is not a priority as the client has presented with a potential sexually transmitted infection. 2. A listing of sexual contacts may be indicated in the event the disease is positively identified. At this time, this step is premature pending the outcome of the diagnostic tests. 3. Obtaining a culture of the potential infection is indicated as the priority. The findings of the culture will be used to determine the next actions of the nurse. 4. The nurse will need to document the findings. It is most important to obtain the culture. Page Ref: 528 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.6: Identify abnormal findings in the physical assessment of the female genitourinary system. MNL Learning Outcome: 22.4. Differentiate normal and abnormal variations of the female genitourinary system observed during physical assessment.
30) The nurse is caring for an adolescent female client who has come to the clinic for an annual physical examination. Which question does the nurse plan to include in the data collection process? 1. "Do you have a boyfriend?" 2. "Do you need birth control?" 3. "Are you attracted to boys?" 4. "Are you sexually active at this time?" Answer: 4 Explanation: 1. The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking specifically about boys may limit the client's response. 2. It is more important to find out about the sexual activity than the birth control initially. A guided discussion may eventually lead to asking these questions. 3. The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking about the attraction to the opposite sex may appear judgmental to the client. 4. It is more important to find out about the sexual activity than the birth control initially. Page Ref: 508, 509 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3: Determine questions about the female genitourinary system to use for the focused interview. MNL Learning Outcome: 22.2. Plan questions about the female genitourinary system for the focused interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 23 Musculoskeletal System 1) The nurse is caring for a client with a right femur fracture. Which category of bone should the nurse identify the femur as when discussing the fracture with the client? 1. Short. 2. Long. 3. Flat. 4. Irregular. Answer: 2 Explanation: 1. Bones are classified according to shape and composition. Short bones include the carpals and tarsals. 2. Bones are classified according to shape and composition. Long bones include the femur and humerus. 3. Bones are classified according to shape and composition. Flat bones include the parietal skull bone and sternum. 4. Bones are classified according to shape and composition. Irregular bones include the vertebrae and hips. Page Ref: 536 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1.NDUeRmSoINnGstTrBa.tCeOkM nowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.1: Describe the anatomy and physiology of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
2) The client is recovering from the surgical repaid of a fractured arm. When discussing the effects of the fracture with the client, which skeletal bone functions should the nurse include in the teaching? Select all that apply. 1. Provide a body framework. 2. Provide movement. 3. Maintain posture. 4. Generate heat. 5. Calcium storage. Answer: 1, 5 Explanation: 1. The skeletal bones provide a framework for the body. 2. Skeletal muscles, not bones, provide movement, maintain posture, and generate heat. 3. Skeletal muscles, not bones, provide movement, maintain posture, and generate heat. 4. Skeletal muscles provide movement, maintain posture, and generate heat. 5. The skeletal bones provide a framework for the body and they store minerals such as calcium and phosphorus. Page Ref: 536 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.1: Describe the anatomy and physiology of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
3) The nurse assessing a client experiencing pain in their right foot observes swelling and inflammation of the foot and deviation of the big toe from the midline associated with crowding of the remaining toes. Which condition does the nurse suspect? 1. Flat foot. 2. Gouty arthritis. 3. Hammertoe. 4. Bunion .Answer: 4 Explanation: 1. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. 2. The toes are common sites for gouty arthritis. In this condition, the metatarsophalangeal joint of the toe is swollen, hot, red, and extremely painful. There is no deviation of the toes. 3. Hammertoe produces flexion of the proximal interphalangeal joint of a toe. The distal metatarsophalangeal joint hyperextends. 4. A hallux valgus, or bunion, causes a deviation of the great toe from the midline and crowding of the remaining toes. This crowding results in deviation. The metatarsophalangeal joint and bursa become enlarged and inflamed. Page Ref: 583 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
4) The nurse asks the client to point their toes up towards their nose during an examination of the lower extremities. Which type of movement is the nurse assessing? 1. Inversion. 2. Plantar flexion. 3. Eversion. 4. Dorsiflexion .Answer: 4 Explanation: 1. Inversion is the movement of pointing the sole of the foot inward. 2. Plantar flexion is the movement of pointing the toes toward the floor. 3. Eversion is the movement of pointing the sole of the foot outward. 4. Dorsiflexion is the movement of pulling the toes upward toward the nose. Page Ref: 541 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Outline the techniques for assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
5) Which instructions should the nurse provide a client to assess the lateral flexion? Select all that apply. 1. "Tilt your head back and look at the ceiling." 2. "Lean your head to the side and attempt to touch your ear to your shoulder." 3. "Bend sideways to the right and to the left while I stabilize your pelvis." 4. "Attempt to raise your shoulders up toward your ears." 5. "Attempt to rotate your head in a circular manner." Answer: 2, 3 Explanation: 1. Tilting the head back and looking toward the ceiling is an example of hyperflexion. 2. Lateral flexion can be assessed by tilting the head to each shoulder with the ear from the same side. 3. Lateral flexion can be assessed by sitting or standing behind the client and while stabilizing the pelvis asking the client to bend sideways to the right and the left. 4. Flexibility and mobility may be assessed by asking the client to raise and lower the shoulders but are not examples of methods to assess lateral flexion. 5. Flexibility and mobility may be assessed by asking the client to rotate the head but it is not an example of methods of lateral flexion. Page Ref: 575 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5.NEUxpRlSaIiNnGthTB e.rCoOleMof evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.4: Outline the techniques for assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
6) The nurse is caring for a client with a knee injury. When documenting this injury in the medical record, the nurse identifies the knee as which type of joint? 1. Saddle. 2. Hinge. 3. Pivot. 4. Plane. Answer: 2 Explanation: 1. Saddle joints consist of an articulating bone having both concave and convex areas (resembling a saddle). The opposing surfaces fit together. The carpometacarpal joints ofthe thumbs are an example. 2. In hinge joints, a convex projection of one bone fits into a concave depression in another. Motion is similar to that of a mechanical hinge. These joints permit flexion and extension only. Examples include the elbow and knee joints. 3. In pivot joints, the rounded end of one bone protrudes into a ring of bone (and possibly ligaments). The only movement allowed is rotation of the bone around its own long axis or against the other bone. An example is the joint between the atlas and axis of the neck. 4. In plane joints, the articular surfaces are flat, allowing only slipping or gliding movements. Examples include the intercarpal and intertarsal joints and the joints between the articular processes of the ribs. Page Ref: 540 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.5: Generate the appropriate documentation to describe the assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
7) The nurse is preparing to assess the posterior spine of a client. Which landmark should the nurse use to determine symmetry? 1. Iliac crests. 2. Twelfth thoracic vertebrae. 3. Posterior superior iliac spine. 4. Paravertebral muscles. Answer: 1 Explanation: 1. The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry. 2. The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry. 3. The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry. 4. The iliac crests are used as landmarks on the posterior spine. They are used to assess for symmetry. Page Ref: 574 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
8) Which degree of wrist movement is an expected finding when assessing extension? 1. 90 degrees. 2. 70 degrees. 3. 30 degrees. 4. 20 degrees. Answer: 2 Explanation: 1. The expected finding of wrist movement for flexion is 90 degrees. 2. The expected finding of wrist movement when assessing extension is 70 degrees. 3. The expected finding of wrist movement for hyperextension is 30 degrees. 4. The expected finding of wrist movement for radial deviation is 20 degrees. Page Ref: 564 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessmenNt UoR f th eGmTuBs.CcuOlM oskeletal system. SIN MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
9) The school nurse is assessing adolescent females for scoliosis. Which area of the spine does the nurse plan to assess? 1. Thoracic. 2. Lumbar. 3. Cervical. 4. Sacral. Answer: 1 Explanation: 1. Scoliosis is the abnormal curvature of the thoracic spine. 2. Scoliosis is the abnormal curvature of the thoracic spine. 3. Scoliosis is the abnormal curvature of the thoracic spine. 4. Scoliosis is the abnormal curvature of the thoracic spine. Page Ref: 564 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
10) The nurse is preparing to perform the bulge test on a client's left knee. When performing the test, which area of the knee should the nurse assess for bulging? 1. Posterior. 2. Medial. 3. Lateral. 4. Anterior. Answer: 2 Explanation: 1. The bulge sign can be assessed to check for the presence of fluid. If fluid is present, there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next, apply pressure to the lateral side of the knee while observing the medial side. In a normal test, no fluid is present. 2. The bulge sign can be assessed to check for the presence of fluid. If fluid is present, there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next, apply pressure to the lateral side of the knee while observing the medial side. In a normal test, no fluid is present. 3. The bulge sign can be assessed to check for the presence of fluid. If fluid is present, there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next, apply pressure to the lateral side of the knee while observing the medial side. In a normal test, no fluid is present. 4. The bulge sign can be assessed to check for the presence of fluid. If fluid is present, there will be a bulging on the medial side. To perform the test, assist the client to a supine position. Use firm pressure to stroke the medial aspect of the knee upward several times displacing any fluid. Next, apply pressure to the lateral side of the knee while observing the medial side. In a normal test, no fluid is present. Page Ref: 569 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Outline the techniques for assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
11) A client comes to the emergency department (ED) complaining of a painful injury to the right knee received while playing basketball. Which examination techniques will the nurse include during the physical assessment of this client? Select all that apply. 1. Inspection. 2. Palpation. 3. Bulge sign testing. 4. Auscultation. 5. Percussion. Answer: 1, 2, 3 Explanation: 1. The nurse would visually inspect the knee's general appearance including the presence or redness, swelling, and dislocation. The knee's appearance would be contrasted with the unaffected knee. 2. The area would be palpated for tenderness and warmth. 3. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee, the medial side is observed for bulging. 4. Auscultation is not used to assess the knee. 5. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs andNaUbRdSoIm ity. It is not used to assess for knee injuries. NGinTaBl.c CaOvM Page Ref: 569 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.4: Outline the techniques for assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
12) The nurse is preparing to assess a client's spine for abnormalities. Which instruction should the nurse provide the client? 1. Sit down and then stand as the nurse looks from the front of the client. 2. Stand, bend back slowly, and then bend to the right and left while the nurse looks from the back. 3. Bend over, stand tall, and stretch arms over the head. 4. Sit down and then lean forward and dangle the arms at the sides of the body. Answer: 2 Explanation: 1. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. 2. The spine should be visually inspected by viewing the back of the client. The client should be asked to stand during this assessment. This will allow the nurse to assess for symmetry. The spine should appear straight when viewed from the back. 3. Bending and stretching will not elicit the needed information about the spine. Range of motion and flexibility may be assessed by asking the client to bend over or stretch. 4. The spine is assessed by asking the client to stand. The nurse will then visually assess the client from the back. Page Ref: 575-576 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N.GCToBn.dCuOcMt comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4: Outline the techniques for assessment of the musculoskeletal system. MNL Learning Outcome: 23.3. Utilize the appropriate techniques and tools for physical assessment of the musculoskeletal system.
13) A client tells the nurse they feel numbness and tingling in their hands after they were instructed to bend their wrist downward and press their hands together. Which condition should the nurse suspect? 1. Arthritis of the wrists. 2. Carpal tunnel syndrome. 3. Crepitus of the wrists. 4. Dupuytren contracture. Answer: 2 Explanation: 1. Arthritis typically causes pain and limitations in movement but not numbness and tingling. 2. Carpal tunnel is a condition caused by compression of the median nerve. The test described is called Phalen's test, and when used on individuals with carpal tunnel syndrome, 80 percent experience pain, tingling, and numbness that radiates to the arm, shoulder, neck, or chest within 60 seconds. Another assessment for carpal tunnel syndrome is called Tinel's sign and is elicited by percussing lightly over the median nerve in each wrist. The test is positive if the client feels numbness, tingling, and pain along the median nerve. 3. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. 4. Dupuytren contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder. Page Ref: 565 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
14) The nurse is assessing a client with the inability to move their fourth and fifth fingers. The nurse notes severe flexion in both of the affected fingers but no complaints of pain during palpation. Based on this data, which diagnosis should the nurse suspect? 1. Dupuytren contracture. 2. Carpal tunnel syndrome. 3. Bursitis. 4. Osteoarthritis. Answer: 1 Explanation: 1. Dupuytren contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder. 2. Carpal tunnel is a condition caused by compression of the median nerve. In carpal tunnel syndrome, the client feels numbness, tingling, and pain in the hands and wrists. 3. Bursitis involves inflammation of the bursae. The condition is manifested by redness, warmth, swelling, and tenderness. 4. Osteoarthritis is the degeneration of the joints. The condition typically causes pain and limitations in movement but not numbness and tingling. Page Ref: 565 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
15) The nurse notes a round mass on the back of a client's wrist. Which question should the nurse ask the client? 1. Do you have a history of rheumatoid arthritis? 2. Do you have a history of osteoarthritis? 3. Do you have a history of ganglion cysts? 4. Do you have a history of carpal tunnel syndrome? Answer: 3 Explanation: 1. Rheumatoid arthritis is an autoimmune disorder that presents with pain and tenderness in the joints. The condition may affect numerous joints. It is a systematic condition in which other body parts may be impacted in varying degrees. 2. Osteoarthritis is a condition in which the joints degenerate. The potential causes may include obesity, trauma, and occupational stressors. Joint pain with use/exercise is the chief symptom of osteoarthritis. It is commonly seen in the hips, knees, and hands. 3. A ganglion is a painless, round, fluid-filled mass. It arises from the tendon sheaths on the dorsum of the wrist and hand. 4. Carpal tunnel syndrome results from compression of the median nerve. It may be associated with occupations requiring repetitive tasks and pregnancy. It may begin with numbness and tingling in the hands and fingers. Over time, the condition may advance toward an inability to grasp objects. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.3: Determine which questions about the musculoskeletal system to use for the focused interview. MNL Learning Outcome: 23.2. Plan questions about the musculoskeletal system for the focused interview.
16) The nurse notes there is a grating sound in a client's joint when they bend and straighten it. Which terminology should the nurse use when documenting this finding? 1. Subluxation. 2. Grinding. 3. Crepitation. 4. Joint dislocation. Answer: 3 Explanation: 1. Subluxation refers to a partial joint location. 2. Grinding sounds may be heard or felt with musculoskeletal disorders but it is not appropriate medical terminology. 3. Crepitation is the medical term used to describe the grating sounds a joint makes when the articulating surfaces have lost their cushioning cartilage. 4. There is inadequate information to determine the joint is indeed dislocated. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.5: Generate the appropriate documentation to describe the assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
17) The nurse assesses a client with tenderness and stiffness in the wrist and elbow. The client reports that their discomfort is worsened with activity. Which condition should the nurse suspect? 1. Carpal tunnel syndrome. 2. Osteoarthritis. 3. Crepitus of the wrists. 4. Dupuytren contracture. Answer: 2 Explanation: 1. Carpal tunnel syndrome is caused by compression of the median nerve. 2. Osteoarthritis is also known as degenerative joint disease. It is associated with pain and stiffness of the joints. Arthritis typically causes pain and limitations in movement but not numbness and tingling. 3. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative joint disease, trauma, or inflammatory conditions. 4. Dupuytren contracture involves inability to extend the fourth and fifth fingers but is a painless, inherited disorder. Page Ref: 578 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
18) When assessing the strength of a client's upper extremities, a full range of motion against gravity with moderate resistance is noted. Which should the nurse document the finding as? 1. Poor. 2. Normal. 3. Fair. 4. Good. Answer: 4 Explanation: 1. A rating of poor, or a 2, would be full range of motion without gravity, or passive motion. 2. Full range of motion against gravity with full resistance is considered normal muscle strength, also rated a 5. 3. A rating of fair, or a 3, would be full range of motion with gravity. 4. A rating of good, or a 4, would be full range of motion against gravity with moderate resistance. Page Ref: 558 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.5: Generate the appropriate documentation to describe the assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
19) The nurse notes swelling and tenderness of the olecranon process during the palpation. Which condition should the nurse suspect? 1. Arthritis. 2. Bursitis. 3. Epicondylitis. 4. Crepitus. Answer: 3 Explanation: 1. Rheumatoid arthritis may result in nodules in the olecranon bursa or along the extensor surface of the ulna. Nodules are firm, nontender, and not attached to the overlying skin. 2. Bursitis is characterized by a painful, inflamed, warm area. 3. Lateral epicondylitis, also called tennis elbow, results from constant, repetitive movements of the wrist and/or forearm. Pain occurs when the client attempts to extend the wrist against resistance. Medial epicondylitis, also called pitcher's or golfer's elbow, results from constant, repetitive flexion of wrist. Pain occurs when the client attempts to flex the wrist against resistance. 4. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. Page Ref: 558 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
20) The nurse observes an exaggerated lumbar curve while inspecting the spine of a client. Which term should the nurse use when documenting the finding? 1. Lordosis. 2. Scoliosis. 3. Kyphosis. 4. Flattened curve. Answer: 1 Explanation: 1. Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. The spine leans to the left or right in a list, and a line drawn from the thoracic one (T1) vertebra does not fall between the gluteal cleft. 2. Scoliosis results when the spine curves to the right or left. It is noted in the thoracic region. 3. Kyphosis is an exaggerated thoracic dorsal curve resulting in asymmetry between the sides of the posterior thorax. 4. A flattened lumbar curve is a concave curvature of the lumbar areas and occurs when lumbar muscles spasm. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.iC enOtMs, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.5: Generate the appropriate documentation to describe the assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
21) The nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The spine has a slight curvature to the right but the client denies complaints of pain. Which term should the nurse use when documenting this finding? 1. Kyphosis. 2. Scoliosis. 3. Spinal list. 4. Lordosis .Answer: 2 Explanation: 1. Kyphosis results in an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. 2. Scoliosis results when the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. 3. A spinal list occurs when the spine leans to the left or right. The condition may be noted in conditions with paravertebral muscle spasms or herniated disks. 4. Lordosis is an exaggerated curve of the lumbar spine. It is noted most in condition such as pregnancy and obesity. Page Ref: 579 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.5: Generate the appropriate documentation to describe the assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
22) The nurse assessing a client's big toe notes hardened nodules on the lateral aspect of the toe, as well as redness, swelling, and pain. Which condition should the nurse suspect? 1. Bunion. 2. Synovitis. 3. Hammertoe. 4. Gout. Answer: 4 Explanation: 1. Bunions are thickening and inflammation of the bursa of the joint of the great toe. 2. Synovitis refers to an inflammation of the synovial membrane. It may be present with pain and swelling but is typically seen more in the knee. 3. In hammertoe, the metatarsophalangeal joint of the toe hyperextends with flexion of the interphalangeal joint of the toe. 4. The manifestations are consistent with a diagnosis of gout, which is a form of arthritis. It results from an excess of uric acid. The uric acid crystals deposit in the affected joints. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Page Ref: 583 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUs RCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
23) The nurse is assessing a client with suspected rheumatoid arthritis (RA). Which musculoskeletal changes would contribute to a positive diagnosis of RA? Select all that apply. 1. Ulnar deviation. 2. Bouchard nodes. 3. Heberden's nodes. 4. Swan-neck deformity. 5. Symmetrical loss of function in extremities. Answer: 1, 4, 5 Explanation: 1. In rheumatoid arthritis, there is chronic inflammation of the metacarpophalangeal and interphalangeal joints leading to ulnar deviation. 2. The nodes that may appear on the fingers such as Bouchard and Heberden's nodes are associated with osteoarthritis. Bouchard nodes are located on the proximal interphalangeal joints. 3. The nodes that may appear on the fingers such as Bouchard and Heberden's nodes are associated with osteoarthritis. Heberden's nodes are hard, typically painless, bony enlargements associated with osteoarthritis that may occur in the distal interphalangeal joints. 4. Another manifestation of rheumatoid arthritis involves what are known as swan-neck contractures. These result when the proximal interphalangeal joints are hyperextended while the distal interphalangeal joints are fixed in flexion. 5. Rheumatoid arthritis impacts the extremities symmetrically. Page Ref: 561, 582 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
24) The nurse is reviewing the records of a child with a protein deficiency and a fractured tibia. Which should the nurse be concerned with? 1. Bone growth. 2. Low bone density. 3. Bone healing. 4. Tissue healing. Answer: 1 Explanation: 1. Protein deficiency interferes with bone growth and muscle tone. 2. Calcium deficiency predisposes a client to low bone density. 3. Vitamin C deficiency inhibits bone and tissue healing. 4. Vitamin C deficiency inhibits bone and tissue healing. Page Ref: 550 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
25) A client tells the nurse they have just lost 75 pounds after gastric bypass surgery. Which condition should the nurse recognize the client is at risk for? 1. Protein deficiency. 2. Vitamin D deficiency. 3. Osteoporosis. 4. Osteoarthritis. Answer: 3 Explanation: 1. A client that has had a recent weight loss is not at risk for protein deficiency. 2. A client that has had a recent weight loss is not at risk for vitamin D deficiency. 3. Clients with a new weight loss are at risk for osteoporosis. 4. A client that has had a recent weight loss is not at risk for osteoarthritis. Page Ref: 550 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
26) The nurse is preparing to assess a client with a suspected tear of the rotator cuff. Which range of motion will the client be unable to perform without lifting or shrugging their shoulders? 1. Flex the elbow. 2. Adduct the shoulder. 3. Abduct the shoulder 4. Supinate or pronate the hands Answer: 3 Explanation: 1. Flexion of the elbow is not affected by a torn rotator cuff. 2. Adduction does not result in the client's inability to shrug or lift their shoulders. 3. A client with a rotator cuff tear will be unable to perform abduction without lifting or shrugging their shoulder. 4. The ability to supinate or pronate the hands is not affected by a rotator cuff tear. Page Ref: 556 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Mobility/Immobility Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
27) A client expresses discomfort when attempting to flex their wrist against resistance. Which should the nurse suspect the client is experiencing? 1. Tendonitis. 2. Subluxation. 3. Medial epicondylitis. 4. Lateral epicondylitis. Answer: 3 Explanation: 1. Overuse or inflammatory processes can result in tendinitis. The inflammation of the tendon results in pain and limitation of movement. 2. Subluxation is a partial dislocation of a joint. 3. Medial epicondylitis results from constant, repetitive flexion of the wrist. Pain occurs when the client attempts to flex their wrist against resistance. 4. Lateral epicondylitis results from constant repetitive movements of the wrist or forearm. Pain occurs when the patient attempts to extend the wrist or forearm. Page Ref: 558 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
28) A client expresses discomfort during a Durkan's test. Which condition should the nurse suspect? 1. Ganglion. 2. Osteoarthritis. 3. Carpal tunnel syndrome. 4. Epicondylitis . Answer: 3 Explanation: 1. A ganglion is a typically painless, round fluid filled mass that arises from the tendon sheaths on the dorsum of the wrist and hand. The Durkan's test is not used to identify ganglion's cysts. 2. Osteoarthritis is a chronic degenerative joint disease. The Durkan's test is not used to evaluate a client for osteoarthritis. 3. The Durkan's test or carpal compression test has been found to be a sensitive and specific indicator in diagnosing carpal tunnel syndrome. 4. Epicondylitis is an inflammatory condition of the elbow. The Durkan's test is not used to evaluate a client with epicondylitis. Page Ref: 564 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct cNoUm ehGeTnBs.C ivOeMand focused physical, behavioral, Rp SIrN psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.4. Differentiate normal and abnormal variations of the musculoskeletal system observed during physical assessment.
29) The nurse is evaluating a client's ability to bend the elbow by bringing the forearm forward and touching the fingers to the shoulder. Which degree of flexion should the nurse anticipate? 1. 90°. 2. 160°. 3. 180°. 4. 200°. Answer: 2 Explanation: 1. The elbow should supinate and pronate to 90°. 2. The expected degree of flexion of the elbow is 160°. 3. The expected degree of flexion of the elbow is 160°. 4. The expected degree of flexion of the elbow is 160°. Page Ref: 559 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessmenNt UoRf SthINeGmTuBs.CcuOlM oskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
30) A client asks the nurse what a shoulder dislocation is. Which response should the nurse provide the client? 1. "Your tendons and muscles have been damaged." 2. "You have a muscle tear at the shoulder." 3. "Your shoulder bone has come apart from the shoulder joint." 4. "Your shoulder is fractured and separated from the joint." Answer: 3 Explanation: 1. A dislocation is a displacement of the bone from its usual anatomical location in the joint. Damaged tendons and muscles are not a shoulder dislocation. 2. A dislocation is a displacement of the bone from its usual anatomical location in the joint. A muscle tear is not the same thing as a dislocation. 3. A dislocation is a displacement of the bone from its usual anatomical location in the joint. 4. A dislocation is displacement of the bone from its usual anatomical location. This condition does not include a fracture. Page Ref: 579 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
31) The nurse is discharging a client with osteoarthritis. Which information should the nurse include in this client's discharge teaching? Select all that apply. 1. Obesity increases the risks of bone, muscle, and joint disorders. 2. Musculoskeletal health is influenced by the diet. 3. Exercise is important in the prevention of osteoarthritis. 4. Smoking and alcohol contribute to the development of osteoarthritis. 5. As the condition progresses, the hands may develop contractures that resemble swan necks. Answer: 1, 2, 3 Explanation: 1. Obesity places an increase in stress on the bones and joints. Obesity is viewed as a risk factor for the development of osteoarthritis. 2. Dietary intake has an impact on musculoskeletal health. Vitamin D and calcium are associated with bone health. Protein intake is associated with healthy muscles. 3. Exercise increases muscle strength and flexibility. 4. Smoking and alcohol are risk factors for the development of osteoporosis not osteoarthritis. 5. Swan-neck contractures are a deformity noted in the hand of an individual diagnosed with rheumatoid arthritis. Rheumatoid arthritis is a systemic disorder of autoimmune origin. Page Ref: 550 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.6: Identify abnormal findings in the physical assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
32) The nurse is assessing a pregnant client. Which finding should the nurse anticipate when assessing the spine? 1. Kyphosis. 2. Scoliosis. 3. Lordosis. 4. Flattened lumbar curve. Answer: 3 Explanation: 1. Kyphosis is an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. 2. Scoliosis is a lateral curvature of the spine. 3. Lordosis is an exaggerated lumbar curve that compensates for the protuberance of the abdomen associated with pregnancy. 4. A flattened lumbar curve is a reduced lumbar concavity that frequently occurs when spasms affect the lumbar muscles. Page Ref: 573, 579 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system. MNL Learning Outcome: 23.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the musculoskeletal system.
33) The nurse is preparing to interview a client with osteoporosis. Which question related to symptoms should the nurse include? 1. "Do you have difficulty breathing?" 2. "Have you had any recent weight gain or loss?" 3. "Are you currently taking any medications?" 4. "Do you feel you get adequate sleep at night?" Answer: 1 Explanation: 1. Difficulty breathing is a symptom that may be associated with osteoporosis. 2. Asking a client about a recent weight gain or loss is a question related to a client's internal environment. 3. Asking a client about current medications is a question related to a client's internal environment. 4. Asking a client if they get adequate sleep is not a specific inquiry about a symptom. Page Ref: 549 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.3: Determine which questions about the musculoskeletal system to use for the focused interview. MNL Learning Outcome: 23.2. Plan questions about the musculoskeletal system for the focused interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 24 Neurologic System 1) The nurse is reviewing the cranial nerves. Which cranial nerves are sensory nerves? Select all that apply. 1. Olfactory nerve (cranial nerve I). 2. Optic nerve (cranial nerve II). 3. Trochlear nerve (cranial nerve IV). 4. Trigeminal nerve (cranial nerve V). 5. Facial nerve (cranial nerve VII). Answer: 1, 2 Explanation: 1. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The optic nerve is a sensory nerve responsible for vision. 2. The optic nerve is a sensory nerve responsible for vision. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. The olfactory nerve is a sensory nerve and is responsible for the sense of smell. 3. The trochlear nerve is a motor nerve responsible for eye movement. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. 4. The trigeminal nerve is a mixed nerve responsible for sensory impulses from the lower eyelid, nasal cavity, and palate. Motor actions of the trigeminal nerve involve teeth clenching and movement of the mandible. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. 5. The facial nerve is a mixed nerve responsible for taste, facial movements, and the production of tears and salivary stimulation. The cranial nerves may be classified by function. The nerves may be sensory, motor, or mixed. Sensory nerves are responsible for receiving sensory information. Motor nerves allow the body to perform an action. Mixed nerves are able to receive sensory information and perform physical activities. Page Ref: 589, 590 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24.1: Describe the anatomy and physiology of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. 2) The nurse is caring for a client having problems with emotional appropriateness as a result of a brain injury. Based on this data, which area of the brain has been damaged? 1. Frontal lobe. 2. Parietal. 3. Occipital. 4. Temporal. Answer: 1 Explanation: 1. The frontal lobe of the cerebrum is responsible for the control of emotions. 2. The frontal lobe of the cerebrum is responsible for the control of emotions. 3. The frontal lobe of the cerebrum is responsible for the control of emotions. 4. The frontal lobe of the cerebrum is responsible for the control of emotions. Page Ref: 587 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
3) The nurse is caring for a client with a traumatic brain injury (TBI). The client begins to experience bradycardia. Which area of the brain is likely responsible for the changes in heart rate? 1. Brain stem. 2. Occipital lobe. 3. Parietal lobe. 4. Temporal lobe. Answer: 1 Explanation: 1. The brain stem is responsible for control of the vital signs. 2. The brain stem is responsible for control of the vital signs. 3. The brain stem is responsible for control of the vital signs. 4. The brain stem is responsible for control of the vital signs. Page Ref: 747 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessmenNt UoRf SthINeGnTeBu.rCoOloMgic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
4) The nurse is assessing a client's muscle tremors associated with Parkinson's disease. Which clinical finding does the nurse anticipate? 1. Fasciculations. 2. Chorea. 3. Rhythmic shaking. 4. Athetoid movements. Answer: 3 Explanation: 1. Fasciculations are muscle twitches. 2. Chores refer to controllable jerking movements as are associated with Huntington's disease. 3. Rhythmic shaking of the hands is a manifestation associated with Parkinson's disease. 4. Athetoid movements are repetitive and slow and are seen with cerebral palsy. Page Ref: 625 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
5) The nurse is performing a neurological assessment on a client experiencing anosmia. Which cranial nerve should the nurse assess? 1. Trochlear (cranial nerve IV). 2. Trigeminal (cranial nerve V). 3. Olfactory (cranial nerve I). 4. Oculomotor (cranial nerve III). Answer: 3 Explanation: 1. The trochlear nerve (cranial nerve IV) is related to vision. Dysfunction of the trochlear nerve may include diplopia or strabismus. 2. The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from scalp, upper eyelid, nose, cornea, and lacrimal gland. Dysfunction of the trigeminal nerve may be associated with a loss of facial sensation. 3. Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (cranial nerve I). 4. The oculomotor nerve (cranial nerve III) is associated with vision. Page Ref: 599 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
6) The nurse is unable to elicit a patellar reflex on a client that is alert and oriented. Which action by the nurse is the most appropriate? 1. Document the findings as normal. 2. Notify the healthcare provider immediately. 3. Look at the medication records for central nervous system depressants. 4. Retest the reflex after having the client use distraction during the exam. Answer: 4 Explanation: 1. Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The absence of the patellar reflex is not normal. Documentation of the reflexes as normal is not appropriate, as a score of 0 is not normal. 2. There is no immediate need to notify the healthcare provider. 3. Medications should eventually be reviewed to determine any impact on the nervous system but this action does not precede attempting to reassess the reflexes. 4. Reflexes are stimulus-response activities of the body. They are fast, predictable, unlearned, innate, and involuntary reactions to stimuli. The individual is aware of the results of the reflex activity and not the activity itself. The reflex activity may be simple and take place at the level of the spinal cord, with interpretation at the cerebral level. Reflex activity is recorded using a 4point scale. Normal reflexes are listed as a 2+. The absence of the patellar reflex is not normal. Before concluding that a reflex is absent or diminished, the test should be repeated. The client should be encouraged to relax. Page Ref: 616 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
7) The nurse is interviewing a client with suspected Lyme disease. Which question is the nurse's priority question? 1. "When was your last seizure?" 2. "Have you been hiking or camping lately?" 3. "What has your temperature been running?" 4. "Do you have an appetite?" Answer: 2 Explanation: 1. There is not any indication that the client has long-term Lyme disease or neurological changes resulting in seizures. 2. Lyme disease is an infection caused by a spirochete transmitted by a bite from an infected tick that lives on deer. This tick exposure may have come from hiking or camping. 3. During the initial period after becoming infected, the client may experience flu-like illnesses but there is no indication that this is the primary concern for the client. 4. An infectious process may result in changes in the client's appetite or dietary habits but this is not the priority area of concern for investigation. Page Ref: 624 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
8) The nurse is preparing to conduct a focused interview on a client who is experiencing back pain. Which questions should the nurse include in the focused interview? Select all that apply. 1. "How long have you been experiencing this pain?" 2. "What activities seem to increase your pain?" 3. "Do you regularly engage in physical activity?" 4. "What things do you do to relieve your pain?" 5. "Are you receiving worker's compensation?" Answer: 1, 2, 4 Explanation: 1. When investigating pain, the nurse will need to assess characteristics of the pain, including duration. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. 2. Investigation of the pain will include information about factors associated with both activities that increase pain and those that relieve it. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. 3. Information regarding routine physical activity is not information that needs to be immediately assessed. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. 4. Activities that will relieve the pain should be included in the focused assessment. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. 5. The nurse does not need to know if the client is receiving worker's compensation in order to complete the assessment process. The focused interview is used to guide the physical assessment. The information obtained is considered in relation to norms and expectations for the system being reviewed. Page Ref: 595 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Determine which questions about the neurologic system to use forthe focused interview. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
9) The nurse is performing the Romberg's test and asks the client to stand with their feet together and eyes closed. Which is an expected finding during this assessment? 1. Swaying from side to side. 2. Exhibiting minimal swaying. 3. Feeling moderately dizzy. 4. Having complete loss of balance. Answer: 2 Explanation: 1. A minimal amount of swaying is normal. Swaying from side to side is not a normal finding. The Romberg's test is used to test coordination and equilibrium. 2. The Romberg's test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is normal. 3. The onset of dizziness is not a normal finding. The Romberg's test is used to test coordination and equilibrium. During the test, the client is asked to stand with feet together and arms at the sides. A minimal amount of swaying is normal. 4. A complete loss of balance is not a normal finding. The Romberg's test is used to test coordination and equilibrium. A minimal amount of swaying is normal. Page Ref: 608, 609 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
10) The nurse is assessing a client that experienced a head injury using the Glasgow Coma Scale. Which findings reflect the motor response portion of the scale? Select all that apply. 1. No response with eyes to commands. 2. Abnormal flexion to pain. 3. Pupil response sluggish. 4. Abnormal extension to pain. 5. Pupils fixed and dilated. Answer: 2, 4 Explanation: 1. No response with eyes to commands. This finding is for the eye opening portion of the scale. The Glasgow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. 2. No verbal response. This finding is for the motor response portion of the scale. The Glasgow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. 3. Pupil response sluggish. This finding is for the eye opening portion of the scale. The Glasgow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. 4. No motor movement. This finding is for the motor response portion of the scale. The Glasgow Coma Scale assesses level of coNnUscRioSIuNsGnTesBs.CoOnMa continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. 5. Pupils fixed and dilated. This finding is for the eye opening portion of the scale. The Glasgow Coma Scale assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye opening, and motor response. The client may score between 3 and 15 points with the tool. Page Ref: 621 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
11) Which cranial nerve is the nurse testing using the technique to touch the client's face with a wisp of cotton while their eyes are closed? 1. Trigeminal nerve (cranial nerve V). 2. Abducens nerve (cranial nerve VI). 3. Facial nerve (cranial nerve VII). 4. Optic nerve (cranial nerve II). Answer: 1 Explanation: 1. The cranial nerve V (trigeminal nerve) is responsible for facial sensations and may be assessed by a wisp of cotton on the face. 2. The cranial nerve VI (abducens nerve) is related to muscle movement of the eye. 3. The cranial nerve VII (facial nerve) is related to facial movements and the sensation of taste. 4. The cranial nerve II (optic nerve) is related to vision. Page Ref: 601 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
12) The nurse has tested a client's sense of smell. Which cranial nerve should the nurse document the findings? 1. I. 2. II. 3. III. 4. IV. Answer: 1 Explanation: 1. Cranial nerve I is the sensory nerve for smell. 2. Cranial nerve II is the optic nerve. Assessment of cranial nerve II (optic nerve) would involveassessment of vision. 3. Cranial nerve III (oculomotor nerve) involves the assessment of vision-related parameters. 4. Cranial nerve IV (trochlear nerve) involves the assessment of vision-related parameters. Page Ref: 600 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
13) The nurse asks the client to stick their tongue out and move it back and forth. Which cranial nerve is the nurse assessing? 1. V. 2. VII. 3. X. 4. XII. Answer: 4 Explanation: 1. The trigeminal nerve (cranial nerve V) is responsible for sensory impulses from the tongue, lower teeth, skin of the teeth, and lower lip. 2. The facial nerve (cranial nerve VII) is responsible for the sense of taste. 3. The vagus nerve (cranial nerve X) innervates the muscles of the throat and mouth for swallowing and talking. 4. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue for swallowing and movement of food during eating, chewing, and speech. Page Ref: 607 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
14) Which instruction for the Romberg's test should the nurse provide the client? 1. "Touch your finger to your nose, alternating hands." 2. "Walk across the room by placing one foot in front of the other, heel to toes." 3. "Walk on your toes, then on your heels, and then on your toes again." 4. "Stand with your feet together, arms at sides, and eyes closed." Answer: 4 Explanation: 1. Touching the finger to the nose with alternating hands is referred to as the finger-to-nose test and is used to assess coordination and equilibrium but is not the same as the Romberg's test. 2. Walking across the room in this manner describes tandem walking. This technique is used to observe gait. 3. Walking in this manner enables the examiner to assess posture. The examiner should note the client's stance and the degree of stiffness or relaxation. 4. The Romberg's test is used to assess coordination and equilibrium. During the test, the client is asked to close their eyes. The degree of swaying demonstrated is evaluated. Page Ref: 609 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
15) The nurse is using stereognosis to assess a client. Which instruction would the nurse provide for the client? 1. "Tell me if you feel one or two objects touching you with your eyes closed." 2. "Identify the object in your hand with your eyes closed." 3. "Identify the number being traced in your hand with your eyes closed." 4. "Open and close your hand each time I tell you to." Answer: 2 Explanation: 1. Asking the client to identify the presence of objects touching them is not an example of stereognosis. 2. Stereognosis is the ability to identify an object without seeing it. It is illustrated by asking the client to identify objects placed in the hands with the eyes closed. 3. Asking the client to identify the presence of objects touching them is not an example of stereognosis. Graphesthesia is the ability to perceive writing on the skin. 4. Asking the client to open and close the hand may be used to assess the ability to follow commands to assess hand strength. This is not an example of stereognosis. Page Ref: 614 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
16) The nurse uses a reflex hammer to gently strike the forearm about two inches above the wrist. Which reflex is the nurse assessing? 1. Brachioradialis. 2. Biceps. 3. Triceps. 4. Achilles .Answer: 1 Explanation: 1. The brachioradialis reflex is initiated by striking the forearm just above the wrist. 2. The biceps reflex is initiated by striking the biceps tendon, while the triceps reflex is initiated by striking just above the olecranon process. 3. The triceps reflex is initiated by striking just above the olecranon process. 4. The Achilles reflex is initiated by dorsiflexion of the foot and striking the Achilles tendon.Page Ref: 618 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
17) The nurse reviewing records notes that a client has a positive Brudzinski's sign. Which clinical manifestation should the nurse recognize validates the assessment finding? 1. Seizure activity. 2. Neck pain and stiffness. 3. Flexion of the legs and thighs. 4. Neck extension. Answer: 3 Explanation: 1. Seizure activity may be seen in meningitis but seizure activity does not constitute a positive Brudzinski's sign. 2. Neck pain and stiffness may be noted with meningitis but this is referred to as nuchal rigidity. 3. Brudzinski's sign is assessed in clients suspected of having meningitis. To assess for this sign, the client is placed in a supine position and assisted to flex the neck. In a positive test, the legsand thighs will also flex. 4. Neck extension is not associated with Brudzinski's sign. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
18) The nurse is assessing cranial nerve XI (spinal accessory). Which statement should the nurse include in the instructions to the client to conduct the assessment? 1. "Shrug your shoulders and turn your head against my hand." 2. "Stick out your tongue and move it from side to side." 3. "Taste these foods and decide which is sweet and which is sour." 4. "Smell these items and identify what they are." Answer: 1 Explanation: 1. The spinal accessory nerve (cranial nerve XI) controls shoulder and neck movements. The examiner planning to test this nerve should ask the client to shrug the shoulders and turn the head. 2. The hypoglossal nerve (cranial nerve XII) is responsible for the movement of the tongue. 3. The facial nerve (cranial nerve VII) is responsible for the sense of taste. 4. Smell is controlled by the olfactory nerve (cranial nerve I). Page Ref: 606 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
19) The nurse is preparing to assess a client's ability to feel vibration, as well as sharp and dull sensation. Which equipment should the nurse use? Select all that apply. 1. Tuning fork. 2. Paper clip. 3. Safety pin. 4. Cotton ball. 5. Tongue blade. Answer: 1, 3 Explanation: 1. Vibration is tested by striking a tuning fork and placing it on bony parts of the client's body. 2. To test for sharp and dull sensation, areas of the client's skin are touched with the sharp and blunt ends of a safety pin, not a paper clip. The client then verbalizes if the sensation is dull or sharp. 3. To test for sharp and dull sensation, areas of the client's skin are touched with the sharp and blunt ends of a safety pin. The client then verbalizes if the sensation is dull or sharp. 4. The trigeminal nerve (cranial nerve V) may be evaluated by using a wisp of cotton to touch the face. 5. The gag reflex may be evaluated by using a tongue blade. Page Ref: 612, 613 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5.NEUxpRlSaIiNnGthTB e .rCoOleMof evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4: Outline the techniques for assessment of the neurologic system. MNL Learning Outcome: 24.3: Utilize the appropriate techniques and tools for physical assessment of the neurologic system.
20) The nurse has assessed a client and notes diminished reflexes. How would the nurse document this finding in the medical record? 1. 4+/0 - 4+. 2. 3+/0 - 4+. 3. 2+/0 - 4+. 4. 1+/0 - 4+. Answer: 4 Explanation: 1. 4+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; and 4+ = hyperactive. 2. 3+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; and 4+ = hyperactive. 3. 2+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; and 4+ = hyperactive. 4. 1+ - Evaluation of reflex responses uses a scale from 0 to 4+. 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; and 4+ = hyperactive. Page Ref: 616 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
21) The nurse is interviewing a client and notes that the left eyelid is drooping. Which term will the nurse use when documenting this finding in the medical record? 1. Ptosis. 2. Nystagmus. 3. Strabismus. 4. Myopia. Answer: 1 Explanation: 1. Ptosis, or a dropped lid, is usually related to weakness of the muscles. 2. Nystagmus is an involuntary movement of the eyeball. 3. Strabismus causes deviation of one or both eyes and is due to lack of muscular coordination. 4. Myopia is a visual disturbance in which the individual is unable to see objects that are at a distance. Page Ref: 600 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
22) A client is unable to perform a simple math calculation during a neurological examination. Which action should the nurse take? 1. Administer a different set of math problems. 2. Continue assessing the other cognitive domains. 3. Ask the client what grade they completed in school. 4. Verbally assess the client's ability to calculate a problem. Answer: 2 Explanation: 1. It is not necessary to administer another set of math problems. If the remaining assessment is unremarkable, a poor response to calculations should not be considered an abnormal finding. 2. The nurse should continue to assess the client. If the remaining assessment is unremarkable, a poor response to calculations should not be considered an abnormal finding. 3. Asking a client what grade they completed in school after they are unable to calculate a math problem is inappropriate. The information should be obtained in the initial interview prior to testing the client. 4. It is not necessary to administer another set of math problems. Attempting to verbally assess the client's ability to calculate a math problem may increase anxiety and inhibit open communication. If the remaining assessment is unremarkable, a poor response to calculations should not be considered an abnormal finding. Page Ref: 598 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
23) The nurse notes that a client has difficulty with ambulation due to an unsteady gait. Which term will the nurse use to document this finding in the medical record? 1. Flaccidity. 2. Paralysis. 3. Hemiparesis. 4. Ataxia. Answer: 4 Explanation: 1. Flaccidity refers to muscle tone. The flaccid body part is not toned but is limp. 2. Paralysis refers to the inability to move parts of the body. 3. Hemiparesis refers to a weakness on one side of the body. 4. Ataxia refers to the loss of balance or coordination. Page Ref: 622 Cognitive Level: Applying Client Need & Sub: Physiological Mobility; Mobility/Immobility Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
24) The nurse notes that a client has decreased sensation on the left side of their body. Which term should the nurse use in the documentation of the finding? 1. Anesthesia. 2. Analgesia. 3. Hypoalgesia. 4. Hypoesthesia. Answer: 4 Explanation: 1. Anesthesia is the inability to perceive the sense of touch. 2. Analgesia is the absence of painful stimuli. 3. Hypoalgesia is a decreased pain sensation. 4. Hypoesthesia is a decreased, but not absent, sensation. Page Ref: 612 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
25) The client suspected of having meningitis verbalizes pain and stiffness in the neck when asked to flex their chin down toward their chest. Which terminology should the nurse use to document the finding? 1. Muscle spasms. 2. Neck strain. 3. Nuchal rigidity. 4. Brudzinski's sign. Answer: 3 Explanation: 1. The presence of muscle spasms are not associated with meningitis and are not elicited in this manner. 2. Neck strain is not associated with meningitis. The assessment of neck strain would not involve having the client flex the chin toward the chest. 3. Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. 4. Brudzinski's sign is assessed in clients suspected of having meningitis. The sign is present when neck flexion causes flexion of the legs and thighs. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
26) While interviewing a client, the nurse notes the client's eyes moving involuntarily. Which terminology should the nurse use to document the finding? 1. Nystagmus. 2. Presbyopia. 3. Anosmia. 4. Polyneuritis. Answer: 1 Explanation: 1. Nystagmus is an abnormal, involuntary eye movement. 2. Presbyopia is an eye disorder in which the individual loses the ability to see objects that are near. 3. Anosmia refers to the absence of the sense of smell. 4. Polyneuritis refers to nerve inflammation. Page Ref: 600 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Physiological Adaptation Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
27) The nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. Which term is appropriate for the nurse to use when documenting this finding in the medical record? 1. Hyperreflexia. 2. Babinski response. 3. Brudzinski's sign. 4. Nuchal rigidity. Answer: 2 Explanation: 1. Hyperreflexia refers to a reflex that is abnormally strong. 2. The Babinski response is fanning of the toes with the great toe pointing downward when the sole of the foot is stimulated. This response is considered abnormal in adults. 3. Brudzinski's sign refers to flexion of the legs and thighs when the neck is flexed and is an assessment used to confirm meningitis. 4. Nuchal rigidity refers to stiffness of the neck and is most often seen in meningitis. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Physiological Adaptation Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmeNnUtRaSllIyNaGnTdBc.CuOltM urally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.5: Generate the appropriate documentation to describe the assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
28) The nurse is preparing a neurological health seminar for the staff on the unit. Which statement would the nurse include in the teaching plan? 1. Older adults lose the ability to taste and smell. 2. Alcohol or drug use increases the risk for neurological disorders. 3. Head injuries are more common in the young adult population. 4. Epilepsy generally occurs in children under age 15. Answer: 2 Explanation: 1. Taste and smell decrease with aging, but the older adult does not completely lose their ability to taste and smell. 2. Alcohol or drug use increases the risk for neurologic disorders. 3. Head injuries are more common in children than adults. 4. Epilepsy occurs across the age span. Page Ref: 595 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | NursinNgU /IRnSteINgra e.dCC GTtB Oo Mncepts: Nursing Process: Planning Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
29) The nurse is preparing to assess the oculomotor (III), trochlear (IV), and abducens cranial nerves (IV) of a client. Which tests should the nurse conduct? Select all that apply. 1. Visual acuity. 2. Peripheral vision. 3. Six cardinal points of gaze. 4. Convergence and accommodation. 5. Direct and consensual pupillary reaction to light. Answer: 3, 4, 5 Explanation: 1. Visual acuity is a test for cranial nerve II, the optic nerve. 2. Peripheral vision is a test for cranial nerve II, the optic nerve. 3. The six cardinal points of gaze is a test for cranial nerves III, IV, and VI. 4. Convergence and accommodation is a test for cranial nerves III, IV, and VI. 5. Direct and consensual pupillary reaction to light is a test for cranial nerve III. Page Ref: 600 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. |NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.4: Outline the tecNhUnRiqSIuNeGs TfoBr.CaOssessment of the M neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
30) The nurse is assessing the motor function of a client. Which finding should the nurse anticipate when the client performs the heel to shin test? 1. The client should be able to balance on one leg. 2. The client should be able to move their heel up their leg. 3. The client should be able to move their heel down the leg. 4. The client should be able to lift their heel to their lower leg. Answer: 3 Explanation: 1. The patient is in a supine position and asked to put their foot below their knee. The patient is then asked to slide their heel along the shin bone to the ankle. A client should be able to smoothly move the heel in a straight line so it does not fall off of the lower leg. 2. The patient is in a supine position and asked to put their foot below their knee. The patient is then asked to slide their heel along the shin bone to the ankle. A client should be able to smoothly move the heel in a straight line so it does not fall off of the lower leg. 3. The patient is in a supine position and asked to put their foot below their knee. The patient is then asked to slide their heel along the shin bone to the ankle. A client should be able to smoothly move the heel in a straight line so it does not fall off of the lower leg. 4. The patient is in a supine position and asked to put their foot below their knee. The patient is then asked to slide their heel along the shin bone to the ankle. A client should be able to smoothly move the heel in a straight line so it does not fall off of the lower leg. Page Ref: 611 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
31) The nurse is assessing a client's triceps reflex. Which nerves should the nurse understand are being assessed? 1. C5 and C6. 2. C6 and C7. 3. L1 and L2. 4. L3 and L4. Answer: 2 Explanation: 1. The biceps reflex is associated with spinal nerve roots C4 and C5. 2. The triceps reflex is associated with spinal nerve roots C6 and C7. 3. Spinal nerve roots L2, L3, and L4 are associated with the patellar reflex. 4. Spinal nerve roots L2, L3, and L4 are associated with the patellar reflex. Page Ref: 617 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.1: Describe the anatomy and physiology of the neurologic system. MNL Learning Outcome: 24.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system.
32) The nurse is observing a client's ambulation abilities and notes a scissors gait. Based on this data, which does the nurse suspect? 1. Parkinson's disease. 2. Multiple sclerosis. 3. Myasthenia gravis. 4. Muscular dystrophy. Answer: 2 Explanation: 1. The client with Parkinson's disease displays stooped posture with a shuffling gait. This is known as a festination gait. 2. A scissors gait is characterized by spastic lower limb movement with stiffness and jerkiness. The knees come together, the legs come in front of each other, and the legs are abducted as short, slow steps are taken. This gait is associated with multiple sclerosis. 3. The client with myasthenia gravis has muscle weakness, and facial abnormalities such as ptosis are consistent with the condition. 4. The client with muscular dystrophy has muscle weakness and may present with a waddling gait or walk on the toes to promote balance. Page Ref: 622 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
33) The nurse is monitoring a client with a traumatic brain injury. Which statements made by the client are associated with the injury? Select all that apply. 1. "I have a headache." 2. "My joints feel very stiff and achy." 3. "I hear ringing in my ears." 4. "The light is bothering my eyes." 5. "My muscles feel very weak." Answer: 1, 3 Explanation: 1. A headache is a subjective finding of a traumatic brain injury. 2. Stiff and achy joints are not associated with a traumatic brain injury. 3. Sensory problems such as ringing in the ears are associated with a traumatic brain injury. 4. Photophobia is not associated with a traumatic brain injury. 5. Muscle weakness is not associated with traumatic brain injury. Page Ref: 623 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6: Identify abnormal findings in the physical assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
34) The nurse is caring for a client with Bell's palsy. In which cranial nerve should the nurse anticipate an abnormal finding? 1. Cranial nerve X. 2. Cranial nerve IX. 3. Cranial nerve VII. 4. Cranial nerve VIII. Answer: 3 Explanation: 1. Cranial nerve X, the vagus nerve, innervates muscles of the throat and mouth for swallowing and talking; other branches are responsible for baroreceptor and chemoreceptor activity. 2. Cranial nerve IX, the glossopharyngeal nerve, produces the gag and swallowing reflexes and taste (posterior third of the tongue). 3. Bell's palsy is a form of temporary facial paralysis. Cranial nerve VII is the facial nerve. The activity of the facial nerve includes the taste of the anterior two thirds of the tongue; facial movements such as smiling, closing of eyes, and frowning; and production of tears and salivary stimulation. 4. Cranial nerve VIII is the vestibulocochlear nerve that is divided into vestibular and cochlear branches. The vestibular branch is associated with a sense of balance or equilibrium and the cochlear branch is associated with a sense of hearing. Page Ref: 590 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the neurologic system. MNL Learning Outcome: 24.4: Differentiate normal and abnormal variations of the neurologic system observed during physical assessment.
35) The nurse is performing a focused neurological assessment on a client. Which question should the nurse include when assessing the client's behaviors? 1. "Do you get headaches?" 2. "Do you need to write things down to remember them?" 3. "Can you tell me what brought you here today?" 4. "Are you currently taking any medications?" Answer: 2 Explanation: 1. Inquiring about headaches is a focused assessment related to pain. 2. Inquiring about the need to write things down to remember them is a question to assess behavior. 3. Inquiring as to why the client has presented for care is a general focused question. 4. Inquiring about medications is an assessment of the client's internal environment. Page Ref: 595 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3: Determine which questions about the neurologic system to use for the focused interview. MNL Learning Outcome: 24.2. Plan questions about the neurologic system for the focused interview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 25 The Pregnant Woman 1) A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. Which information should the nurse include when addressing the client's concern? Select all that apply. 1. The stretch marks will fade but not disappear. 2. Cream will help the skin stay supple. 3. Cocoa butter lotions and creams will clear the marks completely. 4. The marks will lighten to a silvery tone after pregnancy. 5. Wearing supportive undergarments will help support the skin and reduce the appearance of the marks. Answer: 1, 2, 4 Explanation: 1. Striae gravidarum are known as stretch marks. They commonly occur during pregnancy and result from the stretching of the skin to accommodate fetal growth. These marks will not disappear but will fade and lighten after the pregnancy ends. 2. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. 3. These marks will not disappear but will fade and lighten after the pregnancy ends. There is no need for a prescription cream. Over-the-counter preparations can be used to keep the skin soft and supple. 4. These marks will not disappear but will fade and lighten after the pregnancy ends. 5. Wearing supportive undergarments will help promote comfort to the growing abdomen but will not prevent the development of stretch marks. Page Ref: 634 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
2) A client who is 38 weeks pregnant reports increased urinary frequency. Based on this data, which response by the nurse is indicated? 1. "Your reports are consistent with a urinary tract infection." 2. "I will need to check your blood sugar as excessive urination is associated with gestational diabetes." 3. "Reducing your fluid intake will be helpful to manage this problem." 4. "This is normal occurrence in the later stages of pregnancy." Answer: 4 Explanation: 1. During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications that the client has a urinary tract infection. 2. During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. In the absence of other information, this is the most correct response. There are no indications that the client has an elevation in blood glucose levels. 3. The health of the pregnancy requires adequate fluid intake. Reduction of fluid intake is problematic as it will reduce fluids available to the fetus. In addition, the condition is not being caused by an increased oral fluid intake. 4. During the last few weeks prior to delivery, the client will experience lightening. The pressure caused by this event results in frequent urination. It is a normal occurrence. Page Ref: 636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
3) While reviewing a pregnant client's medical record, the nurse notes that the cervix was soft in texture and nontender during the pelvic examination. Which is the appropriate terminology for the clinical finding? 1. Piskacek's sign. 2. Goodell sign. 3. Chadwick sign. 4. Hegar's sign. Answer: 2 Explanation: 1. Piskacek's sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. 2. During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell sign. 3. Chadwick sign is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. 4. Hegar's sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix. Page Ref: 631 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials CompeNtUenc 1..CInOtMegrate theories and concepts RSiIeNsG: TI.B from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
4) A client's fundal height is slightly above the symphysis pubis. Based on this data, how many weeks gestation is the client? 1. 10-12 weeks. 2. 16 weeks. 3. 20-22 weeks. 4. 38 weeks. Answer: 1 Explanation: 1. At 10 to 12 weeks, the fundus is slightly above the symphysis pubis. 2. At 16 weeks, the fundus is halfway between the symphysis pubis and the umbilicus. 3. Between 20 and 22 weeks, the fundus reaches the umbilicus. 4. At 38 weeks, the fundus is above the umbilicus. Page Ref: 630, 632 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.4 DifferentiN atUeRnSoINrm al and abnormal variations of the pregnant GTB .COM woman and fetus observed during physical assessment. 5) The nurse is preparing to measure the abdomen of a client who is 24 weeks gestation. Which is the anticipated height of the fundus? 1. 22 cm. 2. 24 cm. 3. 26 cm. 4. 28 cm. Answer: 2 Explanation: 1. The fundal height at 24 weeks gestation should be at 24 cm. 2. The fundal height at 24 weeks gestation should be at 24 cm. 3. The fundal height at 24 weeks gestation should be at 24 cm. 4. The fundal height at 24 weeks gestation should be at 24 cm. Page Ref: 658 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment. 6) The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy? 1. Objective. 2. Probable. 3. Presumptive. 4. Positive. Answer: 3 Explanation: 1. Objective findings are those things that are measurable, as opposed to subjective findings that are conditions reported by an individual that cannot directly be validated. 2. Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskacek's sign, Hegar's sign, Goodell sign, Chadwick sign, and Braxton Hicks contractions. 3. Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue. 4. Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualizN atUioRnSIoNfGtThBe.C feOtM us with ultrasound or radiology. Page Ref: 640 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
7) The nurse examining a client notes a softening of the cervix. Which terminology should be documented to reflect the finding? 1. Goodell sign. 2. Hegar's sign. 3. Chadwick sign. 4. Ladin's sign. Answer: 1 Explanation: 1. Goodell sign refers to the softening of the cervix. 2. Hegar's sign refers to the softening of the lower uterine segment. 3. Chadwick sign refers to the change in coloration of the mucous membranes of the female genitalia during pregnancy. 4. Ladin's sign refers to the softening of the mid uterus during pregnancy. Page Ref: 631 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
8) The nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odorless discharge from the vagina. Based on this data, which action by the nurse is the most appropriate? 1. Ask the client about vaginal discomfort. 2. Inquire about recent sexual intercourse. 3. Obtain a culture of the discharge. 4. Document the findings as normal. Answer: 4 Explanation: 1. During pregnancy, it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. 2. During pregnancy, it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. 3. During pregnancy, it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of leukorrhea is normal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. 4. During pregnancy, it is normal for vaginal secretions to be increased, white, and odorless, also called leukorrhea. The presence of lNeU ukRoSrIN rhGeTaBi.sCnOoMrmal and does not require a culture or additional subjective information. It is appropriate to document the findings of the nursing assessment. Page Ref: 631 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
9) The nurse is assessing a postpartum client and notes that the peri-pad has whitish-yellow discharge. Which term will the nurse use when documenting this finding in the medical record? 1. Postpartum bleeding. 2. Lochia rubra. 3. Lochia serosa. 4. Lochia alba. Answer: 4 Explanation: 1. To refer to the discharge simply as postpartum bleeding does not provide an adequate description. 2. The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. The initial lochia rubra contains blood from the placental site, amniotic membrane, cells from the decidua basalis, vernix, lanugo from the infant's skin, and meconium. It is dark red and has a fleshy odor and lasts anywhere from 2 days to 18 days. 3. The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called lochia. Once the lochia rubra has subsided, the discharge becomes pinkish and is called lochia serosa. It is composed of blood, placental site exudates, erythrocytes, leukocytes, cervical mucus, microorganisms, and decidua and lasts approximately a week. 4. The uterine lining, or endometrium, returns to the nonpregnant state through the process of a postpartum vaginal discharge called loNchUiRaS. IIN nGthTeB.fCinOaMl stages, the discharge becomes whitishyellow, lochia alba, and is composed of leukocytes, mucus, bacteria, epithelial cells, and decidua. Page Ref: 639 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.5: Generate the appropriate documentation to describe the assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
10) The nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. Which action by the nurse is the most appropriate? 1. Ask the client if she is preparing for breastfeeding. 2. Notify the healthcare provider. 3. Document the findings as normal. 4. Obtain a culture of the discharge immediately. Answer: 3 Explanation: 1. Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. 2. Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. 3. Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by mature milk during the early days of lactation after birth. This substance is produced regardless of whether the woman is planning to breastfeed, making this inquiry unnecessary. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. 4. Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester and is replaced by matNuUreRSmIN ilkGdTB ur.CinOgMthe early days of lactation after birth. This is a normal finding and does not require a culture, additional subjective information, or notification of the healthcare provider. Page Ref: 632 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
11) The nurse is assisting the healthcare provider during a vaginal examination. The healthcare provider notes that the cervix has a bluish-purple change in coloration. Based on this data, which will the nurse document in the medical record? 1. Goodell sign. 2. Leukorrhea. 3. Chadwick sign. 4. Mucous plug. Answer: 3 Explanation: 1. Hormonal changes in pregnancy cause a series of changes to the female genitalia. The vascularity of the cervix increases contributing to the softening of the cervix and is called Goodell sign. 2. Hormonal changes in pregnancy cause a series of changes to the female genitalia. Leukorrhea is a profuse, non-odorous, non-painful, vaginal discharge, which is a normal finding. 3. Hormonal changes in pregnancy cause a series of changes to the female genitalia. Chadwick sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. 4. The endocervical canal is closed by a plug of mucus. This mucus remains in place until the final days of the pregnancy. At that time, it is expelled, producing a discharge referred to as bloody show. Page Ref: 631 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
12) The nurse is discussing dietary recommendations with a client who has been experiencing a larger than recommended weight gain during her pregnancy. The client reports reducing the empty calories and red meat while significantly increasing intake of fish, poultry, fresh fruits, and vegetables. Based on this data, which response by the nurse is the most appropriate? 1. "It looks like you have things under control. Do you have any other questions?" 2. "Have you considered seeing a dietitian for nutritional counseling?" 3. "Tell me more about the meat and fish you are eating each day." 4. "I think we should discuss the risky dietary choices you are making with the healthcare provider." Answer: 3 Explanation: 1. Questions should be sought from the client; however, there are areas for potential problems such as the reduction in protein sources and intake of still-undetermined varieties of fish. 2. Nutritional counseling is within the scope of practice for the nurse and a dietary consult is still premature. 3. Some of the client's actions are positive changes. The reduction of empty calories is a good change. Red meat is a good source of protein and should not be entirely eliminated. Mercury levels can be problematic in some types of fish. The nurse will need to evaluate the types of fish being eaten. Swordfish, shark, king mackerel, and tilefish should be avoided. Intake of white tuna and game fish should also be restricted. 4. The client is making some positive changes and notification of the healthcare provider is premature. Page Ref: 649-650 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.3: Determine questions about the pregnant woman to use for the focused interview. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
13) A client at 33 weeks' gestation calls the healthcare provider's office and reports she was attempting to nap when she became dizzy and felt faint. Which assessment data is the priority in this situation? 1. The position the client was in during the nap period. 2. Dietary intake prior to the episode. 3. History of hyperemesis. 4. No additional data is needed as this is an isolated incident. Answer: 1 Explanation: 1. The client has most likely experienced an episode of supine hypotension. This is caused by compression on the aorta and the inferior vena cava by the pregnant uterus. This is a common occurrence when the client is in the supine position. 2. Dietary factors and the presence of hyperemesis are not implicated in this client's scenario. 3. Dietary factors and the presence of hyperemesis are not implicated in this client's scenario. 4. The nurse must investigate the complaints to ensure client safety. Page Ref: 633 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, usingNdUeRvSeIlNoG pm lly and culturally appropriate TBe.n CtOaM approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
14) The healthcare provider is using Leopold maneuvers to assess fetal positioning. Which maneuver is used to assess the fetal back? 1. First. 2. Second. 3. Third. 4. Fourth. Answer: 2 Explanation: 1. Leopold maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The first maneuver allows for the palpation of the contour of the uterus. 2. Leopold maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The second maneuver will help identify where the fetal back is. 3. Leopold maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The third maneuver determines which part of the fetus is presenting at the pelvis. 4. Leopold maneuvers utilize a specialized palpation of the abdomen in sequence to answer a series of questions to determine the position of the fetus in the abdomen and pelvis after 28 weeks gestation. The fourth Leopold's maneuver is used to determine the depth of the presenting part in the pelvis. Page Ref: 660 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
15) The nurse is preparing to assess the fetal heart tones for a client whose fetus is in the LOA position. Which maternal abdominal location should the nurse use to assess the fetal heart tones? 1. RUQ. 2. LUQ. 3. RLQ. 4. LLQ. Answer: 4 Explanation: 1. The maternal left lower quadrant is the best place to auscultate fetal heart tones for a fetus in a LOA (left occiput posterior) position. 2. The maternal left lower quadrant is the best place to auscultate fetal heart tones for a fetus in a LOA (left occiput posterior) position. 3. The maternal left lower quadrant is the best place to auscultate fetal heart tones for a fetus in a LOA (left occiput posterior) position. 4. The maternal left lower quadrant is the best place to auscultate fetal heart tones for a fetus in a LOA (left occiput posterior) position. Page Ref: 662 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
16) The nurse palpating a laboring client's contraction notes that it is mild. Which component of the contraction should the nurse associate the finding with? 1. Intensity. 2. Duration. 3. Frequency. 4. Length. Answer: 1 Explanation: 1. The intensity of the contraction refers to its strength. Assessing the intensity or strength of contractions is done by palpation and the intensity is described as mild, moderate, or strong. 2. The duration of contractions is measured from the beginning of the contraction until the end of the contraction. 3. The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction. 4. The duration, or length, of contractions is measured from the beginning of the contraction until the end of the contraction. Page Ref: 658 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N.GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
17) The nurse is caring for a pregnant client who desires to know the estimated date of birth (EDB) for the baby. The client reports that the last menstrual period (LMP) was May 10. Using Naegele's rule, which date will the nurse share with client? 1. February 17. 2. May 17. 3. May 24. 4. January 3. Answer: 1 Explanation: 1. Using Naegele's rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. 2. Using Naegele's rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. 3. Using Naegele's rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. 4. Using Naegele's rule to determine EDB, add 7 days to the date of the first day of the last menstrual period; subtract 3 months from the number of the month. Page Ref: 641 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I1N. GCToBn.dCuOcM t comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.4: Outline the techniques for assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
18) The nurse is interviewing a primigravida client who is 17 weeks pregnant. During the data collection, the client reports she has not felt the baby move yet. Which response by the nurse is the most appropriate? 1. "We will listen for the heartbeat today." 2. "You need an ultrasound." 3. "Fetal movement may not be felt until the 18th week." 4. "Do you have reason to believe your baby is not ok?" Answer: 3 Explanation: 1. While all prenatal care appointments at this gestational age and beyond will include an assessment of the fetal heartbeat, this option does not meet the client's need for education. 2. Ultrasounds may be performed to assess for fetal viability but there is no indication at this time the pregnancy is at risk. 3. Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks, possibly earlier in women who have given birth before. This mother is in need of factual information from the nurse. 4. Asking if the client is feeling uneasy about the health of the pregnancy does not meet the client's need for information. Page Ref: 629 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
19) The nurse is examining a client who is 37 weeks pregnant. Which assessment finding would require immediate intervention by the nurse? 1. Patellar reflex 4+/0 - 4+ bilaterally. 2. Heart rate 104. 3. Trace protein in the urine. 4. Weight gain of two pounds in 2 months. Answer: 1 Explanation: 1. Hyperreflexia may be indicative of preeclampsia and there is a need for the nurse to further evaluate this finding. Evaluation of reflexes should be done using the following scale: 0 = no response; 1+ = diminished; 2+ = normal; 3+ = brisk, above normal; and 4+ = hyperactive. 2. Heart rates in pregnant women are normally elevated as a result of the increased circulating volume and increases in metabolic rate. 3. Normal urine components do not include protein; however, the increased workload for the kidneys and the increased GFR may result in episodes of protein in the urine. The presence of protein in the urine warrants investigation but it is not an immediate need, or of the same level of importance of the reflex findings. 4. Weight gain of two pounds in an 8-week period is not excessive and does not require immediate action. Page Ref: 656 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Medical Emergency Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
20) The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse? 1. "I have to get up during the night to void." 2. "I have not felt the baby move today." 3. "I am leaking a yellowish fluid from my breasts." 4. "I have been taking Tylenol (acetaminophen) for my backaches." Answer: 2 Explanation: 1. Urinary frequency is common during the last months of pregnancy as the uterus places pressure on the bladder. 2. The absence or change in fetal movement can signal a problem with the pregnancy. When no fetal movement has been noted in the past 8 hours, there are fewer than 10 movements in 12 hours, there is a change in the usual pattern of movements, or a sudden increase in violent fetal movements followed by a complete cessation of movement, further investigation is warranted. Immediate evaluation of the fetus should take place. 3. Pregnant women begin to produce and secrete colostrum from the breast during pregnancy. 4. Tylenol (acetaminophen) is appropriate for the back pain that accompanies third trimester pregnancy. Page Ref: 649 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
21) The nurse is preparing discuss self-care during pregnancy with a client. Which should the nurse include in this teaching session? Select all that apply. 1. Do not use soap on nipples. 2. Sleep 8-10 hours each night. 3. Eat four servings of dairy products daily. 4. Do not take iron supplements due to constipation. 5. Avoid resting in a back lying position. Answer: 1, 2, 3, 5 Explanation: 1. The use of soap on the nipples will result in drying and should be avoided. 2. Pregnant women are in need of adequate rest and sleep. Sleeping 8 to 10 hours each night is recommended. 3. The dietary needs of the pregnant woman will involve approximately 1,000 mg of calcium daily. The needed calcium can be obtained by ingesting four servings from the dairy group each day. 4. Dietary intake during pregnancy cannot meet the iron required for the needs of both mother and baby. Iron supplements are needed to meet the needs of pregnant women. While constipation may be associated with iron supplementation, discontinuing the medication is contraindicated. The client experiencing constipation should be instructed to increase fluid and fiber intake to promote bowel regulation instead of not taking the needed iron supplements. 5. Lying on the back is contraindicated as the pregnancy progresses. Back-lying positions will result in the compression of the vena cava and may cause reduced perfusion, lightheadedness, and dizziness. Page Ref: 633-649 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Learn cooperatively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
22) A client expresses concern for her unborn baby after she learns her hemoglobin level was higher before her pregnancy. Which information should the nurse be prepared to initially discuss? 1. Dietary intake. 2. Changes in physiology. 3. Supplemental iron intake. 4. Prenatal vitamin supplementation. Answer: 2 Explanation: 1. Dietary intake is important to assess after explaining the normal physiological changes that occur during pregnancy. 2. Physiological anemia is a normal finding in pregnancy. This is important to initially discuss with the client due to their expressed concern. 3. Supplemental iron is important to take during pregnancy but this can be evaluated after explaining the normal physiological changes that occur during pregnancy. 4. Prenatal vitamin supplementation is important to take during pregnancy but this can be evaluated after explaining the normal physiological changes that occur during pregnancy. Page Ref: 633 Cognitive Level: Applying Client Need & Sub: Reduction of Risk Potential; Laboratory Values Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide healthNUteRaScIhNiGnTg,Bh.CeOaM lth counseling, screening, outreach, disease and outbreak investigation, and referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered Care: Learn cooperatively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1: Describe the anatomy and physiology of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
23) The nurse is reviewing the risk factors of pregnancy for women over 35 yrs. Which should the nurse include? Select all that apply. 1. Hypertension. 2. Stillbirths. 3. Gestational diabetes. 4. Premature births. 5. Chromosomal abnormalities. Answer: 1, 3, 4, 5 Explanation: 1. Hypertension is a risk factor of pregnancy for women over 35 years. 2. Stillbirths are not a direct risk factor of pregnancy for women over 35 years. 3. Gestational diabetes is a risk factor of pregnancy for women over 35 years. 4. Premature birth is a risk factor of pregnancy for women over 35 years. 5. Chromosomal abnormalities are a risk factor of pregnancy for women over 35 years. Page Ref: 638 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan. | NLN Competencies: Relationship Centered CaNrUeR: LSeINaG rnTB co.CoOpM eratively and facilitate the learning of others. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
24) During a prenatal counseling session, a client tells the nurse she is concerned she may have a positive HIV test. Which statement by the nurse is indicated? 1. "I understand you are stressed about the outcome of the test." 2. "If you are HIV positive, your baby will also have HIV." 3. "Even if you do test HIV positive, preventive treatments have a good chance of providing protection for your baby." 4. "As long as you do not breastfeed and have a cesarean section, your baby will be protected." Answer: 3 Explanation: 1. It is important to acknowledge the client's feelings about being tested before continuing the conversation. The acknowledgement reflects therapeutic communication. 2. If the client is HIV positive, it does not mean the baby will test positive for HIV or contract the virus. Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. 3. Prophylactic antiviral therapies can significantly reduce the incidence of transmission between mother and baby during the pregnancy. Without treatment, the risk of transmission to the baby is greatest. 4. Although bottle-feeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention. Page Ref: 644 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities, and populations. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.3: Utilize the appropriate techniques and tools for physical assessment of the pregnant woman and fetus.
25) The nurse is discussing the recommended weight gain for a client with a singleton pregnancy. Which recommendation should the nurse reinforce? 1. 28 to 40 lbs. 2. 25 to 30 lbs. 3. 15 to 25 lbs. 4. 11 to 20 lbs. Answer: 3 Explanation: 1. The recommended weight gain for a client with a singleton pregnancy that is underweight is 38 to 40 lbs. 2. The recommended weight gain for a client with a singleton pregnancy that is normal weight is 25 to 30 lbs. 3. The recommended weight gain for a client with a singleton pregnancy that is overweight is 15 to 25 lbs. 4. The recommended weight gain for a client with a singleton pregnancy that is obese is 11 to 20 lbs. Page Ref: 652 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individNuUaRlsS,IN faGmTiBli.eCsO, groups, communities, and populations. | M NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.1: Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman.
26) The nurse is examining a client in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? 1. Pulse of 98 beats per minute. 2. Weight gain of 1.5 pounds in a month. 3. Blood pressure of 148/94 mmHg. 4. Respiratory rate of 26 per minute. Answer: 3 Explanation: 1. The pregnant client's heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. 2. Weight gain should be one pound per month in the second and third trimesters. 3. A pregnant client's blood pressure should not be greater than 140/90 and if elevated could be a sign of gestational hypertension or preeclampsia. 4. The pregnant client's heart and respiratory rates will increase slightly due to an increased circulatory volume and a decrease in intrathoracic space. Page Ref: 633 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
27) The nurse reviewing a client's 1 hour GTT notes that the results are 155 mg/dl. Which should the nurse interpret the findings to indicate? 1. The client needs to repeat the test. 2. The client has gestational diabetes. 3. The client does not have gestational diabetes. 4. The client should follow up with a 3 hour GTT. Answer: 3 Explanation: 1. The test will not be repeated. 2. The results indicated that the client does not have gestational diabetes. 3. The client does not have gestational diabetes. A normal value of a 1 hour GTT is less than 180 mg/dl. 4. It is unnecessary for the client to follow up with a 3 hour GTT. Page Ref: 656 Cognitive Level: Analyzing Client Need & Sub: Reduction of Risk Potential; Diagnostic Tests Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
28) A client is diagnosed with Group B Streptococcus at 37 weeks' gestation. Which prescribed treatment should the nurse be prepared to discuss? 1. A 7-day course of prescribed oral antibiotics. 2. Treatment with IV antibiotics during active labor. 3. Initiation of treatment during the postpartum period. 4. IM antibiotic treatment to facilitate a rapid treatment. Answer: 2 Explanation: 1. Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection. 2. Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. 3. Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. 4. Group B Streptococcus is treated when the client goes into active labor. The treatment involves IV antibiotics. Initiating treatment during labor allows for the transmission of the medications across the placental barrier. Oral and intramuscular antibiotics are not indicated for this infection. Page Ref: 656 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Parenteral/Intravenous Therapies Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
29) A newly pregnant client tells the nurse she takes daily herbal supplements. Which initial action should the nurse take? 1. Instruct the client to discuss the herbal supplementation with the healthcare provider. 2. Advise the client that the supplements may interfere with the prenatal 3. Instruct the client to stop taking the supplements. 4. Ask the client why she is taking supplements. Answer: 3 Explanation: 1. The initial action is to instruct the client to stop taking herbal supplements. Herbal supplements are not regulated and should be avoided during the pregnancy. The client should discuss any additional concerns with the healthcare provider. 2. The initial action is to instruct the client to stop taking herbal supplements. Herbal supplements are not regulated and should be avoided during the pregnancy. The client should discuss any additional concerns with the healthcare provider. 3. The initial action is to instruct the client to stop taking herbal supplements. Herbal supplements are not regulated and should be avoided during the pregnancy. The client should discuss any additional concerns with the healthcare provider. 4. The initial action is to instruct the client to stop taking herbal supplements. Herbal supplements are not regulated and should be avoided during the pregnancy. The client should discuss any additional concerns with the healthcare provider. Page Ref: 822 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Adverse Effects/Contraindications/Side Effects/Interactions Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
30) A pregnant client with hepatitis B asks the nurse if their baby will be born with the virus. Which information should the nurse include in the discussion? 1. "Your baby is not at risk for the virus." 2. "Your baby will be tested immediately after birth." 3. "Your baby will receive an immunoglobulin after birth." 4. "The virus has been transmitted through the placenta." Answer: 3 Explanation: 1. The baby is at risk for the hepatitis B virus. 2. The baby is not tested but will be given an immunoglobulin and an immunization. 3. The baby born to a mother with hepatitis B will be given an immunoglobulin after birth and an immunization. 4. The virus is not transmitted through the placenta. Transmission occurs at birth. Page Ref: 644 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Medication Administration Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.6: Identify abnormal findings in the physical assessment of the pregnant woman. MNL Learning Outcome: 25.4 Differentiate normal and abnormal variations of the pregnant woman and fetus observed during physical assessment.
31) The nurse is preparing to obtain an obstetrical history from a client. Which question should the nurse include? 1. "Do you have a history of infertility?" 2. "What age did you become sexually active?" 3. "Have you ever had a sexually transmitted disease?" 4. "Have you had any spontaneous or induced abortions?" Answer: 4 Explanation: 1. A history of infertility is part of a gynecological history. 2. Age of sexual activity is information obtained as part of a gynecological history. 3. A history of sexually transmitted diseases is assessed during a gynecological history. 4. Part of an obstetrical history includes obtaining information related to spontaneous or induced abortions. Page Ref: 642 Cognitive Level: Applying Client Need & Sub: Pharmacological and Parenteral Therapies; Medication Administration Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.3: Determine questions about the pregnant woman to use for the focused interview. MNL Learning Outcome: 25.2 Plan questions related to the pregnancy for the focused interview of the pregnant woman.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 26 Infants, Children, and Adolescents 1) The nurse is preparing to discuss growth and development with expectant parents. Which growth patterns should the nurse consider prior to discussing the information? Select all that apply. 1. Cephalocaudal direction. 2. Simple to complex. 3. Distal to proximal direction. 4. Generalized response to specific response. 5. Anterior to posterior. Answer: 1, 2, 4 Explanation: 1. Growth and development occur in a cephalocaudal direction, from head to toe. 2. Growth and development proceed from simple to complex; an infant will reach out for an object before actually being able to grasp the object. 3. Growth and development do not proceed from distal to proximal but rather from proximal to distal, i.e., from the center of the body outward. 4. Growth and development progress from general to specific responses; an infant responds to stimuli with the entire body, and an older child will respond more specifically, for example, with a smile. 5. Anterior to posterior does not describe a pattern of normal growth and development. Page Ref: 688 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
2) When reviewing a pediatric client's medical record, which should the nurse consider environmental factors that influence growth and development? Select all that apply. 1. Nutrition. 2. Climate. 3. Heredity. 4. Culture. 5. Religion. Answer: 1, 2, 4, 5 Explanation: 1. Nutrition is an environmental factor that can affect the growth and development of an individual. 2. Climate is an environmental factor that can affect the growth and development of an individual. 3. Heredity drives the physical attributes of growth and development such as stature, gender, and race. 4. Culture is an environmental factor that can affect the growth and development of an individual. 5. Religion is an environmental factor that can affect the growth and development of an individual. Page Ref: 688 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: I.B.3. PNroUvRiSdIeNpGaTtBie.CnOt-M centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
3) Which parental statement reflects appropriate behavior for Piaget's sensorimotor stage of development? 1. "We have started buying more colorful toys." 2. "We play with water toys in the bathtub." 3. "We bought some blocks with numbers." 4. "We have been playing peek-a-boo." Answer: 4 Explanation: 1. Buying more colorful toys fosters visual stimulation as the child experiences physiologic growth and development (nervous system) but does not help the child with cognitive development. 2. Playing with water toys in the bathtub helps a child to develop motor, not cognitive, skills. 3. Providing a child with numbered blocks targets motor skill development, not cognitive development. 4. Playing peek-a-boo helps the infant begin to understand that someone is there even when that person is not visible. Piaget's theory explores how thinking, reasoning, and language develop (cognitive skills). In the sensorimotor stage (birth to 2 years), the infant progresses from responding primarily through reflexes to purposeful movement and organized activity. It is during this stage that the infant begins to recognize objects and develop object permanence, the knowledge that objects continue to exist even though they are not seen. Page Ref: 690 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
4) Which goal reflects a child's accomplishment of the task for Erikson's Stage 4 of development? 1. Watch peers play team sports. 2. Identify one or two pets that would be fun to care for. 3. Complete school homework and have a passing grade within 1 month. 4. Volunteer to help with one or more community projects each week. Answer: 3 Explanation: 1. A child who is observing others playing team sports (not participating) may be afraid to join in for fear of not being an adequate player or team member. This does not demonstrate accomplishment of the task at this developmental level. 2. Identifying one or two pets to care for would not foster a sense of competency, creativity, and perseverance since mastering this task would require actually caring for the pet or pets. 3. Erickson identified 8 stages of personality development in which a person must resolve a conflict based on physiologic and societal expectations. During Stage 4 (ages 6-11 years), the child is presented with the crisis of industry versus inferiority. Industry results in the development of competency, creativity, and perseverance. Inferiority creates feelings of hopelessness and a sense of being mediocre or incompetent. At this age, school is a major focus in a child's life; thus reaching a goal of completing school homework and having passing grades within 1 month would help develop a sense of competency and creativity and would also require perseverance in order to be successful. 4. Volunteering to help with one or more community projects each week is an unrealistic goal for a child of this age. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
5) A parent asks the nurse when their child will have 20/20 vision. Which time frame should the nurse respond to the client with? 1. 1 yr. 2. 3 yrs. 3. 5 yrs. 4. 7 yrs. Answer: 4 Explanation: 1. Children typically do not have 20/20 vision until 7 yrs. of age. 2. Children typically do not have 20/20 vision until 7 yrs. of age. 3. Children typically do not have 20/20 vision until 7 yrs. of age. 4. Children typically do not have 20/20 vision until 7 yrs. of age. Page Ref: 678 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
6) The nurse is interviewing the mother of a toddler who verbalizes concerns that her child uses the toilet to void but refuses to use the toilet for bowel movements and often hides to defecate. Which stage of Freud's psychologic development is this toddler experiencing? 1. Genital. 2. Phallic. 3. Anal. 4. Latency . Answer: 3 Explanation: 1. The genital phase occurs during puberty through adulthood; the individual experiences sexual urges stimulated by hormonal influences and sexual development. 2. The phallic phase occurs during years 4 to 6; pleasure is focused on the genital area. 3. Freud's anal phase follows the oral phase and continues through age 3. The anus becomes the focus for gratification and the child experiences conflict when expectations about toileting are presented. 4. The latency phase occurs during years 5 to 6 when energy is focused on intellectual and physical activities and a time to work on unresolved conflicts. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN CNoU mRpSeItNeGnTcBie.sC:OKMnowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
7) According to Piaget's theory of cognitive development, which behaviors should the nurse expect when assessing a preschool-age client? Select all that apply. 1. Being egocentric and failing to see another's point of view. 2. Focusing on one aspect of a given situation at once. 3. Assuming everyone else in their world sees things as they do. 4. Believing in magical powers of thought to control the universe. 5. Understanding cause-and-effect relationships. Answer: 1, 2, 3, 4 Explanation: 1. The preschooler continues to be egocentric and unable to see another's point of view. 2. Preschoolers demonstrate centration. That is, they focus on one aspect of a situation and ignore others, leading to illogical reasoning. 3. Preschoolers feel no need to defend their point of view because they assume that everyone else sees things as they do. 4. Preschoolers believe their wishes, thoughts, and gestures command the universe. The child believes that these "magical" powers of thought are the cause of all events. 5. Understanding cause-and-effect relationships is developed during the school-age years. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RI.S1I.NInGtTeBg.rCaOteMtheories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
8) While assessing a preschool-age child at play, which behavior indicates that the child is successfully moving through Piaget's cognitive stages of development? 1. The child is able to consider the differing opinions of playmates. 2. The child is able to recall the good time experienced in the previous weekend at the playground and is anticipating going there again the following week. 3. The child reports being able to rationalize why it is better to eat fruit than candy. 4. The child understands that their mother loves them as much as they love the child's older siblings. Answer: 2 Explanation: 1. The ability to consider the points of view of others does not occur until the Concrete Operations stage. 2. The child is able to recall the good time experienced the previous weekend at the playground and is anticipating going there again the following week. This indicates that add the child is progressing without difficulty in Piaget's cognitive theory. Stage 2: Preoperational Skills encompasses ages 2 to 7 years. During this time, the child is able to recall past events and anticipate future events. 3. The ability to consider the points of view of others does not occur until the Concrete Operations stage. 4. Rational thinking begins around the age of 11 and continues into adulthood. This is the stage known as Formal Operations. Page Ref: 690 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
9) A client asks the nurse what the pink patches are on the back of the neck of their newborn. Which newborn finding should the nurse be prepared to discuss? 1. Vernix caseosa. 2. Lanugo. 3. Nevus flammeus. 4. Transient mottling. Answer: 3 Explanation: 1. Vernix caseosa is a white cheese-like mixture of sebum and epidermal cells that cover the newborns skin. 2. Lanugo is fine downy hair that covers the newborn's skin. 3. A nevus flammeus are irregular red or pink patches found most commonly on the back of the neck. The vascular markings disappear spontaneously within a year of birth. 4. Transient mottling is a red or purple blotchy appearance that occurs after birth. Page Ref: 677 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
10) A parent asks the nurse when their baby's anterior fontanel will close. Which information should the nurse provide the parent? 1. 4 weeks to 3 months. 2. 3 to 6 months. 3. 9 to 12 months. 4. 12 to 18 months. Answer: 4 Explanation: 1. The anterior fontanel is diamond shaped and closes between 12 and 18 months of age. 2. The anterior fontanel is diamond shaped and closes between 12 and 18 months of age. 3. The anterior fontanel is diamond shaped and closes between 12 and 18 months of age. 4. The anterior fontanel is diamond shaped and closes between 12 and 18 months of age. Page Ref: 678 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and NewbornCare Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
11) The nurse is preparing to collect data from a parent of a toddler suspected to have a middle ear infection. Which symptoms should the nurse associate with the infection? Select all that apply. 1. Fever. 2. Diarrhea 3. Irritability. 4. Decreased appetite. 5. Inability to sleep laying down.Answer: 1, 3, 4, 5 Explanation: 1. Fever is a symptom of a middle ear infection. 2. Diarrhea is not a symptom associated with a middle ear infection. 3. Irritability is a symptom of a middle ear infection. 4. A decreased appetite is a symptom of a middle ear infection. 5. The inability to sleep laying down is a symptom of a middle ear infection. Page Ref: 679 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
12) The nurse notes that a 3-year-old client has yellow-green nasal discharge. Which type of infection should the nurse suspect? 1. Ear. 2. Frontal Sinus. 3. Throat. 4. Upper respiratory. Answer: 4 Explanation: 1. An ear infection is not characterized by the presence of yellow-green nasal discharge. 2. Frontal sinuses are not developed until age 10 years. Frontal sinus infections only occur in older school age children and adolescents. 3. A throat infection is not characterized by the presence of yellow-green nasal discharge. 4. The presence of yellow-green nasal discharge is characteristic of an upper respiratory infection in a 3-year-old client. Page Ref: 679 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
13) An adolescent male expresses concern to the nurse about their enlarged breast tissue. Which response should the nurse provide the client? 1. "This change will resolve on its own." 2. "This may be due to a hormone imbalance." 3. "Are you experiencing any breast pain?" 4. "Have you noticed any lumps in the tissue?" Answer: 1 Explanation: 1. Temporary breast enlargement in an adolescent male is a normal finding and will resolve on its own. 2. Telling the client they have a hormone imbalance is not appropriate. The client needs reassurance and the concern addressed. 3. The client can be assessed for pain after the discussion about the normal changes in breast tissue. 4. Another concern to adolescent males is transient masses beneath one areola or both. These "breast buds" usually disappear within a year of onset. The client has not reported any lumps or masses. Page Ref: 681 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN CNoU mRpSeItNeGnTcBie.sC:OKMnowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.2. Plan questions related to infants, children, and adolescents for the focused interview.
14) The nurse is preparing to assess the blood pressure of a young child. Which technique should the nurse use to assess the pressure? 1. Left arm. 2. Both arms. 3. Arm and thigh. 4. Right arm. Answer: 3 Explanation: 1. In young children, the blood pressure should be measured on the arm and then the thigh to rule out a significant difference between upper and lower extremity pressure. Such a difference in pressure could indicate a narrowing (coarctation) of the aorta. 2. Both arms are not used to assess the blood pressure. 3. In young children, the blood pressure should be measured on the arm and then the thigh to rule out a significant difference between upper and lower extremity pressure. Such a differencein pressure could indicate a narrowing (coarctation) of the aorta. 4. In young children, the blood pressure should be measured on the arm and then the thigh to rule out a significant difference between upper and lower extremity pressure. Such a differencein pressure could indicate a narrowing (coarctation) of the aorta. Page Ref: 682 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RI.S1I.NInGtTeBg.rCaOteMtheories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.
15) The nurse is assessing a child urine output. The child weighs 64 lbs. Which should the nurse identify as the minimal acceptable output? ml/hr. Answer: 32 ml/hr. Explanation: Normal urine output for children is at least 1 to 2 mL/kg/hr. 64 lbs. = 32 kg. 1 mL × 32 kg = 32 ml/hr. Page Ref: 684 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Elimination Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment. 16) The nurse is preparing to assess a child with exacerbated asthma. Which initial symptoms should the nurse anticipate? Select all that apply. 1. Nasal flaring. 2. Cyanosis. 3. Failure to thrive. 4. Increased respiratory rate. 5. Accessory muscle use.Answer: 1, 4, 5 Explanation: 1. Nasal flaring is a symptom associated with exacerbated asthma. 2. Cyanosis is not an initial symptom associated with exacerbated asthma. 3. Failure to thrive is not associated with asthma. 4. An increased respiratory rate is associated with asthma. 5. Accessory muscle use is associated with exacerbated asthma. Page Ref: 700 Cognitive Level: Understanding Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.
MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment. 17) The nurse is caring for a newborn with a congenital heart disorder. Which should the nurse monitor the client for? 1. Hypothermia. 2. Hypoglycemia. 3. Poor feeding. 4. Fussiness . Answer: 3 Explanation: 1. Hypothermia is not a complication of a congenital heart disorder. 2. Hypoglycemia is not a complication of congenital heart disorder. 3. Poor feeding is a subjective finding in a newborn with a congenital heart disease. 4. Fussiness is not a complication of a congenital heart disorder. Page Ref: 700 Cognitive Level: Analyzing Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. |NNULRNSICNoGmTpBe.CteOnMcies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
18) The parent of a 2-day-old newborn expresses concern that their infant's head is misshapen. Which response should the nurse provide the parent? 1. "Every newborn has a different shaped head." 2. "It is okay, the cranial bones are not yet fused." 3. "I will be taking measurements of the newborn's head." 4. "Your newborn can be fitted for a helmet to reshape their head." Answer: 2 Explanation: 1. Telling a parent that every newborn has a different shaped head does not address the parent's concern. 2. In children under 12 to 18 months, the cranial bones are not yet fused and the head shape may be misshapen, especially in newborns who underwent a vaginal birth. 3. Telling the parent that the newborn's head will be measured does not address the parent's concern. 4. Helmets are not created for a 3-day-old newborn to reshape their head. Page Ref: 695 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing manaNgUeRmSIeNnGt TaB cr.Coss OMthe health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
19) The nurse is preparing to assess the reflexes of a 5-month-old infant. Which reflexes should the nurse anticipate to document? Select all that apply. 1. Palmar grasp. 2. Stepping. 3. Rooting. 4. Tonic neck. 5. Babinski. Answer: 2, 4, 5 Explanation: 1. The palmar grasp reflex is present until 3 to 4 months of age. 2. The stepping reflex is present until 4 to 5 months of age. 3. The rooting reflex is present until 3 to 4 months of age. 4. The tonic neck reflex is present until 2 to 6 months of age. 5. The Babinski reflex is present until 18 to 24 months of age. Page Ref: 686-687 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU e RaSnIdNG qua and safe patient care. | TBl.iCty OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.5: Generate the appropriate documentation to describe the assessment findings for infants, children, and adolescents. MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.
20) The mother of a toddler-age client expresses concern about the child's lower back curving in and the child's belly sticking out. Which action by the nurse is appropriate? 1. Suggest the mother to buy the child some bigger clothes. 2. Give the mother the first available appointment to see the healthcare provider. 3. Contact the healthcare provider to see if an orthopedic referral is necessary. 4. Reassure the mother that this is normal for a toddler. Answer: 4 Explanation: 1. Suggesting the mother to buy the child some larger clothes does not address the concern that there is something abnormal with the child. 2. The mother is describing a normal finding in a toddler; therefore, a visit with the healthcare provider is not needed. 3. There is no need for the nurse to consult with the healthcare provider or consider orthopedic referral since this is a normal finding in a toddler. 4. The mother is describing toddler lordosis (a curving in of the lower back, which produces a potbelly). This is a normal finding in this age group and resolves as the abdominal muscles develop and pull the abdomen in. Page Ref: 682 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RIXS.I3N.GIm mMent holistic, patient-centered TBp.lCeO care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
21) The nurse is preparing to elicit the Babinski reflex on a 6-month-old infant. Which technique should the nurse use? 1. Touch the infant's foot at the base of the toes. 2. Turn the infant's head to one side while the infant is supine. 3. Stroke the plantar surface of the foot from the heel to the toe. 4. Hold the infant upright and allow the feet to touch a surface. Answer: 3 Explanation: 1. Touching the infant's foot at the base of the toes is a technique used to elicit the plantar grasp. 2. Turning the infant's head to one side while the infant is supine is the technique used to elicit a tonic neck reflex. 3. Stroking the plantar surface of the foot from the heel to the toe is the technique used to elicit the Babinski reflex. 4. Holding the infant upright and allowing the feet to touch a surface is the technique used to elicit the stepping reflex. Page Ref: 687 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing manaNgUeRmSIeNnGt TaB cr.CoO ssMthe health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.
22) The nurse is assessing school aged children in a clinic that serves an impoverished community. Which common finding should the nurse anticipate in this population? 1. Chronic illness. 2. Lower weight. 3. Mental health disorders. 4. Developmental delays. Answer: 2 Explanation: 1. There is not an increase in chronic illness among the children of lower socioeconomic status. 2. Children that are of lower socioeconomic status have been found to have lower height and weight than those in other economic groups. 3. There is not an increase in mental health disorders among the children of lower socioeconomic status. 4. There is not an increase in developmental delay among the children of lower socioeconomic status. Page Ref: 688 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing manaNgUeRmSIeNnGt TaB cr.Coss OMthe health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
23) The nurse is reviewing the common foods that cause an allergic reaction in children with a group of parents. Select all that apply. 1. Milk. 2. Eggs. 3. Wheat. 4. Cheese. 5. Shellfish. Answer: 1, 2, 3, 5 Explanation: 1. Milk is a common food that causes allergic reactions in children. 2. Eggs are a common food that causes allergic reactions in children. 3. Wheat is a common food that causes allergic reactions in children. 4. Cheese is not a common food that causes allergic reactions in children. 5. Shellfish is a common food that causes allergic reactions in children. Page Ref: 691 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNG qTuaBl.iCtyOM and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
24) The nurse is preparing to assess a child with fetal alcohol syndrome. Which physical findings should the nurse anticipate? Select all that apply. 1. Facial deformities. 2. Developmental delay. 3. Cardiac defects. 4. Head deformities. 5. Limb deformities. Answer: 1, 2, 4 Explanation: 1. Facial deformities are associated with fetal alcohol syndrome. 2. Developmental delay is associated with fetal alcohol syndrome. 3. Cardiac defects are not specifically associated with fetal alcohol syndrome. 4. Head deformities are associated with fetal alcohol syndrome. 5. Limb deformities are not specifically associated with fetal alcohol syndrome. Page Ref: 691 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/scienNcU eRaSnIdNGqTuaBl.iCtyOM and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
25) A parent of a young child tells the nurse they are worried that their child has had 4 colds over the past year. Which information should the nurse provide the parent? 1. You need to make sure your child has had the flu shot. 2. Colds are common in young children. 3. Keep your child away from other ill children. 4. Make sure everyone is washing their hands in your household. Answer: 2 Explanation: 1. Colds are not related to the flu. 2. Colds are common in young children. Young children may have an average of 6 to 8 colds per year during the cold season, with symptoms lasting up to 2 weeks. 3. It is important to keep the child away from others that may be ill. However, colds can be spread from anyone that is not using good handwashing or exposes themselves to others. 4. Handwashing is very important to prevent the spread of germs but colds can be picked up from other people outside of the household. This also does not address the parent's initial concern. Page Ref: 692 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing manaNgUeRmSIeNnGt TaB cr.Coss OMthe health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
26) The nurse is preparing to assess a child with acute gastroenteritis. Which question is the most important to ask the parent? 1. "Has your child been vomiting?" 2. "Has your child had diarrhea?" 3. "Has your child been drinking fluids?" 4. "Has your child been urinating?" Answer: 2 Explanation: 1. Vomiting may or may not be associated with acute gastroenteritis. 2. Diarrhea is the most common finding associated with acute gastroenteritis. 3. Dehydration is not a direct symptom of gastroenteritis but is caused by diarrhea, possible vomiting, and fever that is associated with the intestinal infection. 4. Oliguria is not a direct symptom of gastroenteritis but is caused by diarrhea, possible vomiting, and fever that is associated with the intestinal infection. Page Ref: 683 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.3: Determine questions about infants, children, and adolescents to use for the focused interview. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
27) The nurse is preparing to assess the musculoskeletal system of a 9-month-old infant. Which finding should the nurse anticipate to include in the documentation? 1. Genu valgum. 2. Genu varum. 3. Lordotic curve. 4. Scoliosis . Answer: 4 Explanation: 1. Genu valgum usually is present in children by the age of 4 years. 2. Genu varum occurs in infants before learning to walk. 3. A lordotic curve of the spine is an anticipated finding in a toddler. 4. Scoliosis is an abnormal finding. Page Ref: 684 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 26.5: Generate the aNpUpRrSoIpNrGiaTtB e.dCoOcMumentation to describe the assessment findings for infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
28) The nurse assessing the musculoskeletal system of a 4-year-old child observes them rising to a standing position after being supine. Which finding should the nurse be concerned about? 1. The child rises without using arm support. 2. The child reaches out for the parent to pick them up. 3. The child places their hands on the floor and straightens their legs. 4. The child places their hands on their knees and pushes their trunk up. Answer: 4 Explanation: 1. The child rises without using arm support is an expected finding. 2. The child that reaches out for a parent to pick them up may be nervous and requires further assessment. 3. A child that places their hands on the floor and straightens their legs is not the most concerning finding but requires reevaluation. 4. Generalized muscle weakness may be indicated if the child places the hands on the knees and pushes up the trunk (Gowers sign). Page Ref: 685 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmaNcoUlRoSgIyN, GmTeBd.CicOaM l management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
29) The nurse is preparing to assess an adolescent. Which should the nurse recognize is a common finding? 1. Somatic complaints. 2. Depression. 3. Substance abuse. 4. Eating disorders. Answer: 1 Explanation: 1. Somatic complaints are common in the adolescent population. 2. Depression is not a common finding in the adolescent population. 3. Substance abuse is not a common finding in the adolescent population. 4. The adolescent is at risk for eating disorders but this is not a common finding. Page Ref: 689 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2: Identify the anNaUtoRm ic, physiologic, developmental, psychosocial, and SI N GTB .C O M cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.
30) The nurse is preparing to assess a 5-year-old child using Piaget's theory of cognitive development. Which stage should the nurse anticipate to use? 1. Formal Operations. 2. Concrete Operations. 3. Preoperational Skills. 4. Sensorimotor. Answer: 3 Explanation: 1. Piaget's Formal Operations is a stage applied from 11 years to adulthood. 2. Piaget's Concrete Operations is a stage applied from 7 to 11 years. 3. Piaget's Preoperational Skills is a stage applied from 2 to 7 years. 4. Piaget's Sensorimotor is a stage that is applied from birth to 2 years. Page Ref: 690 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2: Identify the anNaUtoRm ic, physiologic, developmental, psychosocial, and SI N GTB .C O M cultural variations that guide assessment of infants, children, and adolescents. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
31) The nurse notes an orange hue on the skin of a 11-month-old infant. Which focused assessment question should the nurse ask the parent? 1. "Has your child been sick?" 2. "Does your infant take any medications?" 3. "Can you tell me what foods the baby eats?" 4. "Does your infant attend a childcare center?" Answer: 3 Explanation: 1. This question is important but a general question that is not applicable to the assessment findings. 2. This question is important but a general question that is not applicable to the assessment findings. 3. Ingestion of foods high in carotene such as carrots, sweet potatoes, and squash can result in an orange or yellow hue on the skin. 4. This question is important but a general question that is not applicable to the assessment findings. Page Ref: 691 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmaNcoUlRoSgIyN, GmTeBd.CicOaM l management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3: Determine questions about infants, children, and adolescents to use for the focused interview. MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 27 Older Adults 1) Which should the nurse attribute to the older adult's decreased skin elasticity? Select all that apply. 1. Subcutaneous layer decreases. 2. Elastin fibers decreases. 3. Epidermis thins. 4. Collagen decreases. 5. Sebum production decreases. Answer: 2, 3, 4 Explanation: 1. A decrease in subcutaneous tissue is not a contributing factor to a decreased skin elasticity. 2. Elastin fibers decrease with age contributing to a decreased skin elasticity. 3. The epidermis on an older adult thins which contributes to a decreased skin elasticity. 4. The decrease in collagen results in a decreased skin elasticity. 5. A decrease in sebum production results in dry skin and but does not affect the elasticity of the skin. Page Ref: 706 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
2) An older adult asks the nurse why they are more susceptible to skin cancer. Which response should the nurse provide? 1. "Your skin has become very thin." 2. "The cells in your body that protect you do not work as effectively." 3. "You have a decreased production of melanin which increases your risk." 4. "The age spots on your skin are more prone to turn cancerous." Answer: 3 Explanation: 1. An older adult has an increased risk for skin cancer due to the decreased melanin production. Decreased melanin production leads to a heightened sensitivity to sunlight; skin cancer rates increase with age. 2. An older adult has an increased risk for skin cancer due to the decreased melanin production. Decreased melanin production leads to a heightened sensitivity to sunlight; skin cancer rates increase with age. 3. An older adult has an increased risk for skin cancer due to the decreased melanin production. Decreased melanin production leads to a heightened sensitivity to sunlight; skin cancer rates increase with age. 4. An older adult has an increased risk for skin cancer due to the decreased melanin production. Decreased melanin production leads to a heightened sensitivity to sunlight; skin cancer rates increase with age. Page Ref: 24-25 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
3) The nurse notes that the skin of some older light-skinned clients appears pale. Which changes should the nurse attribute the finding to? 1. Inability to absorb iron. 2. Decreased time in the sun. 3. Decreased vascularity of the dermis. 4. Decrease production in melanin. Answer: 3 Explanation: 1. Some light-skinned older patients may appear pale because of decreased vascularity in the dermis, even though they may be healthy and well oxygenated. 2. Some light-skinned older patients may appear pale because of decreased vascularity in the dermis, even though they may be healthy and well oxygenated. 3. Some light-skinned older patients may appear pale because of decreased vascularity in the dermis, even though they may be healthy and well oxygenated. 4. Some light-skinned older patients may appear pale because of decreased vascularity in the dermis, even though they may be healthy and well oxygenated. Page Ref: 25-41 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and qualityNaUnRdSIsNaG feTpBa.CtiOeM nt care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
4) The nurse notes small bright red spots on an older client's skin. Which terminology will the nurse use to document the finding? 1. Cutaneous horns. 2. Cutaneous tags. 3. Cherry angiomas. 4. Senile lentigines. Answer: 3 Explanation: 1. Cutaneous horns are conical projections from the skin that may occur on any part of the face. 2. Cutaneous tags are small soft skin growths that are common and appear on the neck and the upper chest. 3. Cherry angiomas are small bright red spots that are common in older adults and may increase with age. 4. Senile lentigines appear as hyperpigmented freckles most commonly found on the arms and the back of the hands. Page Ref: 707 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and qualityNaUnRdSIsNaG feTpBa.CtiOeM nt care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.5: Generate the appropriate documentation to describe the assessment findings for older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
5) The nurse performing a community cancer screening observes a conical projection on the anterior ear lobe. Which action should the nurse take? 1. Document the finding as normal. 2. Ask the client how long they have had this. 3. Refer the client to the healthcare provider. 4. Ask the client if they are exposed to the sun frequently. Answer: 1 Explanation: 1. Cutaneous horns are conical projections from the skin that may occur on any part of the face. Cutaneous horns are normal findings and should be documented as such. 2. The lesion known as cutaneous horns are conical projections from the skin that may occur on any part of the face in an older adult. 3. Cutaneous horns are conical projections from the skin that may occur on any part of the face. They are lesions that normally occur in some older adults; therefore, the client does not need a referral to the healthcare provider. 4. Cutaneous horns are conical projections from the skin that may occur on any part of the face. They are lesions that normally occur in some older adults and are not associated with exposure to the sun. Page Ref: 707 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RI.S1I.NInGtTeBg.rCaOteMtheories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
6) The nurse assessing the skin on the face of an older adult observes yellow plaques on the inner canthus of the eyes. Which action should the nurse take? 1. Assess the liver function. 2. Assess the client's vision. 3. Assess the remainder of the skin. 4. Assess the client's ability to produce tears. Answer: 3 Explanation: 1. There is no indication to assess the client's liver function. 2. Visual assessment is a general part of an assessment and is not specifically performed relative to the findings. 3. Xanthelasma are soft, yellow plaques on the lids at the inner canthus. These plaques are sometimes associated with cholesterolemia but usually have no pathologic significance because they appear on persons with normal cholesterol counts. 4. Palpation of the lacrimal glands is part of a head assessment that is performed after inspection and is not solely done based on the assessment finding. Page Ref: 708 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and qualityNaUnRdSIsNaG feTpBa.CtiOeM nt care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
7) The nurse notes that an older client has a light grey ring around the iris. Which should the nurse attribute the finding to? 1. Pterygium. 2. Cataract formation. 3. Deposition of lipids. 4. Loss of pigmentation in the iris. Answer: 3 Explanation: 1. Pterygium is an opaque overgrowth bulbar conjunctiva that can grow over the cornea and block vision. 2. A light gray or white ring surrounding the iris at the corneal margin occurs due to the deposition of lipids. This common finding known as arcus senilis does not affect vision. 3. A light gray or white ring surrounding the iris at the corneal margin occurs due to the deposition of lipids. This common finding known as arcus senilis does not affect vision. 4. A light gray or white ring surrounding the iris at the corneal margin occurs due to the deposition of lipids. This common finding known as arcus senilis does not affect vision. Page Ref: 708 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and qualityNaUnRdSIsNaG feTpBa.CtiOeM nt care. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
8) An older adult asks the nurse how macular degeneration occurs. Which answer should the nurse provide? 1. The optic nerve is damaged. 2. The lens of the eye thickens. 3. The blood vessels in the eyes narrow. 4. The eyes have had prolonged exposure to the sun. Answer: 3 Explanation: 1. Optic nerve damage is associated with glaucoma. 2. Thickening of the lens of the eye is associated with cataracts. 3. Macular degeneration occurs due to narrowing of blood vessels with a granular pigment in the macula resulting in a loss of central vision. 4. Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. Page Ref: 709 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
9) The nurse is reviewing the causes of presbyopia with a client. Which changes in the eye should the nurse include in the discussion? Select all that apply. 1. Narrowing blood vessels. 2. Weakened ciliary muscles. 3. Loss of eye elasticity. 4. Decrease response of the optic nerve. 5. Decreased ability of the lens to change shape. Answer: 2, 3, 5 Explanation: 1. Narrowing blood vessels do not contribute to the occurrence of presbyopia. 2. Weakened ciliary muscles contribute to presbyopia. 3. Loss of eye elasticity contributes to presbyopia. 4. A decreased response of the optic nerve does not contribute to the occurrence of presbyopia. 5. Decreased ability of the lens to change shape contributes to presbyopia. Page Ref: 708 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
10) An older adult asks the nurse why they have trouble hearing some parts of a conversation. Which response should the nurse provide? 1. "The auditory nerve does not function as well." 2. "The tympanic membrane thickens as you age." 3. "There is a loss of hair cells that transmit sound." 4. "There is a decreased blood flow to the tympanic membrane." Answer: 3 Explanation: 1. A decrease in auditory nerve function is not associated with aging. 2. The tympanic membrane becomes paler in color and thicker in appearance with aging but this is not the reason for hearing loss. 3. Older patients may complain that they do not hear consonants well when listening to normal conversation. This is because of the loss of hair cells in the organ of Corti in the inner ear. 4. The tympanic membrane becomes paler in color and thicker in appearance with aging but this is not the reason for hearing loss. Page Ref: 709 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
11) A family member of an older adult tells the nurse they are worried because their father does not eat much. Which contributing factors should the nurse plan to discuss with the family member? Select all that apply. 1. Decreased sense of taste. 2. Diminished olfactory fibers. 3. Decreased saliva production. 4. Diminished gum lines. 5. Decreased motor function of the tongue. Answer: 1, 2, 3 Explanation: 1. A decreased sense of taste and smell may contribute to a decreased appetite and poor nutrition 2. A decreased sense of taste and smell may contribute to a decreased appetite and poor nutrition 3. Decreased saliva production contributes to the diminished sense of taste. 4. Gum recession is not a contributing factor to the decreased appetite of an older adult. 5. A decreased motor function of the tongue is not a contributing factor to the decreased appetite of an older adult. Page Ref: 709-708 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials CompetencieNsU: RI.S1I.NInGtTeBg.rCaOteMtheories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
12) The nurse reviewing the chart of an older adult notes that the client has angular stomatitis. Which assessment finding should the nurse anticipate to include in the documentation? 1. Diminished gum lines. 2. Excessive salivation. 3. Edentulism. 4. Decreased salivation. Answer: 2 Explanation: 1. Diminished gum lines are not associated with angular stomatitis. 2. In some older client's, saliva increases, causing cheilitis (also known as angular stomatitis) which manifests as tissue inflammation at the corners of the mouth. 3. Edentulism is not associated with angular stomatitis. 4. Decreased salivation is not associated with angular stomatitis. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.5: Generate the appropriate documentation to describe the assessment findings for older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
13) The nurse is caring for an older client with pneumonia. Which factors should the nurse recognize compromise the client's airway clearance? Select all that apply. 1. Weakened skeletal muscles. 2. Decreased ciliary function. 3. Dry mucus membranes. 4. Inability to cough. 5. Decreased lung elasticity. Answer: 2, 3, 4 Explanation: 1. Decreased lung elasticity, weakened skeletal muscles, and lost bone density make it more difficult for the older adult to expand the thoracic cage and take a deep breath to expand their lungs. 2. Dry mucous membranes, decreased ciliary function, and the inability to cough compromise airway clearance of an older adult. 3. Dry mucous membranes, decreased ciliary function, and the inability to cough compromise airway clearance of an older adult. 4. Dry mucous membranes, decreased ciliary function, and the inability to cough compromise airway clearance of an older adult. 5. Decreased lung elasticity, weakened skeletal muscles, and lost bone density make it more difficult for the older adult to expand the thoracic cage and take a deep breath to expand their lungs. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
14) The nurse is preparing to assess the lungs of an older adult. Which findings should the nurse anticipate? Select all that apply. 1. Percussed hyperresonance. 2. Slight substernal retractions. 3. Shallow respiratory cycle. 4. Less audible breath sounds. 5. Slightly decreased respiratory rate. Answer: 1, 3, 4 Explanation: 1. The older adult may have trapping of air in the alveoli that will produce a sound of hyperresonance upon percussion. 2. Substernal retractions are not a normal finding that is associated with aging. 3. The older adult has a shallower respiratory cycle because of the decreased vital capacity. 4. Auscultatory sounds may be less audible because of the decreased pulmonary function. 5. The rate of respirations in the older adult is slightly higher than in the middle-aged adult. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
15) The nurse is preparing to assess the cardiovascular system of an older adult. Which findings should the nurse anticipate? 1. Increase in systolic pressure. 2. Decreased resting heart rate. 3. Decrease in systolic pressure. 4. Increase in resting heart rate. Answer: 1 Explanation: 1. Physiologically, systolic blood pressure may increase; however, there may be no significant change in resting heart rate. 2. Physiologically, systolic blood pressure may increase; however, there may be no significant change in resting heart rate. 3. Physiologically, systolic blood pressure may increase; however, there may be no significant change in resting heart rate. 4. Physiologically, systolic blood pressure may increase; however, there may be no significant change in resting heart rate. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and qualityNaUnRdSIsNaG feTpBa.CtiOeM nt care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
16) The nurse is preparing to screen an older client for dementia. Which assessment tool should the nurse use? 1. The Denver II. 2. Mini Cog. 3. Life Experiences Survey. 4. Mini-Mental Status Examination. Answer: 2 Explanation: 1. The Denver II is a screening tool used to assess personal-social, fine motor adaptive, language, and gross motor skills in children between birth and 6 years of age. 2. The MiniCog is an evidence-based, validated screening tool shown to be effective as an initial assessment for identifying persons with dementia. 3. The Life Experiences Survey is used to evaluate the level of stress an individual is experiencing; this is not appropriate for this client's concerns. 4. The Hassles and Uplifts Scale measures attitudes about daily situations; it does not screen for cognitive changes. Page Ref: 714 Cognitive Level: Psychosocial Integrity Client Need & Sub: Health Promotion and Maintenance; Sensory/Perceptual Alterations Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing manaNgUeRmSIeNnGt TaB cr.Coss OMthe health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Outline key considerations for physical assessment of older adults. MNL Learning Outcome: 27.3. Utilize the appropriate techniques and tools for physical assessment of older adults.
17) Which assessment findings in an older adult client does the nurse associate with the normal aging process? Select all that apply. 1. Increased systolic blood pressure. 2. Increased muscle tone. 3. Decreased cardiac output. 4. Increased vital capacity. 5. Decreased renal function. Answer: 1, 3, 5 Explanation: 1. Systolic blood pressure increases due to a decrease in the elasticity of the arteries and increased peripheral vascular resistance. 2. Muscle tone is decreased. 3. Cardiac output is diminished due to alteration in pumping action as the heart muscle thickens. 4. Respiratory vital capacity is decreased as the lungs become stiffer and less efficient. 5. Renal function decreases as blood flow to the kidneys is affected by arteriosclerotic changes and a decrease in the number of nephrons. Page Ref: 710-712 Cognitive Level: Remembering Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human grow thRaSInNdGdTeBv.eClOoM pment, pathophysiology, NU pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
18) Which should the nurse attribute to an older client's increased susceptibility to medication toxicity? 1. Decreased ammonia production. 2. Inability to produce adequate amounts of bicarb. 3. Reduced ability to reabsorb glucose. 4. Decreased ability to clear acids. Answer: 1, 3, 4 Explanation: 1. The older adult also has a reduced capacity to produce ammonia, which interacts with acids. 2. The older adult has the reduced ability to resorb bicarbonate 3. The older adult has the reduced ability to resorb glucose. 4. The older adult has the reduced ability to clear acids. Page Ref: 711 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing PN roUcReSsIsN: As G TsBe.sCsOm Ment Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
19) The nurse is obtaining a focused assessment from a postmenopausal client about genitourinary changes. Which questions should the nurse include in the assessment? Select all that apply. 1. "Have you experienced a decreased libido?" 2. "Are you experiencing any leakage of urine?" 3. "Have you experienced any vaginal dryness?" 4. "Have you experienced a loss of bladder control?" 5. "Have you experienced an increase in vaginal discharge?" Answer: 1, 2, 3, 4 Explanation: 1. Decreased hormone production affects both libido and performance. 2. Postmenopausal women experience a decrease in estrogen that affects the strength of the pubic muscles and may lead to urine leakage, reduced acidity in the lower urinary tract, and urinary tract infection (UTI). 3. Endocrine changes affect size, lubrication, and function of genital structures in both men and women. 4. Diminished bladder elasticity, bladder capacity, and sphincter control also occur as a person ages and can result in problems such as incontinence. 5. Endocrine changes and decreased estrogen result in vaginal dryness. Page Ref: 711 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.3: Determine questions about older adults to use for the focused interview. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
20) An older client tells the nurse they do not understand why they do not have the endurance to exercise like they did when they were younger. Which statement should the nurse provide the client? 1. "The muscles and joints become worn and do not move as easily as they used to." 2. "As individuals get older, there are normal changes that occur in the body, specifically the heart and lungs, that may contribute to decreased endurance." 3. "It is possible that you have not been consistently exercising." 4. "The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs." Answer: 2 Explanation: 1. The reason a client does not have the endurance they did at an earlier age is not due to muscles and joints becoming worn. The cardiac and respiratory changes that naturally occur with aging contribute to a decrease in endurance. 2. The nurse should explain to the client in simple terms that it is normal in the older years to experience a decrease in endurance due to the physiologic changes that occur with aging. Specifically, the heart becomes stiffer, which affects the pumping action, the valves of the heart become less pliable, leading to decreased filling and emptying, and cardiac output and reserve are decreased. This makes it difficult for the heart to adjust quickly to increased demands. The respiratory system is less efficient. Lungs are stiffer, residual air (space where gas exchange does not occur) is increased, and vital capacity (area where gas exchange does take place) is decreased. The respiratory effort is increased to keep up with oxygen demands. Staying active will help a person to build endurance. 3. Telling the client "It is not possible because they have not been consistently exercising" is inappropriate and incorrect." 4. Responding to the client with "The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs" is a medical explanation that the client may not understand. Page Ref: 710, 721 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
21) The nurse is reviewing geriatric syndrome with the family of an older client. Which should the nurse include in the discussion? Select all that apply. 1. Frailty. 2. Polypharmacy. 3. Depression. 4. Stool incontinence. 5. Malnutrition. Answer: 1, 2, 3, 5 Explanation: 1. Frailty is a geriatric syndrome. 2. Polypharmacy is a geriatric syndrome. 3. Depression is a geriatric syndrome. 4. Stool incontinence is not identified as a geriatric syndrome. 5. Malnutrition is a geriatric syndrome. Page Ref: 713 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
22) The nurse is preparing to review the risk for cognitive impairment with the family of an older adult. Which information should the nurse include? Select all that apply. 1. Frailty. 2. Aging. 3. Genetics. 4. Depression. 5. Poor nutrition. Answer: 2, 3, 4 Explanation: 1. Frailty is not an increased risk for cognitive impairment. 2. Factors that increase the risk for cognitive impairment include aging. 3. Factors that increase the risk for cognitive impairment include genetics. 4. Factors that increase the risk for cognitive impairment include depression. 5. Poor nutrition is not an increased risk for cognitive impairment. Page Ref: 714 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
23) Which considerations should the nurse be aware of when obtaining a health history from an older adult? Select all that apply. 1. Sit at eye level facing the client. 2. Consider the stamina of the client. 3. Allow the client to reminisce during the interview. 4. Adjust the questioning according to the client's behavior. 5. Interrupt the client if they are explaining something not understood. Answer: 1, 2, 3, 4 Explanation: 1. Sitting at an eye level facing the client during the interview. 2. Client stamina should be a consideration for the length of a visit or for scheduling more than one visit to complete the comprehensive history and exam. 3. Older adults may reminisce while discussing different aspects of the health history. The information provided can be helpful; however, it may extend the length of time spent on this portion of the patient visit. 4. Patients may display other behavior that can affect accuracy of the health history. It is important to be aware of these tendencies and know how to adjust questioning and/or include additional assessment strategies during the physical exams 5. Try not to interrupt the client when they are discussing their concerns. Page Ref: 716 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity; Therapeutic Communication Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4: Outline key considerations for physical assessment of older adults. MNL Learning Outcome: 27.3. Utilize the appropriate techniques and tools for physical assessment of older adults.
24) An older client tells the nurse they are having difficulty seeing at night when they are driving. Which condition should the nurse suspect? 1. Presbyopia. 2. Cataracts. 3. Glaucoma. 4. Macular degeneration. Answer: 2 Explanation: 1. Presbyopia is not associated with night blindness. 2. Night blindness is associated with cataracts and some retinal diseases. 3. Glaucoma is not associated with night blindness. 4. Macular degeneration is not associated with night blindness. Page Ref: 717 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 27.6: Identify abnorN mUaRl SfiInNdGinTgBs.CinOM the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
25) The nurse is preparing to discuss the changes in the urinary elimination with an older client. Which topics should the nurse discuss? Select all that apply. 1. Urinary retention. 2. Increased urine output. 3. Decreased bladder capacity. 4. Involuntary bladder contractions. 5. Weakening of the urinary sphincters. Answer: 1, 3, 4, 5 Explanation: 1. Urinary retention occurs in the older client. 2. The older client does not experience an increase in urine output. 3. Decreased bladder capacity occurs in the older client. 4. Involuntary bladder contractions occur in the older client. 5. Weakening of the urinary sphincters occurs in the older client. Page Ref: 720 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Aging Process Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults. MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
26) The nurse is preparing to assess a client with nocturia. Which findings should the nurse recognize are specifically associated with nocturia? Select all that apply. 1. Obesity. 2. Stool impaction. 3. Hyperglycemia. 4. Decreased bladder capacity. 5. Weakened bladder and urethral muscles. Answer: 2, 3, 5 Explanation: 1. Obesity is related to stress incontinence. 2. Stool impaction is associated with nocturia. 3. Hyperglycemia is associated with nocturia. 4. A decreased bladder capacity is associated with urinary frequency during the day as well as at night. 5. Weakened bladder and urethral muscles are associated with nocturia. Page Ref: 720 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Elimination Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness coNnUtRinSuIN um oss GT, Ba.cCrO M lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
27) The nurse is preparing to assess a client with benign prostatic hypertrophy (BPH). Which focused question should the nurse ask the client? 1. "Do you have a urinary tract infection?" 2. "Do you experience urinary retention?" 3. "Do you experience urinary frequency?" 4. "Do you have urinary leakage when you cough or sneeze?" Answer: 2 Explanation: 1. A urinary tract infection is not associated with BPH. 2. BPH is a common cause for urinary retention. 3. Urinary incontinence is not associated with BPH. 4. Stress incontinence is not caused by BPH. Page Ref: 720 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3: Determine queNsUtiRoSnIsNG abToBu.Ct OoM lder adults to use for the focused interview. MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
28) The nurse is preparing to obtain a functional assessment from an older client. Which basic activities of daily living (ADL) should the nurse assess? Select all that apply. 1. Cooking. 2. Exercise. 3. Bathing. 4. Dressing. 5. Shopping. Answer: 3, 4 Explanation: 1. Cooking is an instrumental activity of daily living, not a basic ADL. 2. Exercise is an advanced activity of daily living, not a basic ADL. 3. Bathing is a basic ADL. 4. Dressing is a basic ADL. 5. Shopping is an instrumental activity of daily living, not a basic ADL. Page Ref: 723 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults. MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
29) The nurse is reviewing the medical history of a client with onychomycosis. Which disease should the nurse recognize is associated with the infection? 1. Liver disease. 2. Hyperthyroidism. 3. Renal disease. 4. Peripheral vascular disease. Answer: 4 Explanation: 1. Onychomycosis is a fungal nail disease that is not specifically associated with liver disease. 2. Onychomycosis is a fungal nail disease that is not specifically associated with hyperthyroidism. 3. Onychomycosis is a fungal nail disease that is not specifically associated with renal disease. 4. Onychomycosis is a fungal nail disease that is common in adults with peripheral vascular disease. Page Ref: 727 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness coNnUtRinSuIN um oss GT, Ba.cCrO M lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults. MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito) Chapter 28 Complete Health Assessments: Putting the Pieces Together 1) The nurse is preparing to perform a physical examination on a client. Which should the nurse begin the assessment with? 1. Measurements. 2. Appearance and mental status. 3. Vital signs. 4. Inspect the skin, hair, and nails. Answer: 2 Explanation: 1. The vital signs or the client's height and weight can be obtained after the assessment of the client's appearance and mental status. 2. The nurse will begin the examination with the assessment of the client's appearance and mental status. 3. The vital signs or the client's height and weight can be obtained after the assessment of the client's appearance and mental status. 4. The inspection of the skin, hair, and nails is done after the vital signs and measurements have been obtained. Page Ref: 734-735 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: I.B.1. ENlici t patient valu es, preferences, and expressed needs U RSINGTB. CO M as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.1: Perform a health history and general survey for a patient in the community setting.
2) Which clients will require a rapid assessment? Select all that apply. 1. The client had an open appendectomy 2 days ago and is preparing to be discharged today. 2. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. 3. The client has just been received from the Post Anesthesia Care Unit. 4. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. 5. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%. Answer: 3, 4, 5 Explanation: 1. The client who is postoperative day 2 and is preparing to be discharged requires a routine assessment. 2. The client who has been admitted to the unit the day before and is receiving effective treatment requires a routine assessment. 3. The nurse should perform a rapid assessment on a client following a surgical procedure. 4. The nurse who is new to the unit can plan care for the assigned clients by performing a rapid assessment on each of the assigned clients to help the nurse prioritize care. 5. The nurse should perform a rapid assessment on a client who is in distress. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
3) The educator has completed discussing the topic of rapid assessment with the new nursing staff. Which statement by a nurse indicates that further education is required? 1. "The rapid assessment should last approximately 10 minutes." 2. "I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care." 3. "The rapid assessment will help me establish baseline data about the client." 4. "After I perform the rapid assessments on the clients I've been assigned, I can go back and get more information during my routine assessments." Answer: 1 Explanation: 1. The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. 2. It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. 3. The rapid assessment helps the nurse establish baseline data about the client. 4. Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementaNtiUoRnSoIN f cGaTrBe.CpO laM n, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.3: Outline the data to collect in the rapid assessment. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
4) During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerves is the nurse assessing? Select all that apply. 1. IV. 2. V. 3. VI. 4. VII. 5. VIII. Answer: 2, 4 Explanation: 1. Cranial nerve IV is the trochlear nerve that is not associated with facial muscle movement. 2. Cranial V is the trigeminal nerve that can be assessed through the observation of facial expression, movement, and symmetry of facial features. 3. Cranial nerve VI is the abducens nerve that is not associated with facial muscle movement. 4. Cranial VII is the facial nerve that can be partially assessed through the observation of facial expression, movement, and symmetry of facial features. 5. Cranial nerve VIII is the vestibulocochlear nerve that is not associated with facial muscle movement. Page Ref: 735 Cognitive Level: Applying Client Need & Sub: Physiological Adaptation; Alterations in Body Systems Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
5) The nurse is preparing to test the client's peripheral fields of vision. Which cranial nerve is the nurse assessing? 1. I. 2. II. 3. III. 4. IV. Answer: 2 Explanation: 1. Cranial nerve I is the olfactory nerve associated with smell. 2. Cranial nerve II is the optic nerve and can be tested during the assessment of peripheral vision. 3. Cranial nerve III is the oculomotor nerve that is tested when assessing extraocular movements and pupillary reaction to light and accommodation. 4. Cranial nerve IV is the trochlear nerve that controls the superior oblique muscle of the eye. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and EnvironmenNt:UCRoSnINdGuTctBp.CoOpM ulation-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
6) The nurse is preparing to inspect the posterior chest of a client. Which should the nurse anticipate assessing? Select all that apply. 1. Respiratory excursion. 2. Symmetry. 3. Thoracic configuration. 4. Musculoskeletal development. 5. Upper extremity range of motion and movement against resistance. Answer: 1, 2, 3, 4 Explanation: 1. Respiratory excursion is included in the assessment of the posterior chest. 2. The symmetry of the posterior chest is assessed. 3. The thoracic configuration of the posterior chest is assessed. 4. The musculoskeletal development of the posterior chest is assessed. 5. The upper extremity range of motion and movement against resistance is assessed during the inspection of the anterior chest. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
7) The nurse is performing a rapid assessment for assigned clients. Which clients require immediate medical assistance? Select all that apply. 1. The client is pale and is breathing in a shallow manner. 2. The client that is experiencing dyspnea. 3. The client is rating his pain at a 3 out of a 10 on a pain scale. 4. The client is unable to follow directions. 5. The nurse determines that the client's level of consciousness is decreasing. Answer: 1, 2, 4, 5 Explanation: 1. The client who is pale and breathing in a shallow manner may be exhibiting anxiety. This client should receive immediate medical attention. 2. The client who is dyspneic requires immediate medical assistance. 3. The client who is complaining of only mild pain does not require immediate medical assistance. 4. The client who is unable to follow directions should be provided with immediate medical attention. 5. The client who has a decreasing level of consciousness during the rapid assessment should be provided with immediate medical assistance. The rapid assessment lasts less than 1 minute. This client's level of consciousness is decreasing very quickly and indicates that a severe problem is occurring. Page Ref: 741 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
8) The nurse performing a routine assessment is evaluating the client's activity. Which should the nurse include in the assessment? Select all that apply. 1. Environmental hazards. 2. Level of consciousness. 3. Presence and use of assistive devices. 4. Location of the call light. 5. Body posture and position. Answer: 1, 3, 4 Explanation: 1. Environmental hazards related to mobility should be included when assessing the client's activity. 2. The assessment of the client's level of conscious is evaluated during the general survey. 3. The presence and use of assistive devices should be included when assessing the client's activity. 4. The location of the call light should be included when assessing the client's activity. 5. The assessment of the client's body posture and position is evaluated during the general survey. Page Ref: 743 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
9) The nurse has several clients that need routine assessments as well as prescriptions that are due to be administered. A few of the clients do not speak English. Which action should the nurse take? 1. Administer the prescriptions. 2. Locate a hospital interpreter. 3. Use the family member to interpret the information. 4. Perform the assessment and administer the prescriptions. Answer: 2 Explanation: 1. Administering prescriptions without communicating or assessing the client is not an appropriate action. 2. The nurse should locate an interpreter to provide assistance with the assessment and allow the client to ask questions and make decisions about their care. 3. When possible, a staff member should be used as an interpreter. Family members or friends should only be used as interpreters when no other option is available 4. The nurse should locate an interpreter prior to performing the assessment or administering the prescriptions. Page Ref: 743 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Management of Care Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.5: Identify special considerations that guide assessments in community and hospital settings. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
10) The nurse is preparing to assess a client's skin. Which techniques should the nurse be prepared to perform? Select all that apply. 1. Inspection. 2. Percussion. 3. Measure. 4. Palpation. 5. Auscultation. Answer: 1, 3, 4 Explanation: 1. The nurse should be prepared to inspect, measure, and palpate a client's skin. 2. Percussion is not used during the assessment of skin. 3. The nurse should be prepared to inspect, measure, and palpate a client's skin. 4. The nurse should be prepared to inspect, measure, and palpate a client's skin. 5. Auscultation is not used during the assessment of skin. Page Ref: 735 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
11) Which assessment should the nurse perform after assessing a client's appearance and mental status? 1. Assess vital signs. 2. Obtain a height and weight. 3. Instruct the client to change into a gown. 4. Explain the purpose of the health assessment. Answer: 3 Explanation: 1. Vital signs are assessed prior to the assessment of the client's appearance and mental status. 2. A height and weight is obtained prior to the assessment of the client's appearance and mental status. 3. At the completion of the interview, the client should be requested to change into a gown to complete the remainder of the physical assessment. 4. The purpose of the health assessment is discussed in the initial interview. Page Ref: 734 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
12) The nurse is preparing to assess the pain of a young child. Which initial assessment is most appropriate? 1. Ask the parent if the child has been experiencing pain. 2. Use a numerical pain rating scale. 3. Use a FACES pain rating scale. 4. Ask the child to point to any area that is hurting. Answer: 3 Explanation: 1. The parent's information to use for the assessment of pain is inappropriate. 2. The numerical pain rating scale is not an appropriate tool to assess a young child's pain. 3. The FACES pain rating scale is the most appropriate tool to assess the child's pain. 4. The child may be helpful in identifying the location of their pain but this does not identify their perception of the pain. Page Ref: 735 Cognitive Level: Applying Client Need & Sub: Psychosocial Adaptation; Alterations in Body Systems Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
13) Which equipment should the nurse use to evaluate cranial nerve VIII? 1. Safety pin. 2. Pen light. 3. Tuning fork. 4. Wisp of cotton. Answer: 3 Explanation: 1. A safety pin is not used to assess cranial nerve VIII. 2. A penlight is not used to test cranial nerve VIII. 3. Cranial nerve VIII is the vestibulocochlear nerve. A tuning fork will be needed to evaluatebone and air conduction. 4. A wisp of cotton is not used to assess cranial nerve VIII. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
14) The nurse is preparing to assess a client's mouth and throat. Which cranial nerves should the nurse anticipate testing? Select all that apply. 1. X. 2. IX. 3. XI. 4. VII. 5. XII. Answer: 1, 2, 4, 5 Explanation: 1. Cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) are used to assess the position and mobility of the uvula as well as the gag reflex. 2. Cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve) are used to assess the position and mobility of the uvula as well as the gag reflex. 3. Cranial nerve XI (accessory nerve) controls the muscles in the neck and is not assessed during the evaluation of a client's mouth and throat. 4. Cranial nerve VII (facial nerve) is assessed when testing the sense of taste. 5. Cranial nerve XII (hypoglossal nerve) is assessed by asking the client to stick their tongue out. Page Ref: 736 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioNeUcRoSnIoNm icB, .aCnOdMenvironmental assessments of GT health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
15) The nurse is preparing to assess the pulmonic area of a client's heart. Which anatomical location should the nurse place the bell of the stethoscope? 1. Fourth intercostal space left sternal edge. 2. Second intercostal space right sternal edge. 3. Second intercostal space left sternal edge. 4. Fifth intercostal space at the sternal border. Answer: 3 Explanation: 1. The tricuspid valve is located in the fourth intercostal space left sternal border. 2. The aortic valve is located in the second intercostal space right sternal edge. 3. The pulmonic valve is located in the second intercostal space left sternal edge. 4. The mitral valve is located at the fifth intercostal space at the left sternal boarder. Page Ref: 737 Cognitive Level: Understanding Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
16) The nurse is preparing to document the findings of an assessment. Which concepts should the nurse's documentation reflect? Select all that apply. 1. Agency policy. 2. Standard precautions. 3. Patient safety. 4. Primary and secondary data. 5. Professional standards. Answer: 2, 3, 5 Explanation: 1. The agency policy is the framework for which the nurse should use to document but is not a concept that should be reflected in the documentation. 2. The nurse's documentation should reflect the concept of standard precautions. 3. The nurse's documentation should reflect the concept of patient safety. 4. Primary and secondary data are not concepts, but they are components of a health history. 5. The nurse's documentation should reflect the concept of professional standards. Page Ref: 738 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: ConteNxUt RaSnIdNG EnTvBi.rCoOnM ment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
17) The nurse is preparing to assess the cerebellar function of a client. Which testing should the nurse anticipate performing? Select all that apply. 1. Graphesthesia. 2. Finger to nose test. 3. Stereognosis. 4. Heel-shin test. 5. Bilateral tendon reflexes. Answer: 2, 4 Explanation: 1. Graphesthesia is used to evaluate the cortical sensation of touch. 2. The finger to nose test is used to evaluate cerebellar function. 3. Stereognosis is used to evaluate the cortical sensation of touch. 4. The heel-shin test is used to evaluate cerebellar function. 5. Bilateral tendon reflexes are an evaluation of sensorimotor function. Page Ref: 738 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and intNeUrvReSnIN tiG onTsB..C|ONMursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
18) The nurse is preparing to palpate an apical pulse. For which findings should the nurse assess the pulse? Select all that apply. 1. Heaves. 2. Intensity. 3. Rate. 4. Quality. 5. Location. Answer: 2, 5 Explanation: 1. The client's chest is inspected for heaves. 2. The location and intensity are assessed when palpating the apical pulse. 3. The rate is assessed during auscultation of the apical pulse. 4. The quality is a component of the assessment for peripheral pulses. 5. The location and intensity are assessed when palpating the apical pulse. Page Ref: 737 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Health Screening Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
19) The nurse is preparing to perform a rapid assessment. Which should the nurse understand is the primary technique that will be used during the assessment? 1. Observation. 2. Inspection. 3. Auscultation. 4. Palpation. Answer: 1 Explanation: 1. A rapid assessment is primarily performed by using observation. 2. A rapid assessment is primarily performed by using observation. 3. A rapid assessment is primarily performed by using observation. 4. A rapid assessment is primarily performed by using observation. Page Ref: 741 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.3: Outline the data to collect in the rapid assessment. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
20) The educator is discussing prioritizing nursing actions with a nurse. Which statement made by the nurse indicates further teaching is needed? 1. "Nursing actions are prioritized after a rapid assessment." 2. "Nursing actions are prioritized after the data has been collected." 3. "Nursing actions are prioritized after a comprehensive assessment is obtained." 4. "Nursing actions are prioritized after obtaining report on the clients." Answer: 1 Explanation: 1. Prioritizing nursing actions occur after data has been gathered either through a rapid or comprehensive assessment. 2. Prioritizing nursing actions occur after data has been gathered either through a rapid or comprehensive assessment. 3. Prioritizing nursing actions occur after data has been gathered either through a rapid or comprehensive assessment. 4. The client must be assessed either through a rapid or comprehensive assessment before prioritizing nursing actions. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBti.eCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
21) The nurse is preparing to perform a rapid assessment. Which initial action should the nurse take? 1. Enter the room. 2. Perform hand hygiene 3. Note isolation precautions, latex allergies, or fall precautions. 4. Identify yourself and explain that you will be providing care for a given time period. Answer: 2 Explanation: 1. Prior to entering the room, reviewing the isolation precautions, latex allergies, or fall precautions, and identifying self and explaining the period of time that care will be provided, the nurse will perform hand hygiene. 2. Prior to entering the room, reviewing the isolation precautions, latex allergies, or fall precautions, and identifying self and explaining the period of time that care will be provided, the nurse will perform hand hygiene. 3. Prior to entering the room, reviewing the isolation precautions, latex allergies, or fall precautions, and identifying self and explaining the period of time that care will be provided, the nurse will perform hand hygiene. 4. Prior to entering the room, reviewing the isolation precautions, latex allergies, or fall precautions, and identifying self and explaining the period of time that care will be provided, the nurse will perform hand hygiene. Page Ref: 740-741 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment; Establishing Priorities Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.3: Outline the data to collect in the rapid assessment. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
22) A client tells the nurse they do want the alarms turned off on their infusion pump. Which response should the nurse provide? 1. "The alarms are on for your safety." 2. "Let me evaluate why your alarms are going off." 3. "I will turn down the sound so the alarms do not bother you." 4. "It is against the hospital policy to turn off the alarms." Answer: 2 Explanation: 1. The alarms are on for the client's safety but this response does not offer the client a solution. 2. Evaluating the reason why the alarm is going off is the most appropriate response. This response acknowledges the client's statement and conveys concern for the reason the alarms are going off. This also reinforces the commitment to the safety of the client. 3. It is unsafe to turn down the sound of the alarm. 4. Telling the client that it is against hospital policy to turn off the alarms does not address their concern. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
23) The educator is preparing to review the hospital National Patient Safety Goals (NPSG) with a nurse. Which goals should the educator include when discussing the NPSG of using medicines safely? Select all that apply. 1. Review new medications. 2. Document reactions to medications. 3. Record and report medication information. 4. Provide written discharge instructions for each medication. 5. Confirm the client's mediation regimen with the healthcare provider. Answer: 1, 3, 4, 5 Explanation: 1. The nurse will review the client's new medications and check for duplicates, omissions, and contraindications. 2. Documenting reactions to medications are not included in the National Patient Safety Goal of using medications safely. 3. Record and report medication information about the client's current medication regimen. 4. Prior to discharging a client, the client will be provided written instructions for administration of each medication. 5. The medication regimen will be confirmed with the client or the primary healthcare provider. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safety and Infection Control; Accident/Error/Injury Prevention Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN EssentiN alUsRCSoIm pTeBte.CnOciM es: IX.1. Conduct comprehensive NG and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the hospital setting. MNL Learning Outcome: 28.3: Perform a health history and general survey for a patient in the hospital setting.
24) The nurse notices that a client has difficulty moving their head. Which cranial nerve should the nurse assess? 1. X. 2. IX. 3. VI. 4. XI. Answer: 4 Explanation: 1. Cranial nerve X (vagus nerve) is associated with swallowing and speaking. 2. Cranial nerve IX (glossopharyngeal nerve) is associated with taste and swallowing. 3. Cranial nerve VI (abducens) is associated with oculomotor movement. 4. Cranial nerve XI (accessory nerve) governs the movement of the head and shoulders. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Physiological Integrity; Mobility/Immobility Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.1: Perform a health history and general survey for a patient in the community setting.
25) The nurse is preparing to perform a breast assessment for an adult female. Which techniques should the nurse anticipate using during the assessment? Select all that apply. 1. Instruct the client to flex their pectoral muscles. 2. Instruct the client to lean forward. 3. Instruct the client to press their hands on their hips. 4. Instruct the client to lift their arms over their head. 5. Instruct the client to push their upper extremities against resistance. Answer: 2, 3, 4 Explanation: 1. Instructing the client to flex their pectoral muscles is not part of a breast assessment. 2. Instructing the client to lean forward is included in a breast assessment. 3. Instructing the client to press their hands on their hips is included in a breast assessment. 4. Instructing the client to lift their arms over their head is included in a breast assessment. 5. Instructing the client to push their upper extremities against resistance is part of an assessment for range of motion and muscle strength. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness paramNeU teRrSsIiNnGpTaBt.ieCnOtM s, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
26) The nurse is preparing to palpate the inguinal region of a client. For which should the nurse assess the area for? Select all that apply. 1. Bruits. 2. Pulses. 3. Aneurysms. 4. Hernias. 5. Lymph nodes. Answer: 2, 4, 5 Explanation: 1. Auscultation is used to detect bruits. 2. The pulses in an inguinal area should be palpated. 3. Observation of pulsations is used to detect aneurysms. 4. Palpation of the area is used to assess for hernias. 5. The lymph nodes in the inguinal are palpated. Page Ref: 737 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments N anUdRSinIN teGrTveBn.Ctio ns. | OM Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.1: Apply knowledge and skills to conduct a general survey and physical assessment of patients in the community setting. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
27) The nurse is planning to integrate the Romberg test in a client's assessment. During which system assessment should the nurse consider integrating the test? 1. Musculoskeletal. 2. Neurologic system. 3. Mental status. 4. Head, neck, and lymphatics. Answer: 1 Explanation: 1. The Romberg test is performed during the musculoskeletal assessment because the client will be asked to stand for evaluation of other parts of the system. 2. The client will not need to stand during the neurological examination. 3. The mental status examination is not associated with the client's ability to maintain their balance. 4. It is not appropriate to perform a Romberg test when assessing the head, neck, and lymphatics. Page Ref: 737 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsIN : CGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
28) The nurse is preparing to perform a rapid assessment. Which should the nurse plan on including in the assessment? Select all that apply. 1. Vital signs. 2. General appearance. 3. Client identification. 4. Facial expression. 5. Speech for clarity. Answer: 3, 4, 5 Explanation: 1. An overall assessment of the general appearance is deferred for the routine assessment. 2. Vital signs are deferred for the routine assessment. 3. The rapid assessment includes client identification, facial expression, and speech for clarity. 4. The rapid assessment includes client identification, facial expression, and speech for clarity. 5. The rapid assessment includes client identification, facial expression, and speech for clarity. Page Ref: 741 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN CompeteNnUcRieSsI:NCGoTnBt.eCxOtMand Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.3: Outline the data to collect in the rapid assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.
29) Which is the primary purpose for the documentation of a rapid assessment? Select all that apply. 1. Create a care plan for the client. 2. Establish a baseline for ongoing care. 3. Prioritize nursing actions. 4. Communication tool for the client's condition. 5. Prioritize nursing interventions. Answer: 2, 3, 5 Explanation: 1. The rapid assessment is often used as an initial assessment of a group of patients in a nursing assignment. Nurses use the collected data to prioritize their actions and interventions. Additionally, the documentation provides a baseline for ongoing care. 2. The rapid assessment is often used as an initial assessment of a group of patients in a nursing assignment. Nurses use the collected data to prioritize their actions and interventions. Additionally, the documentation provides a baseline for ongoing care. 3. The rapid assessment is often used as an initial assessment of a group of patients in a nursing assignment. Nurses use the collected data to prioritize their actions and interventions. Additionally, the documentation provides a baseline for ongoing care. 4. The rapid assessment is often used as an initial assessment of a group of patients in a nursing assignment. Nurses use the collected data to prioritize their actions and interventions. Additionally, the documentation provides a baseline for ongoing care. 5. The rapid assessment is often used as an initial assessment of a group of patients in a nursing assignment. Nurses use the collected daNtaUtRoSIpNrG ioTrBit.iCzeOM their actions and interventions. Additionally, the documentation provides a baseline for ongoing care. Page Ref: 740 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment; Concepts of Management Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 28.3: Outline the data to collect in the rapid assessment. MNL Learning Outcome: 28.4: Perform a physical assessment for a patient a patient in the hospital setting.
30) Which should the nurse include when performing a routine assessment of the abdomen? Select all that apply. 1. Skin temperature. 2. Urine output. 3. Last bowel movement. 4. Auscultation of vascular sounds. 5. Auscultation of bowel sounds. Answer: 3, 5 Explanation: 1. Skin temperature is not included in the routine assessment of the abdomen; it is included in a skin assessment. 2. Assessing urinary output is included in the genitourinary assessment. 3. Inquiring about the last bowel movement is included in a routine assessment of the abdomen. 4. Auscultation of vascular sounds is not included in a routine assessment; it included in a complete health assessment. 5. Auscultation of bowel sounds is included in a routine assessment. Page Ref: 742 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment Standards: QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise, and evidence. | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychologiNcaUlR , sSpINirGitTuBa.l,CsOoMcioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Conduct populationbased transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.4: Outline the data to collect in the routine assessment. MNL Learning Outcome: 28.2: Perform a physical assessment for a patient in the community setting.