Chapter 1 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is obtaining a health history from a client who reports that he is healthy and has no health concerns. As part of the health history, the nurse documents that the client reported that he has high blood pressure and suffers from a leg ulcer that remains unhealed after 6 months. What is the most appropriate response by the nurse at this point in the interview? 1) “I feel that you may be in denial about your health status.” 2) “Tell me about your definition of being healthy.” 3) “Do you understand what hypertension is?” 4) “Is there anything else you are not telling me?” 1) 2 Explanation: 1. More information is needed before the nurse could describe the client’s viewpoint as denial. 2. A client will have his or her own definition of health, illness, and wellness that is influenced by many factors including age, gender, race, family, culture, religion, socioeconomic conditions, environment, previous experiences, and self-expectations. It is important for the nurse to understand the client’s perspective on health. 3. More information is needed before the nurse can determine that the client has a lack of knowledge. 4. There is not enough information to determine that the client is withholding information from the nurse. Also this statement could come across as the nurse accusing the client. Assessment Analysis Objective 1 Page 4 Difficulty - 1 2) What is the best description of the assessment component of SOAP charting? 1) Objective data obtained from the physical assessment 2) The client’s chief complaint 3) Subjective statements the client makes regarding feelings 4) Conclusions drawn from the data obtained 2) 4 Explanation: 1. Objective data obtained from the physical assessment is an example of the “O” component of SOAP charting 2. The client’s chief complaint is an example of subjective data, the “S” component of SOAP charting.
3. This is another example of subjective data, the “S” component of SOAP charting, because it is information reported by the client. 4. The “A” component of SOAP charting refers to conclusions drawn from the subjective and objective data obtained. Assessment Knowledge Objective 7 Page 7 Difficulty -1 3) A nurse is reviewing a client’s medical record. Which is an example of a constant piece of data? 1) The client has B negative blood type. 2) The blood pressure at 0900 was 110/74 mmHg. 3) The sodium level is 145 mmol/L. 4) The client is 64 years of age. 3)1 Explanation: 1. Constant data are things that do not typically change over time such as race, gender, or blood type. 2. Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age. 3. Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age. 4. Variable data may change within minutes, hours, or days and includes things like blood pressure, pulse rate, blood counts, and age. Assessment Application Objective 4 Page - 5 Difficulty - 2 4) A nurse is developing a handout for clients in a physician’s office. What content areas would be included in this handout to emphasize current changes in the healthcare delivery system? 1) Symptom management, environmental control 2) Management of outbreaks of disease, eradicating the use of toxins 3) Illness care, pain management, prevention of complications 4) Wellness, health maintenance, health promotion, prevention of disease 4) 4 Explanation: 1. Historically the Canadian healthcare system focused on illness and symptom control but this has changed to include a broader focus with an emphasis on wellness, prevention of disease, health maintenance, and health promotion. 2. Management of outbreaks of disease is a function of governmental organizations and health care providers in the community, but is not a focus of individual care. 3. Illness care, pain management, and prevention of complications are addressed by the health care delivery system, but are no longer the primary focus of client care. There is now an emphasis on wellness, health maintenance, and health promotion. 4. The focus of healthcare in the Canada is now on wellness, prevention of disease, health promotion and health maintenance. Assessment Health Promotion and Management
Knowledge Objective 1 Page 3 Difficulty -1
5) What is the best method for the nurse to obtain subjective data during a health assessment?
1) Interviewing a primary source 2) Reviewing an indirect source like health records 3) Completing a physical assessment 4) Obtaining information from a family member 5)1 Explanation: 1. During a health assessment interview, subjective data is best gathered directly from the client, the primary source. 2. Although subjective data can be obtained through secondary or indirect sources such as the family, caregivers, other members of the health care team, or medical records, it is best to obtain such information directly from the client. If secondary sources are used, the nurse must validate subjective data from other sources to ensure the accuracy of the information. 3. Objective data is obtained during the physical assessment. 4. A family member can report subjective data based on perceptions the client has shared with them but it is always best to obtain the subjective data directly from the client when possible. Health Knowledge Objective 4 Page 5 Difficulty - 2 6) A nurse is reviewing a client’s medical records and notes various forms of information. What piece of information is an example of subjective data? 1) Symptoms described by the client 2) Physical examination results 3) Results of radiographic studies 4) Laboratory analysis reports 6) 1 Explanation: 1. Clients can describe feelings or symptoms that cannot be observed by others. This is an example of subjective data. 2. Physical examination results are an example of objective data. 3. Results of radiographic studies are an example of objective data. 4. Laboratory analysis reports are an example of objective data.
Assessment Knowledge Objective 4 Page 5 Difficulty-1
7) A nurse is reviewing a client’s medical records. What is an example of objective data? 1) “I hurt my head.” 2) “I am six-years-old and I’m here because I fell.” 3) Six-year-old Hispanic female sitting on examination table holding a towel to her forehead. 4) Client states that she fell at the playground. 7) 3 Explanation: 1. “I hurt my head” is a statement made by the client and is an example of subjective data. Subjective data are things the client experiences and communicates to the nurse. 2. The nurse did not observe the child’s fall, therefore this information was communicated by the client to the nurse which is an example of subjective data. 3. Objective data is data that can be observed or measured by the nurse. The nurse can see the child holding the towel to her head and can use her birth date to determine her age. 4. Statements the client makes are subjective data. Assessment Knowledge Objective 4 Page 5 Difficulty - 3 8) A nurse is evaluating the plan of care and notes that none of the goals have been met for the client. What should the nurse do next in this situation? 1) Report the lack of achievement of the goals to the physician 2) Review the data and modify the plan 3) Re-formulate the nursing diagnosis to a more realistic one 4) Nothing as long as the client is stable 8) 2 Explanation: 1. Reporting the lack of achievement of the goals to the physician is not appropriate, though, reporting undesirable client physiologic responses may be. 2. The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified. 3. Re-formulating 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. Client achievement of goals is needed regardless of status. Evaluation Application Objective 5 Page 14 Difficulty - 2
9) A nurse is obtaining a health history from the client. What phase of the nursing process is the nurse using? 1) Planning 2) Assessment 3) Diagnosis 4) Interviewing 9) 2 Explanation: 1. Planning is the third phase of the nursing process and can only occur after the completion of the assessment and diagnosis. Obtaining a health history is a component of the assessment phase of the nursing process. 2. Obtaining the health history is a component of the assessment phase of the nursing process. The nurse cannot determine an accurate nursing diagnosis or plan of care without assessment data. 3. Formulating a diagnosis is the second phase of the nursing process and occurs after the completion of the assessment phase. Obtaining the health history is a component of the assessment phase of the nursing process. 4. Interviewing is the technique used by the nurse to obtain a health history from the client. Interviewing is not one of the four phases of the nursing process. Assessment Knowledge Objective 5 Page 11, 12 Difficulty - 2 10) A nurse is developing a plan of care for a client. What types of data must the nurses consider when developing nursing diagnoses? 1) Assessment, planning, and evaluation 2) Subjective and objective 3) Family history, laboratory results 4) Standard and normative 10) 2 Explanation: 1. Assessment involves the collection of subjective and objective data in order to plan and provide care for the client. Planning is the process that occurs after the assessment data has been collected and interpreted. Evaluation is the process of examining the goal to see achievement. 2. The nurse must consider all subjective and objective data collected. The nurse will make a judgment after analysis and synthesis of the collected data. 3. Family history and laboratory data are components of assessment data but the nurse must consider all the objective and subjective data collected not just these two elements of data. 4. Standard and normative data are found on charts (for example, growth charts) or in results of studies to achieve the goal of establishing norms for groups of people. Data collected during the assessment are compared to normative values and standards but the nurse must consider a broader range of data in the process of formulating a nursing diagnosis. Assessment
Knowledge Objective 5 Page 12 Difficulty - 2 11) A nurse is interpreting the findings from a health assessment she completed on a college student with influenza. The student was sent home because the student dormitory was closed due to an influenza outbreak. What determinant of health is present in this situation? 1) Ethnocultural 2) Family 3) Environmental 4) Psychological 11) 3 Explanation: 1. Enthocultural factors are an example of a determinant of health; however, there is no information provided in the scenario that indicates a cultural factor is influencing the student’s health. 2. Family factors are another example of a determinant of health; however, there is no information provided in the scenario that indicates that a family factor is influencing the student’s health. 3. Environmental factors can affect health. Influenza is spread from person to person through coughing and sneezing, particularly in places where people live in close quarters like student housing. There is evidence in this scenario to support an environmental determinant of health has affected this student. 4. Psychological factors are another example of a determinant of health; however, there is not information provided in this scenario to support that a psychological factor is affecting this student’s health status. Health Knowledge Objective 2 Page 4, 10, 11 Difficulty - 2 12) What statement most accurately describes the World Health Organization (WHO) definition of health? 1) Health is the absence of illness, disease, and symptoms. 2) Health is a state of well-being and the use of every power the person possesses to the fullest extent. 3) Health is a culturally defined, valued, and practiced state of well-being 4) Health is a state of complete physical, mental, and social well-being. 12) 4 Explanation: 1. The traditional view of health was the absence of illness and disease but the WHO definition is broader and includes the ideas of complete physical, mental, and social well-being. 2. This statement is a definition of health by the nursing theorist Nightingale and is not the WHO definition of health (Nightingale, 1860/1969).
3. This statement is from Leininger’s model of health and is not the WHO definition of health (Leininger, 1991). 4. This is the WHO definition of health (WHO, 1947). Assessment Comprehension Objective 1 Page 4 Difficulty - 1 13) A nurse is developing a plan of care for a client with surgical incision pain. What is the most appropriate goal statement for this client? 1) The client will verbalize pain relief using an intensity rating in 4 hours. 2) The client will state that they feel fine. 3) The client will state understanding of the cause of pain in 3 days. 4) The client will verbalize no pain. 13) 1 Explanation: 1. “The client will verbalize pain relief" is a goal statement directly related to the nursing diagnosis, it is stated in a positive fashion, and has measurable criteria. 2. “The client will state they feel fine" is not directly related to the surgical pain and is not measurable. 3. Understanding the cause of surgical pain does not measure whether the pain has been reduced. 4. It is unrealistic to expect a client will feel no pain following surgery. The goal statement should be realistic and measurable. Planning Knowledge Objective 5 Page – 13 Difficulty Level - 2 14) A nurse is developing the plan of care and needs to develop interventions to achieve a specific goal. What source should the nurse use to determine interventions? 1) Nursing diagnosis 2) Defining characteristics of the nursing diagnosis 3) Etiology of the nursing diagnosis 4) Client’s stated wishes 14) 3 Explanation: 1. The interventions are derived from the cause of the diagnosis. 2. The defining characteristics provide the background support for the diagnosis. 3. The etiology of the diagnosis is used to determine the interventions. 4. The client’s stated wishes are an important component of planning, and may be included in the list of interventions as appropriate but the primary source of interventions will be related to the etiology of the diagnosis. Planning Knowledge Objective - 5 Page – 13 Difficulty Level - 2
15) Ms. Benoit, 38 years old, is admitted with chest pain. What is an example of a holistic approach to nursing care? 1) Considering all the factors that impact Ms. Benoit’s well-being 2) Completing a thorough chest assessment 3) Reviewing Ms. Benoit’s life style 4) Obtaining a detailed family history 15) 1 Explanation: 1. Holism includes all factors that impact the client’s physical and emotional well-being, including physiological, developmental, psychological, emotional, family, cultural, and environmental factors. 2. The holistic approach should not look at just the physical problem the client is experiencing. 3. A review of lifestyle is important but does not provide a holistic approach. 4. The family history is important but does not include other aspects that may impact physical and emotional well-being. Assessment Application Objective - 4 Page 10 Difficulty - 2 16) A nurse is evaluating the client’s progress toward meeting the following objective of a teaching plan, “The client will list signs of hypoglycemia before discharge.” What missing factor will make it difficult for the nurse to evaluate whether the client has met this objective? 1) Time frame 2) Specific criteria to be met 3) Method of evaluation 4) How the information was taught 16) 2 Explanation: 1. Time frame has been included in the objective. 2. The criteria is too general; the objective needs to be more specific (e.g., list 5 signs). 3. The method of evaluation is not part of the objective. 4. The teaching strategy is not part of the objective. Evaluation Knowledge Objective – 8 Page – 13, 18, 19 Difficulty - 3 17) A nurse is required to teach Mr. Hammond how to administer his insulin injection. What is an appropriate teaching strategy for the nurse to use? 1) Discussion 2) Demonstration 3) Printed directions 4) Role play
17) 2 Explanation: 1. Discussion is best used with cognitive learning. 2. Demonstration and practice are effective strategies for teaching psychomotor skills. 3. Printed material is not effective in teaching a psychomotor skill. 4. Role play will allow an understanding of others point of view but is not effective in teaching a psychomotor skill. Evaluation Knowledge Objective – 8 Page – 19 (Table 1.2) Difficulty - 2 18) A nurse is caring for a newly admitted patient with Methicillin-resistant Staphylococcus Aureus (MRSA). What is the primary goal of the initial health assessment? 1) Determine the client’s current state of health 2) Assess the client’s knowledge about MRSA 3) To determine client allergies 4) Determine how frequently the client is able to change positions 18) 1 Explanation: 1. Health assessment goals are to determine the client’s current state of health and ongoing healthpromotion activities, predict risks to health, and identify health promoting activities. 2. Assessment of the client’s knowledge is important, but is not the primary goal of doing a health assessment. 3. Determining the client’s allergies is important, but the goal of a health assessment is broader. 4. It is important to determine what limitations the client has, but it is not the primary goal of a health assessment. Application Comprehension Objective - 3 Page – 5 Difficulty Level - 3
19) While the nurse assesses a client who is hospitalized for an acute exacerbation of chronic obstructive pulmonary disease, the client becomes short of breath. The nurse recognizes the need to stop the assessment to initiate respiratory support interventions. This is an example of which phase of critical thinking? 1) Collection of information 2) Evaluation 3) Generation of alternatives 4) Analysis of the situation 19) 4 Explanation: 1. The nurse has collected data and has analyzed the situation. 2. Evaluation looks at whether there are omissions in the critical thinking process and whether outcomes have been achieved.
3. This step looks at steps to follow to resolve a problem. 4. The nurses has analyzed the data and drawn valid conclusions. Planning Analysis Objective - 6 Page – 15 Difficulty Level - 2
20) What is an example of subjective data? 1) The bowel sounds are hyperactive in all four quadrants. 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 very pale. 20) 2 Explanation: 1. Bowel sounds are objective data. 2. Subjective data is information the client experiences and communicates to the nurse. 3. This is objective data as it can be seen /felt by the nurse. 4. This is an objective assessment made by the nurse. Assessment Application Objective –4 Page – 5 Difficulty Level - 1 21) A client with hepatitis B is admitted to the hospital. What should the nurse keep in mind regarding client confidentiality? 1) Information sharing is limited to those directly involved in the client’s care. 2) All members of the health care team should be aware of this information. 3) This information should not be included in the client’s chart. 4) The medical records are open to any hospital employee, including administration. 21) 1 Explanation: 1. Confidentiality means that information sharing is limited to those directly involved in the client’s care. 2. Not all members of the health care team have access to the chart, only those who are directly caring for the client. 3. This information should be available to those health care professionals directly involved in the client’s care. 4. Hospital records are only open to those directly related to the care of the client. Assessment Application Objective – 4 Page – 6 Difficulty Level - 3 22) What is included in the planning step of the nursing process?
1) 2) 3) 4)
Setting priorities Teaching the client Making a referral Analyzing the assessment data
22) 1 Explanation: 1. Priority setting, stating goals, and listing strategies to meet the goals are all part of the planning process. 2. Teaching is an intervention. 3. Making a referral is an intervention. 4. Analysis of data is part of determining the nursing diagnosis. Implementation Knowledge Objective – 5 Page – 13 Difficulty Level - 2
23) Mr. James, 59 years old, is hospitalized with end stage liver failure secondary to years of alcoholism. What is the nurse’s first step when using a critical thinking approach to collect information about this client? 1) Organizing the approach to use 2) Identifying assumptions 3) Identifying missing information 4) Identifying any inconsistencies 23) 2 Explanation: 1. Before developing an organized approach to collect information the nurse needs to identify assumptions that may impact the assessment. 2. The nurse needs to identify assumptions that may misguide or misdirect assessment. 3. Identifying gaps in information is important, but the nurse needs to identify assumptions made about the client. 4. It is important to identify and follow-up on inconsistencies in the information, but it is not the first step. Application Comprehension Objective – 6 Page – 14 Difficulty Level - 2
24) In the nurse’s teaching plan, what objective addresses the psychomotor domain? 1) The client will discuss three interventions for low blood sugar. 2) The client will describe four symptoms of low blood sugar. 3) The client will demonstrate how to draw up the correct dose of insulin. 4) The client will define diabetes mellitus. 24) 3
Explanation: 1. This goal is in the cognitive domain. 2. This goal is in the affective domain. 3. This goal is in the psychomotor domain. 4. This goal is in the cognitive domain. Evaluation Comprehension Objective – 8 Page – 18 (Table 1.1), 19(Table 1.2) Difficulty Level - 2 25) Which statement best describes the active role of the nurse as an educator? 1) Nurses must consider learning needs, goals, objectives, content, teaching methods, and evaluation when carrying out client education. 2) Teaching plans are developed for informal teaching when distinct needs are identified or when common needs are recognized. 3) The nurse should refer the client to other health care providers who specialize in the area of need. 4) Teaching is to be delegated to the advanced practice nurse specialist or the nurse educator. 25) 1 Explanation: 1. These are the aspects of client teaching the nurse needs to consider. 2. Informal teaching does not involve teaching plans. 3. The nurse at the bedside has a role in teaching clients and cannot be delegated to others. 4. Teaching can be done in collaboration, but the nurse at the bedside has a role as an educator. Planning Comprehension Objective – 8 Page – 17 Difficulty - 2
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is admitting a client and notes a place for subjective data on the history form. What method will the nurse use to gather the required subjective data? 26) interview Explanation: Subjective data is gathered from the interviews of primary and secondary sources. The interview includes the health history and focused interview. Assessment Knowledge Objective 4 Page 5 Difficulty - 2
Chapter 2 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) What statement most accurately describes the concept of health promotion? 1) A psychological model that attempts to explain and predict health behaviours 2) A process of enabling people to increase control over their health and its determinants 3) The economic and social conditions that influence the health of individuals and their communities 4) Understanding the psychosocial and physical processes of disease in order to promote good health 1) 2 Explanation: 1. This statement describes the Health Belief Model. 2. This statement describes the basis of health promotion. 3. This is a description of the social determinants of health. 4. The medical model fits this description. Assessment Knowledge Objective 1 Page 23 Difficulty 2 2) A couple who both have a positive family history of sickle cell anemia are concerned about the potential of having a child with sickle cell disease. Which statement indicates that the couple wishes to participate in primary prevention? 1) “We both need to be treated for sickle cell anemia before we can have a baby.” 2) “We will have blood tests to determine if we are carriers.” 3) “We need to see a genetics counsellor to discuss the potential for having a child with sickle cell disease.” 4) “Neither one of us has sickle cell disease, so any baby we had would be safe from the disease as well.” 2) 3 Explanation: 1. It is not stated that either partner has sickle cell disease, so there is no need for treatment prior to pregnancy. 2. Both individuals being tested for carrier status would be considered secondary prevention, as it deals with early detection of health problems. 3. Primary prevention focus is to improve or maintain health for the individual. Seeking out a genetics counselor is considered primary prevention. 4. Despite the fact that neither the man nor woman has sickle cell disease, there is still a possibility that a child could be born with the disease, depending on the carrier state of the parents. Diagnosis Application Objective 1 Page 30 and 31 Difficulty = 2 3) A nurse is working to develop a community garden to provide food security for people living in an impoverished area of the city. What social determinant of health is present in this situation? 1) Income and social status 2) Culture
3) Social environment 4) Physical environment 3) 1 Explanation: 1. Food insecurity is largely the result of low income and financial insecurity. The community garden provides impoverished people access to affordable healthy food. 2. The community garden may be helping many marginalized people access healthy food, but it is not changing the underlying factors leading to marginalization. 3. A community garden may bring people together to form a sense of community, but the main determinant of health addressed through a community garden is food security for low income people. 4. Physical environment is generally about clean air, water, and soil. Planning Application Objective 2 Page 23 Difficulty 2 4) A nurse is discharging a client who had a cerebral vascular accident (CVA) and will be cared for at home by her husband. The nurse knows that the client’s husband understands the need for tertiary prevention when he makes which statement? 1) “She will need instruction on using her walker.” 2) “She will need to have her flu shot this year.” 3) “She must have coagulation studies completed weekly.” 4) “She needs to have her cholesterol checked every 2 months.” 4) 1 Explanation: 1. Tertiary prevention focuses on reducing loss of function, maximizing health, and minimizing disability. Learning to use a walker to aid ambulation is an example of tertiary prevention to reduce the loss of function. 2. Having a yearly flu shot is an example of primary prevention. 3. Having blood work taken weekly to review clotting times is a screening procedure and is an example of secondary prevention. 4. Having a cholesterol screening is an example of secondary prevention. Evaluation Application Objective 1 Page 30 and 31 Difficulty 2
5) A nurse works in a large urban hospital using telehealth to provide cardiac consultations to clients in rural settings. What principle of primary health care is evident in this scenario? 1) Public participation 2) Intersectoral cooperation 3) Activism 4) Accessibility
5)4 Explanation: 1. Public participation means that the public is fully involved in decision-making about personal health care and health system issues. This is not the focus in this scenario. 2. Intersectoral collaboration means that there is integration with other sectors that impact health such as education, social services, and justice. 3. Activism is the direct action (for example, political lobbying) taken to support a health goal. Activism is not one of the principles of primary healthcare. 4. Equitable access to health and health services is one of the guiding principles of primary health care that is illustrated in the scenario where a rural population is able to access specialized healthcare through technology. Implement Application Objective 1 Page 24 and 25 Difficulty 2 6) A mother calls the provincial 'Nurse Hotline' concerned about her toddler's flu symptoms. What principle of primary healthcare is evident in this situation? 1) Public participation 2) Intersectoral collaboration 3) Appropriate technology 4) Advocacy 6) 3 Explanation: 1. Public participation means that the public is fully involved in decision-making about personal health care and health system issues. This is not the focus in the scenario. 2. Intersectoral collaboration means that there is integration with other sectors that impact health such as education, social services, and justice. 3. A telephone triage system is an example of an effective and affordable technology used to benefit health and reduce the reliance on emergency departments. 4. Advocacy is not one of the principles of primary healthcare. Implementation Application Objective 1 Page 24 and 25 Difficulty 2
7) A nurse working in a remote northern community has noticed a sharp increase in the number of teens coming to the clinic with sexually transmitted infections (STIs). What strategy is an example of an upstream approach to the problem? 1) Have a condom machine installed in the washrooms at the high school 2) Schedule more nurses to work at the clinic to handle the increased case load 3) Hold an educational session with the students on STIs 4) Provide free condoms at the health clinic 7) 3 Explanation:
1. Upstream approaches address the root cause of the problem. Installing a condom machine will not address the problem if the students don’t use the condoms. The teens need to understand how STIs are transmitted and how to prevent transmission. 2. Having more nurses work at the clinic is a downstream approach because this strategy focuses on treatment rather than the cause of the problem. 3. An educational session is an upstream approach because it provides the nurse with an opportunity to address the cause of the problem such as a lack of understanding about transmission of sexual infections. 4. This strategy does not address the cause of the problem. Providing free condoms will not decrease the incidence of STIs if the condoms are not used or are used incorrectly. Planning Analysis Objective 1 Page 29 and 30 Difficulty 2 8) A group of nursing students are organizing a health fair at the university. What activity is an example of secondary prevention? 1) Provide free condoms at the health booth 2) Have participants complete a screening tool to determine mental health wellness 3) Develop a handout on the adverse effects of alcohol abuse 4) Supply a pamphlet on Canada's Food Guide with a sample meal plan 8) 2 Explanation: 1. This is a primary prevention activity. 2. Secondary prevention focuses on early detection of diseases or conditions in a particular population. Screening tests are an effective method of achieving this goal. 3. A handout on alcohol abuse is aimed at preventing or reducing disease/injury from occurring, which is a primary prevention activity. 4. Providing information on a well-balanced diet is an example of an educational strategy, which is a primary prevention activity. Implementation Analysis Objective 1 Page 30 and 31 Difficulty 2
9) Mr. Smith has been living in a one bedroom apartment with six other people. He has recently been diagnosed with drug resistant tuberculosis (XDR-TB). What nursing action is consistent with the goals of tertiary prevention? 1) Complete TB skin testing on Mr. Smith's roommates 2) Start prophylactic TB medications with each roommate 3) Schedule a daily appointment for the client to be given his TB medication 4) Have the client wear a surgical mask 9) 3 Explanation: 1. Skin testing for TB is a screening procedure; therefore, this is an example of secondary prevention.
2. Providing prophylaxis medications to prevent illness after exposure to a communicable disease is an example of secondary prevention. 3. Having the nurse give the client his medication, known as direct observation and treatment (DOTS), is a tertiary prevention method that involves monitoring medication compliance to treat diseases. 4. The strategy of wearing a mask will prevent or reduce the risk of disease transmission from occurring; this is an example of primary prevention. Implementation Application Objective 1 Page 30 and 31 Difficulty 3 10) Mrs. Singh, 70 years old and a widow of two years, is at the clinic for a follow-up health assessment. Mrs. Singh was diagnosed with hypertension 6 months ago and was started on health plan that includes two different antihypertensive medications, an exercise program, and dietary changes. Mrs. Singh reports that she has not attended the exercise program at the community centre and did not renew her prescription. What question should the nurse ask to better understand the client’s situation? 1) "What social supports do you have at home and in the community?" 2) "What cultural barriers are preventing you from following the health plan?" 3) "What is your financial status?" 4) "What challenges are you experiencing with following the health plan?" 10) 4 Explanation: 1. It is important for the nurse to assess the social determinants of health that may be impacting the client's ability to follow the health plan. The client may or may not lack an adequate social network; therefore, a question that is broader in scope would be of more value to ask at this juncture. 2. It is inappropriate to assume that the client is experiencing cultural barriers. The nurse needs to ask a broader and a more culturally sensitive question. 3. This is a rather abrupt question to initiate a discussion with the client. 4. This question is broad and will allow the client to identify issues she may be having in following the health plan. This question will allow the nurse to assess a wider range of social determinants that may be impacting this client. Assessment Application Objective 3 Page 23 Difficulty 2 CASE 1 A nurse is working with a student council at a local high school to develop a health promotion project that will benefit the entire school. The students identified a need to address bullying within the school. QUESTIONS 11 to 13 refer to this case. 11) The students want to develop anti-bullying policies at the school and have arranged a meeting with the parent advisory committee, teachers, administrators, and other students. What principle of primary health care is evident? 1) Public participation 2) Advocacy 3) Intersectoral collaboration
4) Social justice 11) 1 Explanation: 1. Public participation means that the public is fully involved in decision-making about personal health care and health system issues. All the key stakeholders have been included in the anti-bullying discussions. 2. Although advocacy is an important concept in the Population Health Promotion model it is not a principle of primary health care. 3. Intersectoral collaboration means that there is integration with other sectors that impact health such as education, social services, and justice. This is not case in this scenario. 4. Social justice is an important concept in the Population Health Promotion model; it is not a principle of primary health care. Implementation Application Objective 1 Page 24 and 25 Difficulty 1 12) The nurse is aware of the need for evidence-based decisions to strengthen the development of the antibullying health promotion activities that the student council wants to pursue. What would be a credible source to consult? 1) Bullying sites on the internet 2) A needs assessment completed at the school 3) Another high school's anti-bullying program 4) Peer-reviewed research studies 12) 4 Explanation: 1. There are some wonderful resources available on the internet, but the sites need to be from a credible agency or source. This statement does not indicate the reliability of the internet source. 2. A needs assessment will be an important step in the process of developing a program that meets the unique needs of the school, but this is not an evidence-based source. 3. The evaluation of another school’s policy would be acceptable, but the council needs to make sure that the other school's program was based on credible sources of information tnd address whether the program focused on the right issues, took effective action, and produced sound results. 4. Peer-reviewed research studies that focus on the issue of bullying is the most credible source to use. Implementation Knowledge Objective 4 Page 27 Difficulty 1 13) The student council, in collaboration with the nurse, developed an anti-bullying school program that includes a social marketing campaign, educational sessions, and a safe reporting mechanism. What would be the most effective approach for delivering the educational session? 1) Use an expert like the nurse to deliver the session at a school-wide assembly 2) Have peers deliver the session to each grade 3) Develop a handout that can be distributed throughout the school 4) Make and post a YouTube video.
13) 2 Explanation: 1. Although the nurse would certainly have credibility, peer-led programs are most effective with this age group. Also, a large group is not as effective when it comes to discussion and answering student questions. 2. Peer-led educational programs are effective and smaller groups are more conducive to discussion. 3. Although a handout may be one strategy used as part of a larger educational program, they should not be the only strategy used because it may not reach all of the student body. 4. YouTube videos certainly appeal to this population but it is not the most effective approach to deliver the school-based educational program. This may be one tool used to support the antibullying program. Implementation Analysis Objective 3 Page 33 Difficulty 2 END OF CASE 1 14) What statement best defines the concept of social justice? 1) Entails direct action taken to support a health goal 2) All people have an equal entitlement to health 3) The practice of supporting something or someone 4) Fair distribution of society's benefits, responsibilities, and consequences 14) 4 Explanation: 1. This statement defines the term activism. 2. This is the definition of health equity. 3. This statement describes the term advocacy. 4. This is a definition of social justice. Assessment Knowledge Objective 1 Page 25 and 26 Difficulty 1 15) A nursing student is preparing an educational program concerning breast cancer. The focus of the program is primary prevention. What topic would meet the goal of a primary prevention strategy? 1) A dietary discussion concerning the connection between breast cancer and dietary intake 2) Yearly clinical breast examination 3) Canadian Cancer Society recommendations for mammography 4) Treatment options available for breast cancer clients 15) 1 Explanation: 1. Primary prevention has a focus geared toward health promotion and disease prevention. 2. Yearly clinical breast examination is an example of a secondary level of prevention. 3. The goal of mammography is to screen for early identification of illness which is the focus of secondary prevention. 4. Treatment options are a form of tertiary prevention.
Planning Application Objective 1 Page 30 Difficulty 2 16) A nurse is performing a health assessment. What question will provide the most information about a client’s social support network? 1) “Do you live alone?” 2) “Did you graduate from high school?” 3) “Are you involved in any type of exercise programs?” 4) “Who will assist in your care after discharge?” 16) 4 Explanation: 1. A closed-ended question will not elicit the information required to assess social support networks. 2. This closed-ended question would provide information on educational level but not social support networks. 3. Determining participation in exercise programs will not provide information concerning social structure. 4. An open-ended question will solicit the greatest amount of information and this question will begin a discussion on social support. Assessment Application Objective 2 Page 23 Difficulty 2
17) A nurse is working with an elementary school to develop a healthier school environment. The teachers are particularly concerned about the numbers of overweight children they see in their classrooms. The school is on a tight budget. What would be the most appropriate health promotion strategy to implement at this school? 1) Initiate a lunch hour walking program 2) Implement a quality school meals program 3) Start a course in health education 4) Work with the vending machine company to provide healthier drink and food options 17) 1 Explanation: 1. Increasing the physical activity of the children will help them to maintain a healthy weight. A lunch hour walking program would not cost any money and would be a relatively easy strategy to initiate. 2. Improving the access to health food through a meals program would be a worthwhile initiative; however, it would take some time to implement and there is the potential to impact the school budget in a negative way. 3. This is another worthwhile initiative that would take time and money to implement and would not address the school budget issue. 4. This strategy is workable and would not cost the school anything. The down side of this strategy is that it only targets the students who use the vending machine and would not be applicable to all the students. Implementation
Application Objective 3 Page 32 and 33 Difficulty 2 18) Mr. Walters, 54 years old, had emergency abdominal surgery last night for a perforated bowel. He also has a history of hypertension, type 2 diabetes, and glaucoma. The nurse is administering his morning medications. Which drug classification is a secondary prevention initiative? 1) Enalapril, antihypertensive 2) Metformin, oral anti-diabetic agent 3) Pilocarpine, miotic 4) Enoxaparin, low molecular weight heparin 18) 4 Explanation: 1. Enalapril treats hypertension and is an example of tertiary prevention. 2. Metformin treats hyperglycemia brought on by the type 2 diabetes and is an example of tertiary prevention. 3. Pilocarpine is used to decrease intraocular pressure associated with glaucoma and is tertiary level prevention. 4. Enoxaparin is used to prevent the formation of a deep vein thrombosis in the post-operative period and is an example of secondary prevention. This is an example of using a medication prophylactically to prevent illness. Assessment Analysis Objective 4 Page 30 and 31 Difficulty 3 19) A nurse working in a remote northern community wants to improve the health of the community by decreasing the number of low-birth-weight infants in the community. What strategy would be best to achieve this goal? 1) Establish a public education program on the benefits of eliminating tobacco use during pregnancy 2) Speak about the importance of daily folic acid supplementation in prenatal classes 3) Develop a pamphlet on the benefits of breastfeeding 4) Ask physicians to spend more time discussing nutritional needs during pregnancy 19) 1 Explanation: 1. Smoking during pregnancy doubles the risk of having a low-birth-weight infant. Smoking cessation programs that focus on the benefits of eliminating tobacco use are more successful than those programs that focus on the harmful effects of smoking during pregnancy. 2. Folic acid supplementation is important for fetal neural development but this health strategy does not influence infant birth weight. 3. Breastfeeding provides the infant with important health benefits but this is a post-partum strategy and will not influence the number of low-birth-weight infants in the community. 4. Nutrition is an important factor in a healthy pregnancy but smoking during pregnancy is the single most important determinant in low-birth-weight infants. Planning Application Objective 3
Page 32 Difficulty 3 20) Mr. Bob, 30 years old, is in hospital recovering from injuries sustained in a motor vehicle accident. The nurse notes on the admission history that Mr. Bob is a smoker. The nurse approaches Mr. Bob to assess whether he is interested in strategies to help him quit smoking. What process is the nurse engaging in? 1) Primary prevention 2) Tertiary prevention 3) Health belief modification 4) Health promotion 20) 4 Explanation: 1. The nurse is incorporating health promotion activities within the acute care environment. If the client decided to set the goal to quit smoking that would be primary prevention but at this point the nurse is just exploring the idea with the client. 2. This is not a tertiary prevention activity. 3. The client is not doing anything to change his health behaviours at this point. 4. The nurse is engaging in the process of health promotion by exploring with the client whether he wants to improve his own health. Assessment Application Objective 3 Page 34 Difficulty 2 21) A family has contacted the public health nurse wanting to know more about how to promote their cardiovascular health because they are overweight and sedentary. During the family health assessment the nurse learns that many of the first degree relatives have hypertension and angina. What determinant of health is present in this family? 1) Education 2) Genetic 3) Gender 4) Physical environment 21) 2 Explanation: 1. There is no information about the education level of the family. 2. There is a strong genetic risk factor for cardiovascular disease. 3. Gender can be a risk factor for certain diseases but in this scenario the genetic determinant of health is the dominant influence. 4. Physical environment is generally about clean air, water, and soil. Assessment Knowledge Objective 1 Page 23 Difficulty 1 22) What is an example of an upstream policy that benefits the whole community? 1) Establish a free needle exchange program 2) Develop a campaign on the daily folic acid supplementation for women in childbearing years
3) Seat belt laws for all motorized vehicles 4) Launch HPV vaccination program for girls aged 9 to 13 years 22) 3 Explanation: 1. This initiative would be an upstream strategy to reduce the transmission of HIV and Hepatitis C but it only benefits a small subsection of the general population. 2. This upstream initiative benefits a subpopulation of the community. 3. This upstream approach keeps all members of the community safe. 4. This upstream activity will benefit a small subgroup in the community. Assessment Knowledge Objective 1 Page 29 and 30 Difficulty 3
23) A nurse has been contracted to complete annual spirometry testing for the city's firefighters. What level of prevention is this activity? 1) Primary 2) Secondary 3) Tertiary 4) This is not a prevention activity. 23) 2 Explanation: 1. Primary prevention strategies are designed to prevent or reduce the risk of disease from occurring by improving or maintaining general health, boosting the immune system, or preventing injury. 2. Spiromtery is a screening tool to assess lung health. Secondary prevention focuses on early detection of disease or conditions in a particular population. 3. Tertiary prevention focuses on reducing loss of function, maximizing health, and minimizing disability. 4. Spirometry is an example of a secondary prevention initiative. Planning Knowledge Objective 1 Page 31 Difficulty 1 24) The union at a large industrial company has contacted the occupational health nurse to discuss ways to decrease employee stress. What would be an appropriate stress relieving strategy? 1) Organize a monthly after work social at the bar 2) Arrange for a noon hour yoga class 3) Hold a focus group with the employees 4) Offer one-to-one counselling sessions 24) 3 Explanation:
1. Stress is a determinant of health and the employees need a healthy outlet for their stress. Socializing can be a great way to manage stress, but it would be better if this activity wasn’t linked to alcohol. 2. Yoga may a great way to relieve stress, but a noon hour class will only be available to the employees that work the day shift. 3. It is important to understand the root cause of the stress so that more specific stress reduction strategies can be developed. Holding a focus group with the employees will provide the nurse with the information needed to assist the employees in a meaningful way. 4. Some employees may benefit from one-to-one counseling, but this not an effective method for addressing the company-wide issue of stress. Implementation Application Objective 3 Page 24, 33, and 34 Difficulty 2
25) Mrs. Langois, 48 years old, lives alone in an apartment. She is taking medications to lower her blood pressure. What secondary prevention strategy should the nurse advocate? 1) Get annual flu vaccination 2) Have an annual Papanicolau test 3) Have blood pressure checked monthly 4) Exercise at least three times a week 25) 2 Explanation 1. This is a primary prevention strategy, as it will prevent disease. 2. This is a secondary prevention strategy, as it focuses on early detection. 3. This is a tertiary prevention strategy, as the nurse is monitoring the success of treatment and preventing complications. 4. This is a primary prevention strategy, as it aims to improve or maintain health. Planning Analysis Objective 1 Page 30, 31 Difficulty 2
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) What were the original principles of primary health care as established by the World Health Organization in 1978? (select all that apply) 1) Equitable access to health and health services 2) Public participation 3) Appropriate technology 4) Intersectoral collaboration 5) Reorientation of the health system 6) Promotion of health and prevention of disease and injury 26) 1, 2, 3, 4, and 6 Explanation:
The declaration of Alma-Ata emphasized the need for health providers to work with people to assist them in making decisions about their health and help them understand how to meet health challenges in ways that are affordable, acceptable, and sustainable over the long term. Primary healthcare was developed to guide effective healthcare delivery and incorporates all levels of prevention (primary, secondary, and tertiary) and includes the concepts of accessibility, public participation, health promotion, appropriate technology, and intersectoral cooperation (WHO, 1978). Assessment Knowledge Objective 1 Page 24 and 25 Difficulty 1
Chapter 3 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) The mother of a two-year-old tells the nurse that she is concerned about her child’s lower back curving in and the child’s belly sticking out. How should the nurse respond? 1) Ask the mother to buy the child bigger clothes 2) Give the mother the first available appointment to see the physician 3) Obtain a referral to the pediatric orthopedic clinic 4) Reassure the mother that this is normal for a toddler 1) 4 Explanation: 1. This does not address the mother concerns. 2. There is no need to see a physician as the lordosis and protruding abdomen are normal in toddlers. 3. There is need to make a referral as the lordosis and protruding abdomen are normal in a toddler. 4. Young toddlers have pronounced lordosis, which makes their abdomens protrude. This is a normal finding, and the mother should be assured of this. Intervention Application Objective – 4 Page – 43 Difficulty – 2 2) A nurse is teaching parents of a child in Piaget’s sensorimotor stage of development. What would be an appropriate activity to help the child accomplish developmental tasks of this stage? 1) Buying more colourful toys 2) Playing with water toys in the bathtub 3) Buying some blocks with numbers 4) Playing peek-a-boo 2) 4 Explanation: 1. This stage deals with helping the child learn that objects continue to exist even when not seen. 2. This stage is from birth to 2 years and playing with toys in the tub would not be appropriate. 3. Buying blocks will help with coordination, but not with learning that things still exist when not seen 4. In the sensorimotor stage (birth to 2 years) the infant attains a sense of object permanence, which is the knowledge that objects continue to exist when not seen. Playing peek-a-boo helps the child know that someone is there even when not seen. Evaluation Analysis Objective – 2 Page – 39, 44 Difficulty – 2
3) A nurse is writing a care plan for a pediatric client who is working on Erickson's developmental Stage 4. What would be an appropriate goal for a child in this stage? 1) Stating that the sense of shame and self-doubt has become less intense 2) Helping the child develop a sense of identify and exploring attitudes and beliefs 3) Completing school homework and have passing grades within one month 4) Volunteering to help with one or more community projects each week 3) 3 Explanation: 1. Shame and self-doubt may occur in toddlers if they do not learn independence. 2. This would be a task for the child in Stage 5, Identity vs. Role Confusion. 3. Stage 4 (6–11 years) is 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, and withdrawal from school and peers may result. Reaching a goal of completing school homework and having passing grades within one month would help develop a sense of competency and creativity and would require perseverance to accomplish this goal. 4. Community involvement is seen in later years to prevent isolation and stagnation. Planning Application Objective – 2 Page – 40, 48 Difficulty – 2
4) A nurse is working at a Senior Centre and has just counselled a client experiencing a crisis in Erickson’s Integrity vs. Despair developmental stage. What suggestion would be the most appropriate? 1) Buying a bigger house to house a divorced adult child 2) Getting a pet 3) Cataloguing family pictures 4) Playing sports 4) 3 Explanation: 1. Having an adult child move back in the home may cause the senior to feel like a failure as a parent. 2. A pet can be good company for a senior, but does not address the need for the senior to feel a sense of satisfaction in his/her life at this stage. 3. During the stage of Integrity vs. Despair an individual will either feel contentment and satisfaction with their place in life or feel sadness and a sense of loss. Cataloguing family pictures may bring a sense of satisfaction to the individual. 4. Playing sports may be healthy but does not help the senior reflect on his life and feel a sense of satisfaction. Intervention Application Objective – 2 Page – 40, 53 Difficulty – 2
5) A nurse is interviewing the mother of a toddler who complains that her child continues to hide and have bowel movements in the diaper, but will use the toilet to void. The nurse would correctly tell the mother that the child is in which of the following Freudian phases of psychological development? 1) Genital 2) Phallic 3) Anal 4) Latency 5) 3 Explanation: 1. The genital stage is when sexual urges awake. 2. During this stage the child discovers that the genitals can be a source of pleasure. It is a time of exploration and identifying with the same-sex parent. 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; sexual urges are repressed and the child focuses on the educational and social world. Assessment Application Objective – 2 Page – 39, 45 Difficulty – 1
6) The mother of a 5-month-old infant calls the health unit to report to the nurse that she has noticed that her infant still has tremors of the extremities and chin at times. How should the nurse respond? 1) Reassure the mother that these tremors are a normal part of the infant’s development 2) Give the mother the first available appointment to see the physician 3) Contact the pediatrician to see if he/she wants an EEG to be completed 4) Ask the mother to document the time of day of tremors and come in next week 6) 1 Explanation: 1. Tremors of the extremities or chin of an infant are normal and reflect immature myelinization and will disappear by one year when the myelinization of the efferent pathways matures. 2. The tremors are normal and a referral is not necessary. 3. The need to have an EEG is not indicated. 4. This is a normal behaviour in a 5-month-old infant and it is not necessary to determine a pattern. Intervention Application Objective – 3 Page - 40 Difficulty – 2 7) A nurse is counselling a middle-aged couple. The husband has been told by his wife that both men and women experience decreasing hormonal production during middle adulthood, and he asks the nurse if this is true. How should the nurse respond? 1) “Your wife has obtained some incorrect data.” 2) “Why do you ask?” 3) “Your hormonal levels increase, not decrease with age.” 4) “Your wife is correct. Men do have a decrease in hormone production with aging.”
7) 4 Explanation: 1. Men do experience a decrease in testosterone. 2. The nurse should avoid the use of why questions. 3. Hormone levels decrease in men and women, not increase. 4. During menopause, which usually occurs between ages 40 and 55, progesterone is not produced and estrogen levels fall. Men also have a decrease in hormonal production and experience a gradual decrease in testosterone. Intervention Knowledge Objective – 3 Page – 51 Difficulty –2 8) The father of Danny, 5 years old, tells the nurse that he is concerned that his son cannot ride a tricycle. What action should the nurse take first? 1) Reassure the father that this is normal 2) Refer the father to the pediatrician 3) Complete further growth and development assessments 4) Ask the father about any siblings and when they rode a tricycle 8) 3 Explanation: 1. A child should be able to ride a tricycle at 3 years of age. 2. Before making a referral the nurse should ascertain whether there are any other developmental delays. 3. Gross and fine motor development should be completed after the toddler years, and a preschool child should be able to pedal a tricycle. A nurse should obtain additional assessments related to growth and development for this child. 4. The age that Danny’s siblings rode a tricycle does not negate that Danny is very late in learning this skill. Assessment Application Objective – 3 Page – 44, 46 Difficulty – 2 9) A nurse is working in a health clinic and performing a height and weight check of a young client. When plotting the findings on a growth chart, the nurse notes a slowed growth pattern. What action would be appropriate for the nurse at this time? 1) Obtain an endocrinologist referral 2) Perform a nutritional assessment 3) Wait until the next visit to intervene 4) Assess for circulatory problems 9) 2 Explanation: 1. There is no indicator that there is an endocrine problem. 2. Slowed growth is an early indicator of inadequate nutrition. 3. As malnutrition is the most common cause of slowed growth pattern, a delay will increase the effects of the poor nutrition. 4. Malnutrition is the most common cause of a slowed growth pattern in children.
Assessment Analysis Objective – 4 Page – 55 Difficulty – 3 10) What would be the best assessment tool for a nurse to use for a 14-year-old male who is experiencing behavioural problems? 1) Family Psychosocial Screening 2) Eyberg Child Behaviour Inventory 3) Ages and Stages Questionnaire 4) Child Development Inventory 10) 2 Explanation: 1. This test assesses the psychosocial risk factors associated with developmental problems, including parental abuse. 2. The Eyberg Child Behaviour Inventory is a parent report scale of conduct problems in children ages 2 to 16. 3. This tool is used by parents to assess certain developmental areas in the child. 4. This tool measures general development in children age 15 months to 2 years. Assessment Application Objective – 4 Page – 54 (Table 3.2) Difficulty – 3
11) Aniljit, 6 months old, has been admitted to hospital for observation. The nurse is assessing the family and family interaction and learns that the family recently emigrated from India. The mother does all the care for her son while the father sits in the chair talking on the phone. What would be an appropriate assessment of this family? 1) Compromised family coping 2) A disinterested father 3) Risk for family violence 4) Cultural differences in childrearing 11) 4 Explanation: 1. There is no indication that the family is not coping. 2. The nurse has no basis for this assessment. 3. There is no evidence that family violence is an issue. 4. Paternal and maternal attachment differs between cultures. Planning Application Objective – 6 Page – 57 Difficulty – 2 12) A nurse is completing discharge teaching to the family of a hospitalized elderly adult. What is the most important point for the nurse to include in the teaching?
1) Reduce the amount of odour in the client's immediate environment 2) Install grab bars by the toilet and in the shower. 3) Speak louder as client's hearing decreases 4) Increase the lighting if the client wants to stay up at night 12) 2 Explanation: 1. Although this is important, the elderly have a loss of bone density and are more prone to injury from falls. Teaching to prevent injury is more important than reducing odours. 2. As aging occurs there is a loss of bone density and thus bones become more brittle. It is important to protect the elderly client from falls. Falls are a common problem in the elderly and can result in increased morbidity and mortality. 3. Speaking louder as the client's sense of hearing is reduced is not as important as protecting them from injury. 4. There is a loss of visual acuity, but increased lighting is not as important as protecting the elderly from injury. Implementation Application Objective – 3 Page – 52, 53 Difficulty – 3 13) A nurse is assessing the behaviours of preschoolers using Piaget's theories of development. What behaviour would the nurse expect of this group? 1) Pretending that they are princes and princesses 2) Focusing on many aspects of a given situation at once 3) Assuming everyone else in their world sees things as they do 4) Collecting and sorting objects by size 13) 3 Explanation: 1. Make believe play is commonly seen with the toddler age group. 2. Preschoolers 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. The ability to collect and sort objects is seen in school-age children. Assessment Analysis Objective – 2 Page – 39, 44, 46 Difficulty – 2
14) Mrs. Dubois, 27 years old, is to receive a routine health check-up. What intervention would the nurse include in this check-up? 1) Counselling on injury prevention 2) Vaccines for tetanus and diphtheria 3) Counselling on fluoride supplements 4) Information on diet and exercise 14) 4 Explanation: 1. Counselling for injury prevention is of greater concern for the adolescent age group. 2. Both tetanus and diphtheria immunizations occur in childhood.
3. Fluoride supplements are started in infancy to prevent tooth decay. 4. Interventions for periodic health examinations for ages 25 to 64 include counselling on diet and exercise. Intervention Application Objective – 6 Page – 50, 51 Difficulty –2 15) What behaviour indicates a 5-year-old child is successfully moving through Piaget’s cognitive stage of development appropriately? 1) Considering the differing opinions of their playmates 2) Recalling the good time experienced the previous weekend at the playground 3) Rationalizing why it is better to eat fruit than candy 4) Understanding their mother loves them as much as their older siblings 15) 2 Explanation: 1. The ability to consider the points of view of others does not occur until the Concrete Operations Stage. 2. The client 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. Rational thinking begins around the age of 11 and continues into adulthood. This is the stage known as Formal Operations. 4. The issue of maternal love does not impact this question. Evaluation Application Objective – 2 Page – 39 Difficulty – 2
16) During a routine well child check-up, the mother of a 3-year-old child reports concern with her child’s difficulty becoming toilet trained. When questioned, she reports the child has most difficulty using the toilet for bowel movements. What phase of Freud’s stages of development is the child having difficulty completing? 1) Oral 2) Phallic 3) Anal 4) Latency 16) 3 Explanation: 1. During the oral phase the mouth is the center of pleasure as is the case with newborns. 2. The phallic phase results when the focus of pleasure is on the genitals. 3. The child who is demonstrating difficulty becoming toilet trained is struggling with the anal phase of Freud’s stages of development. During this time the anus becomes the focus of gratification. 4. The latency phase begins between ages 5 and 6 and continues until puberty. This stage is used as a time of resolution for previous conflicts. Assessment
Application Objective – 2 Page – 39, 45 Difficulty – 2
17) Mr. Adams, 73 years old, voices concerns to the nurse regarding the seemingly continued loss of family and friends to illness and death. He states he is better off not making new friends as they will die anyway. What interpretation of this client is most accurate? 1) He is mastering Erickson’s stage of Integrity vs. Despair successfully. 2) He is having difficulty passing through the stage of Generativity vs. Stagnation. 3) He is struggling with the stage of Integrity vs. Despair. 4) Demonstrating unsuccessful completion of the Intimacy vs. Isolation stage of development 17) 3 Explanation: 1. A person successfully mastering this stage will view his life and relationships with contentment. 2. This stage, usually completed by age 65, focuses on a concern for guiding the next generation. A person either demonstrates productivity and creativity or begins to become self-absorbed and non-productive. 3. During the phase of Integrity vs. Despair, the client begins to face the loss of friends and family members. Acceptance of these losses results in successful movement through this stage. Failure to accept this stage of life will result in bitterness. 4. In the phase of Intimacy vs. Isolation adults find mates or face a life of loneliness. Evaluation Analysis Objective – 3 Page – 40, 53 Difficulty – 2 18) Yuri, 3 months old, is hospitalized with a respiratory infection. The parents report they do not believe in responding too rapidly when Yuri is crying, as they do not wish to spoil their child. What response by the nurse is most appropriate? 1) “I agree with your philosophy of child rearing.” 2) “There are many studies which support this belief.” 3) “Responding quickly to your baby’s cries will assist him in feeling secure.” 4) “Children who experience separation anxiety have been spoiled by their parents.” 18) 3 Explanation: 1. Even if this is true, the nurse’s personal beliefs are not relevant. 2. There is no research to support this view. 3. A timely response to infant crying does not result in a spoiled child. It promotes the infant’s sense of security and promotes independence during later stages of development. Children who have received inconsistent nurturing may exhibit clingy, angry, or distrustful behaviours. 4. Separation anxiety is seen when parents leave a 4–6 month old infant and the infant initially responds by crying. Intervention Coping and Adaptation; Application Objective – 5 Page – 42 Difficulty – 1
19) During a well baby check-up, the nurse notices the infant does not demonstrate the expected developmental milestones for this age. What should the nurse do first? 1) Initiate a consultation with social services for a home assessment 2) Get a referral to a pediatrician 3) Ask the parents questions about their play activities with the infant 4) Prepare the family for hospitalization for a neurological assessment 19) 3 Explanation: 1. This may be an option, but the nurse should assess the interactions between the parents and infant promoting development. 2. It is too early to get a referral; the nurse should assess the interactions between the infant and parents. 3. The nurse should first assess the parental knowledge and expectations concerning normal infant development. The parents may not be aware of the appropriate activities that will stimulate the child. 4. There is no need to prepare the parents for a negative outcome at this point in time. Assessment Analysis Objective – 5 Page – 43 Difficulty – 2 20) The parent of a 3-year-old child voices concerns about the child’s potential developmental delays. The parent reports their older child reached milestones significantly ahead of the younger child. An assessment reveals that the child is able to assist in dressing themselves and can play catch. Which response by the nurse is appropriate? 1) “Your child appears to be on target with the expected milestones for age.” 2) “Your older child may simply be smarter than your 3-year-old.” 3) “I would recommend extensive testing to determine the source of the delays.” 4) “Have you spoken with your physician about these delays?” 20) 1 Explanation: 1. The developmental tasks of the child are on track for age. 2. Advising the parent one child is “smarter” than another is potentially damaging, as well as inappropriate. 3. Testing is not warranted at this time. 4. There are not evident delays to review with the physician. Intervention Analysis Objective – 5 Page – 44 Difficulty – 1
21) The nurse is reviewing the developmental behaviours of an 8-month-old infant. Which behaviour indicates the need for follow-up assessments? 1) Can transfer objects from hand to hand 2) Moro reflex present 3) Positive Babinski reflex 4) Pulls self to standing position
21) 2 Explanation: 1. By 5 months an infant can start to transfer objects from one hand to the other. 2. The Moro reflex begins to disappear by 5 months. The presence of this reflex beyond that age warrants follow-up. 3. The positive Babinski reflex begins to disappear at 1 year. 4. Some babies may be able to pull themselves up to a standing position at this age. Assessment Application Objective – 5 Page – 41 (Table 3.1) Difficulty – 3 22) A nurse is performing the data collection for a physical examination on a 16-year-old boy. The boy, who is currently 162 cm, voices concerns about his lack of stature. He asks if he has reached his full height. What response by the nurse is most correct? 1) “You are finished growing at your age.” 2) “Is your father very tall?” 3) “Why do you hope to grow taller?” 4) “You may continue to grow into your early 20s.” 22) 4 Explanation: 1. Skeletal growth may continue until age 25. 2. Although a child’s height may relate to that of the parents, this statement does not respond to the client’s question. 3. Asking the teen about his motivation to grow taller does not respond to his question. 4. The skeletal system growth is completed by age 25. Intervention Application Objective – 5 Page – 50 Difficulty – 2
23) Mrs. Wilmot, 43 years old, reports concern about the weight gained over the past two years despite not having made any significant changes in her diet or exercise patterns. What factor may be responsible for the client’s reported changes in weight? 1) Increasing hormone levels 2) Increase in body mass index 3) Reduction in muscle nerve conduction 4) Hormonal changes of the female climacteric 23) 4 Explanation: 1. During this stage of life, hormone levels begin to decrease. 2. The increase in weight will result in an increased body mass index, not vice versa. 3. The changes in muscle and nerve development are not directly implicated in the body changes being reported. 4. During this client’s stage of development, there is a reduction in hormone levels as menopause approaches. The hormonal changes result in an increase in body weight. The amount of adipose tissue also increases.
Assessment Application Objective – 5 Page – 54 Difficulty – 2
24) The adult children of a 69-year-old man report they are becoming frustrated. They relate they are trying to get their father to “take it easy,” stop working, and reduce his social activities. They feel this will reduce his stress and allow him to live longer. How should the nurse respond? 1) “A slower pace will allow your father to remain productive longer.” 2) “Seniors who lack intellectual challenges demonstrate cognitive declines.” 3) “Reducing your father’s activities will increase his quality of life.” 4) “Retirement will promote rest and relaxation for your father.”
24) 2 Explanation: 1. A decline in activities will result in a decrease in functioning. 2. Studies have shown that seniors who continue to demonstrate intellectual interaction have higher cognitive function levels. 3. There is no evidence to support this. 4. A lack of activity is consistent with declines in function. Intervention Analysis Objective – 5 Page – 53 Difficulty – 3 25) What statement is true about factors that influence the growth and development of children? 1) Children in lower socioeconomic groups tend to weigh more. 2) Poor nutrition in childhood may cause some forms of dementia in older adults. 3) Cognitive and emotional well-being is seen in children who have affluent parents. 4) Growth patterns are primarily determined by nutrition. 25) 2 Explanation: 1. Generally children from lower socioeconomic groups have lower height and weight. 2. Balanced nutrition promotes brain development and prevents some forms of dementia in the older adults. 3. Well-being is related to interactions and activities between the child and parent, not economic status. 4. Growth is primarily determined by genetics. Assessment Application Objective – 6 Page – 55 - 57 Difficulty – 3 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
26) How does growth and development proceed? (Select all that apply) Cephalocaudal direction Generalized response to specific response Distal to proximal direction Simple to complex 26) X_ Cephalocaudal direction X_ Generalized response to specific response Distal to proximal direction X_ Simple to complex Explanation: Growth and development (G and D) does not proceed from distal to proximal but rather from proximal to distal (i.e., from the center of the body outward). G and D does proceed from generalized response to specific response, cephalocaudal direction, and from simple to complex. Intervention Application Objective – 1 Page – 38 Difficulty – 1
Chapter 4 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is preparing an in-service 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.” What term has the nurse defined? 1) Ethnicity 2) Assimilation 3) Ethnocentrism 4) Culture 1) 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 matches the definition described. 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. Planning Knowledge Objective – 1 Page – 65 Difficulty - 2 2) A 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. What would be an appropriate response by the nurse? 1) “What can we do to accommodate your needs during your stay here?” 2) “I will let your doctor know so he can discharge you.” 3) “Fasting is harmful to your body.” 4) “You must have food during times of illness.” 2) 1 Explanation: 1. Many faiths describe circumstances in which fasts may be altered or eliminated during times of illness and hospitalization. Additionally, 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 of, or beneficial to, the client. 2. There is no need to discharge the client. 3. This shows a lack of respect for the client’s beliefs. 4. This shows a lack of respect for the client’s beliefs. Assessment Application Objective – 2 Page – 61 (Box 4-1), 67, 69 Difficulty – 1
3) Mr. Crowfoot, 68 years old, is experiencing severe chest pain. A tribal elder has accompanied him to the hospital at the insistence of the client. The elder 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. What is the best action for the nurse to take in this situation? 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 3) 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 is capable of expressing his wishes and beliefs, and 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. As long as the client can express his wishes there is no need to consult the ethics committee. 4. At the moment, there is no behaviour exhibited that would warrant notifying hospital administration. Assessment Application Objective – 2 Page – 69, 70 Difficulty - 3 4) A nurse is assessing an Asian-appearing teenager, who is fluent in English, participates in high school sports, values riding his dirt bike, and who plans to go to college after graduating from high school. When asked where he is from, he says “Vancouver.” What does this behaviour indicate about the client? 1) He has no interest in answering the nurse’s questions. 2) He is embarrassed about his ethnicity. 3) He has adopted characteristics of the Canadian culture. 4) He is in denial of his Asian heritage. 4) 3 Explanation: 1. There is no indication that he is bored with the interview. 2. There is nothing to support that the teen is embarrassed about his appearance. 3. The teen’s answers indicate that he has adopted characteristics and behaviours of the Canadian culture. Often, those who have not adapted to or adopted the new culture are not fluent in the language of the new culture and do not display certain behaviours and characteristics of the new culture. 4. There is no evidence to support that he wishes to deny his heritage. Assessment Application Objective – 1 Page – 64, 67 Difficulty - 2
5) What should be included in a definition of culture? 1) A community maintained by a shared heritage, language, and religion. 2) The socially transmitted beliefs, behaviours, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision making. 3) The tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others. 4) The identification of an individual or group by shared genetic heritage and biological characteristics. 5) 2 Explanation: 1. An ethnic group is a community maintained by a shared heritage, culture, language, and religion. 2. Culture is the socially transmitted beliefs, behaviours, 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 biological or physical characteristics. Assessment Knowledge Objective – 2 Page – 63 Difficulty - 1
6) A nurse is completing a self-assessment to determine cultural competence. What behaviour would the nurse identify as being culturally competent? 1) Obtaining a ham sandwich for a Jewish client 2) Referring to an Asian client as an Oriental 3) Permitting a Bedouin to sleep on the floor 4) Advising a Catholic client that he will have to take mass at a time that does not interfere with lunchtime 6) 3 Explanation: 1. Jewish persons do not eat pork. 2. Referring to an Asian as an “Oriental” is offensive. 3. Bedouin immigrants from Arabia are nomads who are used to sleeping on the ground. 4. Attending Mass is an obligation of Catholics and takes priority over lunchtime assignments, which can be revised. Intervention Analysis Objective – 2 Page – 61 Difficulty - 2
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1) Creation of reserves 2) Forcing Aboriginal people to speak English 3) Outlawing spiritual practices 4) Restricting self-government
7) 3 Explanation: 1. Although the creation of reserves has impacted health and well-being, it has not had the greatest impact. 2. This was a way to assimilate them, but did not impact health. 3. Outlawing spiritual beliefs and rituals has had an impact on the health and social well-being of Aboriginal people. 4. This has impacted life on the reserves, but has not had the greatest impact on health. Assessment Knowledge Objective – 3 Page – 65 Difficulty - 3 8) A nurse is interviewing a client and wishes to determine the roles of various members of an extended family living together in one household. What statement would be appropriate for the nurse to use to obtain this information? 1) “What language is spoken in your house?” 2) “Are all of your family members working?” 3) “Tell me about the responsibilities of family members in your home.” 4) “Who makes the decisions for your family members?” 8) 3 Explanation: 1. This will not help the nurse understand the roles of the members of the household. 2. This will not provide the nurse with the information needed. 3. The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, but allows verbalization of information to clarify household roles for the nurse. 4. This will tell the nurse who makes decisions but not the roles of the individuals within the household. Assessment Application Objective – 5 Page – 62, 68, 69 Difficulty - 2 9) A nurse manager wants to ensure that the unit is delivering culturally appropriate healthcare. What would demonstrate this approach? 1) Insisting the staff teach clients English during their hospitalization 2) Paying the staff to learn a predominate language 3) Providing written materials in predominate languages 4) Developing phonetically written translation cards for the nurses to use 9) 3 Explanation: 1. This is not the role of the nurse, nor is it practical during hospitalization. 2. Paying the staff to learn a new language is not practical. 3. Translating signage, educational material for clients, and other materials into the languages of predominant groups in the local service area. 4. This may be helpful, but the tone of voice and pronunciation are part of good communication. Planning
Comprehension Objective – 2 Page - 61 (Box 4-1) Difficulty - 1 10) A nurse is interviewing a client and wishes to determine health practices that are important to the client’s beliefs. Which of the following would be appropriate for the nurse to use to obtain this information? 1) “Do you use any nontraditional medicines?” 2) “Tell me what you do to try to improve your health.” 3) “How many times have you been sick in your life?” 4) “How often do you have an annual physical examination?” 10) 2 Explanation: 1. This question may address only one aspect of the client’s beliefs. 2. The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, but allows verbalization of information to clarify health beliefs for the nurse. 3. This question has no bearing on the client’s health practices. 4. This question focuses on one aspect of the health practices. Assessment Application Objective – 5 Page – 68, 69 Difficulty - 2
11) Mrs. Choudary, 73 years old, has been admitted to hospital with pneumonia. Her extended family wants to stay with Mrs. Choudary as she does not speak English. What should the nurse do? 1) Tell the family to select one person who can stay 2) Ask the family to leave so that Mrs. Choudary can rest 3) Arrange for a room at a nearby hotel for the family 4) Discuss the situation with the family to arrive at a compromise 11) 4 Explanation: 1. Telling the family to leave shows a lack of respect for the family and their beliefs. 2. Asking the family to leave is inappropriate. The presence of the family may be important to Mrs. Choudary and may reduce her stress. 3. It is not the nurse’s responsibility to arrange accommodation for family unless asked to do so. 4. The nurse should negotiate a resolution to the problem that meets the needs of Mrs. Choudary, her family, and the hospital. Assessment Application Objective – 5 Page – 66 Difficulty - 2
12) The female nurse is examining a Vietnamese male and notes that he will not make eye contact with her during the assessment. The client appears very uncomfortable and is sweating and flushed. What action would be appropriate for the nurse in this situation? 1) Obtain a blood sugar reading 2) Ask the client if he would like a male to perform the examination 3) Assure the client that the exam will be over quickly 4) Continue with the examination 12) 2 Explanation: 1. There is no indication that the client has diabetes mellitus. 2. The client is Vietnamese and may prefer a same-gender healthcare provider. The nurse needs to gather additional data by asking the client his preferences and allowing verbalization of his discomfort. 3. This does not address the client’s concerns. 4. This shows a lack of respect for the discomfort the client is feeling. Assessment Application Objective – 5 Page – 68, 69 Difficulty - 3
13) A nurse is admitting a client and asks to see all medications taken. Among the bottles are various herbal preparations with unfamiliar names to the nurse. What action should the nurse take? 1) Write down all the names of the herbals and look them up later 2) Tell the client that herbals are ineffective and to throw them away 3) Inform the physician of the herbals 4) Ask the client what they are taken for and how often 13) 4 Explanation: 1. The client is the best source of information. 2. This shows a lack of respect for the client’s beliefs in alternative therapies. 3. Prior to contacting the physician the nurse should determine what herbals are being taken and for what purpose. 4. The nurse must assess prior to intervening and must understand that some cultures use herbal preparations in their health practices. The nurse needs to obtain additional data from the client about what the herbals are used for and how often they are taken. This information should be documented in the client’s record. Assessment Application Objective – 5 Page – 67, 69 Difficulty - 2
14) A nurse is assessing a nine-year-old child who has been admitted to the pediatric unit because of fever and an unexplained rash. Upon skin examination, the nurse notes large circles drawn around patches of the rash in indelible ink. The mother explains that the circles are there to prevent the rash from spreading. What action should the nurse take?
1) 2) 3) 4)
Notify child protective services with suspicion of neglect Explain that drawing on the body will not contain the rash Wash the circles away while cleaning the skin Note the information in the client’s record
14) 4 Explanation: 1. There is no evidence of medical neglect as the client’s family sought healthcare while also practicing a belief related to their culture. 2. The nurse could attempt to teach the futility of such a practice, and the client’s family may seem to accept that, but they are unlikely to believe it. 3. Attempting to wash the circles away is futile as the ink is indelible, and may cause the client and her family to feel belittled and disrespected. 4. The most appropriate action is to document the information in the client’s record. Long-standing cultural beliefs, particularly those about health, are ingrained in the members of a culture and are not easily discarded. Implementation Application Objective – 5 Page – 67, 68 Difficulty - 3
15) A nurse is preparing her client to eat lunch. She notes that the client refuses to look at the food on the meal tray and tells the nurse to take it away. The meal contains a chicken breast, green beans, fruit cocktail, and cottage cheese. What is the nurse’s most appropriate response? 1) “I know you are not hungry so just let me know when you want your tray.” 2) “It is important for you to eat so that you will get better.” 3) “Is there a problem with the food being sent to you?” 4) “I will get you some juice and crackers from the unit kitchen.” 15) 3 Explanation: 1. This is making an assumption and does not address why the client does not look at the food. 2. This may be true, but does not address why the client refuses to eat. 3. The nurse must be alert and aware of cultural preferences related to dietary habits. Further assessment in this situation is needed to obtain data about the client’s inability to look at or eat the food. 4. The nurse is making an assumption about what the client will eat, without checking with the client. Assessment Application Objective – 5 Page – 63 Difficulty - 2
16) While acting as a preceptor for a student nurse, the registered nurse notices the student voices frustration and a lack of appreciation for the healthcare beliefs and practices of clients whose beliefs differ from the student’s own. What action will best assist the preceptor to improve the student’s practice?
1) Advise the student to reduce displays of frustration 2) Encourage the student to look closely at his/her own cultural practices and beliefs 3) Give the student a written reprimand 4) Require the student to meet with a counselor concerning ethnic biases 16) 2 Explanation: 1. Simply reducing the comments and displays of frustration will not address the root cause of the problem. 2. Ethnocentrism is the belief of one’s personal beliefs to be superior to those held by others. The best way to begin to manage and reduce these feelings is to begin the process of self-awareness. 3. Administering a written reprimand will not handle the existing problem. The underlying cause must be handled to resolve the issue. 4. Counselling and discipline may be warranted later in the process if the behaviours continue or worsen. Planning Application Objective – 2 Page – 68 Difficulty - 1
17) What activity, by nurses, will help to ensure culturally safe care? 1) Basing care on the cultural beliefs of the client 2) Becoming familiar with the client’s culture and religion 3) Providing translators for non-English speaking clients 4) Looking at the assumptions and stereotypes held about a particular group 17) 4 Explanation: 1. This is not realistic and may in fact be detrimental to the client’s well-being. 2. The familiarity with the culture and religion does not ensure safe care. 3. Providing translators for all non-English speaking clients may be impossible. 4. To give culturally safe care, the nurse needs to look at the assumptions and stereotypes held about a group. Assessment Psychosocial Adaptation Knowledge Objective – 2 Page – 62, 68 Difficulty - 3 18) When providing an in-service to new graduate nurses, the nurse manager discusses the role of the nurse regarding acceptance of client cultural beliefs. What statement by a participant indicates further teaching is needed? 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) “My knowledge of the cultural values of others will increase in time.” 18) 3 Explanation:
The knowledge and acceptance of one’s own cultural values is essential to the acceptance and awareness of the values of the client. 2. The cultural values and beliefs of the client may require “sensitive” scheduling. 3. The nurse needs to reflect on their own cultural reality. Failure to have self-awareness can result in ethnocentrism. 4. Time and experience will increase the knowledge of the nurse. Evaluation Psychosocial Adaptation Application Objective – 2 Page – 62 (Box 4.2) Difficulty - 3 1.
19) A nurse is collecting data concerning the client’s primary health concern. The client reports having attempted to manage their illness using herbs. What response by the nurse is most therapeutic? 1) “What herbs have been used to manage your condition?” 2) “Does your physician know about your herbal remedies?” 3) “Don’t you realize your recovery may have been impeded by these herbal preparations?” 4) “When was the last dosage of the herbal remedies taken?” 19) 1 Explanation: 1. The comprehensive assessment of health requires the nurses 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 physician. 2. Asking about the physician’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. 3. Closed questions limit the amount of information obtained. Further, they may imply to the client that they have done something wrong. 4. The last dosage of the herbal remedies may be beneficial; however, it is not the most therapeutic question to be asked. Assessment Analysis Objective – 5 Page – 67 Difficulty - 2 20) A nurse is preparing to perform an assessment of the client’s social support systems. Which question will provide the needed information? 1) Where was the client born? 2) What is the primary language spoken in the family home? 3) What nonverbal communication behaviours are observed during the nurse-client interaction? 4) Is there a religious affiliation linked with the cultural affiliation? 20) 4 Explanation: 1. Finding out the location of the client’s birth provides information concerning ethnicity. 2. The language spoken at home will help with determine what type of translator may be required. 3. Communication patterns are identified by the types of nonverbal behaviours observed.
During the data collection phase, data is collected to determine the social organization of the client. Assessment of religious affiliation/cultural affiliation will provide information concerning the social organization of the client. Assessment Analysis Objective – 5 Page – 67 Difficulty - 2 4.
21) While working in an ambulatory care clinic, a client who speaks limited English seeks care. What is the responsibility of the nurse in providing discharge teaching? 1) Ask the client to call in a family member to translate 2) Provide instructions written in English along with the contact number for a translator 3) Seek all available resources to provide information the client will understand 4) Provide a translator fluent in the client’s primary language 21) 3 Explanation: 1. Asking the family to translate is not a good practice as they lack the medical knowledge to translate accurately. 2. This does not ensure that the client understands or will contact the translator. 3. The nurse has the responsibility to seek available resources to ensure the client understands the care and treatment being provided. The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. 4. Translator availability will vary. Implementation Analysis Objective – 5 Page – 60, 61 (Box 4.1) Difficulty - 2
22) Mrs. Lui, 62 years old, is recovering from abdominal surgery. She recently moved to Canada from China. What traditional Chinese cultural concepts may impact the nurse-client interaction? 1) The client may dislike being touched by strangers. 2) Health is associated with being overweight. 3) There is a strong belief that ginseng can cure illness. 4) Ceremonies are an important part in the recognition of illness and disease. 22) 1 Explanation: 1. Some Asian women are modest and do not like being touched by strangers. 2. There is no association between health and being overweight in the Chinese culture. 3. There are over 200 herbals used in traditional Chinese medicine; however, ginseng is used to boost energy and reduce stress. 4. Such ceremonies are part of the traditional beliefs of the Aboriginal peoples. Planning Comprehension Objective – 5 Page – 61, 62, 66, 67
Difficulty - 3 23) An Asian client is preparing for discharge from the hospital. While providing instructions concerning follow-up care, the nurse notes the client is nodding in agreement in response to the nurse’s statements. After completing the discharge teaching, what should the nurse do next? 1) Document the client’s understanding of the discharge instructions 2) Ask the client if she understood the information being relayed 3) Ask the client questions to assess understanding of the information provided 4) Have the client sign the discharge paperwork 23) 3 Explanation: 1. Although it is important to document discharge teaching, the nurse needs to ensure the client understood what was taught. 2. Asking the client if she understands is a closed question and may not determine adequate information. 3. The client’s nodding may simply indicate hearing the information being provided. The nurse should ask questions to assess understanding. 4. The client’s signature on the discharge paperwork may be indicated as a part of the discharge plan but is not the next step that should be taken by the nurse. Evaluation Analysis Objective – 5 Page – 70 Difficulty - 2
24) What is the primary cause of poor health in Canada? 1) Geographical distance from health care facilities 2) Inadequate funding of Canada’s healthcare system 3) Language barriers 4) Poverty 24) 4 Explanation 1. Although access may be a problem, it is not the primary cause of poor health among Canadians. 2. This may impact availability of services and hospital beds but is not the primary cause of poor health among Canadians. 3. Interpreters can translate for the healthcare team. 4. Poverty is the primary cause of poor health among Canadians. Planning Knowledge Objective – 4 Page – 65 Difficulty - 1 25) What statement is true regarding Canada’s Aboriginal population? 1) The 2006 census stated there were less than 1 million Aboriginal peoples in Canada. 2) Infant mortality rates are three times higher than the national average. 3) The Metis have a higher percentage of their population under age 14 than non-Aboriginal people.
4) The majority of First Nations peoples live on reserves. 25) 3 Explanation: 1. The 2006 census reported that there are over 1 million Aboriginal peoples in Canada. 2. The infant mortality rate for status Indian is twice as high as for other Canadians. 3. The Metis are younger than other Canadians. They have 25% of the population under the age of 14. 4. About 60% of the Aboriginal peoples live off the reserve. Assessment Knowledge Objective – 4 Page – 59, 60 Difficulty - 3 26) What is the third largest ‘first language’ group in Canada? 1) Cree 2) Inuktitut 3) Chinese 4) Punjabi 26) 3 Explanation: 1. Cree is spoken by the largest number of First Nations peoples. 2. Inuktitut is the main language of Nunavik and in Nunavut. 3. Currently 3% of the Canadian population speak Chinese languages as their first language. 4. Less than 1% of the Canadian population speak Punjabi as their first language. Assessment Knowledge Objective – 3 Page – 59 Difficulty - 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 27) When preparing to perform a cultural assessment for a client, the nurse is aware of the numerous components which will aid in the identification of ethnicity. When preparing to ask appropriate questions to assess unique needs, which of the following questions will be beneficial? (Select all that apply.) “What is your religious preference?” “Can you identify any food practices which will impact your prescribed plan of care?” “To what ethnic group do you identify yourself?” “Does your mother practice the same religion as you?” 27) 1, 2, 3 Explanation: Ethnicity involves both internal and external identification practices. The components of ethnicity include food, politics, geography, and nationality. The religious practices of the client’s parents do not directly influence the nursing data collection. Assessment Analysis
Objective – 5 Page – 67, 68 Difficulty - 2
Chapter 5 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is caring for a woman who is complaining of chest pain. She states that she was walking from her apartment to the grocery store when the pain became severe. She reported that people were following her. She said she couldn’t really see them but she could hear them talking about “grabbing me.” While the woman is explaining the event, she alternates between wringing her hands and manipulating the items in her purse over and over. The nurse would obtain what further assessment data in this situation? 1) Spiritual affiliations 2) Dietary preferences and habits 3) Review of systems 4) Focused psychosocial interview 1) 4 Explanation: 1. A spiritual assessment is important, but the psychosocial interview would be a priority given the behaviours exhibited. 2. Dietary preferences are important, but the psychosocial interview would be a priority given the behaviours exhibited. 3. The physical examination is conducted after the psychosocial assessment is complete. 4. The woman is exhibiting bizarre behaviour and her story indicates some paranoia; therefore, a focused psychosocial interview is warranted. Assessment Application Objective – 4 Page – 78 Difficulty - 2 2) A nurse is interviewing a client prior to a physical examination. The client tells the nurse, “ I have been experiencing a lot of aches, pains, and abdominal discomfort.” What factor should the nurse suspect is impacting physical health? 1) Income 2) Stress 3) Ethnicity 4) Occupation 2) 2 Explanation: 1. Income can impact physical health; however, stress has the most impact. 2. 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 can impact physical health; however, stress has the most impact. 4. Occupation can impact physical health; however, stress has the most impact. Assessment Knowledge Objective – 2 Page – 74, 77 Difficulty - 1
3) Julian, 17 years old, looks downward and speaks softly when answering questions. He has a flat affect. The nurse identifies a problem with Julian’s self-concept. What would support this conclusion? 1) Increased desire 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 3) 4 Explanation: 1. The increased desire to form lasting relationships may be seen in individuals with healthy or unhealthy self-concepts. 2. Decreased ability to form attachments to other people results from many factors not limited to poor self-concept. 3. Inability to maintain stable employment results from many factors not limited to poor self-concept. 4. Problems with self-concept may manifest in feelings of worthlessness, anxiety, and/or depression, among other issues. Application Knowledge Objective – 4 Page – 76, 79, 83 Difficulty - 2 4) Andrew, 7 years old, was admitted to the hospital following an appointment in the oncology clinic. His mother, who is distraught over his recent leukemic relapse, accompanies Andrew. She is crying and asking, “What did I do wrong?... Why does he deserve this?... Why can’t it be me?” What do these statements indicate to the nurse? 1) Ineffective coping 2) Emotional emptiness 3) Spiritual distress 4) Psychological anxiety 4) 3 Explanation: 1. Those types of statements are common responses to a serious diagnosis and do not indicate ineffective coping. 2. Emotional emptiness requires further evidence, as well, and is not an acceptable term to describe behaviours indicating distress. 3. Questions such as “What did I do wrong?... Why does he deserve this?”, etc. indicate spiritual distress. 4. Further evidence would be required before determining psychological anxiety. Diagnosis Analysis Objective – 4 Page – 73, 83 Difficulty - 2
5) Which client is at greatest risk for suicide? 1) 34-year-old married man who drives a transport truck 2) 18-year-old male who recently broke up with his girlfriend 3) 42-year-old Metis woman who has a fear of closed spaces
4) 21-year-old woman whose sister is cognitively impaired 5) 2 Explanation: 1. There are no characteristics that would place this client at greatest risk. 2. The characteristics of those at highest risk of suicide are: males, ages 15 to 24, Aboriginal ancestry. This client posesses two of these high risk characteristics. 3. Although aboriginal people may be at higher risk, none of the other characteristic increase her risk. 4. Although age of this client places her at risk, none of the other characteristics increase her risk. Assessment Knowledge Objective – 4 Page – 82 (Box 5.1) Difficulty - 2
6) What is the definition of psychosocial health? 1) The state of being emotionally balanced and socially astute 2) Being mentally stable, physically fit, and psychologically well 3) Becoming spiritually and psychologically mature 4) The state of being mentally, emotionally, socially, and spiritually well 6) 4 Explanation: 1. Although the term emotionally balanced is not often used, it is another phrase for emotionally well. 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 psychological health. Being physically fit may influence psychosocial health, but individuals may not be physically fit and still be 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. Assessment Knowledge Objective – 1 Page – 73 (Figure5.1) Difficulty - 1 7) A nurse is conducting a class on health promotion and uses the following definition: “The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.” What has the nurse defined? 1) Physical fitness 2) Emotional health 3) Physical health 4) Psychological well-being 7) 1 Explanation: 1. Physical fitness is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time activities and meeting emergency demands.
2. Physical fitness is an important component of physical and emotional health. Physical fitness influences mental alertness and emotional stability, as well as a general feeling of well-being, which some may call psychological fitness. 3. Physical health is associated with satisfaction of basic needs, quality of life, and psychosocial wellbeing. 4. Psychological well-being refers to a healthy self-identity, positive emotions and an ability to cope with stress. Assessment Knowledge Objective – 2 Page – 74 Difficulty - 1
8) Mrs. Murphy, 47 years old, has recently experienced the loss of three close family members and has withdrawn from all social activities. What is the best tool for the nurse to use to assess Mrs. Murphy’s level of stress? 1) Social Readjustment Scale 2) HOPE 3) Mental Status 4) Spiritual Well-being Scale 8) 1 Explanation: 1. The Social Readjustment Scale rates the stress in Mrs. Murphy’s life. 2. The HOPE is a tool used for a formal spiritual assessment. 3. The Mental Status Examination assesses affect and mood, level of anxiety orientation and speech. 4. The Spiritual Well-being Scale measures religious and existential well-being. Assessment Knowledge Objective – 3 Page – 78, 80, 81 (Table 5.3) Difficulty - 1
9) A nurse administered the Holmes Social Adjustment Scale to her client. The client scored 270. What is the client’s risk of developing a serious illness within the next two years based on stress alone? 1) 25% 2) 33.3% 3) 50% 4) 90% 9) 3 Explanation: 1. The lowest level of risk is 33.3% for those with a score below 150. 2. Individuals with a score below 150 have a 33.3% chance of developing a serious illness within two years. 3. Those with a score between 150 and 300 have a 50% chance of developing a serious illness within two years. 4. Those will a score over 300 have a 90% chance of developing a serious illness within two years. Assessment
Application Objective –3 Page – 81 (Table 5.3) Difficulty – 1 10) Ben, 16 years old, has been admitted for observation. He jokingly tells the nurse, “Sometimes I get so angry that I want to get into my dad’s car and drive it straight into a bus.” What should the nurse do next? 1) Ask Ben if it is easy to get access to his father’s car 2) Tell Ben that lot of teenagers feel this way 3) Talk to Ben’s parents about anger management 4) Explore with Ben ways he might cope with his anger 10) 1 Explanation: 1. Ben has indicated that he has thoughts of suicide, and the nurse needs to determine if he has a method and means at his disposal. 2. This does not address that Ben may be suicidal. 3. The nurse needs to address Ben’s comment about suicide. 4. This may be appropriate but not at this time; the nurse first needs to determine whether Ben has the means to follow through on his suicidal thoughts. Assessment Application Objective – 4 Page – 81 Difficulty - 2
11) Sister MacDonald, 59 years old, has been admitted to hospital. She asks the nurse if they hold mass in the Chapel. What assessment tool should the nurse use to assess spirituality and spiritual needs? 1) Healthy Day Measures 2) Multidimensional Health Profile 3) HOPE 4) Duke Social Support and Stress Scale 11) 3 Explanation: 1. The Health Day Measures is used to measure quality of life. 2. The Multidimensional Health Profile is used to screen for psychological problems. 3. The HOPE is a formal spiritual assessment tool. 4. The Duke Social Support and Stress Scale is used to assess family and non-family support and stress. Assessment Knowledge Objective – 3 Page – 77, 78 (Table 5.1) Difficulty - 1 12) While being interviewed, a client admits to the nurse, “I have been hearing voices and sounds recently.” What would be the nurse’s best response? 1) “How long have you been hearing these voices?”
2) “Tell me about what the voices are tell you to do.” 3) “There must be other things you are hearing.” 4) “Do the voices bother you during the night only?” 12) 2 Explanation: 1. Knowing the length of time a person has had auditory hallucinations is helpful, but is not the most important next question. 2. The most appropriate next question after the client tells the nurse she hears voices is asking the client if the voices tell her what she must do. Command hallucinations are dangerous and may lead to self-destructive or harmful behaviour. 3. Expressing doubt in what the client is telling you may make the client stop answering your questions. 4. Asking whether or not the voices are only bothersome to the client at night does not yield helpful information as hallucinations are not a normal phenomenon and treatment goals would include eliminating the hallucinations. Additionally, the goal of the interview is to obtain the information most important to the treatment plan and is not to dwell on the hallucinations, thereby reinforcing them to the patient. Assessment Application Objective – 3 Page - 82 Difficulty - 2 13) What internal factor can influence psychosocial health? 1) Mother who is bipolar 2) Culture 3) Growing up in a supportive family 4) Spiritual beliefs 13) 1 Explanation: 1. Genetics is an internal factor that can impact psychosocial health. 2. Culture is an external factor. 3. Family support is very important in psychosocial health, but it is an external factor. 4. Religion and spiritual beliefs are important, but are external factors. Assessment Knowledge Objective – 2 Page – 73, 74, 75 Difficulty - 1 14) A nurse is completing the psychosocial history on a newly admitted adult client. The client reports trouble concentrating, rapid heartbeats, irritability, and inability to make decisions. What might the nurse suspect is happening to the client? 1) Stress reaction 2) Role confusion 3) Impending heart attack 4) Dysfunctional anxiety 14) 1 Explanation: 1. A high level of stress may result in symptoms such as irritability, indecisiveness, confusion, pounding heart or pulse, and trouble concentrating, among other symptoms.
2. There is no data to support the concern of role confusion. 3. Symptoms of an impending heart attack may include irritability, confusion, and a pounding heart rate, but there are other more classic symptoms that typically also appear. 4. Symptoms of anxiety include some of the above symptoms, but there is not enough evidence to call it dysfunctional. Diagnosis Application Objective – 4 Page – 77 Difficulty - 2
15) An elderly client, who is hard of hearing, is observed withdrawing form conversation and sitting quietly in the corner of the room. This client’s physical ailment is impacting which psychosocial dimension? 1) Mental 2) Emotional 3) Social 4) Spiritual 15) 3 Explanation: 1. The mental dimension refers to an individual’s ability to reason, to find meaning in, and make judgments from, information, to demonstrate rational thinking, and to perceive realistically. 2. The emotional dimension is subjective and includes feelings. 3. Social functioning refers to the individual’s ability to form relationships with others. 4. The spiritual dimension is beliefs and values that give meaning to life. Diagnosis Analysis Objective – 1 Page – 73 Difficulty - 1 16) Mrs. Petrenko, 53 years old, cares for her elderly mother. Mrs. Petrenko states, “When my mother takes ill, you can predict I’ll be sick in about six weeks.” What does this statement indicate? 1) Her mother has a communicable disease. 2) Mrs. Petrenko has uncared for health problems. 3) Mrs. Petrenko is more ill than her mother. 4) Mrs. Petrenko is experiencing emotional stress. 16) 4 Explanation: 1. There is no evidence that the mother has a communicable disease. 2. There is no evidence that Mrs. Petrenko has health problems. 3. There is no evidence that Mrs. Petrenko is ill. 4. Emotional health affects physical health in several ways. Stress affects the immune system leading to increased susceptibility to infections. During periods of stress or change, the individual is less likely to adhere to positive health behaviours. Evaluation Analysis Objective – 4 Page – 74, 77 Difficulty - 2
17) A client tells the nurse, “I want to make sure my children have every possible opportunity to complete their education.” The nurse realizes this client’s philosophy on education will influence which aspect of her children’s health? 1) Meeting immediate needs 2) Helping to elevate self-concept 3) Contributing to ongoing family disturbances 4) Preventing mental illness 17) 2 Explanation: 1. The client is discussing long-term needs; there is no mention of anything immediate. 2. Better education leads to greater occupational opportunity, better housing, and the ability to participate in a variety of leisure activities. These advantages contribute to the development of high self-worth and self-concept. 3. There is no evidence that there are problems within the family. 4. There is no assurance that education will prevent mental illness. Diagnosis Analysis Objective – 4 Page –75 Difficulty - 2
18) Based on statements made by the client during a physical assessment, the nurse believes the client is at risk for developing a major illness. What statement would cause the nurse to be concerned for this client? 1) “Look at that person’s pants! Don’t they realize how ugly they are?” 2) “That sounds like a good idea! I think I will try that at home.” 3) “I just love spending time outside. It energizes me!” 4) “I set aside a period of time each day for myself.” 18) 1 Explanation: 1. Those who are psychosocially unhealthy will demonstrate pessimism, will openly laugh at others, are a “challenge” to be around, have little fun, and are self-absorbed. 2. The client demonstrates a willingness to try new things. This is consistent with someone who is psychologically healthy. 3. Individuals who are psychosocially healthy will demonstrate a zest for life. 4. Individuals who are psychosocially healthy will attend to their own health and psychological wellbeing. Diagnosis Analysis Objective – 4 Page – 76 Difficulty - 2
19) Mr. Knapp, 41 years old, has hypertension. He stops into the clinic for his weekly blood pressure measurement and tells the nurse that he is in a hurry because he started a new job and has to get back to work. What evidence might indicate that the Mr. Knapp is responding to his new job in a stressful way? 1) Elevated blood pressure 2) Respirations 16 and regular 3) Temperature within normal limits
4) Heart rate 86 and regular 19) 1 Explanation: 1. Physical signs of stress include elevated blood pressure, pulse, and respirations, dilated pupils, increased blood volume, and elevated blood glucose level. 2. Respirations are elevated with stress. 3. With severe stress the body may be more susceptible to infection causing an increase in temperature. Otherwise a normal temperature in not indicative of whether Mr. Knapp is experiencing stress. 4. The heart rate would be elevated with stress.. Assessment Application Objective – 2 Page – 74, 77 Difficulty - 2 20) A nurse is assessing a client’s spiritual and belief patterns and is currently asking the client about participation in organized religion. The nurse is on which step of the HOPE assessment with this client? 1) H 2) O 3) P 4) E 20) 2 Explanation: 1. H focuses on spiritual resources. 2. O focuses on participation in organized religion. 3. P focuses on personal spiritual practices. 4. E focuses on the effects of healthcare and end-of-life issues. Assessment Application Objective – 3 Page – 77 Difficulty - 1 21) Asal, 10 years old, has recently been adopted from an orphanage in Afghanistan by a Canadian couple. What might impact Asal’s psychological health? 1) Access to better education 2) Living with a supportive family 3) Growing up in Canada, a country not in turmoil 4) Being physically healthy 21) 3 Explanation: 1. Better educational opportunity can improve self-esteem. We do not know if this is true for Asal. 2. Although a supportive family positively impacts psychosocial health, we do not have enough information to reach this conclusion. 3. Growing up in Canada may seem to be positive, but to Asal it could be very stressful. She has left behind the people and environment she knew and now needs to learn a new language and new customs. 4. There is no indication that physical well-being is a concern. If Asal is under a lot of stress it may impact her physical health. Assessment Application
Objective – 2 Page – 75 Difficulty - 2
22) A nurse is concerned that a client is having a problem with self-concept. What statement would cause the nurse to have this 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.” 22) 1 Explanation: 1. Clients who are unable to explain a social life or who do not have any fun may be depressed or out of touch with reality. 2. Self-concept refers to how we feel about ourselves. Stating one is the eldest in the family does not indicate anything about the client’s feelings about themself. 3. This comment is positive. A person with a positive self-concept is able to develop and maintain relationships. 4. People with a positive self-concept enjoy spending some time alone. Assessment Analysis Objective – 3 Page – 76, 79, 80 Difficulty - 2 23) Which assessment question would best help the nurse identify the client’s coping ability? 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? 23) 4 Explanation: 1. Questions about friends assess the client’s roles and associations. 2. Questions about social groups assess roles and associations. 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? For 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? Planning Application Objective – 3 Page – 80, 81 Difficulty - 1
24) During an assessment, the nurse observes the client jumping from one idea to another, unable to completely answer any of the assessment questions. What speech pattern is the client using? 1) Circumlocution 2) Flight of ideas
3) Neologisms 4) Echolalia 24) 2 Explanation: 1. Circumlocution means the client is demonstrating numerous digressions. 2. The speech pattern where thoughts and ideas jump round is termed “flight of ideas.” 3. Neologisms are the coining of new words that have significance to the client. 4. Echolalia is the constant repetition of words or phrases that the client hears others say. Diagnosis Analysis Objective – 5 Page – 83 (Box 5.2) Difficulty - 2 25) Mr. Kuromi, 34 years old, has been admitted for observation. He tells the nurse, “Pink happies are flying on me but no woman likes short fish.” What speech pattern is this? 1) Neologism 2) Word salad 3) Clanging 4) Echolalia 25) 2 Explanation 1. Neologism is inverting works or expressions that have meaning to the client. 2. This is an example of a word salad. 3. Clanging is saying words or phrases that sound alike. 4. Echolalia is repeating words that the client hears others say. Diagnosis Analysis Objective – 5 Page – 83 (Box 5.2) Difficulty - 2 26) Mrs. Danachuk, 43 years old, was widowed four months ago. She has missed her third appointment with the health nurse. When called, Mrs. Danachuk is weeping and tells the nurse she was really tired and could not get out of bed this morning. What should the nurse suspect is causing Mrs. Danachuk to feel so tired? 1) Poor nutrition 2) Working too hard 3) Abusing sleep medication 4) Depression 26) 4 Explanation 1. There is no mention that there is a problem with nutrition. Mrs. Danachuk is likely depressed due to the death of her partner. 2. There is no indication that this is a concern. 3. Mrs. Danachuk is likely depressed, but there is no evidence that she is abusing drugs or alcohol. 4. Mrs. Danachuk is likely depressed. A person who is depressed may suffer from sadness, crying spells, insomnia, lack of appetite, weight loss, weight gain, loss of sex drive, constipation, fatigue, hopelessness, irritability, indecisiveness, confusion, pounding heart or pulse, trouble concentrating,
Diagnosis Analysis Objective – 4 Page – 80, 81 Difficulty - 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 27) Mr. Barton, 51 years old, is admitted with a broken arm after a fall. He appears disheveled and has a body odour. The family arrives and expresses surprise at Mr. Barton’s appearance. They report that this is not his normal appearance and that he is usually clean and meticulously groomed. What assessment(s) does the nurse need to complete? (Select all that apply.) Dietary history Psychosocial assessment Memory assessment and orientation Family medical history Lab studies Physical examination 27) _X_ _X_ _X_ _X_
Dietary history Psychosocial assessment Memory assessment and orientation Family medical history Lab studies Physical examination
Explanation: The client’s appearance indicates that there has been some change in mental outlook or condition since last seen by the family. Alternatively, physical illness may have impacted the client’s ability to groom himself appropriately. The physical examination is important to look for complications resulting from not cleaning the skin. A psychosocial history is very important to determine the client’s usual state of psychological health and well-being, and if similar deteriorations have occurred in the past. An assessment of memory and orientation is important because it will affect how the client is cared for, considering the short-term memory loss (if it exists) and lack of orientation to surroundings, if that occurs. Not only safety, but also knowledge gained from this assessment will be important data on which to note improvements or declines in condition. The family medical history may yield some clues if someone in the family has experienced a similar deterioration and now has a condition for which treatment is needed. Lab studies would be ordered by the physician, not completed by the nurse. A dietary history is not indicated at this time. The physical examination may reveal evidence that might require this type of assessment later. Assessment Analysis Objective – 4 Page – 78, 80, 83 Difficulty - 1
Chapter 6 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse has completed a cardiovascular assessment on a college athlete with a pulse of 50 beats per minute. What is the most appropriate interpretation of this assessment finding? 1) This result is outside the normal range, therefore is an abnormal assessment finding. 2) This assessment finding fits within the expected normal range for the adult pulse rate. 3) The client's pulse rate is a variation from the normal but is not a concern. 4) The pulse is abnormal and the nurse must re-assess the pulse rate. 1) 3 Explanation: 1. The normal range for the adult pulse rate is 60 to 100 beats per minute; however, for an athlete with a fit cardiovascular system it is not unusual to have a lower pulse rate. This is not an abnormal finding when put into context. 2. A pulse rate of 50 beats per minute does not fit within the normal range for an adult of 60 to 100 beats per minute. 3. The client's pulse of 50 beats per minute is outside the normal range but is not a concern because this is not an unusual finding for an athlete with a well-developed cardiovascular system. Therefore, this result is not a concern when put into context. 4. The pulse is outside the normal range but is not an unusual finding for a fit adult. It is unnecessary for the nurse to reassess the pulse rate. Assessment Application Objective 4 Page 96 Difficulty = 3 2) A nurse is assessing for fremitus of the client’s chest wall. What is the correct method for performing this assessment? 1) Palmar surface of the fingers 2) Base of the fingers 3) Dorsal surface of the fingers 4) Finger pads 2) 2 Explanation: 1. The palmar surface of the fingers is used to assess position, consistency, texture and size of structures, pain, and tenderness. Fremitus is best perceived with the base of the finger. 2. Vibratory tremors felt through the chest wall are known as fremitus and are best perceived by the examiner when using the base of the fingers — the metacarpophalangeal joints. 3. Temperature is best assessed using the dorsal surface of the fingers. 4. The finger pads are utilized when performing light palpation. Assessment Application Objective 1 Page 88 Difficulty = 2 3) A nurse is assessing a client who appears very anxious and is experiencing abdominal tenderness. What is the best approach to put the client at ease during this portion of the examination?
1) 2) 3) 4)
Palpate known painful areas first Touch the abdomen before palpating it Explain each movement after completion Provide the client with an analgesic
3) 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 abdomen is about to begin and may prevent a startled reaction. 3. The client will be more relaxed if the nurse talks to them during the assessment, explaining each movement in advance rather than after the each movement. 4. Providing an analgesic may decrease the abdominal discomfort but this intervention may not address the client's anxiety about the examination. Assessment Analysis Objective 3 Page 89 Difficulty =1 4) A nurse is using percussion to assess the liver. What sound would the nurse expect to hear? 1) Dullness 2) Hyperresonance 3) Tympany 4) Flatness 4) 1 Explanation: 1. Dullness is a high-pitched tone that is soft and of short duration, usually heard over solid organs such as the liver. 2. Hyperresonance is abnormally loud, heard when air is trapped in the lungs. 3. Tympany is loud, high-pitched, drum-like and characteristic of an organ that is filled with air such as air-filled intestines. 4. Flatness is a high-pitched tone, soft intensity, and short in duration that is typically heard over muscle or bone. Assessment Application Objective 1 Page 91 Difficulty = 3
5) A nurse is examining a client in the Emergency Department. What finding would cue the nurse to complete a detailed neurological assessment? 1) Asymmetry of the client’s smile 2) Grimacing with movement 3) Talking in a loud voice 4) Edema to both legs 5) 1
Explanation: 1. Asymmetry of facial expression is a cue to assess function of cranial nerves. 2. Grimacing, guarding, or wincing when a client moves is a cue to examine for underlying pathology that may indicate joint or muscle problems. 3. Talking in a loud voice is often a cue that the client is suffering from hearing loss. 4. Edema to the legs is a cue that indicates circulatory or heart problems. Assessment Analysis Objective 4 Page 95 Difficulty = 2 6) What is the correct technique to percuss the thorax of an infant? 1) Strike the nondominant hand with a closed fist of the dominant hand 2) Deliver two sharp blows to a hyperextended middle finger of the nondominant hand 3) Place the palmar surface of dominant hand against the body surface and apply gentle pressure. 4) Tap the area being examined directly with the fingertips of the dominant hand. 6) 4 Explanation: 1. This is a description of blunt percussion used for assessing pain and tenderness in the gallbladder, liver, and kidneys. 2. The technique used for indirect percussion is to deliver two sharp blows with the fingertips of the dominant hand to a hyperextended middle finger of the nondominant hand; however this is an inappropriate technique for percussing an infant thorax. 3. This is a description of deep palpation and is not a percussion technique. 4. This is a description of direct percussion, the correct technique used to percuss an infant thorax. Assessment Application Objective 1 Page 89 Difficulty = 3 7) A nurse is auscultating breath sounds on an adult male client and hears a crackling sound over most of the chest. What should the nurse do next? 1) Document this as an abnormal finding. 2) Wet the chest hair and re-auscultate. 3) Ask the client to cough, then auscultate again. 4) Turn the diaphragm of the stethoscope to the bell. 7) 2 Explanation: 1. This may or may not be an abnormal finding and should be ruled out first before documenting. 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 this problem, the hair should be wet before auscultating the area. 3. Coughing may clear bronchial secretions, but this is not the cause of the crackling sound. 4. Friction from the hair will cause an abnormal crackling sound regardless of whether the bell or diaphragm are used therefore switching them won’t make a difference. Implementation
Analysis Objective 4 Page 94 Difficulty =1 8) A nurse is performing an abdominal assessment and has just completed inspection. What is the next step in this assessment? 1) Percussion 2) Palpation 3) Documentation 4) Auscultation 8) 4 Explanation: 1. If percussion was used after inspection there is the potential to alter the natural sounds of the abdomen, therefore auscultation is the next technique to use in order to listen to unaltered sounds. 2. If palpation was used after inspection there is the potential to alter the natural sounds of the abdomen, therefore auscultation is the next technique to use in order to listen to unaltered sounds. 3. It is premature to document because the abdominal assessment is incomplete. The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. 4. Inspection should be performed first followed by auscultation to avoid altering the natural sounds of the abdomen that could occur if either percussion or palpation techniques were used next. Assessment Application Objective 1 Page 87 Difficulty=1 9) A nurse is preparing to examine several clients in the clinic setting. Which client would need the greatest degree of special consideration during a physical examination? 1) Fifty-nine-year-old with influenza 2) Nineteen-year-old who complains of fatigue 3) Three-year-old child in for a well check-up 4) Seventy-eight-year-old with COPD 9) 4 Explanation: 1. Influenza is an acute condition but does not put the client in the same risk category as the older client with a chronic disease. 2. Fatigue in teenagers may indicate anemia but it may be caused by lack of sleep. 3. Assessment approaches and techniques may vary for children, but a healthy three-year-old is not considered at the same risk potential as a client with a chronic respiratory illness. 4. Clients who are frail, weak, debilitated, or suffering from a chronic illness are at greatest risk during physical examination and the exam may be exhausting for them, therefore the nurse will need to adapt the examination accordingly. Assessment Analysis Objective 3 Page 96 Difficulty =2
10) What is the correct technique for moderate palpation of the abdomen? 1) Downward one to two cm 2) Side to side one-half to one cm 3) Upward three to four cm 4) Side to side two to three cm 10) 1 Explanation: 1. Moderate palpation is used to assess underlying structures. The correct technique is to press downward approximately one to two cm while rotating the fingers in a circular motion. 2. A side-to-side motion is not a palpation technique. 3. Deep palpation is to a depth of two to four cm; however the technique calls for a downward motion and not an upward motion. 4. A side-to-side motion is not a palpation technique. Assessment Application Objective 1 Page 89 Difficulty = 3 11) A nurse is assessing a client when he refuses to allow the nurse to continue the examination. What should the nurse do next? 1) Provide a translator to explain the examination process to the client. 2) Document which procedures took place and which were refused. 3) Ask a nurse of the same gender as the client to stay in the room as a witness. 4) Suggest a family member tell the client to allow the examination to proceed. 11) 2 Explanation: 1. Providing a translator may help the client understand the procedure, but the client should be allowed to object to any and all physical examination techniques. There is no indication in this scenario that the client required translation services. 2. Although explaining the reason for a certain procedure may help the client understand its benefit, a client should never be forced, influenced or coerced to agree to any and in all cases. Documentation of which procedures took place and which were refused is extremely important. 3. Allowing a family member to be present during the exam may be helpful, but a family member should not be used to force, influence, or coerce the client. The client's wishes must be respected. 4. Asking another nurse to stay in the room as a witness is not respecting the client's wish to stop the examination. The nurse should document what part of the examination was completed and what was refused. Assessment Application Objective 3 Page 96 Difficulty = 1 12) What special equipment is required to accurately measure the degree of joint flexion? 1) Transilluminator 2) Wood's lamp 3) Sphygmomanometer 4) Goniometer
12) 4 Explanation: 1. A transilluminator is used to detect blood, fluid, or masses in body cavities. 2. Wood's lamp is used to detect fungal infections of the skin. 3. A sphygmomanometer is used to measure blood pressure. 4. A goniometer measures the degree of joint flexion and extension. Assessment Application Objective 2 Page 93 (Table 6.1) Difficulty = 1 13) A nurse is using a Doppler ultrasonic stethoscope to assess a pulse and does not hear anything. What is the most appropriate nursing action? 1) Check the pressure applied to the probe 2) Add more gel to the end of the probe 3) Immediately inform a physician 4) Send the equipment for repair 13) 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 but this step should have been completed prior to beginning the pulse assessment. 3. Informing a physician may be premature until it is determined that the Doppler probe is being used correctly. 4. Sending the equipment for repair is premature at this time. Implementation Analysis Objective 4 Page 94 Difficulty = 2 14) A nurse is using an ophthalmoscope with a red-free filter to assess the optic disc in a client. What colour indicates hemorrhaging of the optic disc? 1) Green 2) Black 3) Red 4) Yellow 14) 2 Explanation: 1. The red-free filter shines a green beam but it is the black colour that indicates an optic disc hemorrhage. 2. The red-free filter shines a green beam used to examine the optic disc for pallor or hemorrhage, which, when present, appears black through this filter. 3. A red-free filter means that red will not be visualized. 4. Yellow is not a colour visualized with an opthalmoscope. Assessment
Application Objective 2 Page 94 Difficulty = 2 15) A nurse is preparing to assess a client’s abdomen. What is the correct order to assess this body area? 1) Inspection, Palpation, Percussion, Auscultation 2) Inspection, Palpation, Auscultation, Percussion 3) Inspection, Palpation, Percussion, Auscultation 4) Inspection, Auscultation, Percussion, Palpation 15) 4 Explanation: 1. Inspection, palpation, percussion, and auscultation is the usual order for assessment except when assessing the abdomen, the order is then inspection, auscultation, percussion, and palpation. 2. Wrong order for an abdominal assessment. The order is inspection, auscultation, percussion, and palpation. 3. Incorrect. Auscultation follows inspection in an abdominal assessment because the bowel sounds may be altered by percussing and palpating the abdomen prior to doing the auscultation. 4. The typical pattern for assessment varies when assessing the abdomen. The order when assessing the abdomen is inspection, auscultation, percussion, and palpation. Planning Comprehension Objective 1 Page 87 Difficulty = 1 16) What initial nursing action can help alleviate a client's anxiety about a physical examination? 1) Provide the client with teaching during the examination 2) Ask another nurse to be present during the physical assessment. 3) Allow the client to void prior to starting the examination. 4) Perform assessments that a client knows such as height and weight 16) 4 Explanation: 1. Providing the client with teaching during the exam is a useful strategy to alleviate anxiety, enhance understanding, and to give the client a sense of partnership in his or her healthcare but this is not an initial nursing action used to alleviate client anxiety about the examination. A highly anxious client may not absorb the teaching information. 2. This may be a useful strategy to help alleviate client anxiety but the nurse must first ask the client if this approach would make him or her more comfortable. In some situations this might increase client anxiety. 3. A client will feel physically more comfortable with an empty bladder but this strategy does not address the client's emotional needs concerning the anxiety about the actual examination. 4. A nurse can alleviate the client's anxiety by approaching the examination gradually by performing simple measurements, such as height, weight, temperature, and pulse which most clients find familiar and nonthreatening. Assessment Application Objective 3
Page 96 and 97 Difficulty = 2 17) What is the best approach to accurately assess for vocal fremitus? 1) The ulnar surface of the fingers of the dominant hand. 2) The dorsal surface of the fingers on the nondominant hand. 3) The palmar aspect of the fingers of the dominant hand. 4) The fingertips of either hand. 17) 1 Explanation: 1. The ulnar surface of the hand including the finger is most sensitive to vibrations such as fremitus and the dominant hand is always more sensitive than the nondominant hand. 2. The dorsal surface of the fingers is best used to assess temperature rather than fremitus (e.g. vibrations) 3. The palmar aspect of the fingers is best used to determine position, consistency, texture, size of structures, pain, and tenderness. 4. The finger pads are used in percussion. Planning Application Objective 1 Page 88 Difficulty = 3 18) A client has an inflamed area on the left forearm. What assessment techniques should the nurse use to assess this area? 1) Percussion 2) Light palpation 3) Moderate palpation 4) Deep palpation 18) 2 Explanation: 1. Percussion would not be an appropriate technique to use to assess an inflamed area. 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. Planning Application Objective 1 Page 88 Difficulty = 1 19) A client has a visible pulsation in the middle of his abdomen. What assessment technique should the nurse use to assess this pulsation? 1) Direct percussion
2) Light palpation 3) Moderate palpation 4) Deep palpation 19) 3 Explanation: 1. Percussion is not an appropriate technique to use in this situation. Direct percussion is used to assess a thorax of an infant or the sinuses of an adult. 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 can 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. Also in this situation deep palpation could result in the rupture of a pulsating mass such as an abdominal aneurysm. Implementation Application Objective 4 Page 89 Difficulty = 2 20) A nurse has documented that a client's lung sounds are hyperresonant. What is the correct interpretation of this assessment finding? 1) Air is trapped in the lungs and has hollow quality. 2) High pitched sound that is drum like in quality. 3) Flat, soft tone that indicates the lung is solidified. 4) Dull, high-pitched tone that is of short duration 20) 1 Explanation: 1. Hyperresonance is an abnormally loud, low tone that is heard when air is trapped in the lungs. 2. A high pitched sound that is drum like is known as tympany and is heard over air-filled intestines. 3. Flatness is a high-pitched tone that is soft and occurs over solid tissue such as muscle or bone. 4. Dullness that is high-pitched and of short duration is normal percussion sound heard over the liver. Assessment Application Objective 4 Page 91 Difficulty = 3 21) A nurse is preparing to percuss the lower lobes of a client’s lungs. What is the appropriate percussion technique to use? 1) Direct percussion 2) Blunt percussion 3) Indirect percussion 4) Any of the percussion techniques 21) 3 Explanation: 1. Direct percussion is used to examine the thorax of an infant and to assess the sinuses of an adult. 2. Blunt is used for assessing pain and tenderness in the gallbladder, liver, and kidneys.
3. Indirect percussion is the technique most commonly used because it produces sounds that are clearer and more easily interpreted when assessing lung fields. 4. The appropriate percussion technique must be used to ensure accurate assessment results and the only appropriate technique to use to percuss the lungs is the indirect percussion technique. Planning Application Objective 4 Page 89 and 90 Difficulty = 2 22) While percussing a client’s lung area the nurse notes a flat tone. What does this flat tone indicate? 1) The nurse is percussing over a bone. 2) A normal finding. 3) The lungs are solidified. 4) Air is trapped in the lungs. 22) 1 Explanation: 1. A flat tone or flatness is characteristic of percussing over solid tissue like muscle or bone. 2. Since the nurse is intending to percuss the lungs this is not a normal finding. Resonance is a normal percussion sound over the lungs. 3. If the lungs were solidified the nurse is more likely to hear dullness similar to what is heard over a solid organ. 4. Hyperresonance is the characteristic sound when air is trapped in the lungs. Evaluation Analysis Objective 4 Page 91 Difficulty = 3 23) While auscultating a client’s lungs, the nurse identifies more than one sound. What is the most appropriate nursing action? 1) Use a different stethoscope. 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. 23) 4 Explanation: 1. It is premature to use another stethoscope. It is not uncommon for a nurse to hear more than one sound at a time; therefore it is important for the nurse to focus on each sound by closing her eyes and concentrating. 2. This might be an appropriate next step after the nurse tries to focus on the sounds by closing her eyes and concentrating. 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 might help the nurse focus on the sound. Assessment Application
Objective 4 Page 91 Difficulty = 2 24) What nursing action would indicate that the nurse is following routine practices during a physical examination? 1) Observe for signs of dizziness when the client takes deep breaths. 2) Explain procedures in advance to alleviate client anxiety. 3) Perform hand hygiene in the presence of the client. 4) Drape the client to preserve privacy and to provide warmth. 24) 3 Explanation: 1. This is an example of providing a safe environment for the client, although this is an important element of a physical examination this is not a routine practice. Routine practices refer to maintaining principles of asepsis and body fluid precautions. 2. This is an example of providing a comfortable environment for the client, although this is an important element of a physical examination this is not a routine practice. Routine practices refer to maintaining principles of asepsis and body fluid precautions. 3. The nurse is require to follow routine practices such as hand washing, use of protective barriers, and the disposal of sharps throughout a physical examination. 4. This is an example of providing a safe and comfortable environment for the client and not routine practices. Assessment Application Objective 5 Page 97 Difficulty = 3 25) What approach will the nurse use to survey the client during the inspection phase of a physical assessment? 1) Start inspection with the painful area first 2) Compare the right and left sides of the body 3) Proceed from a specific focus to a general overview 4) Instruments are only used during the other phases of assessment 25) 2 Explanation: 1. The nurse needs to be aware of the client’s concerns while doing an assessment but generally an inspection begins with a survey of the client’s appearance and a comparison of the right and left sides of the client’s body. The nurse should proceed from a general overview then to specific detail. 2. This is the correct approach. Compare right and left sides of the body for symmetry and proceed from a general overview to specific detail. 3. This approach is backwards. The nurse should proceed from a general overview to specific detail comparing the right and left side of the client’s body for symmetry. 4. Most of the inspection will be done without instruments; however, there are areas of the body (e.g. internal structures of the ear) that require instruments in order to visualize this region of the body. The principle of surveying the general and then the specific still applies therefore instruments will be used after the general survey has been completed.
Assessment Application Objective 1 Page 88 Difficulty = 1 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) What part of the stethoscope is used to auscultate heart murmurs? Draw an arrow to identify this part on the stethoscope. 26) Explanation The deep, hollow end piece, the bell, detects low-frequency sounds such as heart murmurs and should be used when auscultating this type of heart sound. The diaphragm is used to auscultate normal heart sounds. Assessment Application Objective 2 Page 91 Difficulty = 2
Chapter 7 MULTIPLE CHOICE. Choose the one alternative that best answers the question. 1) A nurse is assessing Ami, 2 years old, when the mother tells the nurse that Ami has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasn’t actually taken it but Ami’s skin has felt very warm. What would be the most appropriate response for the nurse? 1) “When our skin feels warm, it means our blood vessels are constricted.” 2) “The only reliable indicator of body temperature is by feeling the forehead.” 3) “Our skin temperature changes when our surroundings change temperature.” 4) “The temperature of the skin is not related to what is happening inside our bodies.” 1) 3 Explanation: 1. Vasoconstriction is a way for the body to prevent heat loss. Vasodilation occurs with increased body temperature to increase loss of heat. 2. To obtain accurate temperature, the core temperature or the temperature of the deep tissues of the body needs to be assessed. 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 actual health status. 4. As body temperature increases the skin will feel warmer. Assessment Application Objective – 5 Page – 102 Difficulty - 2
2) Zavier, 8 months old, is having a well baby examination. During the examination, Zavier has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just can’t “deal with the odour”. What observation should the nurse make? 1) The child may have an illness causing diarrhea. 2) It may be a reflection of the mother-child relationship. 3) The mother is behaving inappropriately. 4) The child may have an illness that is increasing the odour of stool. 2) 3 Explanation: 1. Although the child may have an illness, the mother’s response to the stool is inappropriate. 2. There is insufficient information to draw this conclusion. There is no indication that Zavier is not responding to his mother. 3. Observation of the interaction between Zavier and his mother can provide information suggestive of child abuse. The mother’s demonstration of disgust with any aspect of child’s behaviour or such things as odour or stool can be clues that there may be a problem with the relationship and should be evaluated further. 4. This may be true, but the mother’s response is inappropriate and needs to be investigated further. Assessment Analysis Objective – 5
Page – 100 Difficulty - 3 3) A nursing assistant brings the nurse the following vital signs for a 90-year-old client: Temperature 36.3 o C (oral), BP 165/70 mmHg, Pulse 84 and Respirations 24. After examining the vital signs, what action should the nurse take? 1) Continue to monitor the client. 2) Tell the nursing assistant to recheck the temperature. 3) Obtain an order for an antihypertensive. 4) Obtain an order for oxygen therapy. 3) 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. 2. The vital signs are within normal limits for an elderly client and do need to be repeated. 3. The nurse would need to do an assessment and take history before obtaining an order for an antihypertensive. 4. There is no indication that oxygen is required. Assessment Application Objective – 3 Page – 103, 104, 105, 106 Difficulty - 3 4) A nurse is obtaining the height and weight of an 84-year-old client. The client asks why the height is 2 cm less than last year. What would be the best response by the nurse? 1) “Your bones are weaker and are shrinking.” 2) “I am sure you are mistaken and just don’t remember from last year.” 3) “Your height decreases with age due to bone changes.” 4) “Stand up straighter this time and we will measure again.” 4) 3 Explanation: 1. Bones may become more brittle but they do not shrink. 2. This is an inappropriate response by the nurse. 3. Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect. 4. Older adults may decrease in height due to a thinning of the intervertebral disc. Assessment Analysis Objective – 5 Page – 102 Difficulty - 2
5) A nurse is obtaining the initial vital signs on a client in the emergency room following a seizure. What method should the nurse use for obtaining the client’s temperature?
1) 2) 3) 4)
Axillary Oral Rectal Tympanic
5) 3 Explanation: 1. Although axillary is the safest, it is also the least accurate. 2. If the client starts to seizure while taking an oral temperature the thermometer could cause injury. 3. A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth. 4. A tympanic require the client’s cooperation in order to maintain safety, which is not possible during seizure activity. Assessment Application Objective – 3 Page – 103 Difficulty - 1 6) Mr. Dwyer, 29 years old, is admitted with pneumonia. His vital signs are: Temperature 38.5 0 C (oral), BP 100/70 mm Hg, Pulse Rate 110/min and Respirations 22. The client’s oxygen saturation level is 96%. Which order should the nurse clarify with the physician? 1) Administer PRN antipyretic 2) Administer intravenous fluids 3) Start oxygen therapy 4) Send for chest x-ray 6) 3 Explanation: 1. The vital signs are expected findings with the Mr. Dwyer’s diagnosis and an elevated temperature. 2. The decreased BP is secondary to the elevated body temperature, which results in peripheral vasodilation in an attempt to increase heat loss. The decrease in blood pressure causes an increased pulse rate. Intravenous fluids would be applicable for these reasons. 3. As Mr. Dwyer’s oxygen saturation level is within normal limits oxygen is not indicated at this time. 4. The slight increase in respiratory rate is secondary to the pneumonia as well as the increase in temperature. A chest film would be indicated to determine the extent of pulmonary involvement. Planning Analysis Objective – 5 Page – 105, 106 Difficulty - 3 7) A nurse is caring for a client with an irregular heart rhythm. How long should the nurse count beats for this client when taking a pulse rate? 1) Two minutes 2) A full minute 3) 30 seconds and multiply by 2 4) 15 seconds and multiply by 4
7) 2 Explanation: 1. One minute is required for taking a pulse on a client with an irregular heart rate. 2. With any irregular pulse, the rate needs to be counted for one full minute. 3. If the pulse is regular, then the nurse may count the beats for 30 seconds and multiply by two. 4. A client with an irregular heart rate has the pulse taken for 1 minute. Assessment Application Objective – 4 Page – 105 Difficulty - 1 8) A nurse is admitting a client with diabetic ketoacidosis. The LPN asks the RN if the pulse oximeter needs to be placed on the client. What is the nurse’s best response to the LPN? 1) “Please place the pulse oximeter on the client.” 2) “I will let you know after I complete my assessment.” 3) “Thanks, for that is something I have to do for the client.” 4) “We don’t have an order to do that.” 8) 2 Explanation: 1. The client may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It only reflects the percentage of oxygen saturation of hemoglobin. 2. The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter. 3. There is no indication that the client requires a pulse oximeter. The nurse needs to assess the client first. 4. This would not require a physician’s order, but could be delegated to the LPN. Planning Application Objective – 4 Page – 105, 106 Difficulty - 1
9) What is the purpose of a general survey? 1) Allows for vital signs prior to starting exam. 2) Provides an opportunity for the patient to relax before the exam. 3) Yields information to guide the physical assessment. 4) Provides the information necessary for the diagnosis. 9) 3 Explanation: 1. Vital signs are not part of the general survey. 2. The general survey is part of the examination. 3. The general survey allows the nurse to observe the client and gain clues for guiding the remainder of the assessment. 4. It does not provide information for a nursing diagnosis, but information to guide the physical assessment. Assessment Comprehension
Objective – 1 Page – 99 Difficulty – 1
10) Mrs. Sandler, 34 years old, is being admitted. She is changing her position frequently, wringing her hands, and laughing at inappropriate times. What should the nurse include in the assessment based on this information? 1) Anxiety assessment 2) Mental status testing 3) Attention deficit testing 4) Nutrition assessment 10) 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. One means used to further evaluate the anxiety is the use of an anxiety scale. 2. There is no indication the client is not oriented to time, place and person. 3. There is not indication for this. The behaviours are consistent with someone who is anxious. 4. The behaviours exhibited by the Mrs. Sandler indicate anxiety. Assessment Application Objective – 1 Page – 100 Difficulty - 1
11) Mrs. Kellogg, 69 years old, is admitted with a fractured hip. She points to the painful hip and describes it as a constant throbbing. What would the nurse include in a pain assessment? 1) Precipitating and relieving factors, impact on ADLs, and coping strategies 2) Location, quality, and impact on ADLs 3) Quality, pattern, and precipitating factors 4) Precipitating and relieving factors, location, and impact on ADLs 11) 1 Explanation: 1. Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies and emotional responses. Mrs. Kellogg’s description in the question already includes the quality, location, and pattern. 2. Mrs. Kellogg has already indicated the location and quality of the pain. 3. Mrs. Kellogg has already indicated the quality and the pattern of the pain. 4. Mrs. Kellogg has indicated the location of the pain. Assessment Analysis Objective – 3 Page – 108, 109 Difficulty - 2
12) During an interview with a client, the nurse notes confusion as to day and time. What aspect of the mental status examination should the nurse evaluate further?
1) Affect and mood 2) Orientation 3) Willingness to cooperate 4) Level of anxiety 12) 2 Explanation: 1. There is no indication the affect or mode is a concern. 2. Client’s ability to state their name, location, and the date and time of day assesses for their orientation to person, place, and time. 3. There is no indication that the client is uncooperative. 4. There is no evidence that the client is anxious. Assessment Application Objective – 2 Page – 100 Difficulty - 1
13) Mr. Sandhu, 85 years old, is admitted with arteriosclerosis. His blood pressure at 06h00 is 172/98 mm Hg. What factor may contribute to Mr. Sandhu’s blood pressure? 1) Blood pressure is increased in obese people 2) Arteriosclerosis increases blood vessel elasticity 3) Blood pressure is highest in the morning 4) Blood vessels lose their elasticity with age 13) 4 Explanation: 1. There is no indication that Mr. Sandu is obese. 2. Arteriosclerosis results in hardened and rigid arteries, which are less compliant. This requires greater ventricular force and leads to increased blood pressure. 3. Blood pressure is usually lower in the morning. 4. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. Assessment Comprehension Objective – 4 Page – 106 Difficulty - 2 14) What is the meaning of the numbers in a blood pressure reading? 1) Bottom number is the pressure between ventricular contractions 2) Bottom number is a reflection of cardiac output 3) Top number is the result of the heart rate 4) Top number reflects the pressure of blood generated when the right ventricle contracts 14) 1 Explanation: 1. The bottom number is the diastolic pressure. This is a reflection of the heart at rest. 2. The diastolic pressure, bottom number, is not a direct reflection of cardiac output. 3. The diastolic pressure, bottom, number, is a result of the heart at rest. 4. Systolic pressure (top number) is the pressure of blood at the height of a wave produced by left ventricular contraction. Assessment
Comprehension Objective – 3 Page – 106 Difficulty - 1
15) A nurse needs to take a blood pressure on a thin client, and the only cuff available is a standard sized cuff. The nurse would correctly anticipate what readings? 1) Accurate reading 2) Falsely elevated reading 3) Reading will depend of the overall health of the client 4) False low reading 15) 4 Explanation: 1. The bladder of the blood pressure cuff must be appropriate for both the length and width of the client’s arm. The width of the bladder should be 40% of the circumference of the limb. The length should be 80% of the circumference of the limb. 2. If the bladder is too narrow, the blood pressure reading will be falsely high. 3. The reading will be impacted by the size of the blood pressure cuff. 4. If the bladder is too wide, the blood pressure will be too low Assessment Application Objective – 4 Page – 107 Difficulty - 1
16) Mrs. Choi, 48 years old, had a left-sided mastectomy two days ago. The nurse has delegated vital signs on this client to an unregulated health care provider. What specific instructions would the nurse provide in delegating this task? 1) Take the blood pressure on the right arm 2) Use the electronic blood pressure machine 3) Take the blood pressure on the left arm 4) Take the blood pressure on both arms for a baseline 16) 1 Explanation: 1. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. In these situations, the opposite arm should be utilized. 2. Even with the use of a electronic blood pressure machine the nurse must indicate that the left arm is not to be used. 3. Blood pressure must not be taken on an arm with a shunt, trauma, or disease. 4. Blood pressure must not be taken on the left arm. Planning Application Objective – 5 Page – 107 Difficulty - 1
17) Mandy, 6 weeks old, needs her vital signs taken as part of a well baby assessment. What represents appropriate routes and sequence for obtaining vital signs on Mandy? 1) Rectal temperature, respirations, pulse rate 2) Respirations, pulse rate, blood pressure, rectal temperature 3) Respirations, apical pulse rate, axillary temperature 4) Oral temperature, respirations, pulse rate, blood pressure 17) 3 Explanation: 1. Although a rectal temperature is the most accurate, an axillary should be done in infants to avoid the risk of rectal perforation. 2. Blood pressure is not a routine vital sign taken on a healthy infant. The rectal route would not be used on an infant due to the risk of rectal injury. 3. Respirations and apex should be taken first as Mandy may cry when her temperature is taken. 4. An oral temperature is an inappropriate route to take a temperature on an infant. Assessment Application Objective – 3 Page – 108 Difficulty - 3 18) A nurse educator is preparing an in-service on pain management for the staff. One of the staff nurses asks what the most important part of a pain assessment would be. What is the most appropriate response by the nurse educator? 1) “Pain is only partially subjective and primarily a physiological 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 admission diagnosis is important.” 3) “If you observe the client sleeping, they are not experiencing very much pain.” 4) “The response to pain is unique and based on numerous factors which need to be assessed.” 18) 4 Explanation: 1. Pain is entirely subjective and a personal experience. Vital signs are less important in pain assessment. 2. Pain is a unique experience and is whatever the person says it is. 3. Pain is a subjective and personal experience. The nurse should not rely on observations to give an accurate assessment. 4. Pain is a subjective experience, and the response is unique to each individual. The factors which impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. As nurses, a patient’s level of pain cannot be determined by their physiologic response only. Assessment Comprehension Objective – 3 Page – 108, 109, 110 Difficulty - 2
19) A nurse observes the client walking into the room and climbing up on the examination table. What aspect of the general survey has the nurse completed? 1) Mobility status
2) Subjective assessments related to ambulation 3) Activity tolerance 4) Strength of upper and lower extremities 19) 1 Explanation: 1. During a general survey, the nurse observes the client performing routine activities. This allows the nurse to begin to gather data about the client’s mobility. This data will then be incorporated into the remainder of exam and history. 2. Observation is considered objective and not subjective. 3. The purpose of this is not to observe tolerance to activity. 4. This does not assess strength in the upper and lower limbs. Assessment Application Objective – 2 Page – 99, 100 Difficulty - 1 20) How can a nurse assess a client’s mental status within the general survey? 1) Observe the client walking into the examination room. 2) Ask the client to describe elements of his health history. 3) Study the client’s clothing selections. 4) Notice the client’s ability to make eye contact during the examination. 20) 2 Explanation: 1. Observing the client walking into the examination room would help assess mobility. 2. The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behaviour. Asking the client to describe elements of his health history would help assess mental status. 3. Studying the client’s clothing selections would help assess physical appearance. 4. Noticing the client’s ability to make eye contact would help assess client behaviour. Planning Application Objective – 2 Page – 100 Difficulty - 1 21) During a physical assessment the client asks the nurse repeatedly, “Is everything ok?” What is the most appropriate interpretation of this client's behaviour? 1) A poor self concept 2) Inappropriate affect 3) Effective body image 4) Anxiety 21) 4 Explanation: 1. Evidence of a poor self concept would include poor personal hygiene practices. 2. An inappropriate affect would be demonstrated by the client responding inappropriately to a situation, such as laughter when discussing the death of a pet.
3. Body image would be assessed by the way the client is dressed. 4. A client’s level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if “everything is ok” could be evidence of worry about the outcome of the examination. Diagnosis Analysis Objective – 5 Page – 100 Difficulty - 2
22) Mrs. Davidson, 72 years old, has edema of her lower extremities despite being prescribed medication for this symptom. What should the nurse do first? 1) Discuss the finding with the client’s physician. 2) Provide the client with support hose. 3) Review the client’s current medications. 4) Document the finding in the medical record. 22) 3 Explanation: 1. The nurse should complete Mrs. Davidson’s assessment before contacting the physician. 2. Providing the client with support hose might not be beneficial or indicated at this time. 3. The nurse should discuss Mrs. Davidson’s current medications because elderly clients might be prescribed multiple medications which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of Mrs. Davidson’s medication schedule and history. 4. Documenting the finding is important, however, it is not something that should be completed first. Planning Application Objective – 5 Page – 101 Difficulty - 2 23) Mr. Cohan, 34 years old, tells the nurse that he is “180 cm. tall and weighs 91 kg.” Upon assessment the client is found to be 175 cm. tall with a weight of 101 kg. What does this discrepancy indicate about Mr. Cohan? 1) Does not have a scale at home 2) Self-image is not in sync with actual findings 3) Didn’t want to tell the truth 4) Trying to hide a chronic illness 23) 2 Explanation: 1. The nurse has no way of knowing if Mr. Cohan has a scale at home to use or not. 2. The best reason for the inconsistency is that Mr. Cohan has a different image of himself than what is objectively measurable. 3. The inconsistency between reported height and weight and actual height and weight does not mean Mr. Cohan is being dishonest.
4. There is no indication that this is true. Diagnosis Analysis Objective – 5 Page – 101 Difficulty - 1 24) Mrs. Choi, 83 years old, says to the nurse, “I’m losing weight from my waist up but gaining it in my legs.” What would be an appropriate response? 1) “Subcutaneous tissue decreases in the upper body as a person ages.” 2) “Your diet must be working, to an extent.” 3) “This happens to everyone. Don’t worry about it.” 4) “Let’s talk about your diet to see why you’re gaining weight in your legs.” 24) 1 Explanation: 1. The older client may appear thinner, even when properly nourished, because of loss of subcutaneous fat deposits from the upper body. Fat deposits on the abdomen and hips may increase. 2. The nurse should not assume the client has been on a diet or has changed his/her diet. 3. The nurse should not make generalized statements nor should the nurse tell the client to be unconcerned. 4. The loss of upper body weight and the increase in mass in the legs is not related to diet. Implementation Analysis Objective – 2 Page – 102 Difficulty - 2
25) A resident in an extended care facility had a low body temperature in the morning and has a higher temperature at 19h00. What does this variation in temperature indicate? 1) The morning temperature was assessed incorrectly 2) The resident is developing an infection 3) The resident is experiencing stress 4) The temperatures reflect diurnal variations 25) 4 Explanation: 1. There is no evidence to suggest the morning temperature was not assessed correctly. 2. There is no evidence that the resident is developing an infection other than the higher evening body temperature. 3. There is no evidence that the resident is experiencing stress other than the higher evening body temperature. 4. The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day. Diagnosis Analysis Objective – 4
Page – 103 Difficulty - 1 26) During the assessment of a client with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. What would these findings suggest to the nurse? 1) The client is a child and these are normal findings. 2) The client could have an abdominal infection. 3) The client is anxious. 4) The client’s medications are causing the blood pressure to be low. 26) 2 Explanation: 1. The average pulse rate of infants and children is higher than that of teens and adults, there is no evidence to suggest this client is a child. 2. The best selection is the client could have an abdominal infection since the client is experiencing abdominal pain in addition to the low blood pressure and elevated pulse rate. 3. The pulse rate increases in response to stress, fear, and anxiety, however there is no evidence to suggest this client is anxious. 4. There is also no information to suggest any of the client’s medications are causing the low blood pressure and higher than normal pulse. Diagnosis Analysis Objective – 4 Page – 104 Difficulty - 3 27) In taking a client’s blood pressure, the nurse assessed the following: First sound heard: 136; Swishing sounds: 120; Tapping sounds: 100; Muffled sounds: 98; Sounds stop: 76. What blood pressure would the nurse document? 1) 136/76 mm Hg 2) 120/76 mm Hg 3) 120/98 mm Hg 4) 136/98 mm Hg 27) 1 Explanation: 1. The first sound is recorded as the systolic blood pressure and the last sound is recorded as the diastolic blood pressure. 2. The systolic blood pressure is the point at which the first sound is heard. 3. The systolic blood pressure is the point at which the first sound is heard and the diastolic blood pressure is the last sound that is heard.. 4. The diastolic blood pressure is the last sound that is heard. Implementation Comprehension Objective – 3 Page – 108 (Box 7.1) Difficulty - 1
28) What location should the nurse use to assess the pulse of an 11-month-old infant?
1) The femoral artery 2) The brachial artery 3) The apical site 4) The radial artery 28) 3 Explanation: 1. The femoral artery is not the most reliable site for taking a pulse in an infant. 2. The brachial artery is not reliable for taking an infant’s 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 radial artery may be difficult to palpate in an infant. Implementation Application Objective –3 Page – 104 Difficulty - 1
29) Mrs. Wayne, 42 years old, has pain due to spinal stenosis. She identifies her current pain level to be 5 on a scale from 0 to 10. Mrs. Wayne’s vital signs are all within normal limits. What does this indicate about Mrs. Wayne’s pain? 1) Less than she is rating. 2) A defense mechanism. 3) Worse than she is rating. 4) Ongoing, yet controlled with coping mechanisms. 29) 4 Explanation: 1. Pain is an entirely subjective and personal experience. The nurse should not assume the client is experiencing less pain then is reported. 2. There is no evidence to suggest the client is using pain as a defense mechanism 3. Pain is an entirely subjective and personal experience. The nurse should not assume the client is experiencing more pain than is reported. 4. The best conclusion for the nurse to make is this client’s pain is ongoing; however the client has effective coping strategies which aid in the control of the pain. Diagnosis Analysis Objective – 5 Page – 109 Difficulty - 1 30) Mr. Fitzhugh, 68 years old, has been admitted for elective surgery. The nurse notes he is overweight, walks with a slight limp, has difficulty hearing the nurse’s questions, and his breathing appears to be laboured. What should the nurse do first? 1) Review his nutritional intake 2) Do a height and weight 3) Use an otoscope to assess his ears 4) Complete a respiratory assessment 30) 4 Explanation: 1. Although the nurse may want to review Mr. Fitzhugh’s food intake, it is not the priority.
2. Height and weight are not the priority when Mr. Fitzhugh has difficulty breathing. 3. An ear assessment would not be a priority at this time. 4. As Mr. Fitzhugh has laboured breathing, the nurse needs to complete a respiratory assessment in the event he needs oxygen. Diagnosis Analysis Objective – 5 Page – 99 Difficulty - 3
SHORT ANSWER. Write the word or phrase that best answers the question.
31) A client appears disheveled in appearance, with uncoordinated clothes, body odor, and uncombed hair. What would the nurse assess during the history and physical exam? (Select all that apply.) Anxiety Depression Mental illness Self concept 31) X_ Anxiety X_ Depression X_ Mental illness X_ Self concept Explanation: The way a client dresses and maintains physical hygiene may provide clues to sense of self-esteem and body image as well as be an indicator of mental illness, anxiety, or depression. Assessment Analysis Objective – 1 Page – 100 Difficulty - 1
Chapter 8 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is assessing a teenager's pain level. The client is clearly uncomfortable but when the nurse asks for a description of the pain the client says, “It just hurts. Why can’t I have something?” What should the nurse do? 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) Do a set of vital signs to confirm the client has pain 1) 2 Explanation: 1. Leaving the room will not provide effective pain management and the nurse will not have the required assessment data to act on the client's pain. 2. People who are not feeling well or who are in pain may have difficulty with open-ended questions, such as “Describe….” The nurse may be better able to obtain an accurate description of the client's pain by having the client respond to descriptive words with a yes or no response. 3. Asking the client what they would like for pain is not appropriate without a complete assessment. 4. The client has clearly stated that he is in pain. According to McCaffery & Pasero, 1995, "pain is whatever the experiencing person says it is, existing whenever he or she says it does". The vital signs may provide more data about the pain but the vitals should not be used to confirm or disprove what a client has stated about his pain. Assessment Application Objective 5 Page 120 Difficulty = 2 2) A nurse is working at a pain clinic and is preparing an orientation for new staff nurses. What principle of pain management would the nurse correctly choose to include in this orientation? 1. Validation by the nurse assessing the pain. 2. Unpleasant sensations typically experienced upon movement 3. Whatever the experiencing person says it is 4. Very subjective so observations must be used to assess levels and intensity 2) 3 Explanation: 1. The nurse’s role is not to validate the client’s report of pain but to assess and assist in alleviating or managing the pain. 2. Pain involves unpleasant sensations, though not always limited to movement. At times, the cause of the pain is not determined at the time the client reports it. 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 trusted in order to effectively manage it. Diagnosis
Knowledge Objective 1 Page 113 Difficulty = 1 3) A client arrives in the Emergency Department complaining of chest and arm pain. The client also reports jaw pain, but states that the chest pain hurts more. The nurse observes the client rubbing his left arm. What is the most accurate description of this client's pain? 1) Phantom 2) Radiating 3) Intractable 4) Cutaneous 3) 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. Cutaneous pain is pain experienced in the skin or subcutaneous tissues. 4. Intractable pain is resistant to relief and is typically associated with advanced malignancy Assessment Knowledge Objective 3 Page 116 Difficulty =1 4) A nurse is caring for two clients who have sustained similar injuries as a result of a motor vehicle accident. Neither has received any pain medication in six hours and both have asked. However, one client is in greater distress than the other. What pain theory is useful in explaining this phenomenon? 1) Pattern 2) Specificity 3) Stress 4) Gate control 4) 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. Specific theory holds that pain neurons are specific and unique and the specific pain neurons transport the sensations directly to the brain. 3. Pain can result in both physiologic and psychologic stress for the individuals experiencing pain but the stress of pain does not explain why people respond differently to the same pain stimulus. 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 different people. Assessment Knowledge Objective 2 Page 114 Difficulty = 3
5) A client with chronic pain from spinal stenosis has asked the nurse for assistance with pain management. The client is well dressed and composed, with normal vital signs. The nurse observes that the client grimaces when sitting but rates the pain at only 2 out of 10. What is the best explanation for this client's response to pain? 1) Only certain movements cause pain. 2) Is not in severe pain and does not need treatment. 3) The pain is getting better. 4) Has adapted to the pain and is able to control behaviours. 5) 4 Explanation: 1. While this may be accurate the nurse cannot assume that this is the case without a full assessment. This statement also doesn't acknowledge that the physiological and psychological responses to chronic pain are different than what occurs with acute pain. 2. The client has stated that he is there for assistance with pain management. The nurse has not completed the assessment; therefore, the nurse should not jump to conclusions about the client's pain status or the treatment options. 3. The client has stated that he is there for assistance with pain management; therefore, assuming that the client’s condition is improving without further assessment is irresponsible. In addition, only the client can determine whether the pain is improving or not. 4. People with chronic pain develop their individual coping styles to deal with pain, discomfort or suffering. Also, physiological responses may be marked in acute pain but because of central nervous system adaptation, physiological responses are likely to be absent. Therefore, behavioural and physiological responses are not good indicators of pain. Assessment Analysis Objective 3 Page 121 and 122 Difficulty = 1 6) A nurse is caring for a client with sickle cell anemia who rates his pain as 7 out of 10. This client is moving around easily and is eating well, but has asked for pain medication. What is the most appropriate nursing action? 1) Wait 30 minutes and see if the client is still requesting the pain medicine. 2) Administer half the ordered does of pain medication. 3) Administer the pain medication if it has been longer than the ordered interval. 4) Notify the physician that the client is faking his pain. 6) 3 Explanation: 1. Since pain occurs whenever the experiencing person says it does, the nurse should accurately assess and treat the pain with the pain medication, if that is what is ordered, therefore if the analgesic is due it should be given and not held for another 30 minutes. 2. There is no evidence in the case scenario to support this action and it does not support the definition of pain. 3. Since pain occurs whenever the experiencing person says does, the nurse should accurately assess and treat the pain with the pain medication that is ordered. 4. This is an inappropriate action to take because the nurse is not honouring the definition of pain. Implementation Comprehension
Objective 1 Page 113 Difficulty = 2 7) What type of unidimensional pain assessment tool would be most appropriate for assessing the location of the pain with a preschooler? 1. Simple Verbal Descriptive Scale 2. Oucher Scale 3. Body Diagram scale 4. McGill Pain Questionnaire 7) 3 Explanation: 1. This tool does not assess location of the pain but intensity of the pain. Although a preschooler is developing the ability to describe pain intensity and location the tool needs to be age appropriate. 2. The Oucher Scale is a great scale to use with children to determine pain intensity but not location of the pain. 3. The Body Diagram scale presents an outline of the body. The individual is asked to point or mark on the picture to show the location of the pain. This tool is age appropriate and will assess location of the pain. 4. The McGill Pain Questionnaire is a multidimensional tool used to assess two or more elements of pain. This tool is used when pain is prolonged. Assessment Application Objective 5 Page 122 Difficulty = 2 8) A nurse is caring for a client with back discomfort and administers ibuprofen (Advil). What nociception process is being disrupted with the administration of ibuprofen? 1) Transduction 2) Transmission 3) Perception 4) Modulation 8) 1 Explanation: 1. Ibuprofen blocks the production of prostaglandin. When prostaglandin, a biochemical mediator, isn’t released the nociceptors are not sensitized thus stopping the process of transduction. 2. In the transmission phase, the pain impulse travels from peripheral nerve fibers to the spinal cord then to the brain stem, 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. Implementation Knowledge Objective 2 Page 114 Difficulty = 3
9) A nurse is interviewing a client who reports having daily migraines. The nurse decides to further assess the impact of the client’s pain. What would be the most appropriate assessment tool? 1) Psychological well-being inventory 2) Body Diagram tool 3) Intensity Rating scale 4) Brief Pain Inventory 9) 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. Unidimensional tools such as the Body Diagram are useful for assessing the location of acute pain at the time the client is experiencing pain bur will not provide information on how pain interferes with the person’s ability to function. 3. Unidimensional tools such as an Intensity Rating scale are useful for assessing acute pain but only assesses one aspect of pain and will not provide information on the impact of pain on daily living. 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. Assessment Knowledge Objective 5 Page 122 Difficulty = 3 10) What statement best defines the concept of pain threshold? 1. The amount of pain stimulation a person requires in order to feel pain. 2. The individual autonomic responses to pain such as heart rate. 3. The maximum amount of pain that an individual is willing to endure. 4. The excessive sensitivity to pain that is unique to the client. 10) 1 Explanation: 1. An individual's pain threshold is the amount of pain stimulation the person requires to feel pain. 2. This statement describes pain reaction which is the autonomic nervous system responses to pain such as heart rate and blood pressure. 3. This statement is the definition for pain tolerance. 4. An excessive sensitivity to pain is the definition of hyperalgesia. Assessment Knowledge Objective 1 Page 117 Difficulty = 1 11) A client has recently been discharged after a right above the knee amputation. The client tells the home care nurse that his right foot hurts. What type of pain does this client have? 1) Phantom 2) Radiating 3) Intractable 4) Cutaneous
11) 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 and is more common with an advanced malignancy 4. Cutaneous pain is pain experienced in the skin and subcutaneous tissues. Assessment Knowledge Objective 3 Page 117 Difficulty = 1 12) A nurse is assessing a client admitted with chronic back pain. What subjective data would the nurse anticipate the client reporting? 1) Sudden onset 2) Interferes with daily activities 3) Is diaphoretic 4) Short in duration 12) 2 Explanation: 1. Acute pain usually has a sudden onset associated with an injury, illness or surgery whereas chronic pain is recurring and lasting longer than 6 months. 2. Chronic pain is prolonged, usually recurring or persisting over six months or longer, and interferes with functioning and activities of daily living. 3. Acute pain is associated with sympathetic nervous system responses like diaphoresis whereas chronic pain results in normal vital signs. In addition, diaphoresis is something a nurse can observe therefore this is objective data. 4. Acute pain is trigger by illness, injury, or surgery and resolves with healing. Assessment Knowledge Objective 3 Page 116 Difficulty = 2 13) Susie, 13 months old, requires a venipuncture. Her parents ask the nurse what they can do to help with this procedure. What should the nurse do? 1) Have the parents leave the area during the procedure. 2) Tell the parents to touch and reassure the infant during the procedure. 3) Wait until the infant is asleep to do the procedure. 4) Administer an analgesic thirty minutes before the procedure. 13) 2 Explanation: 1. Having the parents leave the area may cause the infant to react very strongly to the painful stimulus.
2. The nurse understands that the presence of supportive people may affect the infant’s perception of the severity of the pain, and the parents will provide reassurance and security. In addition, using tactile stimulation such as touch may be helpful in soothing the infant and reducing the pain. 3. The infant is likely to react negatively if awakened from a sound sleep by painful stimuli. 4. Administering an analgesic is inappropriate as the infant is not yet experiencing the pain, and after the relatively quick procedure is over, the infant should no longer feel any pain. Implementation Application Objective 4 Page 118 and 119 (Table 8.3) Difficulty = 1 14) A client, 47 years old, continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip. While giving report to the next shift, the nurse who cared for the client during the day states, “I just do not know why she still needs medication 4 days after surgery. The client we had last month with the same injury and procedure did not need any medication after 2 days.” Which response by a nursing colleague best illustrates client advocacy? 1) “I just think this client needs more because of their age.” 2) “Have you tried getting the doctor to order oral pain medications to see if they work?” 3) “Wouldn’t you want all of the pain medication you could have if you were in traction?” 4) “Everyone does not have the same pain perception or response to a similar injury.” 14) 4 Explanation: 1. This response does not address the nurse's bias or misconception about pain control. Also there is no research to support the notion that an adult (e.g. 47 years) will have more pain simply based on age. 2. This response does not address the nurse's bias or misconception about pain control. Contacting the doctor would be an appropriate action if the nurse was providing regular analgesic and it was ineffective. 3. This response does not address the nurse's misconception about pain control and the fact that she is not acting in the client's best interest. The Gate Control theory of pain states that individuals will respond differently to a similar stimulus; therefore, McCaffery & Pasero's definition of pain must be adhered to in order to respond appropriately to client pain. 4. Based on the definition by McCaffery & Pasero, pain is “whatever the experiencing person says it is, existing whenever he or she says it does.” This definition supports each client’s need for individualized pain management. Implementation Analysis Objective 1 and 2 Page 113 and 114 Difficulty = 2 15) A teenage client has multiple fractures following a motor vehicle accident. What nursing intervention would be useful in reducing the client's perception of pain? 1) Suggest listening to music as a distraction 2) Use imagery to turn off "pain switches" 3) Administering morphine intravenously as ordered 4) Try diversion techniques like blowing bubbles 15) 1
Explanation: 1. Non-pharmacologic interventions are cognitive-behavioural strategies that can be applied to reduce the sensation and affective components of pain. This is possible as a result of the location in the brain (cortical structures) where the pain perception is determined. Listening to music is an age appropriate distraction technique that may reduce the client's perception of pain. 2. Although guided imagery can be an effective intervention to reduce the client's perception of pain, this particular strategy is more appropriate for the school-age child than an adolescent. 3. Administering medication is a pharmacological intervention and is an example of reducing the second step in the transmission of pain and not the perception of pain. 4. Although distraction can be an effective intervention to reduce the client's perception of pain this particular strategy is more appropriate for the toddler and preschooler than an adolescent. Implementation Application Objective 2 Page 115 and 118 (Table 8.3) Difficulty = 2 16) A nursing student is reviewing the home medications of a client who has just been admitted with chronic back pain. The nursing instructor asks the student why the client is on a tricyclic antidepressant. What response by the student demonstrates her understanding of this medication and chronic pain? 1) “This drug is treating the client's depression as a result of long term chronic pain.” 2) “There is an increase in Substance P resulting in pain and this drug inhibits this response” 3) “This medication inhibits the reuptake of serotonin thus decreasing the pain.” 4) “The client needs a medication to block the nociceptors to control pain." 16) 3 Explanation: 1. Although this medication is an antidepressant it is often used to manage chronic pain by improving modulation of the pain. There is no evidence in the client history to suggest depression. 2. Substance P serves as a neurotransmitter that enhances the movement of impulses across the synapse. This medication does not affect this process. 3. Tricyclic antidepressants inhibit the reuptake of norepinephrine and serotonin. This action increases the modulation phase and decreases the pain stimuli response. 4. This medication does not block nociceptors. Assessment Analysis Objective 2 Page 115 Difficulty = 3 17) A nurse is performing a physical assessment on a young adult with undiagnosed acute abdominal pain. The client is unable to communicate verbally. What finding is the best indicator that the client is in acute pain? 1) Temperature of 38.10C 2) Pulse rate of 100 3) Dilated pupils 4) Blood pressure of 120/84 mmHg 17) 2
Explanation: 1. 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. Temperature is not part of the sympathetic response. The elevated temperature is possibly an indicator infection but it is not an indicator of pain. 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. A heart rate of 100 is out of the normal range for a young adult. Tachycardia occurs with acute pain. 3. Dilated pupils are another sign of a sympathetic nervous response that can occur as part of physiologic response to pain; however it is not the best indicator of pain. An increased pulse is a better indicator of a physiologic pain response. 4. The client has normal blood pressure. Normal vital signs are typical with chronic pain rather than with acute pain. Evaluation Analysis Objective 2 Page 116 (Table 8.2) Difficulty = 2 18) What type of nociceptor fiber is responsible for the transmission of dull, aching pain? 1. A-beta 2. A-delta 3. C-alpha 4. C 18) 4 Explanation: 1. A-beta fiber is a large myelinated fiber that transmits touch and vibration. 2. Nociceptor A-delta fibers will transmit sharp, localized pain from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord. 3. There is no such fiber. 4. Nociceptor C fibers transmit the dull, aching pain from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal cord. Assessment Knowledge Objective 2 Page 114 Difficulty = 2 19) Jake, 12 years old, is brought to the emergency room after falling on his arm during a football game. The nurse tells Jake that pain medication will be administered through the intravenous line; he begins to scream and wave his unhurt arm. The parents ask the nurse why their child is behaving this way. What is the nurse’s best response? 1) “He is just immature for his age.” 2) “I am sure he is just scared.” 3) “He might have also hit his head during the fall.” 4) “He may be thinking of another time when he had to get a “shot” for pain.” 19) 4 Explanation:
1. This is an inappropriate response by the nurse. The child's response is not immature but a strong indicator that this child may have had a previous pain experience and is anticipating the same pain experience this time. 2. Assuming the child is just “scared” is not something the nurse can be “sure” of, as it is never safe to assume anything as a definite. The nurse would need to explore this further with the child and the parents. The nurse also needs to consider that she triggered the child's response when she spoke of the intravenous. 3. The child's response of screaming and waving his arm are not signs of a head injury but of a child who is afraid of what is going to happen next (e.g. the perceived shot). 4. A client’s pain reaction may be a behavioural response to a similar or previous situation when pain was experienced. This is a learned response and method of coping with the pain. Many children remember getting a “shot” for pain, or getting an immunization. Seeing the syringe and/or needle may trigger this pain reaction. Evaluation Analysis Objective 4 Page 117 and 119 Difficulty = 2 20) What physiologic process is responsible for the reflexive action of withdrawing one's hand away from a hot stove even before one is aware of the pain? 1. Modulation 2. Open gate reflex 3. Autonomic nerve response 4. Proprioceptive 20) 4 Explanation: 1. Modulation is a physiologic response to pain but it is not the reflex described in the question. 2. There is no such thing as an open gate reflex. 3. The autonomic nervous response may get triggered once the individual perceives the pain but the initial reflexive withdrawing of the body part is the proprioceptive reflex. 4. The proprioceptive reflex occurs when pain receptors are stimulated resulting in the involved muscle group to contract and protectively withdraw the body part from the heat source. Assessment Knowledge Objective 2 Page 116 (Figure 8.4) Difficulty = 3 21) What source of assessment data will be most reflective of a client’s pain response following openheart surgery? 1) Family report of pain 2) Response from the client based on the use of a pain tool 3) Observation of client behaviors while asleep 4) Measurement of vital signs 21) 2 Explanation: 1. The use of a standardized pain tool that allows the client to describe the intensity of the pain will most accurately capture the client's experience with pain since pain is a subjective experience.
2. The family may perceive the client to be in pain when the client is not. 3. Observations of behaviour 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. Assessment Analysis Objective 5 Page 122 Difficulty = 1 22) A nurse in a health clinic is interviewing a client, 75 years old, who has joint pain. The client verbalizes that the pain has been present for a few years. What age related variations must the nurse consider while interviewing this client? 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. 22) 4 Explanation: 1. Generally older clients withhold complaints of pain or consider it unacceptable to admit or show pain. 2. There is no other information given to suggest that the client has another reason for the visit besides the joint pain. It is important that nurses don’t make assumptions about the client situation when the data is incomplete. 3. There is no other information given to suggest that the client is depressed. Further assessment is required of the client. 4. Age and developmental stage of a client will influence both the reaction to and the expression of pain. For example, the older adult may perceive pain as part of the aging process, may have decreased sensation of the pain, and may withhold complaints of pain because of fear that the treatment prescribed may limit their independence, or may consider it unacceptable to admit or show pain. Assessment Application Objective 5 Page 118 (Table 8.3) Difficulty = 2 23) A male, 19 years old, of Middle Eastern descent is in the hospital for a ruptured appendix. His parents are at the bedside the majority of his waking hours. The nurse caring for him during the day observes that he denies any pain during the day shift. The night nurse reported that the client had requested pain medication every 4 hours during the night. What is the most likely explanation for the difference in the client's analgesic requirements? 1) The night nurse had more time to spend with the client. 2) The client was afraid or lonely at night and is trying to get attention. 3) He may not report pain in the presence of his parents based on their influence or cultural beliefs. 4) The request for analgesic medication at night was to help him sleep. 23) 3 Explanation:
1. This answer does not account for the psychosocial and environmental factors that will influence a person’s ability to identify and seek pain relief. Factors such as culture, religion, family, and role within the family. 2. The client may feel more afraid at night but this answer demonstrates a limited view on the potential impact that psychosocial and environmental factors have on this client's ability to express pain and to receive analgesics during the day shift in the presence of his family. 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 in pain. The presence of family members, especially adult family members in this situation, may influence the reporting of pain. The client may not want to contradict the perceived parental expectations of how an adult male in their culture responds to pain. 4. It is more likely that the client's ethnocultural background is influencing both his expression of pain and ability to accept treatment modalities regarding pain during the day shift but is free to acknowledge his pain and ask for pain relief when away from family members. Assessment Application Objective 5 Page 119 Difficulty = 2 24) A nurse is assessing a postoperative client that reports a pain level of 10 on a 0 to 10 scale. The client is grimacing and appears anxious. What should the nurse do? 1) Administer pain medication if it has been longer than the ordered interval. 2) Offer to call the pastoral service to provide spiritual counseling. 3) Obtain an order for an anti-anxiety medication. 4) Call the family to come in and stay with the client. 24) 1 Explanation: 1. Pain needs to be well managed with pain medications given on a scheduled basis, so that the pain does not get “out of control.” Poorly managed or untreated pain will influence every aspect of an individual’s health and well-being. 2. Once the pain is under control, the nurse can assess other factors influencing the client’s pain response. Spiritual counseling may not be helpful if the pain is not managed effectively. 3. Relieving the anxiety may help in alleviating pain and should be considered with other forms of pain management. However, relieving anxiety will be easier if the pain is managed effectively. 4. The presence of family members may provide comfort to the client, but is not the priority intervention. Implementation Application Objective 5 Page 119 Difficulty = 1 25) A client has an ankle sprain as a result of an injury sustained in a soccer game. The client describes the pain as “spread out” rather than localized. What type of pain is likely based on the origin of the injury? 1. Visceral 2. Cutaneous 3. Non-progressive 4. Deep somatic
25) 4 Explanation: 1. Visceral pain results from stimulating pain receptors in the abdominal cavity, cranium, and thorax. The pain is frequently caused by stretching of the tissues, ischemia or muscle spasms. The pain is diffuse and may be described as burning, aching, or there is the sensation of pressure. A bowel obstruction can result in visceral type pain. 2. Cutaneous pain originates in the skin or subcutaneous tissue. A paper cut is an example of this type of pain. 3. Neuropathic pain often develops when there is damage to the peripheral or central nervous system and may not have a stimulus. This pain is describes as burning, dull, and aching. 4. Deep somatic pain arises from ligaments, tendons, bones, blood vessels and nerves. The pain is often described as diffuse (e.g. spread out). An ankle sprain is an example of an injury that can result in deep somatic pain. Assessment Knowledge Objective 3 Page 116 Difficulty = 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) What type of receptor is responsible for transmitting the sensation of pain? 26) Nociceptors Explanation: This is a clear definition of the term nociceptors. Assessment Knowledge Objective 2 Page 114 Difficulty = 2
Chapter 9 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A client weighs 77 kg, is 170 cm tall, and has a body mass index (BMI) of 23. How should the nurse interpret this finding? 1) Mild malnutrition 2) Normal 3) Overweight 4) Obese class I 1) 2 Explanation: 1. An adult with a BMI of < 18 is considered underweight. Malnutrition is defined as insufficient nutrient intake or stores. 2. An adult BMI of 23 is within the range of normal of 18.5 and 24.9. 3. A BMI 25-29.9 is classified as overweight 4. Obese class I has a BMI of 30-34.9 Assessment Comprehension Objective 7 Page 132 (Table 9.3) Difficulty = 2 2) A nurse is using a dietary recall tool to obtain a nutritional history on a client. What is a limitation of using this assessment tool? 1) Clients do not remember liquid intake from day to day. 2) It does not reflect food preferences of the client. 3) Clients do not provide reliable nutritional information. 4) It does not reflect occasional food habits. 2) 4 Explanation: 1. A diet recall or a 24-hour recall is not intended to examine the client's day to day intake. A diet recall is a snapshot of the client's intake (e.g. food, beverages, and nutritional supplements) in a 24-hour period. 2. It does not need to reflect food preferences. The diet recall does reflect all food and liquids taken in during the previous 24 hours. 3. It is not the most reliable way of obtaining information because this method relies on the client’s memory; however, it is considered somewhat reliable and a useful tool for nutritional assessment. 4. One limitation of the 24-hour dietary recall is that it does not, or may not, reflect significant food habits that occur occasionally but not on the day recalled. Assessment Knowledge Objective 5 Page 128 Difficulty = 1 3) A nurse is obtaining a tricep skinfold measurement on a client. What is the correct landmark for this assessment? 1) Midpoint of the arm equidistance from the scapula and the elbow
2) Five centimeters below the scapula and centered 3) Use left the arm, 2 cm above the olecranon process of the elbow 4) Go three finger breadths below the acromion process on the right arm 3) 1 Explanation: 1. Tricep skinfold measurement is 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. Incorrect. This measurement technique does not ensure equidistance between the scapula and elbow. 3. The right side of the body is used for taking skinfold measurements to ensure consistency; however, this technique is incorrect because it is not equidistance between the elbow and scapula. 4. Using the right arm is appropriate but the measurement technique is incorrect because it is not equidistance between the elbow and scapula. Assessment Application Objective 5 Page 133 and 134 (Figure 9.4) Difficulty = 2 4) What limitation should the nurse be aware of when using the body mass index (BMI) to assess a client's weight? 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) BMI is used to determine an individual’s risk for obesity 4) 2 Explanation: 1. BMI is widely used to assess appropriate weight for height using a formula and has been validated. 2. A clinical limitation of body mass index is the assumption that all individuals have equal body composition at each given weight. This has not been found to be true. The amount of muscle mass, body fat, and bone mineral content varies according to high level of fitness, race, and ethnic differences. 3. BMI is easily calculated using the standard formula and has a relationship with height and weight. 4. BMI is not used to determine the risk for obesity; rather, it provides data to determine obesity. Assessment Knowledge Objective 5 Page 132 Difficulty = 1 5) A nurse is performing a nutritional assessment and is concerned about undernutrition in a client. What condition would cause the nurse to suspect this nutritional disorder? 1) Renal failure 2) Hypertension 3) Wound that will not heal 4) Delayed menopause 5) 3
Explanation: 1. There are many causes of kidney failure. Malnutrition is not the most likely cause of this disease. 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 a nutritional concern. Assessment Knowledge Objective 1 Page 126 Difficulty = 1 6) A client appears anemic. What diagnostic tests would the nurse anticipate the physician ordering to assess the client’s anemia? 1) Prealbumin and hematocrit 2) B12 and folate 3) Albumin and transferrin 4) Blood urea nitrogen (BUN) and electrolytes 6) 2 Explanation: 1. Prealbumin measures overall nutritional status within the last 2 to 3 weeks but does not give specific information on anemia. Hematocrit is an indicator of red blood cell mass and is affected by anemia but it is not a specific diagnostic test used to assess anemia. 2. Vitamin B12 and folate are essential building block for red blood cell synthesis; consequently these diagnostics tests are valuable in assessing the type of anemia. 3. Albumin assesses protein and overall nutritional status but is not used to assess anemia. Transferrin may provide some information about the type of anemia. 4. BUN is used to assess renal function and electrolytes provide information on hydration and acidbase balance. Implementation Application Objective 3 Page 140 (Table 9.5) Difficulty = 2 7) Ms. Lawrence, 20 years old, is 14 weeks pregnant and seeking prenatal care. She tells the nurse that she likes to eat ice and occasionally eats dirt. How can the nurse best describe the client’s eating practices? 1) Faddism 2) Religious influence on eating practices 3) Pica 4) Culturally based practice 7) 3 Explanation: 1. Faddism is defined as a trendy food and /or nutrition beliefs (e.g. Raw food diet) 2. There is no evidence that the client’s desire to eat ice and dirt is influenced by a religious practice 3. Pica is an abnormal craving for or eating nonfood items such as the dirt 4. This is not a culturally based food choice or practice Assessment
Application Objective 7 Page 130 (Box 9.3) Difficulty = 1 8) A nurse is admitting a female client, 69 years old, who is obese and has a possible hip fracture. What health issue is most likely to develop as a result of the client’s obesity? 1) Decubiti 2) Degenerative joint disease 3) Chronic pain 4) Gestational diabetes 8) 2 Explanation: 1. There is no cause and effect association between obesity and decubiti; however the potential immobility due to the fracture definitely increases the risk for decubiti formation. 2. Overweight and obesity are risk factors for degenerative joint disease and functional and mobility problems. 3. There is no relationship between obesity and chronic pain. Chronic pain develops as a result of a previous injury or trauma and not the weight alone. 4. An obese person is at increased risk for Type II diabetes, as well as gestational diabetes, but this client is beyond child-bearing age. Diagnosis Knowledge Objective 2 Page 125 and 141 Difficulty = 2 9) A nurse is teaching a client about appropriate serving sizes for foods. What would be a useful way of estimating the size of a single serving of meat? 1) Tennis ball 2) As big as a fist 3) Approximately 175 grams 4) Deck of cards 9) 4 Explanation: 1. The size of a tennis ball is a good analogy for estimating the size of a medium piece of fruit. 2. Using the analogy of a fist helps to estimate the portion for grains, pasta, and salad. 3. The recommended portion size for a piece of meat is 85 grams. A portion size of 175 grams is double the recommended portion size. Furthermore, a client would have difficulty visualizing the portion size when given in grams versus an everyday object. 4. The recommended portion size for animal proteins is 85 grams, which can be correctly estimated by comparing to the size of a deck of cards. Implementation Knowledge Objective 9 Page 128 (Figure 9.2) Difficulty = 2 10) What type of anthropometric measurement uses electroconduction to assess body composition?
1) 2) 3) 4)
Bioelectrical Impedance Analysis (BIA) Near-Infrared Interactance Dual X-ray Absorptiometry (DEXA) Body Plethysmography
10) 1 Explanation: 1. BIA is a noninvasive tool for assessing body composition by employing the principles of electroconduction through water, muscle, and fat. 2. This device measures body fat at specific sites by passing infrared light through tissue and measuring the reflected light. 3. DEXA is primarily a research tool that uses X-ray technology to measure body composition. 4. Plethysmography is also a research tool that measures air volume displacement by the body similar to underwater weighing techniques. Assessment Knowledge Objective 3 Page 134 Difficulty = 2 11) A public health nurse is going to assess the nutritional status of an 86-year-old client. What nutritional screening tool would be most useful to the nurse? 1) WAVE tool 2) REAP tool 3) DETERMINE checklist 4) Canada Food Guide 11) 3 Explanation: 1. This tool was designed as a handy pocket card that reminds the healthcare professional of important components to assess during the examination. The WAVE tool may be helpful in assessing the elderly client but it is not the best tool for the job. 2. The REAP tool is a questionnaire that clients complete before a clinic or office visit. If the 86 year old client was able to complete such a questionnaire it may be a useful tool to gather nutritional information but it is not the best tool for the job. 3. The DETERMINE checklist was specifically designed for assessing nutritional status of individuals above 80 years of age. This tool provides a nutritional risk score and was validated for use with community-based older adults. This is the best tool to use in this client situation. 4. The Canada Food Guide is a document that provides advice about good dietary habits. It is not a nutritional screening tool. Implementation Application Objective 8 Page 143 Difficulty = 3 12) What individual would be most at risk for protein-calorie malnutrition? 1) A child, 6 years old, with diarrhea for 2 days. 2) A client, 3 days post-operative, receiving intravenous fluids only. 3) A child who overeats breads but eats no fruits and vegetables. 4) A client, 50 years old, who has been an alcoholic for 15 years.
12) 4 Explanation: 1. This child is at risk for dehydration. It takes longer than 2 days to develop protein-calorie malnutrition. 2. A client will not develop protein-calorie malnutrition from 3 days on IV fluids. 3. It is possible to develop caloric overnutrition (e.g. overeating bread) and be nutrient-specific undernourished (e.g. lack of fruits and vegetables) but this is not an example of protein-calorie malnutrition. 4. Alcoholics are often protein-calorie malnourished due to eating poorly, limiting their supply of essential nutrients and affecting both energy supply and structure maintenance. Furthermore, alcohol interferes with the nutritional process by affecting digestion, storage, utilization, and excretion of nutrients. This person has had a long history of alcoholism. Assessment Application Objective 2 Page 126 (Box 9.1) Difficulty = 2 13) What is the correct description of anthropometric measurements? 1) Obtained by dividing weight in kilograms by height squared 2) Any scientific measurement of the body 3) Use of growth chart evaluations to plot height and weight 4) Estimates of skin fold thicknesses 13) 2 Explanation: 1. This is a description of how to calculate Body Mass Index (BMI). BMI is only one example of an anthropometric measurement. 2. Anthropometric measurements are any scientific measurements of the body. They may include height, weight, measurement of body fat, and muscle composition. 3. They are not simply growth chart evaluations or calculations using combinations of numbers. 4. They may include measurements of skin fold thickness. Assessment Knowledge Objective 3 Page 130 Difficulty = 1 14) A nurse is preparing an in-service for staff on the risk factors for poor nutritional health. What is a risk factor for overnutrition? 1) Sedentary lifestyle 2) Poor dental health 3) Extreme age 4) Depression or loneliness 14) 1 Explanation: 1. A sedentary lifestyle contributes to overnutrition because excess calories are not burned off. There is an imbalance between caloric intake and calories burned. 2. This is a risk factor for undernutrition
3. Extremes in age (e.g. prematurity or over 80 years of age) contribute to undernutrition 4. Depression or loneliness may contribute to overnutrition but it can also be a risk factor for undernutrition, it depends on the individual, some overeat while others under eat. Assessment Knowledge Objective 2 Page 126 (Box 9.1) Difficulty = 2 15) A 24-year-old client visits the nurse practitioner’s office for a routine yearly gynecological exam. The client tells the nurse that she is trying to get pregnant and wants to know why it is important to take a multi-vitamin that contains folic acid. How should the nurse respond? 1) “Folic acid can prevent neural tube defects in the neonate. 2) “Everyone should take vitamin supplements.” 3) “Folic acid can help with your chances of getting pregnant.” 4) “Most people do not get enough folic acid.” 15) 1 Explanation: 1. Folic acid is essential for all women of childbearing potential. It is important for a healthy outcome of a pregnancy. A pregnant female who consumes less than required amounts of folic acid may place her unborn child at risk for certain birth defects, such as neural tube defects. 2. Not everyone needs vitamin supplements particularly if their dietary intake is balanced and appropriate. 3. It does not help a person become pregnant; however, by taking folic acid while trying to conceive the vitamin will be present in the body if the woman becomes pregnant. 4. This is a generalization that is not accurate. Most people will have sufficient folic acid levels if their dietary intake is balanced and appropriate. Implementation Application Objective 8 Page 125 and 127 (Box 9.2) Difficulty = 1 16) A nurse is teaching an overweight client how to use a food diary. What would be the best method for the client to estimate recommended portion sizes? 1) Digital photographs illustrating portion sizes 2) Food scales 3) Use analogies such as a deck of cards 4) Plastic containers 16) 3 Explanation: 1. Digital photographs can be a useful tool for estimating portion size but it is not always practical or convenient to carry around this item. 2. Having a client use food scales can be helpful when preparing foods at home but not realistic when estimating portion sizes at restaurants. 3. Determining portion sizes is difficult for most clients. By using everyday items such as a deck of cards to determine meat sizes or a golf ball to determine a tablespoon measurement, a client can learn to visually estimate appropriate portions.
4. Having a client use plastic containers can be helpful when preparing foods at home but not realistic when estimating portion sizes at restaurants. Implementation Application Objective 9 Page 128 (Figure 9.2) Difficulty = 3 17) A Jewish client is admitted to the medical unit. What statement by the nurse demonstrates cultural sensitivity to the client’s nutritional needs? 1) “I have ordered Kosher meals for you.” 2) “Do you have any special dietary considerations?” 3) “I see from your last admission you follow a regular diet.” 4) “Your family will need to bring in your Kosher foods.” 17) 2 Explanation: 1. The nurse is assuming that the client eats Kosher food. It is important to avoid applying general knowledge about religious food practices to all people within a group. 2. This response allows the client to explain any special dietary needs such as allergies, food likes and dislikes, as well as particular cultural or religious food practices. 3. This assumes that the information from the last admission is correct. There may be changes to the client’s dietary practices since the last admission. 4. Assumes that the client is Kosher. It is important to avoid applying general knowledge about religious food practices to all people within a group. Assessment Application Objective 9 Page 141(Box 9.5) Difficulty = 1 18) A nurse has collected data on clients who have visited a health fair in the mall. Which client is most in need of a detailed nutritional assessment? 1) A female, 21 years old, who has just begun college and has gained 5 pounds in the first semester 2) A male, 30 years old, with a BMI of 24 and a waist circumference of 91 cm 3) A male, 50 years old, who reported that, he lost 10 pounds in 6 weeks without even trying 4) A female, 35 years old, who has 30% body fat 1 year after the birth of her first child 18) 3 Explanation: 1. This is not an excessive amount of weight gain over a 4 month period and is a reflection of a change in activity and/or nutrition due to being at college. 2. A male with a BMI of 24 and a waist circumference of 91 cm is within the normal range. 3. Unintentional weight loss is considered clinically significant and requires further assessment. The cause is not readily apparent and may be due to a disease process. 4. A body fat range of 20% to 30% is within the normal range for females. Furthermore, she has experienced recent body changes due to being pregnant. Assessment Analysis Objective 7 Page 131 and 132
Difficulty = 3 19) What circumstance could result in an inaccurate waist circumference (WC) measurement? 1) Abdominal fat that is pendulous 2) Pear shaped distribution of adipose tissue 3) Pregnant female 4) Ascites due to polycystic kidney disease 19) 1 Explanation: 1. WC validity can be limited when large amounts of abdominal fat become pendulous because of the effects of gravity and are no longer situated along the waistline. 2. WC may not be an appropriate measurement for a person that has increased subcutaneous fat but is distributed around the hips (e.g. pear shape) versus the abdomen (e.g. apple shape). 3. WC is not a valid nutritional assessment tool for the pregnant female 4. WC is not a valid nutritional assessment tool for individuals with medical conditions associated with increases in abdominal girth due to fluid (e.g. ascites). Assessment Knowledge Objective 3 Page 132 Difficulty = 1 20) A female client, 78 years old, is in the physician’s office for a routine physical exam. She asks for an explanation of why skinfold measurements are not done on her anymore. How should the nurse respond? 1) “Those tests are just not as accurate anymore.” 2) “As a person ages, the test is not as accurate.” 3) “The body mass index (BMI) test is easier to use.” 4) “A detailed dietary history will give us the information that we need.” 20) 2 Explanation: 1. The accuracy of the skinfold measurements is improving as new reference standards are being published and becoming more population specific; therefore, this response by the nurse is not correct. 2. This is a correct response because changes in skin elasticity and connective tissue also affect skinfold accuracy with age. 3. The BMI is easier to use, but does not give as detailed data about actual body fat and muscle mass. 4. A diet history is an important part of a nutritional assessment, but does not give body composition values. Implementation Application Objective 8 Page 134 Difficulty = 1
21) A nurse is preparing to draw blood to measure transferrin and albumin levels on a 2-year-old child recently adopted from Africa. The child is below the 10th percentile for weight and height when plotted on a growth chart. What is the purpose of the blood work? 1) Used to assess the extent of malnutrition 2) Looking for macrocytic anemia 3) Screening for sickle-cell disease 4) The child may have polycythemia 21) 1 Explanation: 1. Transferrin and albumin may be low in a child who is malnourished. A low albumin is a good indicator of depleted visceral stores and chronic malnutrition. 2. This child could have anemia due to the malnutrition but the blood work required to assess for this particular type of anemia would be a B12 and a folate. 3. The child would have been tested at birth for sickle-cell disease. The test used to assess sicklecell anemia is a hemoglobin S, not transferrin and albumin. 4. Polycythemia is an increase in the number of red blood cells and this can not be assessed with the blood work being drawn. Implementation Application Objective 3 Page 139 (Table 9.5) Difficulty = 2 22) A nurse interviewing a client, 68 years old, discovers that the client is taking 23 herbal and vitamin supplements daily. Which response by the client indicates the need for nutritional teaching? 1) “I have been taking all of them for over 20 years now.” 2) “My wife also takes the same things.” 3) “My doctor in my old town recommended most of them.” 4) “I know that I do not eat right all of the time, so they will keep me healthy.” 22) 4 Explanation: 1. This response may require further assessment of overall nutrition but as it stands this response does not indicate a current problem. 2. This response may require further investigation and an assessment of overall nutrition but this response does not indicate a current problem. 3. This response may require further investigation but this response does not indicate a current problem. 4. Over supplementation of herbs, vitamins, minerals, and sports products may be dangerous. The older adult has physiological body changes that may change how the supplements affect the body. Many supplements have effects on medications the client may be taking, whether they are overthe-counter or prescribed medications. Use of supplements is not intended to replace healthy nutrition on a routine basis. This client needs education before there are problems. Assessment Analysis Objective 2 Page 130 (Box 9.3) Difficulty = 2 23) A client is 165 cm tall and weighs 75 kg. What is this person’s body mass index (BMI)?
1) 2) 3) 4)
26.6 27.5 24.5 25.6
23) 2 Explanation: 1. This is incorrect. 2. The formula for calculating BMI is weight (kg)/height2 (meters). Therefore 75kg/1.652 m = 27.5 3. This is incorrect 4. This is incorrect Assessment Knowledge Objective 3 Page 132 Difficulty = 3 24) A nurse is calculating the percent weight change of a 40-year-old female, weighing 71kgs one month ago, and 64 kgs on current examination. What is the weight loss percentage for this client? 1) 5.25 2) 7 3) 9.85 4) 12 24) 3 Explanation: 1. Incorrect response. 2. The client lost 7 kgs but this is not the percentage of weight loss. 3. 9.85% or approximately 10% ▪ The formula for calculating percent weight change is: (prior weight – current weight)/prior weight x 100. ▪ [71 kgs - 64 kgs/71kgs] x 100 = 9.85% ▪ 9.85% percent is then rounded up to 10% 4. Incorrect calculation. Assessment Knowledge Objective 3 Page 132 (Box 9.4) Difficulty = 3 25) A nurse is preparing to do a waist circumference on an obese 69-year-old male. What landmark is used when marking a site guide for measuring waist circumference? 1) Just below the umbilicus 2) Lateral ilium 3) The ischium 4) Mid rectus abdominis 25) 2 Explanation: 1. Measuring just below the umbilicus can be unreliable since obesity can change the position of the umbilicus.
2. Use of the bony landmark on the lateral border of the ilium is recommended when marking a site guide for the measurement. By standing behind the client and palpating the right hip, the nurse can locate the lateral ilium. A line should be drawn at the uppermost lateral line of the ilium at the midaxillary point. 3. The ischium is located below the ilium and forms the lower and back part of the hip bone. The ischium is not a bony landmark for waist circumference measurement. 4. The rectus abdominis muscle is not a landmark for this measurement. Assessment Application Objective 8 Page 132 and 133 (Figure 9.3) Difficulty = 1
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A graduate nurse in orientation notices that a dietician evaluates each postoperative client’s chart. What is the rationale for this practice? (Select all that apply.) 1) Meet a regulatory agency requirement 2) Determine nutritional needs 3) Check for any cultural dietary considerations 4) Check to see if there are any potential food-drug interactions 26) 2, 3, 4 Explanation: The assessment of a client’s nutritional health requires a collaborative approach by multi-disciplines. Postoperative clients may have different nutritional needs to promote healing. The nutritional selections suggested need to incorporate a client’s religious or cultural considerations, or the plan will not be a feasible one for the client. As medications may change postoperatively, assessing for potential interactions with foods may prevent a problem in the future. Many regulatory agencies require nutritional screening of clients, but there are many variations of the requirements and they not are necessarily specific to the postoperative client. Implementation Application Objective 4 Page 127, 130 (Box 9.3), 140, and 141 (Box 9.5) Difficulty = 1
Chapter 10 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.
1) A nurse is interviewing a client and notes a puzzled facial expression. What should the nurse say? 1) “Can you tell me if you understand?” 2) “You look confused.” 3) “Do you understand the procedure?” 4) “Do you have any questions?” 1) 2 Explanation: 1. Closed-ended questions (those that can be answered with one word) do not give any extra information and add little to gathering data. 2. Posture, eye contact, and facial expression add depth to the intended message. The use of openquestions allows the client to elaborate. The nurse is reflecting the non-verbal cues from the client. 3. This is a closed-ended question. 4. This does not indicate that the client appears confused based on the non-verbal. Implementation Analysis Objective – 2 Page – 148 (Table 10.1), 149 Difficulty - 2
2) A nurse is obtaining a family health history when the client reports that a grandparent had Diabetes Mellitus. Where in the health history should the nurse document this information? 1) Health practices 2) Family genogram 3) Past medical history 4) Present health/illness 2) 2 Explanation: 1. Health practices and beliefs about health and illness are important for the nurse to ascertain and are included in a general cultural assessment. 2. A genogram is a representation of family relationships and medical history and is the most effective method of recording large amounts of data gathered from a family’s health history. 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. Assessment Application Objective – 7 Page – 156 (Table10.2), 161 (Figure 10.4) Difficulty - 1
3)
What statement by the nurse would show empathy? 1) “Have you talked this over with your family?”
2) “I’m going to stay with you through the procedure.” 3) “The physician will have to answer that question.” 4) “I understand you’re concerned about your procedure.” 3) 4 Explanation: 1. This statement will help to build a trusting relationship. But it does not demonstrate empathy. 2. This statement shows a willingness to help the client, but is not empathy. 3. This is delaying the client getting information and does not show empathy. 4. Showing understanding and support of the client’s experience or feelings through actions and words demonstrate empathy. Implementation Analysis Objective – 5 Page – 151 Difficulty -2 4) What is a primary source of information the nurse might utilize to collect data? 1) Past medical records 2) The client 3) Family members 4) The physician 4) 2 Explanation: 1. Past medical records are a secondary source. 2. The client is considered the primary source of information. 3. The family is a secondary source. 4. The physician is a secondary source. Assessment Application Objective – 6 Page – 152 Difficulty - 1 5) A nurse is completing the third phase of the health history. What piece of information would the nurse include during this interaction? 1) Biographic data about the client 2) Information about the client’s current health status 3) Data from previous medical records 4) Clarification of previously obtained data 5) 4 Explanation: 1. Biographic data about the client (age, DOB, etc.) is included in the preinteraction phase. 2. Information about why they are seeking care (i.e., what brought them to the healthcare facility) is included in the initial interview phase. 3. Data from previous medical record is included in the preinteraction phase. 4. The purpose of the third phase is to clarify previously obtained assessment data, gather missing information about a specific health concern, update and identify new diagnostic cues as they occur,
guide the direction of a physical assessment as it is being conducted, and identify or validate probable nursing diagnoses. Assessment Application Objective – 6 Page – 153, 154, 155 Difficulty - 2
6) A nurse is interviewing an elderly client who has not received a formal high school education. What is the best approach for the nurse to take in this situation? 1) Allow family members to provide the interview information. 2) Develop a new interview format for this client. 3) Adhere to the standard format provided by the facility. 4) Use appropriate words and techniques for this client. 6) 4 Explanation: 1. Family members can provide support, but are not the primary source for information, and clients who are children should be allowed to participate as much as they are able. 2. The nurse would not create a new format. This would be too time consuming. 3. Standard formats provide a guide, but need to be adjusted according to the client’s needs and capabilities. 4. The nurse must consider many aspects of the client and their ability to participate in the interview process such as: culture, language, alterations in senses (blindness, hearing deficits), developmental level, and age. Word usage and overall communication will differ when interviewing children and adolescents or clients with developmental level that differs from the norm. Implementation Analysis Objective – 2 Page – 146 Difficulty - 1
7) Mrs. Nagi, 71 years old, has been readmitted to hospital. She does not speak English. What primary source of information should the nurse use to obtain the health history? 1) Have a translator to assist in talking with Mrs. Nagi. 2) Get the information from a family member. 3) Talk to the nurse who previously cared for Mrs. Nagi. 4) Review Mrs. Nagi’s previous chart. 7) 1 Explanation: 1. The client is a primary source of information. The translator will facilitate communication with Mrs. Nagi. 2. The family is considered to be a secondary source of information. 3. Other health care professionals are considered to be secondary sources of information. 4. Past medical records are a secondary source of information. Assessment Application Objective – 6
Page – 152 Difficulty - 2
8) A client tells the nurse that they have been using herbal remedies to treat their chronic illness. What would be the nurse’s best response? 1) “Tell me what you are taking so I can see if it is appropriate.” 2) “Can you tell me what herbal products you are currently using?” 3) “You should not trust all those remedies.” 4) “It’s great you are trying everything possible to treat your illness.” 8) 2 Explanation: 1. It would be important for the nurse to ascertain what the remedies include, but would it not be appropriate for the nurse to decide their usefulness. 2. As informed consumers, clients are also using a variety of information sources for themselves or family members and are consequently more likely to be informed about recommendations for screening and preventive measures. The nurse needs to ensure the physician has this information to ensure the herbals do not interfere with medications the client may be taking. 3. The nurse should not negate the effect of herbal remedies until the nurse knows what the client is taking and how they are affecting the client. 4. Clients may not be able to judge the reliability of such remedies and may be using products that interfere with their current therapies or are harmful. Implementation Analysis Objective – 8 Page – 159 Difficulty - 1 9) A nurse is obtaining information about a client’s past medical history. What source would begin to provide the nurse with this data? 1) Medication list 2) Lifestyle choices 3) Immunization records 4) Current relationships 9) 3 Explanation: 1. The medication list is related to current history. 2. The description of the client’s health patterns depicts a “lifestyle thread” that allows the nurse to see sets of related traits, habits, or acts that affect the client’s health, which then can be compared to standard health patterns, and identification of risk potential or subsequent nursing diagnoses can be determined. 3. 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. 4. Current relationship information is related to current history. Assessment Application Objective – 7
Page – 159, 160 Difficulty - 2
10) A nurse is interacting with a client and desires to show sensitivity to religious beliefs and customs. Which statement by the nurse would be appropriate during this interaction? 1) “I will tell the hospital Chaplin to see you daily.” 2) “Do you attend church on a regular basis?” 3) “Your amulet cannot be taken to surgery.” 4) “Where would you like to keep your bible?” 10) 4 Explanation: 1. The nurse would not arrange this unless the client has asked for daily visits from the hospital Chaplin. 2. This may be seen as a judgmental question. 3. Arrangements can be made for important religious objects to be taken into surgery. They need to be labeled in the event they become separated from the client. 4. Religious beliefs can influence perceptions about health and illness, and it is important to gain information about customs so the best care can be provided to the client. By allowing the client to have those things that provide meaning and support nearby, the nurse provides spiritual care for the client. Implementation Analysis Objective – 2 Page – 162 Difficulty - 2
11) A nurse is interviewing a client and wants to engage in effective communicating. What technique should the nurse use to decode the client’s messages? 1) Use words and symbols that convey a message 2) Listen actively and attentively 3) Be alert for non-verbal messages 4) Develop and transmit an idea 11) 2 Explanation: 1. Choosing words and symbols to convey a message is the definition of encoding. 2. Decoding a message makes communication successful and may break down if the nurse fails to listen attentively and actively. 3. Attending is giving full attention to verbal and non-verbal messages. 4. Developing and transmitting an idea is how communication takes place. Implementation Application Objective – 2 Page – 147 Difficulty - 1
12) What is an appropriate opening question to start a health history? 1) “What is your current occupation?”
2) “What led up to you seeking help with your health?” 3) “What medications are you currently taking?” 4) “What surgeries have you had?” 12) 2 Explanation: 1. Asking personal questions may cause the client to shut down and given less information. 2. The opening questions are purposely broad and vague to let the client adjust to the questioning nature of the interview. 3. This is a personal question and opening questions should be broad and vague to allow the client adjust. 4. This is a specific question and the opening questions should be broad and vague. Implementation Analysis Objective – 2 and 6 Page – 154 Difficulty - 2
13) A nurse is interviewing a client who is in acute pain. What action would be the best choice for the nurse during this interview? 1) Interview the family for the information 2) Attempt to reduce the pain and complete the interview later 3) Document why the interview could not be completed 4) Ask the client if they can complete the interview 13) 2 Explanation: 1. Although secondary sources (family members, the medical record, and other members of the healthcare team) can be used to gather data, the client provides the primary information and should be the first choice for data assessment when possible. 2. The ability to participate in an interview is diminished when the client is experiencing unrelieved or acute pain. The nurse must focus on measures to help relieve pain, and gather in-depth information at another time. 3. Pain reduction is the primary goal in this situation, as the interview must be completed in order to obtain necessary data. 4. The client will not be able to concentrate and provide as in-depth information as possible if experiencing pain; regardless of how fast or slow the process takes. Implementation Analysis Objective – 6 Page – 154 Difficulty - 2
14) A nurse is preparing to do a health history on a client. What would be most appropriate in planning for the interview? 1) Stand at the bedside to conduct the interview 2) Sit about 0.25 meters away from the client. 3) Provide water and tissues for the client. 4) Conduct the interview in the lounge provided for clients 14) 4
Explanation: 1. The nurse should be at the same height as the client. If the nurse is standing or sitting higher than the client it may make the client uncomfortable. 2. The nurse should sit about 0.5 to 2.0 meters away from the client. This prevents the nurse from getting into the client’s personal space. 3. Providing the client with water and tissues allows the client to take sips while answering questions. The tissues may be required if some questions cause the client to weep. 4. The interview should be conducted in private. If it is done at the bedside then the nurse should use a soft voice. Assessment Analysis Objective – 6 Page – 153 Difficulty - 2 15) A client is prescribed the use of a machine to aid with sleep apnea but doesn’t want to use it. What response by the nurse would aid in determining the client’s reluctance to use prescribed medical treatment? 1) “I guess the machine is complicated to use.” 2) “You’re not alone; many clients don’t use their sleep apnea machines.” 3) “I’m sure your doctor will figure something out about your sleep apnea.” 4) “Tell me what you think about the machine.” 15) 4 Explanation: 1. The nurse should not assume that the client doesn’t know how to use the machine. 2. The nurse should not assume that many clients do not use the same machine. 3. The nurse shouldn’t transfer the client’s non-adherence to prescribed medical treatment on the physician. 4. The best response for the nurse to make is to assess why the client doesn’t want to use the machine. This will help the nurse determine the support and teaching the client will need. Planning Application Objective – 2 Page – 146, 147, 148 (Table 10.1) Difficulty - 2 16) A nurse says to a client, “It sounds like you don’t like your new job because it’s more stressful than you anticipated.” What communication technique is the nurse using? 1) Listening 2) Paraphrasing 3) Questioning 4) Attending 16) 2 Explanation: 1. Listening is paying undivided attention to what the client says and does. 2. Paraphrasing is restating the client’s basic message to test if it was understood. 3. Questioning is the use of questions to gain insight. 4. Attending is providing the client with undivided attention.
Assessment Application Objective – 2 Page – 148 (Table 10.1) Difficulty - 1 17) A client tells the nurse about two abortions she had while in university. The nurse responds, “What university did you go to?” This response is evidence of which type of barrier to communication? 1) Cross-examination 2) Changing the subject 3) False reassurance 4) Use of technical terms 17) 2 Explanation: 1. Cross-examination is when questions are repeatedly directed to a client causing the client to feel threatened. 2. This nurse is changing the subject which shows insensitivity to the client’s thoughts and feelings. This happens when the nurse is not at ease with the client’s comments and is unable to deal with the content. 3. False assurance occurs when the nurse assures the client of a positive outcome when there is no basis for believing in it. 4. Use of technical terms is when the nurse uses terms or jargon specific to the medical field. Assessment Application Objective – 3 Page – 149 Difficulty - 1
18) The nurse is assessing a client through the use of an interpreter. After one response, the interpreter says to the nurse, “I think she’s really sick but doesn’t want to tell you.” How should the nurse respond to the interpreter? 1) Ask the interpreter to ask the client, “What other health issues have you been experiencing?” 2) “Tell me why you think that.” 3) “Are you sure? She hasn’t said anything to me.” 4) “I think so too, especially when she wouldn’t answer my one question about pain and sleeping.” 18) 1 Explanation: 1. The nurse should ask the interpreter to ask the client about other health issues. 2. It is important to avoid discussing the client with the translator, leaving the client out of the conversation. 3. The nurse should not argue with the interpreter while the interview is in progress. 4. The nurse should not discuss the client with the interpreter. Assessment Analysis Objective – 4 Page – 150, 151 (Box 10-1) Difficulty - 2
19) While conducting a health history, the nurse stands and uses the examination room sink to document client information. Afterwards the nurse states, “The doctor will be in to see you in a few minutes,” and leaves the room. What is the nurse demonstrating to the client? 1) Concreteness 2) A lack of genuineness 3) Positive regard 4) Empathy 19) 2 Explanation: 1. Concreteness means speaking to the client in specific terms instead of vague generalities. 2. Genuineness is the ability to present oneself honestly and spontaneously. This nurse is demonstrating a lack of genuineness. Her non-verbal communication may indicate a distancing from the client. 3. Positive regard is the ability to appreciate and respect another person’s worth and dignity with a nonjudgmental attitude. 4. Empathy is the capacity to respond to another’s feelings and experiences as if they were your own. Assessment Analysis Objective – 5 Page – 151 Difficulty - 2 20) A client comes into the Emergency Department speaking incoherently. What should the nurse do to obtain information about the client’s current health status? 1) Talk with the immediate family members who brought the client to the hospital. 2) Call the Medical Records department to obtain other records for the client. 3) Call the client’s physician. 4) Conduct a thorough physical assessment and document the health history as unable to obtain. 20) 1 Explanation: 1. 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 if indicated. This client is incoherent and is accompanied by family members. The nurse should talk with the family members. 2. Calling Medical Records for other admission information might be appropriate at a later time. 3. Phoning the physician might be appropriate at a later time. 4. The nurse should not document the health history as unable to obtain since family members are available to provide this information. Planning Analysis Objective – 8 Page – 152 Difficulty - 3
21) A nurse says to a client, “Before we provide any care to you, I will need to spend about 30 minutes talking about your current problem and any other health issues that might impact how you are feeling right now.” In which phase of the health assessment interview is the nurse participating? 1) Closure of the Interview 2) The Initial Interview 3) The Clarification Interview 4) Preinteraction 21) 2 Explanation: 1. There is no specific phase termed “closure of the interview.” This nurse is conducting the initial interview with this client. 2. The initial interview occurs when the nurse uses a period of time to talk with the client and document any information that would aid in care for the current health issue. 3. There is no clarification interview. 4. Preinteraction is when the nurse prepares to meet the client and reviews any available background information. Implementation Application Objective – 6 Page – 154 Difficulty - 1
22) A nurse is conducting a psychosocial history with a client. What question would be included in this assessment? 1) Have you noticed any change in your vision? 2) Are you the head of your family? 3) Have you had any major surgeries? 4) How long have you worked for your current employer? 22) 4 Explanation: 1. Assessment of vision would be included in the Review of Body Systems. 2. This is part of biographical data. 3. Surgical history is a part of medical history. 4. Elements of the Psychosocial History within the Health History include occupational history, education, financial background, roles and relationships, family, social structure/emotional concerns, and self-concept. Implementation Application Objective – 7 Page – 156 (Table 10.2), 161 Difficulty -1 23) During the course of a health history the nurse would like to review a client’s medications. What should the nurse include in the assessment? 1) The place in the home where the medications are stored. 2) List of all the medication the client has ever been prescribed. 3) List of all over-the-counter and herbal preparations the client is taking.
4) The number of dosages left for each medication the client is taking. 23) 3 Explanation: 1. Where in the home the medications are stored is not part of the medication history. 2. The medication history is limited to the medications and herbals the client is currently taking. 3. Information about medications should include all prescribed and over the counter medications. The use of home remedies, folk remedies, herbs, teas, vitamins, dietary supplements or other substances should also be listed. 4. It is unlikely the client would know this and it is not part of the medication history. Implementation Application Objective – 7 Page – 159 Difficulty - 2 24) During the assessment of an elderly female from another cultural group, the client says, “Please call my husband in. I want him in the room with me.” What should the nurse do in response to this client’s request? 1) Escort the husband into the room. 2) Document that the client refuses the assessment. 3) Ask the client to wait a few minutes until the assessment is completed. 4) Ask another nurse to assist with the assessment.
24)1 Explanation: 1. The nurse should respect the wishes of the client and the client’s culture by requesting the presence of the husband in the room. 2. The client is not refusing the assessment and should not be documented as such. 3. The nurse should not ask the client to wait until the assessment is completed. 4. The nurse should not ignore the client’s request. Implementation Analysis Objective – 4 Page – 161, 162 Difficulty - 2 25) What is helpful when communicating with a client who does not speak English? 1) Sit facing the translator and client 2) Discuss each question and answer with the translator 3) Use a member of the client’s family to translate 4) Look at the client while telling the translator what to say 25) 4 Explanation 1. The nurse should sit with the translator facing the client. If the client is very anxious the translator might sit beside the client.
2. The nurse should refrain from having a discussion with the translator. The translator should only translate what is said by the nurse and the client. 3. Official translators should be used whenever possible. They understand the medical terminology and can translate what the nurse states. 4. The nurse is talking with the client and thus should look at the client when asking questions, even when a translator is used. Implementation Application Objective – 2 Page – 150, 151 (Box 10.1) Difficulty - 2 26) What is a genogram? 1) Depiction of a client’s support systems. 2) Representation of family relationships. 3) Pictorial of family relationships and health history. 4) Graphical display of all system’s in a client’s life. 26) 3 Explanation 1. A genogram depicts a client’s family relationships and health history. 2. The genogram does more then depict family relationships. It also depicts each family member’s healthy history. 3. A genogram is a picture of family relationships and health history. 4. This is an ecomap. Assessment Application Objective – 9 Page – 161 Difficulty - 1 27) Mrs. Matthews, 63 years old, tells the nurse she was a social drinker. What should the nurse do next? 1) Document that Mrs. Matthews does not drink alcohol. 2) Ask what she currently drinks at social gatherings. 3) Inquire whether Mrs. Matthews smokes. 4) Ask Mrs. Matthews how many drinks she had per week. 27) 4 Explanation 1. The nurse should document this but needs to determine how much the Mrs. Matthews drank and for how many years. 2. The nurse needs to determine what ‘social drinking’ means to Mrs. Matthews. She has already stated she no longer drinks alcohol. 3. Before moving on to another topic the nurse needs to determine what social drinking means to Mrs. Matthews. 4. The nurse needs to determine how much Mrs. Matthews drank and for how long. Assessment Application Objective – 8 Page – 160
Difficulty - 3 28) What is the purpose of a health history? 1) Gather data about the cause of the health problem 2) Document responses to potential and actual health concerns 3) Collect objective data about the current health problem 4) Document findings from a physical assessment 28) 2 Explanation 1. This is the focus of the medical history taken by the physician. 2. The health history is a comprehensive record of the client’s past and present health. The focus is on the client’s response to a health concern as a whole person. 3. The health history is subjective data about the client’s current and past health. 4. The physical examination occurs after the health history has been taken. Knowledge Application Objective – 1 Page – 146, 155 Difficulty - 1
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 29) While observing a nurse interacting with a client, the nursing student notes that the client will not talk with anyone in the room. Which comment by the nurse would have been non-therapeutic or harmful in this interaction and could have facilitated this silence from the client? (Select all that apply.) “I’m not sure what time the procedure will be, but I will check for you.” “I’ll try to explain things before they happen to you.” “You shouldn’t feel scared; there is nothing to worry about.” “Let’s not talk about your surgery now; it will only make you worry.” “I’m not sure what time the procedure will be, but I will check for you.” “I’ll try to explain things before they happen to you.” X “You shouldn’t feel scared; there is nothing to worry about.” X “Let’s not talk about your surgery now; it will only make you worry.” Explanation: Non-therapeutic interactions interfere with the communication process by making the client uncomfortable, anxious, or insecure, and these include giving false reassurances, passing judgment, changing the subject, cross-examination, use of technical terms, and insensitivity. Therapeutic communication techniques include being honest and straightforward with responses. Implementation Analysis Objective – 3 Page – 149, 150 Difficulty - 2 29)
Chapter 11 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is assessing a client with liver disease and notes that the skin, mucous membranes, and sclerae are yellowish in colour. How should the nurse document this finding? 1) Cyanosis 2) Jaundice 3) Carotenemia 4) Uremia 1) 2 Explanation: 1. Cyanotic skin is bluish in colour. 2. The nurse’s findings indicate jaundice, which is due to increased levels of bilirubin in the blood. 3. Carotenemic skin has a yellow-orange tinge. 4. Uremic skin is pale and yellow, but is associated with renal, and not liver, disease. Assessment Application Objective – 11 Page –176, 177 (Table 11.1) Difficulty - 1 2) What assessment finding of a 2 to 3-day-old newborn’s skin may require treatment? 1) Tiny white facial bumps 2) Dark spots on the sacral area 3) Irregular red patches on the back of the neck 4) Yellow skin colour 2) 4 Explanation: 1. Milia are tiny white facial papules due to sebum and will resolve within a few weeks of birth. 2. Harmless skin markings requiring no intervention include gray, blue, or purple spots (Mongolian spots) on the buttocks or sacral area . 3. Vascular markings also called stork bites on the back of the neck and disappear within the first year. 4. Yellowing of skin and mucous membranes in an infant who is 3-4 days old is physiological jaundice, but may require treatment with fluids and phototherapy., Evaluation Application Objective – 9 Page – 173 Difficulty - 1 3) A nurse is admitting a client with skin vitiligo, which is highly visible even from a distance. The client asks you to put a ‘No Visitors’ sign on the door and has called the family to tell them not to visit. What primary problem may occur with this client? 1) Risk for loneliness 2) Decrease in self-esteem 3) Defensive coping 4) Disturbed body image
3) 4 Explanation: 1. A visible skin disorder may trigger psychosocial problems. Due to a disturbed body image the client is asking to be alone. 2. A disturbance in self-esteem may occur, but the primary problem is a disturbance in body image. 3. There is no evidence that the client is defensive or highly anxious. 4. The client with vitiligo, a skin condition with patchy depigmented areas over some or all of the following body areas: face, neck hands, feet, and body folds, may suffer a severe disturbance in body image. Diagnosis Analysis Objective – 8 Page – 176 (Table 11.1), 186 (Figure 11.16) Difficulty - 2 4) A nurse is performing a skin assessment on a client and notes a round, elevated, fluid-filled mass approximately 0.5cm in size. How should the nurse document this finding? 1) Papule 2) Tumor 3) Macule 4) Vesicle 4) 4 Explanation: 1. A papule is an elevated, solid, palpable mass. 2. Tumors are elevated, but solid, hard, or soft palpable and extend deeper into the dermis. 3. A macule is a flat, nonpalpable change in skin colour. 4. The area described is a vesicle and may be caused by herpetic lesions, poison ivy, and small burn blisters. Assessment Analysis Objective – 11 Page – 199, 200 (Figure 11.40) Difficulty - 1 5) A nurse is conducting a health history on a client’s integumentary status and wants to obtain data related to risk factors. What would be an appropriate question? 1) “Does your skin itch?” 2) “Have you noticed a change in the colour or size of a mole?” 3) “Have you noticed any pain around your cuticles?” 4) “How much time do you spend outdoors?” 5) 4 Explanation: 1. This question is related to concerns or injuries the client may have. 2. Changes in moles may be a result of being outdoors, but it is not a risk factor. 3. This question will learn about a symptom but not a risk factor. 4. Health behaviours that may increase risk for health issues include exposure to the sun, failure to use a sun block, use of soaps and chemicals on the body, tattoos and body piercings. Assessment Application Objective – 4
Page – 181, 182 Difficulty - 2 6) How should the nurse assess for jaundice in a client with dark skin? 1) Use a bright lamp and a magnifying glass 2) Inspect the lips, oral mucosa, sclera, conjunctivae, and palms 3) Assess the skin the same way you would inspect any client 4) Document "unable to assess" for jaundice 6) 2 Explanation: 1. A bright light and magnifying glass will not help. Jaundice is difficult to detect in people with dark skin. 2. Changes in skin colour may be difficult to evaluate in clients with dark skin. Inspect areas of the body with less pigmentation such as the lips, oral mucosa, sclera, palms of the hand, and conjunctivae. 3. Jaundice is more difficult to detect in people with dark skin. 4. The nurse can assess the lips, oral mucosa, sclera, palms of the hand, and conjunctivae and thus it is not appropriate to state “unable to assess”. Assessment Analysis Objective – 7 Page – 176 (Table 11.1) Difficulty - 2
7) A nurse is planning to do a head to toe assessment of the skin, hair, and nails of a client from Vietnam. The interpreter, a relative who speaks Vietnamese and English, has been authorized by the client to be present to translate. What should the nurse do first? 1) Perform hand hygiene and don gloves. 2) Ask the client to remove all clothing, put on a gown, and lie down. 3) Tell the client that an official interpreter needs to be present. 4) Explain the procedure and ask if you may touch the client's head. 7) 4 Explanation: 1. Before donning gloves the nurse should explain the procedure to reduce client anxiety. 2. Before having the client undress the nurse should explain what is included in the assessment. 3. The client has authorized the family member to be the interpreter. Asking the family member to leave may increase the client’s anxiety. 4. Explaining the procedure reduces anxiety in the client. The client's cultural beliefs may be such that the client does not want you to touch their head. You must seek clarification on this issue before proceeding to examine the scalp for lesions. Assessment Analysis Objective – 5 Page – 177, 185 Difficulty - 2
8) A nurse is caring for a client who is a long-time smoker and notes clubbing of the fingers. What technique would the nurse utilize to validate this assessment? 1) Place the hands out straight with the palm sides down
2) Place two of the same fingers from each hand together 3) Place two index fingers together tip to tip 4) Place two thumbs touching side by side 8) 2 Explanation: 1. This will not validate clubbing. 2. To assess clubbing you can use the Schamroth technique in which you ask 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. Two corresponding fingers are used. 4. Two fingers should be placed together to create a diamond to assess for clubbing. Assessment Application Objective – 6 Page – 192, 215 (Figure 11.86) Difficulty - 2
9) A nurse is performing an assessment of a client's skin, hair, and nails when the client becomes pale and diaphoretic. What action should the nurse take first? 1) Call the physician 2) Ask about anxiety and explain procedures 3) Lower the client’s head 4) Give the client orange juice with extra sugar 9) 2 Explanation: 1. The nurse would not call the physician before taking vital signs and reducing the client’s anxiety. If the blood pressure drops and there is an increase in pulse the physician should be called. 2. Anxiety can cause the client to have pallor and be diaphoretic. This can often be resolved by recognizing the anxiety and explaining the procedure(s). 3. The client is anxious and the nurse should try to reduce anxiety by explaining the assessment procedure. 4. There is no indication at there is a drop in blood sugar. Implementation Application Objective – 3 Page – 185 Difficulty - 2
10) A nurse is assessing a female client and notes facial hirsutism. The client asks the nurse why this has happened to her. How should the nurse respond? 1) “You need to take vitamins.” 2) “There is no known cause for this condition.” 3) “Your diet is not nutritionally balanced.” 4) “You may have some hormone imbalances.” 10) 4 Explanation: 1. This is not an appropriate response. 2. Hirsutism is generally due to an endocrine disorder.
3. Hirsutism is not related to diet. 4. Hirsutism is 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. Diagnosis Application Objective – 8 Page – 213 (Figure 11.81) Difficulty - 2 11) A nurse is inspecting the fingernails of a client with a diagnosis of polycythemia. What finding would be expected with this diagnosis? 1) Pale nail beds 2) Horizontal white bands 3) Spoon shaped nails 4) Bright red nail beds 11) 4 Explanation: 1. Pale nail beds are associated with anemia or peripheral arteriosclerosis. 2. Horizontal white bands in the nails are seen is chronic hepatitis. 3. Spoon nails may be related to iron deficiency. 4. The client with polycythemia has nails that appear bright red due to a pathological increase in red blood cells. Assessment Analysis Objective – 8 Page – 192 Difficulty - 2
12) A nurse is assessing a teenaged male client and notes a musky odour. The client states that this is embarrassing for him and that he showers daily. What action should the nurse take in this situation? 1) Suggest that he use a scented soap 2) Obtain a dietary referral 3) Reassure the teen that this is normal 4) Educate the teen about masturbation 12) 3 Explanation: 1. This is a normal development at puberty. An antibacterial soap may help by reducing bacteria. 2. The musky odour is not related to diet. 3. The apocrine glands are dormant until the onset of puberty when they become active and produce secretion of water, salts, fatty acids, and proteins. This secretion is released into hair follicles primarily in axillary and anogenital areas and when mixed with bacteria on skin surface produces a musky odour. This is part of normal growth and development (G and D) and is best approached with education about G and D and good hygiene practices. 4. The musky odour is unrelated to masturbation. Intervention Application Objective – 8 Page – 171 Difficulty - 3
13) A nurse is caring for a client complaining of a painful, hot area in the leg. The area is red and swollen. What should the nurse do? 1) Palpate the area 2) Put client on bed rest 3) Put ice on the area 4) Notify the physician 13) 4 Explanation: 1. Red-hot, swollen, painful areas are not to be palpated as these signs and symptoms indicate presence of inflammation and possible infection and the slightest disturbance may spread the infection into deep skin layers. 2. There is no indication that bedrest is required. 3. Ice should not be applied, heat will increase circulation to the area. 4. The physician should be notified as this is likely due to an inflammation or possible infection in the area. Intervention Analysis Objective – 10 Page – 189 Difficulty - 2
14) A nurse is assessing the skin of a newborn infant and notes a bright red, raised lesion on the lateral aspect of the thigh. The mother has expressed concern about this area, and asks the nurse if it should be removed. What would be the best response for the nurse in this situation? 1) “Your pediatrician can make a surgical referral for you.” 2) “These types of lesions usually disappear by age 3.” 3) “You should be happy your baby is healthy overall.” 4) “It really is not that noticeable.” 14) 2 Explanation: 1. This is a hemangioma and will disappear without treatment. 2. The lesion described is a hemangioma, which is a cluster of immature capillaries that can be found on any part of the body. These lesions usually disappear by age 3, and no intervention is needed. 3. It is inappropriate to tell the mother she should be happy that the infant does not have more serious problems. 4. The mother should not be told to ignore lesions. Assessment Analysis Objective – 9 Page – 196 (Figure 11.29) Difficulty - 3 15) A nurse is assessing the skin of an elderly client and notes purplish patches of irregular shapes on both lower extremities. What action should the nurse take? 1) Document the findings and notify the physician. 2) Ask the client how long the patches have been present. 3) Ask the client what the patches are. 4) Document that the client has bruises.
15) 2 Explanation: 1. The nurse should determine how long the patches have been present before calling the physician. 2. The patches describe purpura, which may be related to bleeding disorders, scurvy, or capillary fragility in the elderly. The nurse must ascertain if these patches have arisen suddenly or may have been caused by trauma to the areas. 3. It is unlikely the client will know what the patches are. 4. The nurse should determine how long the patches have been present before documenting. Assessment Analysis Objective – 7 Page – 198 (Figure 11.34) Difficulty - 3 16) A client tells the nurse about “sores in the mouth.” The nurse notes crusted lesions on the lips and inside the cheek. What type of skin lesion would the nurse suspect? 1) Herpes simplex 2) Dermatitis 3) Herpes zoster 4) Varicella 16) 1 Explanation: 1. The lesions described are typical for herpes simplex, which is a viral infection that produces such lesions. 2. Dermatitis is an inflammation of the skin. 3. Herpes zoster, also known as shingles, occurs commonly in the elderly and produces clusters of vesicles on the skin. 4. Varicella (Chickenpox) is seen over the entire body. Diagnosis Application Objective – 8 Page – 207 – 210 (Figure 11.66) Difficulty - 2
17) A nurse is performing a skin assessment on a client and notes an elevated, irregular band of scar tissue on the left arm. What term should the nurse use to document this finding? 1) Fissure 2) Keloid 3) Ulcer 4) Scar 17) 2 Explanation: 1. A fissure is a crack in the skin extending to the dermis. 2. The area described is a keloid, which is an area of excess scar tissue due to excessive collagen formation during healing. 3. An ulcer is a deep area of skin loss that may bleed. 4. A scar is connective tissue left after healing, but is flat and usually linear. Assessment Analysis
Objective – 11 Page – 204 (Figure 11.52) Difficulty - 1
18) A nurse is caring for a postoperative client who had abdominal surgery. The client has verbalized concern that their scar is purplish in colour. How should the nurse respond? 1) “I am sure you are glad your surgery was a success.” 2) “Having a scar was unavoidable.” 3) “You can have plastic surgery to remove the scar later.” 4) “The colouration is normal and will fade with time.” 18) 4 Explanation: 1. This statement does not address the client’s concern. 2. The nurse is not dealing with the client’s question. 3. The nurse should not suggest plastic surgery. 4. New scars may be red or purple in colour and will fade to silvery or white with time. Implementation Application Objective – 3 Page – 203 (Figure 11.51) Difficulty - 2 19) Rebecca, 16 years old, has acne and is pregnant. A nurse is completing a health history to assess the skin, hair, and nails. What question would be most important for the nurse to include in the interview? 1) “Do you use any skin creams?” 2) “Do you use sunscreen and try to avoid exposure to the sun?” 3) “Have you had any nail changes?” 4) “Have you lost any hair during your pregnancy?” 19) 1 Explanation: 1. Topical medications may be absorbed through the skin and harm the fetus. Those that can cause birth defects include Retin A, antifungal agents, minoxidil for hair growth. Other topical medications that can harm the baby include: antibiotics, steroids, and medication for muscle pain. 2. This question should be asked but it is not the most important question. 3. Nail changes occur during pregnancy. This question is not as important as whether the woman uses skin creams. 4. Hair changes occur during pregnancy. It is more important to ask about use of skin creams. Assessment Analysis Objective – 9 Page – 174, 184 Difficulty - 3
20) Andrew, 15 years old, has extensive acne over his face and upper neck. He asks the nurse why this is happening to him. How should the nurse respond? 1) “Expensive creams will take care of the problem.” 2) “You are not washing your face enough.” 3) “I have seen a lot worse.” 4) “This is a normal part of being a teenager.”
20) 4 Explanation: 1. This is a normal occurrence in adolescence and expensive creams will not help. 2. This is an inappropriate response as the nurse does not know how often Andrew is washing his face. 3. This comment does not address Andrew’s question. 4. During adolescence, the oil glands increase their production of sebum, which is the origin of acne. Implementation Application Objective – 9 Page – 173 Difficulty - 2 21) A nurse is assessing a client’s skin and notes that the colour appears similar to chalk. What description would the nurse use when documenting this finding? 1) Pallor 2) Cyanosis 3) Erythema 4) Jaundice 21) 1 Explanation: 1. Pallor, or paleness of the skin, may occur with hypoxia, cold environment, stress, shock, hypotension, and anemia. 2. Cyanotic skin has a mottled blue colour. 3. Erythema is redness of the skin. 4. Jaundiced skin has yellow undertones. Diagnosis Application Objective – 11 Page – 176, 177, (Table 11.1) Difficulty - 1 22) A nurse is preparing to assess a client’s integumentary status. What techniques will the nurse use to conduct this assessment? 1) Inspection and percussion 2) Inspection and auscultation 3) Percussion and palpation 4) Inspection and palpation 22) 4 Explanation: 1. Percussion is not used to assess the integument. 2. Auscultation is not used in assessing the integument. 3. Percussion is not used to assess the integument. 4. Physical assessment of the skin, hair, and nails is conducted by inspection and palpation. Planning Application Objective – 6 Page – 178, 184 Difficulty - 1
23) During the assessment of a client’s integument the nurse notes “vitiligo present bilateral hands.” What would the nurse have seen to lead to this conclusion? 1) An abnormal loss of melanin in patches 2) Grouped vesicles 3) Nodules with ulcerations 4) Dark, asymmetrical coloured patches 23) 1 Explanation: 1. Vitiligo is an abnormal loss of melanin in patches, typically occurring over the face, hands, or groin. 2. Vesicles are not seen in vitiligo. 3. There are no nodules or ulcerations with vitiligo. 4. There is localized depigmentation in vitiligo. Diagnosis Application Objective – 11 Page – 186 (Figure 11-16) Difficulty - 2 24) After the completion of an integumentary status assessment, the nurse documents “+1 edema right lower leg.” How might the nurse describe the edema? 1) Deeper pitting, no obvious distortion 2) Pitting is severe, legs are grossly distorted 3) Slight pitting, no obvious distortion 4) Pitting is obvious, legs are swollen 24) 3 Explanation: 1. This is +2. 2. This is +4. 3. 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. 4. This is +3. Diagnosis Analysis Objective – 8 Page –188 (Figure 11.19) Difficulty - 1
25) A nurse is planning to assess the integument of a client with dark skin. What finding would indicate the presence of cyanosis in this client? 1) Yellow-orange tint to the palms 2) Bluish tinged nail beds 3) Yellow hue in the eyes 4) Cherry red lips 25) 2 Explanation: 1. This is likely due to carotenemia due to high level of carotene in the blood. 2. Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae in clients with darker skin colour. 3. A yellow tint to the sclerae is due to jaundice. 4. Red lips may be caused by an elevated hemoglobin and stasis of blood in capillaries.
Diagnosis Application Objective – 9 Page –176, 177 (Table 11.1) Difficulty -1 26) A nurse is planning to document the appearance of herpetic lesions found over a client’s nose and mouth region. What term would the nurse most likely use to describe the appearance of the lesions? 1) Pustular 2) Papular 3) Pruritic 4) Scaly 26) 1 Explanation: 1. Pustular refers an elevated, pus-filled vesicle most likely seen in acne and herpes. 2. The term papular refers to an elevated, solid, palpable mass with circumscribed border. 3. Pruritic refers to itching. The nurse is describing the appearance of the lesion. 4. Scaly refers to shedding flakes of greasy, keratinized skin seen in psoriasis, and eczema. Diagnosis Application Objective – 11 Page –199, 200 (Figure 11.42), 208 Difficulty -2 27) During the assessment of an elderly client’s integument the nurse notes small areas of dark freckles on the client’s hands. What may have caused this finding? 1) Hyperpigmentation of the skin 2) Decrease in melanin production 3) Decreased blood perfusion of the dermis 4) Increase in sebum production 27) 1 Explanation: 1. The nurse is describing “liver spots” or small areas of hyperpigmentation over the client’s hands. This is due to hyperplasia of melanocytes, especially in sun-exposed areas of the client’s epidermis. 2. The decrease in melanin would lighten the skin. 3. This will make the person look pale. 4. The increase in sebum would make the skin oily. Diagnosis Application Objective – 9 Page – 174 Difficulty - 2
28) How would the nurse document the presence of several abdominal lesions that appear in distinct clusters? 1) Confluent 2) Annular 3) Grouped
4) Discrete 28) 3 Explanation: 1. Confluent lesions run together. 2. Annular lesions are single and circular in shape . 3. The lesions described are group lesions due to the clusters. 4. Discrete lesions are separate. Diagnosis Analysis Objective – 11 Page – 205 (Figure 11.56) Difficulty - 3
29) Mrs. Gifford, 32 years old, tells the nurse she has a scaly, reddened, elevated mass on the back of her left hand. It has grown quite quickly over the past two weeks. What type of lesion should the nurse suspect? 1) Squamous cell carcinoma 2) Eczema 3) Psoriasis 4) Contact dermatitis 29) 1 Explanation 1. The lesion described is a squamous cell carcinoma. It grows very rapidly. 2. Eczema presents as reddened papules and vesicles that ooze and weep. They can cause intense itchy. 3. Psoriasis is a thickening of the skin in dry, silvery, scaly patches. 4. Contact dermatitis is an inflammation of the skin due to an allergy. Diagnosis Analysis Objective – 10 Page – 209 - 211, (Figure 11.73) Difficulty – 2 30) What is the purpose of the skin? 1) Protect the body from cold 2) Prevent infection 3) Assist in regulating body temperature 4) Help to synthesize Vitamin B12 30) 3 Explanation 1. The skin helps to regulate body temperature, but it does not protect the body from cold. 2. The skin is a barrier to the invasion of bacteria, but the skin does not prevent infection. 3. The skin helps the body regulate body temperature. 4. The skin helps to synthesize Vitamin D. Assessment Analysis Objective – 1
Page – 170 – 172 Difficulty - 1 31) What stratum is the outermost layer of epidermis on the soles of the feet? 1) Basale 2) Granulosum 3) Germinativum 4) Corneum
31) 4 Explanation 1. The stratum basale is the deepest layer of the epidermis. 2. The stratum granulosum is the middle layer. 3. The strata germinativum is another name for the strata basale. 4. The outermost layer is the stratum corneum. Assessment Analysis Objective – 1 Page – 170, 171 (Figure 11-1) Difficulty - 1 32) Ms. Dhalliwal, 22 years old, has recently moved to Canada from India. She has white skin and pale blond hair. How should the nurse document Ms. Dhalliwal’s appearance? 1) Pallor 2) Vitiligo 3) Tinea versicolour 4) Albinism 32) 4 Explanation 1. Pallor would not account for the pale blond hair. 2. Vitiligo is loss of pigment in patches. This would not account for the pale, blond hair. 3. Tinea versicolour is a common fungal infection and causes patchy pale areas. 4. Albinism appears as white skin, white or pale blond hair, and pink irises. Assessment Analysis Objective – 10 Page – 176, 177 (Table 11.1) Difficulty - 3 33) A nurse is conducting a health history on a client. What question might the nurse ask related to lifestyle behaviour? 1) “Do you use a sunscreen with a sun protection factor? 2) “Have you changed your diet recently?” 3) “Have you had eczema in the past?” 4) “Are you exposed to x-rays at work?” 33) 1 Explanation
1. Health or lifestyle patterns are habits or acts that may affect the client’s health.. 2. This question is related to the internal environment which includes diet, medications and stress levels. 3. This question is dealing with past history of skin disorders. 4. This questions deals with the environment at home, work and in social environments. Assessment Application Objective – 4 Page – 181, 182 Difficulty - 3 34) Aniljit, 4 years old, has recently moved to Canada from Pakistan. The nurse notes that he has a purplishred marking over his left buttock. How should the nurse document this finding? 1) Bruising from a spanking 2) Port-wine stain 3) Mongolian spot 4) Hemangioma 34) 2 Explanation 1. The nurse does not have enough evidence to draw this conclusion. 2. Port-wine stain is an irregularly shaped lesion ranging in colour from pale red to deep purple-red. It does not disappear. 3. Mongolian spot is a grey, blue, or purple spots in the sacral and buttocks areas of newborns. It disappears within the first year of life. 4. A hemangioma is a bright red, raised lesion about 2 to 10 cm (1 to 4 in.) in diameter. It usually disappears by age 3. Assessment Analysis Objective –11 Page – 173, 196 (Figure 11.30) Difficulty - 3 35) What equipment does the nurse require to complete an assessment of the integument? 1) Magnifying glass 2) Stethoscope 3) Infrared lamp 4) Sterile gloves 35) 1 Explanation 1. A magnifying glass is used to allow the nurse to see the integument more closely. 2. A stethoscope is not required. 3. A Wood’s lamp (UV lamp) is used not an infrared lamp. 4. Clean gloves are used unless indicated otherwise due to an open lesion the nurse is examining. Assessment Analysis Objective –7
Page – 184 Difficulty - 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 36) Mrs. Potvin, 79 years old, is having an assessment of her integument. What finding (s) may be noted in a client of this age? (Select all that apply.) Cutaneous horn Lentigines Skin tags Angiomas 36)
X_ Cutaneous horn X_ Lentigines X_ Skin tags X_ Angiomas
Explanation: Common skin lesions of older adults include all of the choices listed. Assessment Application Objective – 9 Page – 174 Difficulty - 1
Chapter 12 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is palpating an adult client’s neck and is unable to palpate any lymph nodes. How will the nurse interpret this finding? 1) Probably due to an infection 2) Cause to inspect for further malformations 3) A normal finding in adults 4) Reason for referral to an ear, nose, and throat specialist 1) 3 Explanation: 1. If an infection were present, the lymph nodes of the surrounding area would be tender and possibly enlarged. 2. Lymph nodes of the head and neck are non-palpable in adults; consequently there is no need to do a further inspection. 3. The lymph chains of the adult neck are non-palpable; therefore, this would be a normal finding in the physical examination. 4. Lymph nodes of the head and neck are non-palpable in adults; therefore there is no need to make a referral to a specialist. Assessment Application Objective 8 Page 221 and 226 Difficulty = 1 2) A nurse is examining a client’s neck. What is the correct technique to palpate the trachea? 1) Palpate while the client is swallowing 2) Move the finger laterally, first to the right and then to the left 3) Ask client to lower chin and turn head slightly to the right 4) Stand behind the client and ask the client to turn their head 2) 2 Explanation: 1. This is the technique used to palpate the thyroid gland. 2. The correct method to palpate the trachea includes palpation of the sternal notch. Then move to the midline of the neck and next gently palpate the cricoid cartilage. Move the finger laterally, first to the right and then to the left to identify the lateral borders of the trachea. 3. This is also a technique used to palpate the thyroid gland. 4. The thyroid is palpated from behind and palpated more easily when the client swallows but not the trachea. Assessment Application Objective 2 Page 229 Difficulty = 2
3) A nurse is assessing a client with hypothyroidism. What symptom is the client likely to report? 1) Intolerance to heat
2) Depression 3) Insomnia 4) Exophthalmos 3) 2 Explanation: 1. Intolerance to heat is a symptom of hyperthyroidism. 2. Depression is a common symptom associated with hypothyroidism. 3. Insomnia occurs with hyperthyroidism 4. Exophthalmos (bulging eyes) is something the nurse can observe and it occurs with hyperthyroidism. Assessment Knowledge Objective 8 Page 240 Difficulty =2 4) A nurse is using the posterior approach to palpate the thyroid gland on a client. What is the correct method for performing this physical assessment? 1) Use right thumb to push the trachea aside and palpate with left thumb and fingers 2) Observe the thyroid as the client swallows water 3) Use the bell of the stethoscope to identify a bruit 4) Left hand is used to displace the trachea, palpate with the fingers of the right hand 4) 4 Explanation: 1. This describes the method used when palpating the thyroid from the front of the client. 2. This is the appropriate method to inspect the thyroid gland. The question was about how to correctly palpate the thyroid. 3. This is the technique used to auscultate an enlarged thyroid gland. The question was how to correctly palpate the thyroid gland. 4. The correct procedure for examining the thyroid using a posterior approach is to use the left hand to push the trachea to the right, then use light pressure to palpate the thyroid with the fingers of the right hand. Assessment Application Objective 7 Page 230 Difficulty = 3 5) What is the only bone in the body that does not articulate with another bone? 1) Pinna 2) Hyoid 3) Axis 4) Zygomatic 5) 2 Explanation: 1. The pinna is the ear. 2. The hyoid is the only bone in the body that does not articulate directly with another bone. 3. Axis is the second cervical vertebra that allows movement of the head.
4. The zygomatic bone is a fused facial bone that provides structure to the face. Assessment Knowledge Objective 1 Page 219 Difficulty = 1 6) A nurse is performing a physical examination on Olivia, a newborn. The mother expresses concern about the flattened areas on each side of Olivia’s head. How should the nurse respond? 1) “The baby needs a neurological evaluation.” 2) “This is normal and will resolve in a few days.” 3) “The baby will need plastic surgery.” 4) “What shape is your husband’s head?” 6) 2 Explanation: 1. This is an inappropriate response because the infant's head is normal. 2. Infants born by vaginal delivery experience moulding, which is shaping of the head as it passes through the vaginal canal. This will resolve in several days. 3. This is an inappropriate response because the infant is experiencing moulding as a result of a vaginal delivery. 4. This is an inappropriate response because the moulding is due to a vaginal delivery. Assessment Application Objective 8 and 9 Page 221 Difficulty = 1 7) A nurse is auscultating the temporal artery and hears a soft blowing sound. What is the appropriate term to use to document this finding? 1) Murmur 2) Occlusion 3) Stenosis 4) Bruit 7) 4 Explanation: 1. The sound described is not a murmur, which is heard when auscultating the heart, and the nurse should not document any conclusive diagnoses from assessment findings. 2. If the temporal artery was occluded there would be no sound of blood flow on auscultation 3. A stenosis is what will cause the soft blowing sound which is called a bruit. 4. A bruit can be heard through the bell of the stethoscope as a soft, blowing sound and is indicative of narrowing of the vessel. Assessment Application Objective 11 Page 228 Difficulty = 1 8) A client tells a nurse that she suffers headaches that come on suddenly; recur over a period of days followed by a period of remission. What type of headache is this client experiencing?
1) 2) 3) 4)
Classic migraine Tension Cluster Premenstrual
8) 3 Explanation: 1. A classic migraine is preceded by an aura and the acute phase typically lasts 4 to 6 hours. 2. A tension headache, also known as a muscle contraction headache is due to sustained contraction of muscles in the neck, head, or upper back. Onset is gradual and is associated with stress, overwork, or premenstrual syndrome. 3. The client has described a cluster headache. 4. A premenstrual headache is a tension headache. Assessment Knowledge Objective 8 Page 236 Difficulty = 1 9) A nurse is testing a client’s cranial nerves by applying downward pressure on both shoulders while the client is asked to do a shoulder shrug. What cranial nerve is being assessed? 1) IX 2) X 3) XI 4) XII 9) 3 Explanation: 1. IX is the glossopharyngeal and can be assessed by checking the taste. 2. Cranial nerve X is the Vagus nerve and can be assessed by checking the gag reflex or having the client swallow. 3. Cranial nerve XI innervates the primary muscles of the neck (sternocleidomastoid) and shoulders (trapezius). 4. XII is the hypoglossal and innervates the muscles that move the tongue Assessment Application Objective 1 Page 218 Difficulty = 3 10) A nurse is assessing a client's temporomandibular joint (TMJ) and notes a crackling sound on movement. How should the nurse document this finding? 1) Crepitation at TMJ 2) Soft clicking noise at TMJ 3) Melasma noted on movement 4) The TMJ is normal 10) 1 Explanation: 1. Crepitation is the term used to describe the crackling sound noted on movement of the TMJ.
2. This would be incorrect documentation because a soft clicking noise at the TMJ is a normal finding and a crackling sound is called crepitation and indicates joint problems. 3. Melasma is a blotchy pigmented spots that may develop on the face of a pregnant woman and is not related to the TMJ 4. This would be incorrect documentation. If the TMJ is normal the sound would be a soft clicking noise and not a crackling sound. Assessment Application Objective 11 Page 228 Difficulty = 2 11) A nurse is assessing an infant and needs to document normal assessment findings of the fontanels. What is the appropriate documentation? 1) Fontanels diamond shaped 2) Moulding of head noted around fontanels 3) Anterior and posterior fontanels level with the skull 4) Fontanels sunken 11) 3 Explanation: 1. The anterior fontanel is diamond shaped but the posterior fontanel is triangular shaped; therefore this documentation is inaccurate. 2. Incorrect, moulding occurs as the baby’s head moves through the vaginal canal during delivery and will be influenced by the presenting part of the head. 3. The anterior fontanel is diamond shaped, and the posterior is triangular in shape, and they should be firm and even with the scalp — slight pulsations are normal. 4. Sunken fontanels may be indicative of dehydration and is not a normal sign. Assessment Application Objective 11 and 9 Page 221 Difficulty = 2 12) A new immigrant from India presents with a history of goitre. During the assessment the nurse notes an enlarged thyroid gland. What question is a priority in this health history? 1) “How long have you had this problem?” 2) “Where do you purchase your medication?” 3) “Do you work around hazardous chemicals?” 4) “What type of salt do you use in your diet?” 12) 4 Explanation: 1. This is an important question to gain general information; however, the nurse needs to assess whether the client is indeed using iodized salt, especially regarding the client’s past history and present symptomatology. 2. This is helpful information but not essential at this point in the assessment in light of the client's past history and present symptomatology. 3. This question is important but not the priority given the client's health status.
4. Thyroid disease is common where iodine is limited and deficient amounts of iodine cause goiter. The nurse needs to know this information particularly since the client comes from a country where iodine is limited. Assessment Analysis Objective 3, 9, and 10 Page 222 Difficulty = 3 13) A nurse is auscultating the thyroid gland and notes a bruit. What does this finding indicate? 1) Increased blood flow 2) A normal finding 3) Occurs with hypothyroidism 4) Stenosis of the thyroid artery 13) 1 Explanation: 1. If the thyroid is enlarged, blood flows through the arteries at an accelerated rate, producing a soft, rushing sound and is detected with the bell of the stethoscope as a bruit. 2. A thyroid bruit is not a normal finding. 3. Hypothyroidism usually produces a smaller than normal thyroid gland with decreased blood flow. 4. This is not a normal finding and is not indicative of arterial stenosis as is the case in the temporal or carotid vessels. Assessment Application Objective 8 Page 231 Difficulty = 2
14) A nurse is demonstrating palpation of the lymph nodes to a nursing student. What is the correct method to use during this examination? 1) Strong, deep pressure 2) Rubbing side to side 3) Gentle, circular pressure 4) First on one side, then on the other 14) 3 Explanation: 1. Strong, deep pressure can push the nodes into the muscle and underlying structures, making them difficult to find. 2. Rubbing side to side is not the correct technique for palpating lymph nodes. 3. Palpation of the lymph nodes should be done by exerting gentle, circular pressure using the finger pads of both hands. 4. Nodes should be palpated on both sides simultaneously for comparison. Implementation Application Objective 7 Page 231 Difficulty = 2
15) Carol, 16 weeks gestation, is concerned about the dark spots that have appeared on her face. How should the nurse respond? 1) "This often occurs in pregnancy and unfortunately is permanent". 2) "This is due to hormonal changes and will subside after childbirth". 3) " I think you have had too much sun exposure". 4) "This is a result of using birth control pills for many years". 15) 4 Explanation: 1. This is a normal occurrence in pregnancy called melasma but it is rarely a permanent change. Melasma will dissipate after pregnancy. 2. The dark spots on her face (melasma) are a normal occurrence in pregnancy due to hormonal changes and will subside after childbirth. 3. This is not related to sun exposure but is due to hormonal changes that occur in pregnancy. 4. Melasma can occur while on the pill but this is not relevant in this client situation since the pigmentation has appeared during her pregnancy. Assessment Application Objective 3, 8, and 9 Page 222 and 226 Difficulty = 2
16) A nurse is assessing a client with complaints of sudden, intermittent headaches for the past several months. The client states that the headaches start after seeing flashes of lights and is accompanied nausea. What type of headache is this client describing? 1) Premenstrual 2) Tension 3) Migraine 4) Cluster 16) 3 Explanation: 1. A premenstrual headache is a tension headache 2. A tension headache, also known as a muscle contraction headache is due to sustained contraction of muscles in the neck, head, or upper back. Onset is gradual and is associated with stress, overwork, or premenstrual syndrome. 3. 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. 4. Cluster headaches come in waves over a specific period and then disappear for intervals. Cluster headaches are not precipitated by an aura. Diagnosis Analysis Objective 8 Page 236 Difficulty = 1 17) A nurse is assessing a newborn infant. The infant's head tilts to one side and the sternocleidomastoid muscle is shortened. What is the correct medial term to describe this finding? 1) Craniosynostosis 2) Acromegaly
3) Hydrocephalus 4) Torticollis 17) 4 Explanation: 1. Craniosynostosis is early closure of the sutures, which causes head elongation. 2. Acromegaly is enlargement of the skull and cranial bones due to increased growth hormone, which would not be the cause in an infant 3. Hydrocephalus is enlargement of the head caused by inadequate drainage of cerebrospinal fluid. 4. Torticollis is a spasm of the sternocleidomastoid muscle on one side of the body that can cause the muscle to shorten and the head to tilt to one side. Torticollis often occurs as a result of a birth trauma. Assessment Knowledge Objective 8 Page 239 Difficulty = 1 18) A nurse is caring for a client diagnosed with hyperthyroidism. What symptom would the nurse suspect? 1) Irritability 2) Weight gain 3) Constipation 4) Fatigue 18) 1 Explanation: 1. Irritability is a classic sign of hyperthyroidism. 2. Weight gain is a symptom of hypothyroidism. 3. Constipation occurs in hypothyroidism. 4. Fatigue is associated with hypothyroidism. Assessment Application Objective 8 Page 240 Difficulty =2 19) A nurse is palpating a pregnant client’s thyroid which is slightly enlarged. What is the most appropriate way for the nurse to document this finding? 1) Client appears to have Grave’s disease. 2) Thyroid gland within normal limits. 3) Thyroid gland has a palpable mass. 4) Thyroid gland midline and round, but slightly enlarged. 19) 4 Explanation: 1. Grave’s disease causes most pathologic hyperthyroidism in pregnancy, but diagnosing a condition is beyond the scope of nursing practice. 2. It may be a normal finding in pregnancy, but the physician will make any diagnosis. 3. Although a slightly enlarged thyroid can be a normal finding in pregnancy, any palpable mass should be documented according to size, shape, and location.
4. This is correct because it clearly states what the nurse assessed without making a diagnosis beyond the scope of the nurses practice. Assessment Analysis Objective 9 Page 226 and 230 Difficulty = 2 20) A nurse is planning care for a client with hypothyroidism. What is the priority nursing diagnosis for a client experiencing this disorder? 1) Nutrition, less than body requirements 2) Risk for injury 3) Activity intolerance 4) Ineffective health maintenance 20) 3 Explanation: 1. This nursing diagnosis does not related to this health issue 2. The client is not at risk for injury because of hypothyroidism 3. The client experiencing hypothyroidism generally has lack of energy and fatigue. These factors lead to activity intolerance. 4. This diagnosis does not relate to the scenario. Diagnosis Analysis Objective 10 Page 233 Difficulty = 2 21) A nurse is performing an assessment of the head and neck. What assessment techniques would the nurse include in the examination? 1) Inspection, palpation, auscultation 2) Palpation, auscultation, percussion 3) Inspection and auscultation 4) Percussion and palpation 21) 1 Explanation: 1. Physical assessment of the head and neck requires the use of inspection, palpation, and auscultation. 2. Percussion is not a technique used in assessing the head and neck. 3. This option does not include auscultation which is an important technique to use in assessing the head and neck. 4. Percussion is not a technique used in assessing the head and neck. Inspection and auscultation are important techniques used in assessing the head and neck. Assessment Application Objective 6 Page 226 Difficulty = 2 22) What muscles form the posterior triangle of the neck? 1) Mandible, midline of the neck, and sternocleidomastoid
2) Clavicle, midline of the neck, and trapezius 3) Manubrium, Mastoid, and scapulae 4) Clavicle, sternocleidomastoid, and trapezius 22) 4 Explanation: 1. These muscles form the anterior triangle of the neck. 2. This is incorrect and is a combination of the muscles that form either the anterior or posterior triangle of the neck. 3. The mastoid and manubrium are bones. 4. This is correct. Assessment Knowledge Objective 1 Page 219 (Figure 12.4) Difficulty = 2 23) A nurse is taking a physical assessment examination and has been asked to palpate the submandibular lymph node. What is the landmark for locating this lymph node? 1) Behind the tip of the mandible at midline 2) At the junction of the posterior and lateral walls of the pharynx at the angle of the jaw 3) On the medial border of the mandible 4) Behind the ear, over the outer surface of the mastoid bone 23) 3 Explanation: 1. This describes the location for the submental lymph node. 2. This is the landmark for the retropharyngeal (tonsillar) lymph node. 3. This is the correct landmark. 4. This is the location of the posterior auricular lymph node. Assessment Application Objective 2 Page 221 Difficulty = 2 24) A nurse is examining Jude, 3 months old, and notices plagiocephaly. What question should the nurse ask Jude’s mother? 1) "How much alcohol did you drink during your pregnancy?" 2) "Did the baby experience a birth trauma?" 3) "How is Jude positioned in his crib?" 4) "When did Jude’s sutures fuse?" 24) 3 Explanation: 1. This is an inappropriate response because plagiocephaly is a flat occipital prominence and has nothing to do with alcohol intake during pregnancy. 2. Inappropriate response. Plagiocephaly is a flattening of the occipital prominence and has nothing to do with a birth trauma. 3. Correct. Plagiocephaly develops from placing the infant on their backs to sleep or from using infant boards which flatten the back of the head.
4. Incorrect. This question relates more to craniosynostosis than plagocephaly. Assessment Application Objective 3 and 8 Page 222 Difficulty = 3
25) Mr. Jones, 70 years old, has sudden onset of unilateral facial paralysis. The physician suspects the client has a Bell's palsy. What cranial nerve is involved in this disorder? 1) VII 2) XI 3) X 4) V 25) 1 Explanation: 1. Cranial nerve VII is the Facial nerve that controls movement of the face. In Bell's palsy this cranial nerve is affected resulting in facial paralysis on the affected side. 2. XI, the Accessory nerve controls shoulder shrug and neck muscles and is not involved in Bell's palsy. 3. Cranial nerve X, the Vagus nerve, controls the pharynx and is not involved in Bell's palsy. 4. Cranial nerve V, the Trigeminal nerve, controls mastication and is not involved in Bell's palsy. Assessment Knowledge Objective 1 Page 237 Difficulty = 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse needs to palpate the submental lymph node on a client. Draw an arrow to the spot where the nurse would palpate.
3) Explanation: The submental lymph node is located behind the tip of the mandible at the midline. Assessment Application Objective 1 Page 221 and 232 (Figure 12.14) Difficulty = 1 27) A nurse is assessing an infant diagnosed with Down syndrome. What characteristics would the nurse expect to find during this examination? (Select all that apply) Slanted eyes Cleft palate and lip Flat nasal bridge and nose Protruding tongue Shortened neck Drooping eyelids 27)
X
Slanted eyes Cleft palate and lip X Flat nasal bridge and nose X Protruding tongue X Shortened neck Drooping eyelids Explanation: Down syndrome is not characterized by the presence of cleft palate and lip nor drooping eyelids. Assessment Knowledge Objective 8 Page 238 Difficulty = 2
Chapter 13 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse will be performing a distance vision test on a client. What equipment should be used for this examination? 1) Ophthalmoscope 2) Snellen chart 3) Rosenbaum chart 4) Pen light 1)2 Explanation: 1. An ophthalmoscope is used to assess the fundus. 2. A Snellen chart is used to assess distance vision. 3. A Rosenbaum chart is used to assess near vision. 4. A Pen light is used to assess peripheral vision, fields of gaze, or pupillary response. Assessment Analysis Objective 7 and 8 Page 251 Difficulty = 1 2) During an interview with the nurse a 24 –year-old client reports difficulty with near vision. What term should the nurse use to document this finding? 1) Astigmatism 2) Myopia 3) Presbyopia 4) Hyperopia 2) 4 Explanation: 1. In astigmatism the cornea curves more in one direction than another as a result light is refracted and focused on 2 focal points on or near the retina. Vision may be blurred or doubled. 2. Myopia (nearsightedness) meaning the client can see near but has difficulty with distance vision. In this condition the light rays focus in front of the retina. 3. Changes in near vision, especially in clients over 45, can indicate presbyopia, impaired near vision resulting from a loss of elasticity of the lens related to aging. 4. In younger clients, this condition is referred to as hyperopia (farsightedness) meaning that the client can see far but has difficulty with near vision. In this condition the light rays focus behind the retina. Diagnosis Analysis Objective 12 Page 254 and 266 (Figure 13.26 Difficulty = 2
3) A nurse is triaging clients in an ophthalmology office. What client condition requires immediate intervention? 1) Anisocoria 2) Periorbital edema 3) Blepharitis 4) Acute glaucoma 3) 4 Explanation: 1. Aniscoria is unequal pupil size, which may be a normal finding. 2. Periorbital edema involves the eyelid and shouldn’t require immediate attention. 3. Blepharitis is an inflammation of the eyelid and does not need immediate assistance. 4. Acute glaucoma is a result of sudden increase in intraocular pressure caused by blocked flow of fluid from the anterior chamber. This client requires immediate medical attention. Assessment Analysis Objective 11 Page 271 Difficulty = 2 4) A nurse is performing a visual examination because a client has reported black dots appearing in the visual fields. The client asks the nurse if the black dots are a sign of a serious problem. How should the nurse respond? 1) “The black dots are known as floaters and are usually normal.” 2) “You may have cataracts.” 3) “You may have glaucoma.” 4) “We need to refer you to an eye surgeon immediately.” 4) 1 Explanation: 1. Black dots or spots are known as floaters. Floaters are considered normal unless they obstruct vision. 2. Floaters are not associated with cataracts so this is an inappropriate response by the nurse. 3. Floaters are not associated with glaucoma so this is an inappropriate response by the nurse. With glaucoma clients report seeing halos around lights. 4. This is an inappropriate response because floaters are normal so a referral to an eye surgeon is not warranted. Assessment Analysis Objective 3 Page 248 Difficulty = 1 5) A nurse is completing a health history interview on a young adult. What question will provide information about the client's health behaviours related to eye health? 1) "Do bright lights bother you?" 2) "Do you routinely wear sunglasses during the summer?" 3) "Have you ever been bothered by spots in front of your eyes?" 4) "Does anyone in your immediate family have diabetes?" 5) 2
Explanation: 1. This question is more appropriate for an older client because it provides information about a common aged related physiologic change to the eye. This question does not get at the client's health behaviours. 2. This question will provide information about the client's health behaviours in relation to preventing cataract development by protecting the eyes from sun damage. 3. This question gets at common concerns related to the eye but does not provide information on client health behaviours. 4. This question will elicit information on family health history which may have a bearing on the client but does get at health behaviours. Assessment Analysis Objective 4 Page 249 Difficulty = 1 6) A nurse is preparing to use an ophthalmoscope to examine a client with an emmetropic eye. How should the nurse position the diopter wheel? 1) Minus numbers 2) Zero 3) Positive numbers 4) Really does not matter 6)2 Explanation: 1. Negative or minus number are used in the myopic eye. 2. The diopter wheel should be positioned at 0 (zero) in the emmetropic (normal) eye. 3. For hyperopic eye positive numbers are used on the diopter. 4. This is incorrect. The diopter position is important because it corrects for problems of refraction and allows the examiner to clearly view the retina. Assessment Comprehension Objective 6 Page 261 (Figure 13.21) Difficulty = 2 7) A nurse is assessing the visual fields of a 38-year-old female who reports recent changes in visual abilities. What statement by the nurse would be appropriate? 1) “The changes could be related to increased pressure within the eye.” 2) “These changes are probably related to your age.” 3) “These changes require a prescription for glasses.” 4) “It is possible you have taken narcotics recently?” 7) 1 Explanation: 1. Visual fields are the total area in which objects in the periphery can be seen while the eye remains focused on a central point. One of the causes of changes in visual fields is increased intraocular pressure. 2. Incorrect statement. A change in visual fields is not more common in one particular age group than another. 3. Incorrect statement. A change in visual fields is not corrected with prescription glasses.
4. Abnormal pupillary response occurs in narcotic use. Diagnosis Analysis Objective 3 Page 267 Difficulty = 2 8) A nurse is performing the cover test and notes inward turning of the eye. What is the correct term to use to document this finding? 1) Nystagmus 2) Emmetropia 3) Esophoria 4) Exophoria 8) 3 Explanation: 1. Nystagmus is rapid fluttering of the eyeball. 2. Emmetropia is the normal refractive condition of the eye in which light rays are brought into sharp focus on the retina. 3. Esophoria is the inward turning of the eye and is detected in the cover test. 4. Exophoria is the outward turning of the eye, which is also detected in the cover test. Assessment Application Objective 12 Page 269 Difficulty = 2 9) A nurse is performing a vision test with a client. With a Rosenbaum chart in place the nurse asks the client to read the letters from top to bottom. How will the nurse position the client to ensure the accuracy of this examination? 1) Must be exactly 6 m from the chart 2) Seated at eye level 0.5 to 1 m from the nurse 3) Should be 35.5 cm from the chart 4) Ensure one eye is covered while reading the chart 9) 3 Explanation: 1. This is the distance from the Snellen chart used to assess distance vision. 2. This is the client position for testing visual fields by confrontation. 3. The Rosenbaum chart is used to assess near vision; therefore, the client needs to be positioned 35.5 cm from the chart. 4. Testing near vision requires the client must read the Rosenbaum chart with the right eye covered, then with the left eye covered, and finally with both eyes uncovered. Diagnosis Evaluation Objective 5 and 7 Page 253 Difficulty = 2 10) When assessing the eyes of a client, the nurse notes severe redness of the iris and cornea. The client reports pain in the eye as well. What term should the nurse use to document this finding?
1) 2) 3) 4)
Blepharitis Iritis Conjunctivitis Mydriasis
10) 2 Explanation: 1. Blepharitis is inflammation of the eyelids. 2. Iritis is a serious disorder characterized by redness around the iris and cornea, irregularly shaped pupil, visual changes, and aching pain. 3. Conjunctivitis is an infection of the conjunctiva. 4. Mydriasis refers to fixed and dilated pupils. Assessment Comprehension Objective 12 Page 274 Difficulty = 1 11) A nurse is assessing the eyes of an 82-year-old client. What age related physiologic change should the nurse anticipate? 1) Thin, yellow lens 2) Larger size pupils 3) Quicker pupillary light reflexes 4) Decrease in lacrimal secretions 11) 4 Explanation: 1. As the client ages, the lens continues to thicken and yellow, forming a dense area that reduces lens clarity. 2. The pupils may be smaller in size. 3. The pupillary light reflex is slower with age. 4. Older adults experience a decrease in lacrimal secretions resulting in a dryness of the eyes. Assessment Application Objective 10 Page 246 Difficulty = 1
12) A nurse will be giving a distance visual acuity test to a 3- year-old child. What type of chart will be required for this examination? 1) Rhinne 2) Rosenbaum 3) Snellen E 4) Webber 12)3 Explanation: 1. There is a Rhinne test for hearing but there is not a Rhinne chart. 2. This chart is used to assess near vision. 3. This chart is used to assess distance vision in children and non-English speaking clients.
4. There is no such chart. Assessment Knowledge Objective 8 and 10 Page 251 Difficulty = 2 13) Doug and Tyler, student nurses, are studying for a midterm. Tyler asks Doug to explain Adie's pupil. What would be the best answer? 1) Both pupils are small, irregular, and nonreactive to light. 2) Unequal papillary size than may be normal or may indicate disease. 3) Fixed and dilated pupils due to central nervous system damage. 4) Unilateral sluggish pupillary response also known as a tonic pupil. 13) 4 Explanation: 1. This description is of Argyll Robertson Pupils. 2. Anisocoria is an unequal papillary size that may be normal or may indicate central nervous system disease. 3. Mydriasis refers to fixed and dilated pupils due to sympathetic nerve stimulation, glaucoma, central nervous system damage, or deep anaesthesia. 4. This description is of Adie's pupil Assessment Knowledge Objective 9 Page 270 (Figure 13.33) Difficulty = 3 14) A nurse is caring for a client recovering from an occipital lobe stroke who is demonstrating vision changes. The client's spouse asks the nurse what has caused the vision changes. How should the nurse respond? 1) “An eye specialist needs to consult on the cause of the vision changes” 2) “The visual changes were probably present before the stroke occurred.” 3) “The stroke was in the occipital area of the brain, which is responsible for vision.” 4) “I think another stroke is occurring I need to do an immediate assessment.” 14) 3 Explanation: 1. There is not enough information to jump to this conclusion. The most plausible cause of the vision changes is the occipital lobe stroke because this part of the brain is responsible for interpretation of impulses transmitted to this region of the brain from the optic tracts. 2. Inappropriate response because the nurse is not explaining the connection between the occipital lobe and vision. 3. Optic tracts encircle the brain, and impulses are transmitted to the occipital lobe of the brain for interpretation. 4. There is no evidence that the client is having another stroke. Diagnosis Analysis Objective 1 and 3 Page 243 Difficulty = 1
15) What type of vitamin deficiency can cause night blindness? 1) A 2) B 3) D 4) E 15) 1 Explanation: 1. A deficiency in vitamin A can cause night blindness. 2. A vitamin D deficiency can lead to anemia. 3. A vitamin D deficiency causes rickets. 4. A deficiency in vitamin E can lead to neurological problems. Assessment Comprehension Objective 1 Page 246 Difficulty = 1 16) A nurse is interviewing the mother of a three-week-old infant. What statement by the mother would require teaching by the nurse? 1) “My baby’s eyes will stay blue.” 2) “I can get my baby to follow bright objects.” 3) “I know that my baby’s crossed eyes won't be permanent.” 4) “My baby should not have tears.” 16)1 Explanation: 1. By about the third month of age, the colour of the eyes begins to change to a more permanent shade. 2. Before six weeks of age, infants will fixate on a bright or moving object. 3. The infant may have crossed eyes normally until four months of age. 4. Little to no tears is present at birth and do not begin to appear until around the fourth week. Assessment Analysis Objective 10 Page 245 Difficulty = 1 17) A nurse would like to assess the fusion reflex in a client. What assessment technique should the nurse use? 1) Corneal light reflex 2) Cover test 3) Testing by confrontation 4) Cardinal Fields of Gaze 17) 2 Explanation: 1. The purpose of corneal light reflex is to observe the reflection of light on the cornea. 2. The cover test is used to assess the balance mechanism (fusion reflex) that keeps the eyes parallel. 3. Testing by confrontation is used to assess visual fields and not the fusion reflex. 4. Testing the six Cardinal Fields of Gaze assesses the movements of the eye and muscles of the eye. Assessment
Application Objective 7 Page 256 Difficulty = 2 18) A nurse is going to perform the cover test on a client? How should the client be prepared for this examination? 1) Seated approximately 0.5 to 1 m away from the examiner 2) Explain to the client when the light is first seen to say "now" or "yes". 3) Tell the client that the testing will take place in a darken room. 4) Look at a fixed point while covering one eye and then repeat with the other eye. 18) 4 Explanation: 1. This is the client position for the Visual Fields by Confrontation test 2. Prior to performing a peripheral vision test the client must be told to indicate when the light is first seen to ensure accuracy in the testing procedure. 3. The room light is dimmed to test pupillary response. 4. The client must look at a fixed point and then cover one eye. The nurse will observe the uncovered eye, which should remain focused on the designated point. The test is then repeated with the other eye. Implementation Analysis Objective 5 Page 256 Difficulty = 2 19) During an eye examination, the nurse finds a client is able to read all lines on the Snellen chart without difficulty. How should the nurse document this finding? 1) Reading vision normal 2) Vision 20/20 3) Distance vision normal 4) Vision 14/14 19) 3 Explanation: 1. The Snellen chart is used to assess distance vision not near (reading) vision. 2. 20/20 vision is a score that can be achieved on the Snellen chart and is used as the standard reference for vision. A person that can read all lines on the Snellen chart has better than 20/20 vision 3. A client that can read all lines on the Snellen chart has better than 20/20 vision; therefore has normal distance vision. Without the actual score from the distance vision test the most appropriate way to document the results of this eye test is that the distance vision is normal. 4. 14/14 vision is a normal result on the near vision test using the Rosenbaum chart. Diagnosis Application Objective 12 Page 252 (Figure 13.7) Difficulty = 2 20) A client is found to need corrective lenses for myopia. How should the nurse explain the purpose of the lenses to the client?
1) 2) 3) 4)
“Your glasses will help you to see things that are close to you better.” “Your glasses will help you to see things that are farther away better.” “Your glasses will help you to read small print better.” “Your glasses will help you to improve your eyes’ ability to focus.”
20) 2 Explanation: 1. Hyperopia is the inability to see objects up close. 2. Myopia is the inability to see objects at a distance. 3. Presbyopia causes difficulty in the focus on small print at close ranges. 4. Astigmatism causes blurred or double vision when eyes attempt to focus. Implementation Analysis Objective 3 Page 252 and 266 Difficulty = 2 21) A nurse is assessing a client’s visual fields by confrontation. What instructions should the nurse provide the client in preparation for this eye test? 1) "Follow the pen light with your eyes only." 2) "Keep both eyes uncovered and focus on the examiners forehead." 3) "Cover one eye with the card." 4) "Say no when you can no longer see the light." 21) 3 Explanation: 1. This is the instructions for performing the six Cardinal Fields of Gaze. 2. Inappropriate instructions, this is not how confrontation is performed. 3. Confrontation is used to test visual fields and is done by asking the client to cover one eye with a cover and look directly into the examiner's opposite eye. An object is advanced from the periphery to the midline. 4. Incorrect instructions. During the confrontation examination the client is to say "now" or "yes" when the object or light is first seen. Implementation Application Objective 5 Page 254 Difficulty = 2 22) A nurse is assessing an infant and notes the left eye deviates inward while focusing on an object. How should the nurse document this finding? 1) Strabismus 2) Myopia 3) Hyperopia 4) Presbyopia 22) 1 Explanation: 1. Strabismus is a condition in which the axes of the eyes cannot be directed at the same object. This infant specifically has esophoria (inward turning of the eye). 2. Myopia is the inability to see objects at a distance.
3. Hyperopia is the inability to see objects up close. 4. Changes in near vision, especially in clients over 45, can indicate presbyopia, impaired near vision resulting from a loss of elasticity of the lens related to aging. Assessment Analysis Objective 12 Page 268 (Figure 13.30) Difficulty = 1 23) A client being assessed by a nurse is found to have a poor consensual light response. How should the nurse interpret this finding? 1) A potential abnormality of cranial nerve III 2) Evidence of retinal degeneration 3 An indication of macular degeneration 4) Evidence of Horner's Syndrome 23) 1 Explanation: 1. When evaluating pupillary response, the unilluminated, or consensual pupil should constrict at a slightly longer rate than the direct pupil. When this does not occur, it may be indicative of cranial nerve III damage. 2. Retinal degeneration presents as dark or opaque spots on the retina, an irregularly shaped optic disc, and lesions or hemorrhages on the fundus. 3. Macular degeneration presents as a loss of central vision. 4. Horner's Syndrome occurs due to blockage of the sympathetic nerve stimulation on one side of the face. The signs and symptoms on the affected side are: small, regular pupil that is nonreactive to light, ptosis, and anhidrosis (loss of sweating). Diagnosis Analysis Objective 9 Page 257 Difficulty = 3 24) During a physical assessment the nurse suspects the client has entropion. What did the nurse observe? 1) Eversion of the lower eyelid 2) Firm, nontender nodule on the eyelid 3) Swollen, red hair follicles 4) Inversion of the lid and eyelashes 24) 4 Explanation: 1. Ectropion is eversion of the lower eyelid caused by muscle weakness. 2. A stye causes swelling and redness in the affected eye. 3. A chalazion is a firm, nontender nodule on the eyelid arising from infection of the meibomian gland. 4. Entropion is inversion of the lid and lashes caused by muscle spasm of the eyelid. Diagnosis Analysis Objective 9 Page 273 Difficulty = 2
25) During a physical assessment the nurse suspects the client has ptosis. What did the nurse observe? 1) Eversion of the lower eyelid 2) Swollen and puffy eyelids 3) Drooping of the eyelid 4) Redness of the iris and cornea 25) 3 Explanation: 1. Ectropion is eversion of the lower eyelid caused by muscle weakness. 2. Periorbital edema refers to swollen, puffy eyelids. 3. Ptosis is drooping of the eyelid. 4. Iritis causes redness of the iris and cornea. Diagnosis Analysis Objective 9 Page 258 and 274 Difficulty = 1 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is caring for a client who is 30 weeks pregnant. The client has various visual complaints and asks the nurse whether the changes are permanent. What signs and symptoms are usually normal in this stage of pregnancy and should disappear after delivery? (Select all that apply.) 1) Edema of eyelids 2) Blurred vision 3) Visual changes 4) Intolerance of contact lenses 5) Eye dryness 26) 2, 3, 4, 5 Explanation: The pregnant female may complain of dry eyes and may discontinue wearing contact lenses during her pregnancy. The pregnant client may also describe visual changes due to shifting fluid into the cornea. Blurriness or distorted vision can occur because of temporary changes in the shape of the eye during the last trimester of pregnancy. These symptoms are usually not significant and disappear after childbirth. Eyelid edema is not a common problem associated with pregnancy. Diagnosis Analysis Objective 10 Page 246 Difficulty = 1 27) What structure(s) in the eye are responsible for refraction? (Select all that apply.) 1) Aqueous humor 2) Sclera 3) Iris 4) Crystalline lens 5) Cornea 27) 1, 4, 5 Explanation:
Several structures of the eye help with the deflection or refraction of the light rays. The structures responsible for refraction include the cornea, aqueous humor, crystalline lens, and the vitreous humor. The sclera is the white fibrous part that is seen anteriorly; it does not assist with refraction. The iris controls the amount of light that enters the eye. Assessment Comprehension Objective 1 Page 243 Difficulty = 1
Chapter 14 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse notes in the physical exam done by the physician that the client has a positive Romberg. What should the nurse do to help the client meet elimination needs? 1) Provide a bedside commode 2) Allow the client to walk independently 3) Obtain an order for a catheter 4) Limit fluid intake 1) 1 Explanation: 1. A positive Romberg sign indicates problems with the vestibular apparatus that controls coordination and balance, cerebellar ataxia, or sensory loss. This client would have difficulties ambulating without this control. The nurse must provide safety for this client, which may require obtaining a bedside commode, which would decrease the need for ambulation to the bathroom. 2. The client has problems with the vestibular apparatus that controls coordination and balance, cerebellar ataxia, or sensory loss. This client would have difficulties ambulating safely. 3. Catheter insertion is not indicated for this client 4. Limiting fluids is not indicated in this situation. Implementation Application Objective – 11 Page – 295, 296 Difficulty - 2 2) Mr. Jarvis works with heavy machinery and until recently was not required to use hearing protection. He tells the nurse that he has experienced a gradual change in his hearing over the past 5 years. What finding would the nurse anticipate when performing the Rinne test? 1) Shorter bone conduction of sound 2) Longer air conduction of sound 3) Shorter air conduction of sound 4) Sound lateralization of one ear 2) 3 Explanation: 1. Longer bone conduction would be anticipated. 2. Longer bone conduction would be anticipated. 3. The Rinne test compares air and bone conduction. Given the client’s history, the nurse would suspect nerve damage resulting from occupational exposure to loud noises. The finding would be longer bone conduction of sound and shorter air conduction of sound due to the damage of the structures within the ear that transmit sound. 4. The Weber test is used to identify sound lateralization. Assessment Analysis Objective – 8 Page – 294, 295 (Figure 14.17A and 14.17 B) Difficulty - 3 3) What assessment techniques are used to assess the ears, nose, mouth and throat? 1) Transillumination and palpation
2) Auscultation and percussion 3) Transillumination and conduction 4) Conduction and percussion 3) 1 Explanation: 1. The assessment techniques include: transillumination, palpation, percussion and inspection. 2. Auscultation is not used to assess the ears, nose, mouth and throat. 3. Conduction is not an assessment technique used with the ears, nose, mouth and throat. 4. Conduction is not an assessment technique used with the ears, nose, mouth and throat. Assessment Application Objective – 7 Page - 290 Difficulty - 1 4) A nurse is assessing the tympanic membrane of a client in the emergency room and notes the presence of a bluish colour. What should the nurse suspect in this situation? 1) Previous tympanostomy tubes 2) Use of a hearing aid 3) Diagnosis of gout 4) Head trauma 4) 4 Explanation: 1. Scarring from tympanostomy tubes would appear as white areas on the tympanic membrane. 2. The use of a hearing aid does not discolour the tympanic membrane. 3. Tophi is associated with gout. 4. The presence of a bluish tinge in the tympanic membrane is due to blood in the middle ear and may be indicative of head trauma. Diagnosis Analysis Objective – 9 Page - 290, 293, 306 Difficulty - 1 5) Ms. Jarvis, 41 years old, states she suffers from headaches and malaise. The nurse completes an assessment and finds that Ms. Jarvis has severe pain across the bridge of her nose, on the forehead, and beneath both eyes when these areas are palpated. What disorder should the nurse suspect? 1) Sinusitis 2) Acute allergies 3) Migraines 4) Rhinitis 5) 1 Explanation: 1. Pain is common over the nose, forehead, and beneath the eyes when an infection or inflammation is present in the sinuses. 2. The data does not lead to suspicion of acute allergies. 3. While the pressure and congestion of the sinuses may contribute to the client’s headache, the assessment findings do not correspond with symptoms of migraine headaches. These tend to be more diffuse across the head and not localized in the sinus area.
4. Rhinitis will result in nasal congestion, the findings relate to a sinus infection. Assessment Application Objective – 11 Page – 308 (Figure 14.39) Difficulty - 2
6) A nurse is presenting a class to high-school teenagers about the risks of chewing tobacco. What early sign of oral cancer should the nurse include in the presentation?? 1) Excessive salivation 2) Ulcerations on the lip or tongue 3) Sore throat 4) Bleeding gums 6) 2 Explanation: 1. Excessive salivation does not occur. 2. One of the earliest signs of cancer of the mouth is an ulcer or lesion in the oral mucosa. 3. A sore throat is a sign of throat cancer 4. Bleeding gums are not signs of oral cancer. Assessment Application Objective – 9 Page – 286, 313 (Figure 14.51) Difficulty - 2 7) A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days. What assessment would be a priority for the nurse is this situation? 1) Obtain a blood pressure 2) Check for deviated septum 3) Check stools for blood 4) Obtain nasal cultures 7) 1 Explanation: 1. Hypertension is a contributory factor to the occurrence of nosebleeds that are persistent. 2. Assessment of septal deviation is not indicated in this situation. 3. Clients often swallow blood with frequent nosebleeds, which would cause the stool to appear black in colour. This is a normal finding. 4. Nasal cultures are not indicated in this situation. Assessment Analysis Objective – 11 Page – 307 (Figure 14.36) Difficulty - 2
8) A nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that she brushes and flosses her teeth three times a day and does not understand why they are swollen and bleed. How should the nurse respond? 1) “You are experiencing a normal change during pregnancy.” 2) “You may have oral cancer.”
3) “You need to increase the frequency of your oral hygiene.” 4) “You need a dental referral for gingivitis.” 8) 1 Explanation: 1. Gingival hyperplasia (enlargement of the gums) is a normal physiologic change with pregnancy. There is an increase in blood flow and vessels in the mouth leading to enlarged gums. 2. Early signs of oral cancer are manifested by ulcers in the lower lip and tongue. 3. Poor dental hygiene are manifested by swollen red gums that will bleed when brushed, and will show separation of the gum from the tooth. 4. Advanced gingivitis is manifested by swollen, red gums. Implementation Analysis Objective – 10 Page - 283 Difficulty - 3
9) Tamara, 20 months old, is being discharged following treatment of an ear infection and fever. What should the nurse include in the discharge teaching to the parents? 1) “It is important to not prop the baby’s bottle at bedtime.” 2) “You should use water at bedtime instead of milk.” 3) “You must rinse the baby’s mouth out at night.” 4) “You must perform oral hygiene more often.” 9) 1 Explanation: 1. A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice when Tamara goes to bed. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter and more horizontal auditory tube. 2. These liquids should not be replaced with water due to nutritional needs. 3. Rinsing the Tamara’s mouth out at bed time will not resolve the problem if the bottle is propped. 4. Increasing the oral hygiene frequency will not improve this situation if bottle propping is occurring. Implementation Application Objective – 10 Page - 283, 289 Difficulty - 3
10) A nurse is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. What should the nurse do first to better visualize this structure? 1) Pull down and back on the pinna, then reinsert the otoscope 2) Reposition the otoscope while still in the auricle until the tympanic membrane can be seen 3) Remove the otoscope, reposition the auricle, then reinsert the otoscope 4) Defer the examination for this client to the physician and document rationale 10) 3 Explanation: 1. Pulling down and back is recommended in children because of the shape of their auditory canal. 2. The otoscope is removed before it is repositioned. 3. To avoid trauma to the ear, the otoscope is to be removed and the auricle is to be repositioned for better visualization.
4. The examination should not be deferred Assessment Application Objective – 6 Page - 294 Difficulty - 2 11) A nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently, has a fever, and is pulling at both ears. The child has no cough, congestion, or drainage from the ears and the temperature is normal. What conclusion would the nurse make from these findings? 1) Respiratory infection 2) Otitis externa 3) Strep throat 4) Otitis media 11) 4 Explanation: 1. There is no assessment data that suggest respiratory infection since it would present with cough, congestion, or shortness of breath. 2. Otitis externa is an infection of the external auditory canal manifested by red edematous ear canal and purulent drainage. 3. A bacterial illness such as strep throat is often determined by cultures and the presence of white patches in the throat. 4. The auditory canal of infants is shorter and has an upward curve that persists until about the age of three. 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 often display the behaviour of pulling at their ears that is consistent with the diagnosis of a middle ear infection. Assessment Analysis Objective – 7, 10 Page - 283, 306 (Figure 14.31) Difficulty - 2
12) A nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. What action should the nurse take first? 1) Administer oxygen 2) Provide a warm drink 3) Type and cross for blood 4) Administer IV fluids 12) 1 Explanation: 1. While pallor may indicate anemia that requires blood transfusions, the cyanosis is a key assessment finding that will indicate hypoxia and the need for oxygen. 2. Providing a warm drink will not correct the problem in this situation. 3. The nurse may wish to cross and type the client, but it would not be the first action taken. 4. Breathing interventions must be performed prior to circulatory interventions (IV fluids). Implementation Analysis Objective – 11 Page - 299 Difficulty - 2
13) A nurse is examining a client’s ears and notes that the right ear is occluded with wax. How should the nurse remove the earwax? 1) A cerumen spoon to remove the wax 2) Irrigation with warm sudsy water 3) A cotton swab soaked in warm mineral oil 4) Irrigation with a cold solution 13) 1 Explanation: 1. Mineral oil and peroxide soften the earwax so it can 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. 2. Soapy solutions would cause irritation to the ear canal and may harden wax. 3. Cotton swabs and sharp instrument should never be inserted into the ear because of the risk of injury to the tympanic membrane. 4. Cold solutions may harden wax. Implementation Application Objective – 11 Page – 292, 302 Difficulty - 2 14) A nurse assessing the nasal passages of client notes the presence of watery discharge. The client mentions sneezing and nasal congestion. What condition`would the nurse suspect? 1) Rhinitis 2) Previous epistaxis 3) Sinusitis 4) Nasal polyps 14) 1 Explanation: 1. The symptoms exhibited are those of rhinitis, a nasal inflammation due to viral infection or allergy. 2. Sinusitis is an inflammation of the sinuses usually following an upper respiratory infection and causes facial pain and purulent discharge. 3. Previous epistaxis may cause congestion, but not watery discharge. 4. Nasal polyps are pale, round, firm, nonpainful overgrowth of nasal mucosa. Diagnosis Analysis Objective – 8 Page – 307, 308 Difficulty - 1 15) A nurse is assessing the oral cavity of a client and notes a blackish coating over the tongue. What questions should the nurse ask the client? 1) “Have you ever had this happen before?” 2) “Have you eaten licorice lately?” 3) “Are you taking anti-seizure medication?” 4) “How often do you brush your tongue?” 15)3 Explanation: 1. It is not important for the nurse to determine if the condition has occurred previously
2. The presence a black coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use. 3. Gingival hyperplasia may occur after prolonged use of phenytoin (Dilantin). 4. This finding is not related to oral hygiene. Diagnosis Analysis Objective – 4 Page – 311 (Figure 14.45) Difficulty - 2
16) A client with a sore throat is also having difficulty hearing. What disorder might the client be experiencing? 1) Infected tonsils 2) Sinus infection 3) Inner ear infection 4) Middle ear infection 16) 4 Explanation: 1. Infected tonsils may contribute to a sore throat but should not impact hearing. 2. Fever, chills, or a dull, pulsating pain in the cheeks or teeth may accompany sinusitis. 3. An infection of the inner ear would impact balance. 4. The Eustachian, or auditory tube, connects the middle ear with the nasopharynx; therefore an infection may be present in both areas concurrently. Assessment Analysis Objective – 11 Page – 306, 308, 309 Difficulty - 3 17) During a Weber test, a client is found to have increased hearing in the right ear. What does this finding indicate? 1) Conductive hearing loss in the left ear 2) Perforated left eardrum 3) Cerumen or otitis media in the right ear 4) Normal aging 17) 3 Explanation: 1. The conductive loss would be in the right ear. 2. The perforated eardrum would be in the right ear. 3. During the Weber test, sound heard in, or lateralized to, one ear indicates either a conductive loss in that ear or a sensorineural loss in the other ear. Conductive losses may be due to a buildup of cerumen, an infection such as otitis media, or perforation of the eardrum of the affected ear. 4. This is not part of normal aging. Diagnosis Analysis Objective – 9 Page - 295 Difficulty - 3
18) A nurse is assessing a client and finds small raised lesions on the rim of the ear. What would contribute to this finding? 1) Hypertension 2) Gout 3) Kidney failure 4) Heart disease 18) 2 Explanation: 1. This is not related to high blood pressure. 2. Small, raised lesions on the rim of the ear are known as tophi and indicate the presence of gout. 3. Kidney failure may cause the client to have a breath that smells of ammonia. 4. Heart failure will not create these findings. Diagnosis Analysis Objective – 9 Page - 291, 307 (Figure 14.34) Difficulty - 1 19) Mrs. Ming, 78 years old, says “I can’t seem to hear as well as I used to.” What should the nurse suspect is contributing to the hearing loss? 1) Cochlea atrophy 2) Otitis externa 3) Presbycusis 4) Otitis media 19) 3 Explanation: 1. This does not apply in this situation. 2. Otitis externa would cause itching but not hearing loss. 3. Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis. 4. Otitis media is a middle ear infection and may cause hearing loss, but Mrs. Ming does not present with any other signs. . Diagnosis Analysis Objective – 10 Page - 283 Difficulty - 2
20) Mr. Webster, 31 years old, is having his ears assessed with an otoscope. What should the nurse do first? 1) Turn the light on 2) Ask the client to tilt head forward 3) Explain the procedure 4) Pull the pinna down 20) 3 Explanation 1. The light would be turned on, but after the nurse has explained the procedure to the client. 2. The head is tilted to the side away from the nurse. 3. Before doing the examination, the nurse should explain the procedure to Mr. Webster. 4. The pinna is pulled down in children and pulled up in adults.
Assessment Application Objective – 3, 5 Page – 290 - 293 Difficulty - 1 21) What is the purpose of the tragus? 1) Equalized ear pressure 2) Hold receptors necessary for hearing 3) Protects the anterior meatus of the auditory canal 4) Attaches the tongue to the floor of the mouth 21) 3 Explanation 1. The eustachian tube connects the middle ear with the nasopharynx. This tube helps to equalize air pressure on both sides of the tympanic membrane. 2. The cochlea, a spiral chamber that contains the receptors for hearing. 3. The tragus is a stiff projection that protects the anterior meatus of the auditory canal. 4. The anterior portion of the tongue is attached to the floor of the mouth by the frenulum. Assessment Application Objective – 2 Page - 277 Difficulty - 1 22) What is the normal finding for a Rinne Test? 1) Equal sound to both ears 2) Maintain position without swaying 3) Sound heard twice as long by air conduction 4) Correctly repeat phrases whispered by the nurse 22) 3 Explanation 1. This is the Weber test uses bone conduction to assess hearing. 2. The Romberg test assesses equilibrium. 3. The Rinne test compares air and bone conduction of sound. Normally, the sound is heard twice as long by air conduction as by bone conduction after bone conduction stops. 4. This is the whisper test that assess hearing acuity for high-frequency sounds. Diagnosis Analysis Objective – 8 Page – 294 Difficulty - 1 23) A nurse is assessing a client and notices an ammonia-like mouth odour. What may cause this finding? 1) Poor dental hygiene 2) Oral cancer 3) Kidney disease 4) Diabetic acidosis 23) 3 Explanation
1. Poor dental hygiene will contribute to a mouth odour, but not one that smells of ammonia. 2. Oral cancer will not cause this finding. 3. Kidney disease will produce a smell of ammonia on the breath. 4. Diabetic acidosis will result in a sweet, fruity breath odour. Diagnosis Analysis Objective – 9 Page - 301 Difficulty -2 24) Jenny, 8 years old, has been admitted following a bicycle accident. The nurse notes her tympanic membrane has a bluish tinge. How should the nurse document this finding? 1) Scarred tympanic membrane 2) Normal colour for a child 3) Tophi present 4) Hemotympanum 24) 4 Explanation 1. Scarring of the tympanic membrane would appear as white patches. 2. Normally the tympanic membrane is pearly grey. 3. Tophi are white nodules on the external rim of the ear 4. Hemotympanum, a bluish tinge to the tympanic membrane, is due to blood in the middle ear. Diagnosis Analysis Objective – 12 Page – 305 (Figure 14.29) Difficulty 25) How should a nurse assess for a perforated nasal septum? 1) Ask the client 2) Use a nasal speculum 3) Shine a penlight up into one naris 4) Palpate the nose 25) 3 Explanation 1. The client may not be aware that the nasal septum is perforated. 2. A nasal speculum is used to assess the nasal cavity. 3. By looking up the other naris the nurse will see the light if there is a perforation.. 4. Palpating the nose will not detect a perforated nasal septum. Diagnosis Analysis Objective – 8 Page – 310 (Figure 14.42) Difficulty - 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A client is having difficulty maintaining equilibrium. The nurse realizes the portion of the ear involved with this symptom would be the .
26) vestibule of the labyrinth Explanation: The ears are divided into three areas: the external ear, the middle ear, and the inner ear. All three are involved in hearing, but only the inner ear is involved in equilibrium. The inner ear is also called the labyrinth. Assessment Comprehension Objective – 1 Page - 278 Difficulty - 1 27) The nurse is assessing the ears of an Asian client and notes that the cerumen is very dark in colour. The
nurse would document this finding as
.
27) normal Explanation: Cerumen appears dry and gray to brown in Asians and Native Americans. Assessment Comprehension Objective – 1 Page - 283 Difficulty – 1
Chapter 15 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is preforming auscultation on a client who has significant atelectasis in the right lower lung field. What would the nurse anticipate hearing in this area of the lung? 1) Sonorous wheeze 2) Increased whisper pectoriloquy 3) Decreased breath sounds 4) Lack of tactile fremitus 1) 3 Explanation: 1. A sonorous wheeze (rhonchi) would be heard in narrowed or fluid filled airways. 2. With atelectasis one would expect to have a decrease in the voice sounds such as whisper pectoriloquy. 3. This is what you would expect to hear in the right lower lobe due to collapsed alveoli. 4. A lack of tactile fremitus does occur in atelectasis but this is found on palpation and not on auscultation. Assessment Application Objective 10 Page 340 and 349 Difficulty = 3 2) A nurse is performing a respiratory assessment on a pregnant client at term. She finds that her breathing pattern is faster at rest than her normal, non-pregnancy state. The client also states that she has dyspnea. How should the nurse interpret these findings? 1) Expected for third trimester of pregnancy. 2) Evidence of chronic pulmonary disease. 3) Abnormal findings that require reporting. 4) Abnormal findings, but not significant. 2) 1 Explanation: 1. Shortness of breath, dyspnea, and a respiratory rate increase of approximately two breaths per minute are normal findings of pregnancy, especially in the last trimester as the chest expands to accommodate the growing baby. 2. Chronic pulmonary disease would not be conclusive with only these findings — further testing including pulmonary function tests would be performed before this diagnosis was given. 3. This is not an abnormal finding in the third trimester of pregnancy. 4. This is not an abnormal finding in the third trimester. Assessment Application Objective 9 Page 322, 323, and 328 Difficulty = 1 3) A nurse is percussing the anterior chest of an elderly client. What would the nurse expect to find in this client?
1) 2) 3) 4)
Tympany Flatness Dullness Hyperresonance
3) 4 Explanation: 1. Tympany is heard when percussion is performed over a gastric air bubble. 2. Flatness is heard over muscle (see Chapter 6). 3. Dullness is heard over bone, organs, consolidated lungs, or over a tumour. 4. As a client ages, the function of the respiratory system becomes less efficient — lungs lose their elasticity, muscles begin to weaken, and bones lose their density. Trapping of air in the alveoli will produce a hyperresonance sound upon percussion of the chest. Assessment Application Objective 9 Page 323 and 344 Difficulty = 2 4) A nurse is assessing an infant’s respiratory rate and sees that the infant is primarily using abdominal muscles. How should the nurse interpret this finding? 1) An indicator of respiratory dysfunction. 2) Accessory muscles are assisting with breathing. 3) A normal pattern. 4) A slightly irregular pattern. 4) 3 Explanation: 1. Abdominal breathing is a normal finding in an infant; therefore this is not an indicator of respiratory dysfunction. 2. The use of accessory muscles (intercostal muscles and sternocleidomastoid) would be a worrisome finding for a client of any age group. Using the abdominal muscles is normal in an infant. 3. Abdominal breathing is the normal pattern for an infant and continues during childhood until ages five to seven years when the child develops costal breathing patterns. 4. The use of abdominal muscles is normal and not an irregular pattern for this age group. Assessment Application Objective 9 Page 322 Difficulty = 1
5) Bob presents to the street nurse, with a persistent cough that is productive for rust coloured mucus. What health issue does Bob likely have based on this finding? 1) Pneumonia 2) Asthma 3) Tuberculosis 4) Pleural effusion 5) 3 Explanation:
1. Typically the mucus produce in a lung infection like pneumonia is greenish yellow in colour. 2. Asthmatics produce a large amount of yellow mucus that is often accompanied with a wheeze. 3. Rust coloured mucus is associated with tuberculosis. 4. Mucus production does not generally occur with a pleural effusion. Assessment Application Objective 10 Page 325 Difficulty = 2 6) A nurse is monitoring a client’s respiratory rate. What is the most accurate method for the nurse to use in assessing respiratory rate? 1) Count only the respirations that are audible. 2) Ask the client not to talk while you listen to his respirations. 3) Lay a hand on the client’s chest to count. 4) Count without the client knowing what is happening. 6) 4 Explanation: 1. Not all clients have audible respiratory cycles and this would not be an effective method to ensure accuracy. 2. If a client knows his/her respirations are being counted, it may alter the normal breathing pattern. 3. 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 move and might cause the client anxiety, which would affect the respiratory rate. 4. Correct. Do not tell the client that you are counting respirations as it may alter the normal breathing pattern. Assessment Application Objective 6 Page 333 Difficulty = 2 7) While palpating respiratory expansion the nurse notes unilateral chest movement. What health issue is most likely to cause this alteration? 1) Acute bronchitis 2) Pneumothorax 3) Abdominal pain 4) Pneumonia 7) 2 Explanation: 1. Acute bronchitis is more likely to cause dyspnea or wheezing than absence of air movement on one side. 2. A pneumothorax is the result of air moving into the pleural space causing a partial or complete collapse of the lung on the affected side which is evident by unilateral decrease or delay in chest expansion. 3. Abdominal pain typically results in dyspnea and guarding of the area. Chest expansion should remain equal. 4. Pneumonia usually causes dyspnea. Decreased chest expansion on the affected side can occur but is not a typical finding.
Assessment Analysis Objective 10 Page 334 and 351 Difficulty = 2 8) A nurse auscultates low-pitched, continuous respiratory sounds that have a snoring quality. How should the nurse document this finding? 1) Rhonchi 2) Rales 3) Crackles 4) Wheezes 8) 1 Explanation: 1. Rhonchi are low pitched and have a snoring quality 2. Rales are intermittent, non-musical, brief sounds. 3. Crackles can also be called rales. Course crackles are lower in pitch, moist and are discontinuous sounds. 4. Wheezes are high pitched with a shrill quality and are continuous. Assessment Application Objective 11 Page 340 (Table 15.2) Difficulty = 2 9) A client is 1 day post-operative for a left lower lobectomy. The nurse is palpating around the chest tube insertion site and notes crepitus. What has caused the crepitus? 1) Mucus plug in the left bronchus. 2) Air leaking into subcutaneous tissue. 3) Increase fremitus from fluid in the lung on the surgical side 4) Consolidation of the alveoli in the affected lung 9) 2 Explanation: 1. A mucus plug would not cause crepitus. A wheeze would be more likely with an obstructed bronchus. 2. Subcutaneous emphysema (air leaking into the subcutaneous tissue) is a common occurrence with a chest tube. On palpation the area feels crunchy which is called crepitus. 3. Fremitus is a vibration felt on palpation and occurs when there is fluid in the lungs. 4. Consolidation is identified through auscultation. Assessment Analysis Objective 10 Page 342 and 333 Difficulty = 2 10) A nursing instructor is observing a student during the respiratory assessment of a client. How will the student demonstrate proper technique for auscultating the posterior thorax? 1) Base to apices of the lungs 2) Side to side moving toward the bases
3) First down one side of the thorax, then the other 4) Midaxillary line to bases then to the apex of the lungs 10) 2 Explanation: 1. Auscultation should move from the apices to the bases of the lungs. 2. Auscultation should start at the apices of the lung moving from side to side comparing sounds while moving toward the bases and finally laterally to each midaxillary line. 3. This is incorrect because the nurse cannot accurately compare sounds in the corresponding intercostal spaces. 4. Wrong order. See number 2 for the correct technique. Assessment Application Objective 2 and 7 Page 338 (Figure 15.16) Difficulty = 1 11) A nurse is percussing the posterior thorax of a client with emphysema. What sound does the nurse anticipate hearing? 1) Resonance 2) Hyperresonance 3) Fremitus 4) Bronchial 11) 2 Explanation: 1. The usual sound in the posterior thorax is resonance but this sound changes in disease states such as emphysema. 2. Hyperresonance occurs in conditions such as emphysema when there is an over inflation of the lungs. 3. Fremitus is a palpable vibration on the chest wall when the client speaks. 4. Bronchial sounds are normal breath sounds heard next to the trachea on auscultation not on percussion. Assessment Application Objective 8 Page 336 and 350 Difficulty = 3 12) During auscultation where are vesicular breath sounds heard on the thorax? 1) Over the lung fields 2) Over the trachea 3) Next to the trachea 4) Between the scapula 12) 1 Explanation: 1. This is correct. Vesicular breath sounds are normal sounds heard over the lungs. 2. Tracheal sounds are over the trachea. 3. Bronchial sounds are heard next to the trachea. 4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum.
Assessment Knowledge Objective 6 Page 338 (Table 15.1), 339 (Figure 15.17), and 345 (Figure 15.22) Difficulty = 1 13) Jordan, 3 years old, has an obstructed airway. The nurse hears a loud high pitched crowing on inspiration. What is the medical term used to document this finding? 1) Rhonchi 2) Sibilant wheeze 3) Stridor 4) Friction rub 13) 3 Explanation: 1. Rhonchi are sonorous wheezes that occur on both inspiration and expiration. This sound indicates a narrowed or a fluid filled airway. 2. Sibilant wheeze occurs primarily on expiration and is associated with diminished airflow due to asthma, infection, or a foreign body. 3. Stridor has a distinctive crowing sound that can be heard without a stethoscope and is indicative of an obstructed airway. 4. A friction rub sounds like a grating or rubbing sound because of inflammation of the pleura. Assessment Analysis Objective 11 Page 340 (Table 15.2) Difficulty = 2 14) A nurse is assessing a client’s respiratory pattern and notes periods of deep breathing alternating with periods of apnea. What term should be used to document this assessment finding? 1) Hypoventilation 2) Cheyne-Stokes 3) Orthopnea 4) Eupnea 14) 2 Explanation: 1. Hypoventilation is too shallow or too slow breathing. 2. The breathing described is a Cheyne-Stokes pattern. 3. Orthopnea is difficulty breathing when lying down. 4. Eupnea is normal breathing. Assessment Application Objective 11 Page 329 (Box 15.01) Difficulty = 1 15) A student nurse is asked to describe how to assess for bronchophony. What instructions should the student give the client during the assessment? 1) "Say "E" each time I put the stethoscope on your chest." 2) "Whisper 1, 2, 3 when directed to do so."
3) "Say ninety-nine when I place the stethoscope on your chest." 4) "Take slow deep breathes in and out when directed to do so." 15) 3 Explanation: 1. This statement is appropriate for assessing egophony but not bronchophony. 2. This statement is appropriate for assessing whisper pectoriloquy. 3. This is the appropriate instructions for assessing bronchophony. 4. This is how to assess breath sounds and not voice sounds. Assessment Application Objective 6 Page 341 Difficulty = 2 16) Amrita, is 36 week pregnant and reports having shortness of breath. How should the nurse respond to Amrita’s concern? 1) "This is due to a decrease in oxygen demand." 2) "You must be having Braxton Hicks contractions." 3) "This is common at this point in the pregnancy." 4) "The enlarged uterus can decrease lung expansion." 16) 4 Explanation: 1. This is incorrect. Maternal and fetal demand for oxygen increases leading to dyspnea. 2. She may be experiencing Braxton Hicks contractions which are normal in the last trimester but these contractions will not cause shortness of breath. 3. This is correct but it does not provide the client with a rationale for this physiologic change. 4. During the third trimester, the enlarging fetus/uterus puts pressure on the diaphragm thus causing decreased lung expansion resulting in shortness of breath. Assessment Analysis Objective 3 Page 322 and 328 Difficulty = 2 17) What is the landmark used to locate the angle of Louis? 1) Manubrium 2) First rib 3) Clavicle 4) Xiphoid process 17) 1 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 first rib is obscured by the clavicle consequently it is not used as a landmark. 3. The clavicle articulates with the sternum but is not used as a landmark for the angle of Louis. 4. The xiphoid process is a landmark used to identify the level of the diaphragm. Assessment Comprehension
Objective 2 Page 341 Difficulty = 1 18) During auscultation where are bronchial breath sounds heard on the thorax? 1) Over the lung fields 2) Over the trachea 3) Next to the trachea 4) Between the scapula 18) 3 Explanation: 1. Vesicular breath sounds are heard over the lungs. 2. Tracheal sounds are over the trachea. 3. Bronchial sounds are heard next to the trachea. 4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum. Assessment Knowledge Objective 6 Page 338 (Table 15.1), 339 and 341 Difficulty = 1 19) What landmarks are used to auscultate the bronchi? 1) From below the scapula down to the 6th intercostal space (ICS) 2) Above the suprasternal notch on each side 3) At the 2nd and 3rd ICS on either side of the sternal border 4) At the 5th ICS, at the midclavicular line 19) 3 Explanation: 1. This is the position for auscultating the lungs. 2. This is the position for auscultating the trachea. 3. This is the correct position for auscultating the bronchi. 4. This is the position for auscultating or palpating the apex of the heart Assessment Knowledge Objective 2 Page 345 Difficulty = 2 20) During a health history interview the nurse wants to know more about a client's health behaviours. What question would elicit information on health behaviours? 1) "Do you have a cough?" 2) "Is there a family history of allergies?" 3) "Do you get the seasonal flu shot?" 4) "Are you exposed to respiratory irritants in the workplace?" 20) 3 Explanation: 1. This is an example of a question related to common concerns related to illness. 2. This is an example of a question used to gain information on past or family health history.
3. This question will provide information on the client's health behaviour/practice. 4. This is an example of a question that will elicit information on the physical environment. Assessment Application Objective 4 Page 326 Difficulty = 2 21) A client, 45 years old, with emphysema is being assessed by the nurse. What physical finding would the nurse expect to find in this client? 1) Pectus excavatum 2) Barrel chest 3) Scoliosis 4) Pigeon chest 21) 2 Explanation: 1. Pectus excavatum is also called funnel chest because the chest has a caved-in or sunken appearance. 2. Clients with chronic obstructive pulmonary disease often have barrel chests due to an increase in the anterioposterior diameter of the chest wall from over inflation of the alveoli. 3. Scoliosis is a lateral deviation of the spine that causes one scapula to be elevated. 4. Pigeon chest, or pectus carinatum, is a congenital abnormality characterized by forward displacement of the sternum. Assessment Application Objective 9 Page 330(Box 15.3) and 350 Difficulty = 1 22) The nurse is examining a client who is diagnosed with a fracture of a floating rib. Which rib is fractured? 1) 9 2) 5 3) 1 4) 12 22) 4 Explanation: 1. The ninth rib articulates with the cartilage of rib 7. 2. The first seven ribs articulate with the body of the sternum. 3. The first seven ribs articulate with the body of the sternum. 4. The eleventh and twelfth ribs are called floating ribs, because they do not articulate anteriorly. Assessment Knowledge Objective 1 Page 318 Difficulty = 1 23) During auscultation where are bronchovesicular breath sounds heard on the posterior thorax? 1) Over the lung fields 2) Over the trachea
3) Next to the trachea 4) Between the scapula 23) 4 Explanation: 1. Vesicular breath sounds are heard over the lungs. 2. Tracheal sounds are over the trachea. 3. Bronchial sounds are heard next to the trachea. 4. Bronchovesicular breath sounds are heard between the scapula and next to the sternum. Assessment Knowledge Objective 6 Page 338 (Table 15.1) and 339 (Figure 15.17) Difficulty = 1 24) A student nurse is practicing auscultation on a classmate and is concerned that the voice sounds were muffled. How should the instructor respond to this concern? 1) "This is an expected finding in areas of lung consolidation." 2) "This is an anticipated finding in the normal lung." 3) "The voice sounds should be loud and clear." 4) "The voice sounds should be absent in this situation." 24) 2 Explanation: 1. In consolidated lung tissue voice sounds will be loud and clear. 2. Voice sounds are heard as muffled sounds in the normal lung. Voices sounds are only assessed when pathology is suspected and is not part of the routine physical examination. 3. This is true when there is lung consolidation but not in normal lung tissue which is most likely the situation when practicing auscultation on a classmate. 4. Voice sounds may be absent in situations such as atelectasis, pleural effusion, or a pneumothorax. This is unlikely in this situation when students are practicing auscultation on one another. Assessment Application Objective 8 Page 340 and 341 Difficulty = 1 25) A nurse notes a client’s respirations are less than 10 breaths per minute. What is the appropriate terminology to use in documenting this finding? 1) Bradypnea 2) Tachypnea 3) Apnea 4) Atelectasis 25) 1 Explanation: 1. Bradypnea is slow, regular respirations less than 10 per minute. 2. Tachypnea is rapid, shallow respirations greater than 24 per minute. 3. Apnea is the cessation of breathing lasting from a few seconds to a few minutes. 4. The findings do not indicate atelectasis, which is alveolar or lung collapse. Assessment
Application Objective 11 Page 329 (Box 15.1) Difficulty = 1 26) A nurse is preparing to percuss a client's chest. How should the nurse position the client for this assessment? 1) Ask the client to lean forward and round the shoulders. 2) Have the client raise his arms over his head and sit up straight. 3) Have the client stand for this portion of the examination. 4) Ask the client to flex the neck and extend arms on a bedside table. 26) 1 Explanation: 1. This is the correct position. 2. It is unnecessary for the client to raise his arms in the air. This position does not facilitate the assessment and it may be difficult for an older client to hold this position. 3. This is unnecessary and in fact may make it difficult for the nurse to complete the assessment on a client much taller than the nurse. 4. This is an over exaggeration of the correct assessment position. Assessment Application Objective 5 Page 336 Difficulty = 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 27) A nurse is preparing to interview a client with asthma. What topics should the nurse include during this interview to determine triggering factors? (Select all that apply.) Workplace environment Presence of pets Age of onset Diet preferences 27)
X X X
Workplace environment Presence of pets Age of onset Diet preferences
Explanation: Factors affecting a client’s respiratory status and especially a client with asthma include exposure to chemicals, fumes, and textile fibers that may trigger respiratory compromise. Pet dander and some foods will also contribute to respiratory changes. Age of onset is not vital to identify triggering factors. Assessment Application Objective 4 Page 323 and 348 Difficulty = 1 28) Draw an arrow to the area where tracheal breath sounds would be heard:
28) Explanation: Tracheal breath sounds are heard over the trachea when the client inhales and exhales. They are harsh and high pitched. Assessment Comprehension Objective 1 Page 345 Difficulty = 1
Chapter 16 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is performing an assessment on a newborn and notes a thin, milky discharge from the infant’s nipple. What should the nurse document? 1) Common finding in newborns 2) Highly irregular finding 3) Congenital anomaly 4) Specimen sent for culture 1) 1 Explanation: 1. The breast tissue of newborns is sometimes swollen because of exposure to estrogen during pregnancy. Some infants may produce a thin discharge called “witch’s milk,” which subsides as the infant’s body eliminates maternal hormones. 2. This may be seen in some infants and is a normal finding. 3. This does not indicate an anomaly. It is a normal finding in the newborn. 4. A specimen would not be taken as the fluid is a normal secretion from the breast tissue due to maternal hormones. Assessment Application Objective – 8 and 11 Page – 357 Difficulty – 2 2) A female client is hospitalized with tissue destruction of the left pectoralis major and serratus anterior muscles due to motor vehicle accident. What should the nurse include in the discharge teaching for the immediate post-hospitalization period? 1) Plastic surgery 2) Support bras 3) Physical therapy 4) Prosthetic device 2) 2 Explanation: 1. Plastic surgery may be necessary in the future but will not provide breast support now. 2. The major function of the muscles of the chest wall is to support breast and lymphatic tissue. Undergarments, which provide needed support after discharge, are an important part of the client’s recovery — for emotional as well as physical health. 3. Physical therapy will not provide the support needed at this time. If the muscles have been to seriously damages – exercise will not help. 4. A prosthesis will not provide the breast support on discharge. This may be an option in the future. Implementation Analysis Objective – 10 Page – 357 Difficulty – 3
3) A nurse is using inspection to assess the breasts of a female client. What finding might the nurse obtain using this assessment technique? 1) Symmetry 2) Skin thickening 3) Tenderness 4) Hard nodules 3) 1 Explanation: 1. Symmetry is the only finding that the nurse would assess using the technique of inspection when examining the breasts. 2. Skin thickness can only be assessed by palpating the breasts. 3. Tenderness may occur on palpation or reported by the client during the history. 4. Nodules would be discovered using the technique of palpation. Assessment Comprehension Objective – 6 Page – 364 Difficulty – 1
4) A nurse is taking a history of her client. What should alert the nurse to possible increased risk for breast cancer? 1) Menarche at age 14 2) Drinking a glass of wine each night 3) Having unprotected sexual contact with unknown partners 4) Smoking two packs of cigarettes daily for four years 4) 2 Explanation: 1. There is an increase the risk for breast cancer in women who start to menstruate before age 12. 2. Excessive alcohol use increases the risk of breast cancer. 3. Unprotected sex with multiple partners would increase the risk of cervical cancer and sexual transmitted infections. 4. Smoking will increase the risk of lung cancer. Assessment Application Objective – 4 Page – 358, 361 Difficulty – 2
5) A nurse is performing a clinical breast examination on a client and asks her to raise her arms over her head. The client asks the nurse why this is necessary. How should the nurse respond? 1) “It is the only way to look for nipple retraction.” 2) “It allows any masses to bulge forward and be seen.” 3) “This is the best position to look for skin dimpling.” 4) “This is the only position to detect Paget’s disease.” 5) 3 Explanation:
1. Nipple retraction or inversion can be seen with the client sitting with arms at her side. 2. Obvious masses may be evident when the woman is sitting with her arms at her side. Masses are rarely visible with inspection. 3. Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client’s arms over the head. 4. Paget’s disease is 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. Implementation Application Objective – 7 Page – 365, 376 (Box 16.1) Difficulty – 2
6) What causes galactorrhea? 1) Endocrine disorders 2) Breast malignancy 3) Breastfeeding 4) Breast infection 6) 1 Explanation: 1. Galactorrhea is lactation not associated with childbearing and occurs most commonly with endocrine disorders or medications, including some antidepressants and antihypertensives. 2. Unilateral discharge from the nipple is suggestive of benign breast disease, an intraductal papilloma or cancer. 3. Galactorrhea is lactation that is not associated with pregnancy and breastfeeding. 4. Infections of the breast cause enlargement and tenderness of the axillary lymph nodes. Assessment Application Objective – 8 Page – 370 Difficulty – 1 7) A nurse is examining a client with a history of fibrocystic breast disease. What would the nurse expect to find during this assessment? 1) Yellow discharge from the nipples 2) Hard, fixed nodes 3) Bloody discharge from the nipples 4) Nipple retraction 7) 1 Explanation: 1. Discharge from the nipples may be clear, straw-colored, milky, or green. 2. Hard, fixed nodes are suggestive of cancer of lymphoma. 3. Bloody nipple discharge is associated with cancer. 4. Retraction of the nipple is seen in mammary duct ectasia and breast cancer. Assessment Analysis Objective – 8 Page – 374 Difficulty – 1
8) A nurse is teaching a client with fibrocystic breast disease. What should the nurse teach about symptom relief? 1) Limit salt intake 2) Avoid fat in the diet 3) Wear a loose fitting bra 4) Drink tea instead of coffee 8) 1 Explanation: 1. Symptom management includes such things as pharmacological hormones, diuretics, limiting caffeine, wearing a supportive bra, and decreasing salt intake may help relieve symptoms of breast pain and tenderness, especially in the premenstrual period. 2. There is no evidence to prove that limiting fat intake will relieve symptoms. 3. A supportive bra will decrease breast discomfort. 4. Tea contains caffeine and limiting caffeine intake has not been proven to be effective. Implementation Application Objective – 8 Page – 374 Difficulty – 2
9) A nurse is teaching a group of high school males about breast health. What statement would indicate the teaching was effective? 1) “I only need to be concerned if I have pain in my chest.” 2) “I’ll be able to know about problems if I see changes in my chest.” 3) “I know that I need to have regular breast examinations as my mother has breast cancer.” 4) “Breast cancer is not something I have to worry about.” 9) 3 Explanation: 1. Pain may or may not be present. Chest pain may be unrelated to the breast tissue. 2. Since the most common area for nodules to occur in the male breast is near the nipple, other signs like dimpling, asymmetry, and areolar color changes may not be as noticeable. 3. There is an increased rate in breast cancer in males when a primary female relative has breast cancer. 4. The rates for male breast cancer are low – but 1% of males will have breast cancer. Implementation Analysis Objective – 3 Page – 371, 377 Difficulty – 2 10) Millie, 16 years old, expresses concern about breast tenderness and darkening of the nipples and areolae. She tells the nurse that her breast feel bigger. How should the nurse respond? 1) Ask Millie if she might be pregnant. 2) Tell Millie this is normal during adolescence. 3) Recommend Millie see her physician immediately. 4) Refer Millie for a mammogram. 10)1
Explanation: 1. The changes in the breasts are commonly seen in pregnant women. 2. These are not normal changes but indicators that Millie may be pregnant. 3. There is no reason to refer Millie to her physician as these are normal changes seen in pregnancy. 4. There is no indication that a mammogram is needed. Implementation Analysis Objective – 9 Page – 358 Difficulty – 3 11) Mrs. Dunlop, 40 years old, is being interviewed by the nurse about breast cancer risks. Which comment would indicate Mrs. Dunlop understands the risks associated with breast cancer? 1) “My family history is negative so I do not need to worry.” 2) “I will have a clinical breast examination every three years.” 3) “I know my risk for breast cancer increases with age.” 4) “A mammogram every year is my goal.” 11) 3 Explanation: 1. All women are at risk for breast cancer and should be aware of the screening guidelines. 2. It is recommended that women age 40-49 have a clinical breast examination every 2 years. 3. The risk of breast cancer increases with age, especially after 35-40 years old. 4. Women age 40-49 should discuss with the physician the benefits and risks of mammography. Assessment Analysis Objective – 9 Page – 354, 358, 361, 373 Difficulty – 2
12) A nurse is compiling statistics for a breast cancer awareness presentation for a group of women. What fact about breast cancer should the nurse include? 1) Monthly self-breast examination reduces the mortality rate 2) Incidence of breast cancer is declining 3) Late menarche increases the risk for breast cancer 4) Having children before age 30 decreases the risk of breast cancer 12) 4 Explanation 1. Self-breast examination is no longer recommended. There is no evidence that this reduced mortality rates. 2. The incidence of breast cancer remains high. 3. A woman who starts menstruating before age 12 is at greater risk of developing breast cancer. 4. A woman who has no children or starts having children after age 30 has an increased risk. Implementation Comprehension Objective – 3 Page – 358, 361, 362, 376 Difficulty – 2
13) Why should the nurse palpate for the Tail of Spence? 1) It can show the difference between fibrocystic disease and fibroadenomas. 2) Peau d’orange may occur here over other areas of the breast. 3) Breast cancer occurs more frequently in this area. 4) It does not contain any lymph nodes. 13) 3 Explanation: 1. It would be difficult to detect by palpation alone the difference between fibrocystic disease, breast cancer, and fibroadenomas — correlating physical symptoms with physical findings during exam and possibly a biopsy would make the definitive diagnoses. 2. Peau d’orange and Paget’s disease are changes in the breast skin and nipple area associated with forms of cancer. 3. The incidence of breast cancers is highest in the upper outer quadrant, including the axillary tail of Spence. 4. There are several lymph nodes in the axillary area. Assessment Application Objective – 1 Page – 363, 367 Difficulty – 2
14) A menopausal woman comes to the clinic with a history of thin, watery nipple discharge with blood present. What breast disorder should the nurse suspect? 1) Intraductal papillomas 2) Fibrocystic disease 3) Breast malignancy 4) Mammary duct ectasia 14) 1 Explanation: 1. Intraductal papillomas are the primary cause of nipple discharge in women who are not pregnant or lactating and are more commonly found in menopausal women. 2. Fibrocystic disease is first seen when women are in their twenties, and discharge may be strawcolored, clear, milky, or green. 3. Although the discharge may be clear or watery with breast cancer, the primary cause of discharge is intraductal papilloma. 4. Discharge associated with mammary duct ectasia is thick and sticky. Assessment Application Objective – 8 Page – 374, 375 (Figure 16.24) Difficulty – 3 15) A nurse is teaching a prenatal class about lactation when one of the clients asks how milk is produced. What structure in the breast is responsible for milk production? 1) Lactiferous ducts 2) Montgomery’s glands 3) Acini cells 4) Areola
15) 3 Explanation: 1. The lactiferous ducts carry milk from the acini cells to the nipple. 2. The Montgomery glands are sebaceous glands on the areola. 3. The acini cells are contained within the lobules that produce milk. 4. The areola is the pigmented tissue surrounding the nipple. Implementation Comprehension Objective – 9 Page – 355 Difficulty – 2 16) During a client’s breast examination, the nurse palpates a small, subclavicular node on the right side of the client’s chest. What should the nurse do next? 1) Call in a physician 2) Document the location of the node 3) Schedule a mammogram for the next available appointment 4) Continue with the exam 16) 4 Explanation: 1. The nurse should complete the examination to ensure she has all the information from the examination before calling the physician. 2. Documentation of the client’s report to corroborate findings is also important but should be done after the examination has been completed. 3. Any follow-up would be determined by the physician along with the client’s input. 4. It would be important for the nurse to complete the exam — in order to document size, location of any and all palpable masses. Assessment Analysis Objective – 10 Page – 359 Difficulty – 3
17) Mrs. Beliveau, 42 years old, has fibrocystic breast disease. She asks the nurse if this disorder will lead to cancer. How should the nurse respond? 1) “There is not a link between this disease and cancer incidence.” 2) “Why are you so worried about this?” 3) “You will need to ask the physician that question.” 4) “This disease is a form of cancer.” 17) 1 Explanation: 1. There is no direct link between fibrocystic disease and the incidence of cancer. 2. This response does not address the clients concerns about cancer. 3. There is no need for the client to ask her physician this question. 4. The disease is not a form of cancer. Implementation Application
Objective – 8 Page – 374 Difficulty – 2
18) A nurse working in a First Nations community is teaching breast health to a group of 50 to 70 year old women. What information should the nurse include in her teaching? 1) High alcohol consumption by aboriginal women places them at higher risk than Caucasian women. 2) Clinical breast examinations are recommended every 5 years after age 50. 3) Aboriginal women should have a yearly mammogram. 4) Annual clinical breast examination in recommended. 18) 4 Explanation: 1. There is no basis for this assumption. The highest risk for breast cancer after age 40 is in white women. 2. Clinical breast examinations are recommended at least every two years. 3. Mammograms should be done every two years for this age group. 4. Annual clinical breast examination is recommended for women over 50 years of age. Implementation Application Objective – 9 Page – 354, 358, 376 Difficulty – 3 19) What suspensory ligaments provide the breast with their contour? 1) Cowper’s 2) Pectoralis 3) Serratus 4) Cooper’s 19) 4 Explanation 1. Cowper’s is a gland found in the urethral sphincter of the male. 2. Pectoralis major is a muscle in the chest. 3. Serratus anterior is a muscle in the chest. 4. Cooper’s is a ligament that supports the breast. Assessment Knowledge Objective – 1 Page – 355 Difficulty – 1 20) What hormone contributes to breast development in girls at puberty? 1. Progesterone 2. Growth hormone 3. Prostaglandin 4. Placental lactogen
20) 1 Explanation 1. Estrogen and progesterone are the two hormones responsible for breast development in girls at puberty. 2. The growth hormone promotes bodily growth. 3. Prostaglandin acts on smooth muscle. 4. Placental lactogen is a hormone produced by the placenta in pregnant women. Implementation Knowledge Objective – 1 and 9 Page – 357 Difficulty – 1 21) Mr. James, 52 years old, weighs 65 kg and has enlarged breast tissue. How should the nurse document this finding? 1) Mr. James is obese 2) Gynecomastia 3) Fibroadenoma 4) Galactorrhea 21) 2 Explanation 1. Although obesity can cause breast enlargement in men, Mr. James is not obese based on his weight. 2. Gynecomastia is the proper term for breast enlargement in men. 3. Fibroadenoma, a benign breast tumor, is seen more frequently in women in their teens and early 20’s. 4. Galactorrhea is the term use for lactation not associated with childbearing. Assessment Comprehension Objective – 11 Page – 358. 371, 377 (Figure 16.28) Difficulty – 3 22) What should the nurse include in a health history before doing a breast examination? 1) Number of sexual partners the woman has had 2) Age of menarche 3) The woman’s bra size 4) Age of her first sexual experience 22) 2 Explanation 1. The number of sexual partners is a risk factor for cervical cancer. 2. The onset of menstruation before age 12 results in an increased risk for breast cancer. 3. The bra size is not relevant in a health history. 4. The age of a woman’s first sexual experience does not increase her risk for breast cancer. Assessment Knowledge Objective – 4 Page – 361, 362 Difficulty – 2
23) What equipment does the nurse require to perform a clinical breast examination? 1) Sterile gloves 2) Metric ruler 3) Large pillow 4) Stethoscope
23) 2 Explanation 1. Clean, disposable gloves are needed in the event there is nipple discharge or infection. 2. A ruler will allow the nurse to measure the diameter of any masses in the breast. 3. A small pillow or towel is placed under the shoulder when palpating the breast. 4. A stethoscope is not required when assessing the breasts. Assessment Knowledge Objective – 7 Page – 363 Difficulty – 3 24) Mrs. Milne, 28 years old, requires a breast examination. She tells the nurse that she will not expose herself. What should the nurse do? 1) Do the examination as quickly as possible to minimize exposure 2) Have Mrs. Milne do the examination herself 3) Palpate Mrs. Milne’s breasts through the gown 4) Explore with Mrs. Milne her rationale for this decision 24) 4 Explanation 1. This ignores Mrs. Milne’s comment. 2. The nurse should do the examination to ensure it is thorough and complete. 3. Palpating the breast through the clothing may not allow small masses to be felt, norwill the nurse be able to inspect the breasts. 4. The nurse should determine the basis for this comment before proceeding. Implementation Application Objective – 3 Page – 358, 359 Difficulty – 3 25) What is a normal finding when inspecting the breasts? 1) Nipples pointing upward and inward 2) 15 to 20 lobes per breast radiating from the nipple 3) Areola is specked with small papillae 4) Lumpiness of the breasts that disappears with menstruation 25) 3 Explanation 1. The nipples point upwards and outwards. 2. This is not something the nurse sees when inspecting the breasts. 3. These are Montgomery’s tubercles. 4. This is physiological modularity and would not be apparent when inspecting the breasts.
Assessment Comprehension Objective – 1 Page – 355, 360, 364, 365 Difficulty – 3 26) Mrs. Singh, 81 years old, is having a clinical breast examination. What is a normal finding in a woman this age? 1) A decrease in adipose breast tissue 2) Increased breast firmness 3) Nipples are smaller 4) Areola is more darkly pigmented 26) 3 Explanation 1. With menopause the glandular tissue is replaced with fatty tissue. 2. Breasts become less firm with age and become pendulous. 3. Nipples become smaller and flatter. 4. There will be no change in the color of the areola. Assessment Knowledge Objective –1 and 9 Page – 358 Difficulty – 1 27) Miranda, 16 years old, asks the nurse about a ‘mammary ridge’. What information should the nurse include in her answer? 1) A line from right to left axilla over the nipples 2) A ridge of breast tissue from the axilla to the umbilicus 3) The presence of breast tissue in the axilla 4) A ridge of breast tissue from the axilla to the groin 27) 4 Explanation 1. The mammary ridge is a line of supernumerary nipples or breast tissue from each axilla to the groin. 2. The line extends to the groin. 3. Breast tissue in the axilla is termed axillary tail or Tail of Spence. 4. The breast tissue develops during embryonic stage, extending from the each axilla to the groin. The breasts develop on the thorax and the rest usually atrophy. Assessment Knowledge Objective – 1 Page – 355, 356 (Figure 16.4) Difficulty – 1
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 28) A nurse is conducting a breast health workshop for a group of women. What would the nurse include in this workshop when outlining environmental risk factors for breast cancer? (Select all that apply.)
Caucasian race Positive family history Low socioeconomic status Hormone replacement therapy Reaching age 35-40 28) X X X
Caucasian race Positive family history Low socioeconomic status Hormone replacement therapy Reaching age 35-40
Explanation: Being Caucasian is a cultural consideration, and reaching age 35-40 is a life span consideration, neither of which are environmental in origin. Having a positive family history, a low socioeconomic status, and taking hormone replacement therapy are all environmental considerations Planning Comprehension Objective – 9 Page – 361 Difficulty – 1
29) A nurse is preparing a poster on self breast examination and is labeling the anatomical structures of the breast. Identify the area that the nurse should label as the Tail of Spence.
29) Explanation: The Tail of Spence, also called the axillary tail, is the portion of breast tissue that extends superiolaterally into the axilla. Assessment Comprehension Objective – 1 Page – 355 (Figure 16.1) Difficulty – 2
30) A nurse is examining the breasts of a female client. What assessment techniques will the nurse use during this examination? (Select all that apply.) Inspection Palpation Percussion Auscultation
30)
X X
Inspection Palpation Percussion Auscultation
Explanation: Inspection and palpation are the only techniques utilized in the examination of the breasts. Assessment Comprehension Objective – 6 Page – 363 Difficulty – 1
Chapter 17 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) What is the correct landmark for locating the point of maximal impulse? 1) Second intercostal space, right sternal border 2) Second intercostal space, left sternal border 3) Third intercostal space, left sternal border 4) Fifth intercostal space, midclavicular line 1) 4 Explanation: 1. This is the landmark for auscultating the S2 heart sound. 2. The S2 heart sound can also be auscultated at this location. 3. This landmark also called Erb's point is used to auscultate both the S1 and S2 heart sounds. 4. The point of maximal impulse or PMI is located at the fifth intercostal space at the midclavicular line. Assessment Application Objective 2 Page 405 Difficulty = 1 2) A nurse is conducting a cardiac assessment on a healthy older adult. What age related physiologic change would the nurse anticipate with this client? 1) Increased resting heart rate 2) Decreased cardiac output 3) S4 heart sound 4) Decreased stroke volume 2) 3 Explanation: 1. The resting heart rate in the older adult may show no significant change; however, in the healthy older adult there may actually be a decrease heart rate. 2. Cardiac output may remain stable. 3. S4 heart sound is a common finding in older adults who do not have identified cardiovascular disease. 4. Stroke volume may increase slightly when the client is at rest. Assessment Application Objective 9 Page 383 Difficulty = 2
3) A client, 39 years old, has increasing fatigue with a history of rheumatic fever as a child. The nurse hears a diastolic murmur at the apex with the client in the left lateral recumbent position. The murmur is described as rumbling without radiation. What condition is present? 1) Tricuspid regurgitation 2) Mitral regurgitation
3) Mitral stenosis 4) Pulmonic stenosis 3) 3 Explanation: 1. Tricuspid regurgitation is a high-pitched, systolic murmur heard over the tricuspid area. 2. Mitral regurgitation is a high-pitched, blowing systolic murmur with radiation to the axilla. 3. The murmur associated with mitral stenosis is best heard at the apex in the left lateral recumbent position. It is a low-frequency diastolic murmur, which does not radiate. It is often caused by rheumatic fever or a cardiac infection. 4. Pulmonic stenosis is a harsh, systolic murmur heard best over the pulmonic area with radiation to the neck. Diagnosis Analysis Objective 10 Page 415 Difficulty = 3 4) A nurse is assessing a client with atrial fibrillation. What finding would the nurse anticipate? 1) Heart rate of 58 2) Irregular heart rhythm 3) Elevated blood pressure 4) Increased urine output 4) 2 Explanation: 1. The heart rate in atrial fibrillation is most often rapid with rates of 110-180 beats per minute. 2. Atrial fibrillation is dysrhythmic atrial contraction with no regularity or pattern, which leads to an irregular heart rhythm. 3. The heart rate is most often rapid, which decreases cardiac output and in turn decreases blood pressure. 4. The heart rate is most often rapid, which decreases cardiac output resulting in diminished renal perfusion that leads to decreased urine output. Assessment Application Objective 8 Page 422 Difficulty = 1
5) A student nurse is calculating the cardiac output for a 30-year-old client. The client's resting heart rate is 70 beats per minute with a stroke volume of 75 mls. How should the student interpret this finding? 1) The low cardiac output is consistent with an athlete. 2) This is too high for a client of this age. 3) This is expected in a healthy adult. 4) The result indicates cardiac pathology. 5) 3 Explanation: 1. The cardiac output is 5.25 L/min which is within the range for a normal adult (e.g. 4 to 8L/min). Most athletes have resting heart rates in the 50s or lower so it is unlikely this person is an athlete.
2. The cardiac output is within the normal range for an adult. 3. A normal adult cardiac output is 4 to 8L/min and this client's cardiac output is 5.25 L/min. Cardiac output = stroke volume x heart rate for 1 minute (e.g. 75mls x 70/min = 5250 mls/min or 5.25 L/min). 4. There is no evidence to support that there is cardiac pathology since the cardiac output is within the expected range for a normal adult. Assessment Application Objective 1, 9, and 10 Page 390 Difficulty = 3 6) A student nurse noted that a client had up and down head bobbing in time with the apical pulse. The student asks the instructor to explain this assessment finding. How should the instructor respond? 1) "Bobbing is created by pulsatile waves of regurgitated blood that echo upward toward the head." 2) "This is the classic head bob associated with Parkinson's disease due to a deficiency in dopamine." 3) "A ventricular septal defect can result in a holosystolic murmur that presents as a head bob." 4) "The abnormal pulsations occur due to a weakening of the aorta indicating an abdominal aneurysm." 6) 1 Explanation: 1. This is a sign of severe aortic regurgitation. The pulsatile waves of regurgitated blood reverberate toward the head resulting in a head bob that is synchronous with the heartbeat. 2. Although a tremor in the head can occur with Parkinson's disease it does not synchronize with the heartbeat and it is not typically described as an up and down head bob. 3. A ventricular septal defect is a congenital heart defect that results in regurgitation of blood thorough the opening between the ventricles resulting in a holosystolic murmur. Head bobbing is not a sign of this disorder. 4. Prominent pulsations in the abdomen is indicative of an aneurysm but it will not present has head bobbing. Assessment Analysis Objective 8 Page 402 Objective = 2
7) A nurse is reviewing the history and physical for a 69-year-old client admitted with hypertension. The nurse notes the apical impulse is 2 cm in diameter and is displaced laterally. What health issue should the nurse suspect? 1) Left ventricular hypertrophy 2) Ventricular tachycardia 3) Pulmonary hypertension 4) Myocardial infarction 7) 1 Explanation: 1. If the apical impulse or point of maximal impulse (PMI) is laterally displaced this is an indicator of left ventricular hypertrophy. In addition, if the PMI is palpated in an area greater than 1 cm in diameter the following conditions may be present: left ventricular hypertrophy, severe left ventricular volume overload, or severe aortic regurgitation.
2. Ventricular tachycardia is a rapid, regular heartbeat as high as 200 beats per minute but this condition does not displace the PMI. 3. A heave or pulsations palpated over the left sternal border at the either 3rd or 4th intercostal space may indicate pulmonary hypertension but this is different from a displaced PMI. 4. Displacement of the apical impulse would not be consistent with a myocardial infarction. Diagnosis Analysis Objective 10 Page 405 and 407 Difficulty = 3 8) During a cardiac assessment of a 78-year-old client with no history of cardiovascular disease the nurse hears a soft sound directly before S1, at the apex of the heart with the bell of the stethoscope. There is no change in this sound with position or respirations. What should the nurse do? 1) Notify the physician immediately because this is always an abnormal finding 2) Document the finding as normal in older adults 3) Obtain a 12 lead ECG as this is consistent with dysrhythmias 4) Monitor fluid status closely due to ventricular volume overload 8) 2 Explanation: 1. In this situation, it would be appropriate to point out the finding to the physician when reviewing the client’s chart, but it is not necessary to notify the physician immediately as this is a common finding in older adults without cardiovascular disease. 2. S4 occurs towards the end of diastole and is a result of the vibration of the valves, papillae and ventricular walls during the second phase of ventricular filling related to atrial contraction. It is heard best at the apex. An S4 sound is a common finding in older adults without identified cardiovascular disease. Ventricular compliance decreases with age which results in an increased resistance to filling with resultant increases in vibration. 3. This is an unnecessary step because an S4 is common in older adults without cardiovascular disease. 4. S4 is not an indicator of ventricular volume overload therefore monitoring fluid status is unnecessary. Implementation Analysis Objective 8 and 9 Page 383, 392, and 410 Difficulty = 2 9) A nurse is percussing a client's heart and notes a dull sound that extends into the midaxillary region of the thorax. What does this finding indicate? 1) A normal finding 2) Heart enlargement 3) Pulmonary hypertension 4) Aneurysm 9) 2 Explanation: 1. This is not a normal finding because the dullness extends beyond the area of a normal sized heart. 2. An enlarged heart emits a dull sound on percussion over a larger area than a heart of normal size. 3. The finding described does not correlate with pulmonary hypertension. 4. The finding described does not correlate with an aneurysm.
Assessment Application Objective 8 Page 408 Difficulty = 2 10) What cardiac assessment finding may be present in a healthy pregnant woman at 35 weeks gestation? 1) Atrial gallop 2) Ejection click 3) S3 4) Bruit 10) 3 Explanation: 1. An atrial gallop (S4) can be a normal finding in children, well-conditioned athletes and even in healthy older adults but is not a normal finding in pregnancy. 2. An ejection click occurs in damaged pulmonic and aortic valves; therefore, is not an expected finding during pregnancy. 3. S3 also called a ventricular gallop may be present in pregnant women during their third trimester. As blood flows into the ventricles vibration may occur causing this heart sound. 4. A bruit is a loud blowing sound that is an abnormal finding and is often associated with a narrowing of the carotid artery. Assessment Application Objective 9 Page 383 Difficulty = 2
11) A nurse is listening to heart sounds on a 19-year-old client. The nurse notes a splitting of S2 at the end of inspiration. How should the nurse interpret this assessment finding? 1) A normal finding caused by the semilunar valves closing at slightly different times. 2) An unusual finding and the physician must be notified of this result. 3) This is also called an atrial gallop and is heard in well-conditioned athletes. 4) This is abnormal and indicates a damaged pulmonic valve. 11) 1 Explanation: 1. This is a normal occurrence in some individuals due to the aortic valve closing slightly faster than the pulmonic valve. As a result, a split sound is heard (instead of dub, one hears t-dub). 2. This is a normal finding; therefore, it is unnecessary to contact a physician. 3. An atrial gallop is another name for the S4 heart sound that may be heard in well-conditioned athletes. 4. Incorrect. If the client had a damaged pulmonic valve the nurse would hear an ejection click and not a split S2. Implementation Analysis Objective 1 Page 383 Difficulty = 1
12) During a health history interview the nurse wants to know more about a client's health behaviours. What question would elicit information on health behaviours? 1) "Do you experience activity intolerance?" 2) "Does your heart disease affect your ability to carry out activities of daily living?" 3) "How would you describe your personality?" 4) "Describe your weekly physical activity?" 12) 4 Explanation: 1. This is an example of a question related to common concerns related to illness. It is also a closeended question that will elicit a yes or no answer and will not provide more detailed information. 2. This is an example of a question used to gain information on past health history. This is also a closeended question. 3. This is an example of a question that will elicit information about the internal environment. 4. This question will provide information on the client's health behaviour/practice. Assessment Application Objective 4 Page 397 and 398 Difficulty = 2 13) A nurse is assessing a client who is 7 months pregnant. What assessment finding would be normal for this client? 1) Increased systolic and diastolic blood pressures when standing 2) Apical impulse is pushed laterally and to the left 3) Irregular heart rate 4) Diastolic murmur 13) 2 Explanation: 1. Blood pressure should be at pre-pregnancy levels during the last trimester. 2. During pregnancy, the heart is displaced to the left and upward. The apex is pushed laterally and to the left. 3. The presence of an irregular heart rate is not a normal finding during pregnancy. 4. A diastolic murmur is not normal a finding during pregnancy. Assessment Application Objective 9 Page 392 Difficulty = 2 14) Jackson, 2 weeks old, has been diagnosed with Coarctation of the Aorta. His mother asks the nurse to explain what has happened to her son. What is the most appropriate response by the nurse? 1) "This is an opening between the aorta and the pulmonary artery that should have closed 48 hours after Jackson's birth." 2) "This is a complicated congenital heart defect that involves four different areas of the heart that can be fixed surgically." 3) "This is a condition results in a narrowed artery restricting blood flow out of the left ventricle into the systemic circulation." 4) "Jackson has a heart defect that results in oxygenated and deoxygenated blood to mix together."
14) 3 Explanation: 1. This statement describes Patent Ductus Arteriosus. 2. This statement describes the congenital heart defect, Tetralogy of Fallot. 3. This is the correct answer. In Coarctation of the Aorta the severely narrowed aorta restricts blood flow from the left ventricle into the aorta and out into the systemic circulation. 4. This statement describes a ventricular septal defect where blood from the left ventricle (oxygenated blood) mixes directly with blood in the right ventricle (deoxygenated blood). Assessment Knowledge Objective 8 and 9 Page 419 Difficulty = 1 15) A client asks the nursing student to explain the purpose of the bundle branches. How should the student respond? 1) "These fibers receive an electrical impulse from the sinoatrial (SA) node." 2) "Also known as the Purkinje fibers, this tissue penetrates into the heart to facilitate conduction." 3) "Has an intrinsic rate of 60 to100 per minute and will fire if the atrioventricular (AV) node fails." 4) "Are like expressways of conducting fibers that spread the electrical current to the ventricles.” 15) 4 Explanation: 1. This statement describes the atrioventricular (AV) node and the bundle of His. 2. This is incorrect. The Purkinje fibers arise from the right and left bundle branches. 3. The bundle branches are capable of initiating electrical charges in case both the SA node and AV node fail; however, the intrinsic rate averages 40 to 60 per minute and not 60 to 100 per minute, which is the intrinsic rate of the SA node. 4. This is the best explanation of the role of the bundle branches in the heart. Assessment Application Objective 1 Page 386 Difficulty = 2 16) A nurse is reviewing the history on a 72-year-old client and notes the following findings: peripheral edema, jugular venous pulsations of 6 cm above sternal angle at 45 degrees, and an enlarged liver. What health condition is most likely present based on these assessment findings? 1) Pulmonary edema 2) Left-sided heart failure 3) Myocardial infarction 4) Right-sided heart failure 16) 4 Explanation: 1. Left-sided failure results in pulmonary congestion and pulmonary edema. 2. Left sided heart failure causes blood to back up into the pulmonary system producing pulmonary edema. 3. Failure may be caused by a myocardial infarction (MI); however symptoms of failure are not diagnostic of an MI.
4. With right-sided failure, the right ventricle is ineffective as a pump, which leads to congestion and back up of blood into the systemic circulation. The most reliable clinical finding indicative of rightsided failure is increased jugular vein distention. This is a reflection of the increased pressure in the right atrium. Another sign associated with right-sided failure is peripheral edema and hepatomegaly, an enlarged liver. Diagnosis Analysis Objective 10 Page 396, 403, and 415 Difficulty = 1 17) The cardiac auscultation on a 16-year-old reveals a splitting of the second heart sound. The intensity varies with respirations and is only audible in the supine position. What is the best explanation for the cause for this extra sound? 1) Pulmonary stenosis 2) Inspiration causes the aortic valve to close slightly faster than the pulmonic valve 3) Increased blood volume causes the mitral valve to close more forcefully 4) Delayed ventricular contraction 17) 2 Explanation: 1. Often people with pulmonary stenosis have no symptoms but if symptomatic will present with cyanosis, rapid breathing, fainting, and low energy. 2. Splitting of S2 is a normal finding and most frequently heard in children and young adults. Pressures are higher in the left side of the heart and depolarization occurs sooner. Complete ejection of volume takes longer on the right so the pulmonic valve closes just slightly later than the aortic. This difference is greatest during inspiration because of the increase in intrathoracic pressure. Position will also affect a physiologic split as venous return is decreased with sitting and standing. 3. This is not related to splitting of S2 and the mitral valve closing would cause an S1 heart sound. 4. This does not relate to splitting of S2. Assessment Analysis Objective 8 Page 383 Difficulty = 2 18) A nurse is assessing a client with left-sided weakness and notes a loud, blowing sound over the right carotid artery. What term should be used to document this finding? 1) Atrial kick 2) Thrill 3) Cardiac index 4) Bruit 18) 4 Explanation: 1. Atrial kick is the term used to describe the additional blood volume that exits the atria into the ventricle during ventricular filling and is a normal physiologic response. 2. Thrills are soft vibratory sensations that when palpated indicate a cardiac pathology. 3. Cardiac index is a valuable diagnostic measurement on the effectiveness of the pumping action of the heart.
4. A bruit, which is a loud, swishing or blowing sound, is most often associated with a narrowing or stricture of the carotid artery. Diagnosis Analysis Objective 11 Page 410 Difficulty = 3 19) During a cardiac assessment the nurse notes a heave across the third and fourth intercostal space at the left sternal border. What health issue is most likely present based on this assessment finding? 1) Left ventricular hypertrophy 2) Right ventricular hypertrophy 3) A normal heart 4) Aortic regurgitation 19) 2 Explanation: 1. Left ventricular hypertrophy will result in a heave at the apex. 2. A heave is a forceful movement upward of the chest wall caused by the upward thrusting of the ventricle during systole. It can occur with hypertrophy of either ventricle and is secondary to increased workload. A heave associated with right ventricular hypertrophy will be seen or felt at the left sternal border at the 3rd or 4th intercostal space. 3. In the normal heart there should no pulsations, heaves, or vibratory sensations in this location. 4. In aortic regurgitation the vibratory sensation will be over the apex felt in a downward and lateral position from where the normal PMI should be palpated. Assessment Analysis Objective 8 Page 405 Difficulty = 3 20) A nurse is assessing a full-term newborn, 18 hours old. What would the nurse expect to find? 1) Heart rate of 175-180 beats per minute 2) Heart rate of 115-120 beats per minute 3) Blood pressure of 60/40 mm Hg 4) Blood pressure of 100/60 mm Hg 20) 2 Explanation: 1. The heart rate of a newborn initially may be as high as 175-180 beats per minute but should decrease over the next 6 to 8 hours. 2. The average heart rate of a newborn is about 115-120 beats per minute. 3. This blood pressure is more typical of a preterm newborn. 4. The blood pressure of a full-term infant may average 70/50 mm Hg; therefore the reading of 100/60 mm Hg is too high for a newborn that is 18 hours old. Assessment Application Objective 9 Page 392 Difficulty = 2
21) A nurse is teaching the student nurse about heart sounds when the student asks what causes the S1 heart sound. What is the correct response? 1) “It results from closure of the semilunar valves.” 2) “You hear it when there is ejection of blood from the atria.” 3) “It results from the closure of the atrioventricular (AV) valves.” 4) “It is due to the onset of atrial relaxation.” 21) 3 Explanation: 1. Incorrect. This is what causes the S2 hear sound. 2. Incorrect. The ejection of blood from the atria is a description of diastole. 3. The S1 heart sound results from closure of the atrioventricular AV valves. 4. Incorrect. S1 is due to the atrioventricular valves closing. Assessment Application Objective 1 Page 382 Difficulty = 1 22) A student nurse is inspecting a client's chest for pulsations. How should the client be positioned to best complete this inspection? 1) Orthopneic 2) Sim's 3) Lying prone 4) Low to mid-Fowler’s 22) 4 Explanation: 1. This is a variation of high Fowler's position used for people who have difficulty breathing. This position obscures the chest and would not allow visualization of the anterior thorax. 2. This position is a variation of the lateral position with the client on the left side. Sim's position is used for rectal exams or administering enemas. This position does not allow good visualization of the anterior chest. 3. Prone position means the person is positioned on their abdomen thus does not allow visualization of the anterior chest. 4. To inspect the chest for pulsations the client should be observed first in the upright position and then at a 30-degree angle, which is low to mid-Fowler's position. Assessment Application Objective 5 Page 404 Difficulty = 1 23) What assessment technique should the nurse use to best assess a thrill? 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 23) 2 Explanation:
1. A thrill is a vibratory sensation best assessed through palpation. It is unlikely that a thrill can be visualized through inspection. 2. A thrill is a vibratory sensation best assessed through palpation. 3. Percussion is not the appropriate technique to use to assess a thrill. 4. During auscultation a murmur can be heard but the accompanying thrill is best assessed through palpation. Assessment Application Objective 6 and 7 Page 407 Difficulty = 1 24) What is the correct landmark for hearing S1 the loudest? 1) Left sternal border at 4th intercostal space 2) Left sternal border at 2nd intercostal space 3) Right sternal border at 2nd intercostal space 4) Erb's point 24) 1 Explanation: 1. Correct. In this location S1 should be louder than the S2 sound because the closure of the tricuspid valve is best auscultated here. 2. Incorrect. In this location S2 should be louder than S1 because this site is over the pulmonic valve. 3. Incorrect. In this location S2 should be louder than S1 because this site is over the aortic valve. 4. Incorrect. Erb's point located at the left sternal border at the 3rd intercostal space is where S1 and S2 are heard equally loud. Assessment Application Objective 2 Page 409 Difficulty = 2 25) What is the correct landmark for hearing S2 the loudest? 1) Left sternal border (LSB) at fifth intercostal space 2) Left midclavicular line at fifth intercostal space 3) Right midclavicular line at third intercostal space 4) Right sternal border at second intercostal space 25) 4 Explanation: 1. This is not a landmark. The closest landmark to this location is LSB at the 4th intercostal space where S1 should be louder than S2. 2. This is the landmark for the point of maximal impulse and where S1 is loudest. 3. This is not a landmark for assessing heart sounds. Right midclavicular line is away from the heart. 4. This is the correct landmark to hear S2 loudest. Assessment Application Objective 2 Page 409 Difficulty = 1
26) A nurse has completed a cardiovascular assessment and is going to document that a ringlike structure was noted in the margin of the client's cornea. What term should the nurse use to document this finding? 1) Xanthelasma 2) Arcus 3) Noonan syndrome 4) Presbyopia 26) 2 Explanation: 1. Xanthelasma is the yellowish cholesterol deposits seen on eyelids and are indicative of premature atherosclerosis. 2. Arcus is the term used for the ringlike structure found in the cornea. 3. Noonan syndrome is a genetic disorder that is associated with congenital heart defects. 4. Presbyopia is the inability to accommodate for near vision that occurs with aging. Assessment Application Objective 11 Page 402 Difficulty = 2 27) A nurse has just completed a cardiac assessment and noted that the apical pulse was greater than the carotid pulse. What action should the nurse take? 1) No action required as this is a normal finding 2) Document this as a pulse deficit 3) Notify the physician immediately 4) Apply a cardiac monitor 27) 2 Explanation: 1. This is not a normal finding therefore must be documented. 2. An apical pulse greater than the carotid pulse indicates a pulse deficit. 3. Although this requires further evaluation by the physician, it is not an emergent situation. 4. This action is not going to provide any further information. Implementation Application Objective 11 Page 410 Difficulty = 1 28) A nurse is assessing a 20-year-old client and notes the presence of bilateral earlobe creases. What should the nurse do? 1) Refer the client to a plastic surgeon 2) Document this finding as normal 3) Document the finding and alert the physician 4) Ask the client if this is a result of piercings 28) 3 Explanation: 1. Bilateral earlobe creases, especially in the young adult, is often associated with coronary artery disease. A plastic surgeon is not required to manage this situation. 2. This is not a normal finding.
3. Bilateral earlobe creases, especially in the young adult, is often associated with coronary artery disease. The physician should be alerted to this finding. 4. Inappropriate response because ear piercings have nothing to do with the bilateral earlobe creases. Implementation Analysis Objective 8 Page 403 Difficulty = 1 29) A nurse is interviewing a client with congestive heart failure and wants to determine any recent changes in the client’s condition. What question would the nurse ask to obtain this data? 1) “Have you noticed an increased need to urinate at night?” 2) “Is there any change in your usual bowel elimination?” 3) “Are you still smoking?” 4) “Have you experienced chest pain in the last week?” 29) 1 Explanation: 1. Increased urination during the night is associated with heart failure. The fluid that has been retained in the legs is reabsorbed when lying down. This change in the client's condition may indicate that the client is retaining more fluids than usual due to the poor pumping ability of the heart. 2. This question may provide useful general health information but it won't provide specific information about recent changes in relation to the client's recent cardiac health. 3. This information does not provide information on the status of this current cardiac health. 4. This information is important but it provides more information about angina than it would about physical changes related to congestive heart failure. Assessment Analysis Objective 3 Page 396 Difficulty = 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 30) What assessment techniques would the nurse include in a cardiovascular examination? (Select all that apply.) 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 30) 1, 2, 3, 4 Explanation: Physical assessment of the cardiovascular system requires the use of each of the assessment techniques listed. Assessment Comprehension Objective 6 Page 400 Difficulty = 1
Chapter 18 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is assessing the pulse behind the client’s knee. What is the name of this pulse? 1) Brachial 2) Dorsalis pedis 3) Popliteal 4) Posterior tibial 1) 3 Explanation: 1. The brachial pulse is located in the antecubital region. 2. The dorsalis pedis pulse is located on the top of the foot. 3. The popliteal pulse is located on the posterior aspect of the knee. 4. The posterior tibial pulse is found behind the medial malleolus of the ankle. Assessment Application Objective 1 Page 425 Difficulty = 1
2) A nursing student is assessing the carotid pulses of a client. What action by the student would cause the instructor to intervene? 1) Asks the client to turn the head slightly. 2) Pushes firmly into the side of the neck. 3) Palpates both pulses simultaneously. 4) Notes the rate, rhythm, and amplitude. 2) 3 Explanation: 1. To palpate the carotid pulse more easily the client's head must be turned slightly. 2. This artery requires firm pressure in order to palpate the pulse. 3. The carotid pulse should be palpated one at a time to prevent a drop in blood pressure or a reduction in the pulse rate from stimulation of the baroreceptors. 4. The student would be expected to assess rate, rhythm, and amplitude of the carotid pulse. Assessment Application Objective 7 Page 436 Difficulty = 1 3) A nursing student is learning blood pressure technique and asks the instructor why it is necessary to palpate the systolic pressure prior to the procedure. How should the instructor respond? 1) “You can record this if you cannot hear the blood pressure well.” 2) “Only do it when your client is bradycardic.” 3) “It helps to avoid inaccuracy when obtaining the blood pressure.” 4) “It can tell you if there is a variance between arms.” 3) 3
Explanation: 1. This is not the rationale for assessing the palpable systolic pressure. 2. Assessing a palpable systolic blood pressure is done regardless of whether the client has bradycardia or not. 3. Assessing the palpable systolic pressure helps to 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. To detect a variance between arms the blood pressure must be taken in each arm and the results compared. Assessment Application Objective 7 Page 434 Difficulty = 1 4) While a nursing student is assessing a client's blood pressure the client asks the nursing student what is a normal blood pressure reading. How should the student respond? 1) “That depends on the individual.” 2) “A normal reading is 140/80.” 3) “Ask the nurse looking after you.” 4) “Normal is considered less than 120/80.” 4)4 Explanation: 1. This is incorrect because blood pressure norms are established nationally and applied to the individual. 2. A normal reading is less than 120 systolic and less than 80 diastolic. 3. This is an inappropriate response by the student because the nursing student should know the norms and is not addressing the client's question. 4. The Canadian Hypertension Education Program Blood Pressure Guidelines for Adults (2009) outlines a normal blood pressure as <120 systolic and <80 diastolic. Assessment Application Objective 3 Page 433and 435 (Table 18.1) Difficulty = 1 5) A nurse is taking the blood pressure of a client and obtains a difference of 15 mm Hg in the systolic readings between the arms. How should the nurse interpret this finding? 1) Inaccurate technique 2) Arterial obstruction 3) Client anxiety 4) Normal findings 5)2 Explanation: 1. It is unlikely that the nurse would get this much of a discrepancy in the results even with inaccurate technique. 2. A difference of 10 mm Hg or more between arms may indicate an obstruction of arterial blood flow to one arm and is considered an abnormal finding. 3. Client anxiety can result in a high blood pressure but not a discrepancy of more than 10 mm Hg between the arms.
4. This is not a normal finding. Diagnosis Application Objective 10 Page 434 Difficulty = 1 6) In the assessment of a female client who is seven months pregnant, the nurse notes mild peripheral edema. The remainder of the examination is normal. What is the most appropriate nursing action? 1) Notify the physician immediately 2) Obtain an order for a diuretic 3) Document the findings 4) Ask the client to limit sodium intake 6)3 Explanation: 1. Mild peripheral edema is common in the third trimester and since the rest of the assessment was normal it is unnecessary to notify the physician immediately. This is not an urgent situation. 2. An order for a diuretic is not appropriate at this time based on the client's assessment findings. 3. As the uterus grows, there is increasing pressure on the iliac vein and inferior vena cava. This results in decreased venous return and increased venous pressure in the lower extremities. This increased venous pressure often results in peripheral edema. If the rest of the assessment is normal the client does not have pregnancy-induced hypertension. This information needs to be documented but no further action is required as this time. 4. In general this is a good practice but this an unnecessary intervention at this time because the edema is an expected physiologic change for the third trimester of pregnancy. Diagnosis Application Objective 9 Page 428 and 432 Difficulty = 2 7) A nurse is calculating a client's ankle-brachial index (ABI). The systolic blood pressure for the dorsalis pedis is 135 mm Hg and the brachial blood pressure is 150 mm Hg. How should the nurse interpret this finding? 1) Within normal limits 2) Mild arterial disease 3) Moderate arterial blockage 4) Severe arterial disease 7) 2 Explanation: 1. An ankle-brachial index of 1.0 -1.2 is within normal limits and this client has an ABI of 0.9. 2. To determine the client's ABI divide the dorsalis pedis pressure by the brachial pressure (135/150). The client's ABI is 0.9 which is in the category of mild arterial disease. 3. An ABI of 0.5-0.8 is the range for moderate arterial disease. 4. Severe disease is an ABI of ≤ 0.5. Diagnosis Analysis Objective 8 Page 437 (Table 18.2)
Difficulty = 3 8) What is the landmark for locating the epitrochlear lymph node? 1) Behind the elbow to the groove between the bicep and tricep muscles 2) Locate the anterior border of the axilla 3) Palpate along the inferior and medial aspect to the inguinal ligament 4) Posterior border of the axilla below the scapulae 8) 1 Explanation: 1. This is the landmark for the epitrochlear lymph node which drains the forearm and the third, fourth, and fifth fingers. 2. To locate the subpectoral lymph nodes the nurse must palpate along the anterior border of the axilla. 3. This is the landmark for the inguinal lymph nodes. 4. The subscapular lymph nodes are found in the posterior region of the axilla. Assessment Analysis Objective 2 Page 439 and 440 (Figure 18.12) Difficulty = 2 9) What equipment is required to perform the Trendelenburg test? 1) Sphygmomanometer 2) Doppler 3) Stethoscope 4) Tourniquet 9)4 Explanation: 1. The sphygmomanometer is used to assess blood pressure. 2. A Doppler is used to auscultate peripheral pulses. 3. A stethoscope is used to auscultate blood pressure. 4. A tourniquet is used in the Trendelenburg test to assess valve competence. Assessment Analysis Objective 7 Page 442 (Figure 18.14A) Difficulty = 1 10) A nurse is assessing a client admitted to the hospital for congestive heart failure and notes nonpitting edema of the left arm, as well as bilateral 1+ ankle edema. The client’s history is positive for a myocardial infarction and left mastectomy. What is the likely cause for the edema in the left arm? 1) Impaired lymphatic drainage 2) Noncompliance with medication regimen 3) Right sided heart failure 4) Excessive intake of sodium 10)1 Explanation: 1. Removal of lymph nodes will result in decreased drainage of lymph from the area. This results in lymph fluid accumulating in the interstitial spaces. Lymph is also high in protein, which increases
the oncotic pressure in the interstitial space, which further enhances the movement of fluid into that area resulting in edema. With breast surgery, there is often the removal of lymph nodes. With chronic lymphedema, the edema is nonpitting and the area is often indurated. 2. There is no evidence of medication noncompliance. 3. Peripheral edema resulting from right-sided heart failure would be bilateral and pitting. 4. There is no evidence of excessive sodium intake. Diagnosis Analysis Objective 8 Page 454 and 437 Difficulty = 3 11) A nurse is caring for an immobile client and is planning care to prevent vascular complications that may occur. What would the nurse include in the plan of care? 1) Meticulous skin care 2) Turn, cough, deep breath 3) Physical therapy for tolerated activity 4) Increased protein intake 11) 3 Explanation: 1. Although this is important to the client's overall care, providing skin care will not prevent a deep vein thrombosis. 2. This intervention is important for maintaining respiratory health but it will not address potential vascular complications. 3. Immobile clients are at risk for a deep vein thrombosis, which can be prevented with maintenance of some activity level. 4. Increased protein intake will aid in tissue repair but will not prevent a deep vein thrombosis. Implementation Application Objective 10 Page 450 Difficulty = 2 12) During an assessment of a client's hand the nurse observes: flattening of the angle of the nails, rounding of the fingertips, and spongy nails with a bluish coloured nail bed. What condition would the nurse suspect? 1) Raynaud's disease 2) Nutritional deficit 3) Venous insufficiency 4) Chronic hypoxia 12)4 Explanation: 1. Raynaud's disease causes intermittent pallor or cyanosis followed by rubor of the fingers. The finger nails are not affected in this disorder. 2. Different types of nutritional deficits can impact the nails but will not cause clubbing or cyanosis. 3. Venous insufficiency typically affects the legs and symptoms include fullness, swelling, fatigue, and restless legs. There may also be skin discolouration. 4. Clubbing or rounding of the fingertips, flattening of the nails, spongy nails, and cyanosis of the nail bed are all consistent with chronic hypoxia or oxygen deprivation.
Diagnosis Analysis Objective 10 Page 436 Difficulty = 2 13) A nurse is caring for a client requiring arterial pressure monitoring. The physician is preparing to place a catheter into the client’s radial artery. Prior to this procedure, what assessment must the nurse do? 1) Allen test 2) Homans' sign 3) Corrigan's pulse 4) Compression test 13)1 Explanation: 1. The Allen test is used to evaluate the patency of both the radial and ulnar arteries. When a catheter is placed into the radial artery, a risk is occlusion of that artery. Prior to placement it is important to assure that the ulnar artery is patent so that blood flow will be maintained to the hand if radial occlusion occurs. 2. Homans' sign is used to assess for a deep vein thrombosis. 3. Corrigan's pulse is not an assessment but a type of abnormal pulse associated with aortic valve regurgitation. 4. The compression test is used to determine the length of varicose veins. Assessment Application Objective 6 Page 433, 438, and 439 (Figure 18.11) Difficulty = 3 14) A female client being examined by the nurse exhibits severe swelling in one entire arm, while the remaining arm is normal in size. What question would the nurse ask the client? 1) “How much salt do you have in your diet?” 2) “Does the other arm swell also?” 3) “Tell me about your past surgical procedures.” 4) “Tell me if you feel self-conscious about your arm.” 14)3 Explanation: 1. Unilateral swelling of one limb is not related to salt intake. 2. With lymphedema the swelling is unilateral and will not affect the other arm. 3. The client has lymphedema, which is unilateral swelling associated with obstruction in lymph nodes. This is a common finding in clients with previous mastectomy, which is the rationale for the nurse inquiring about surgical procedures. 4. This question is inappropriate because it is insensitive. Assessment Application Objective 3 Page 454 Difficulty = 1
15) During a health history interview the nurse wants to know more about a client's health
behaviours. What statement would elicit information on health behaviours? 1) "Tell when you first became aware of the ankle ulcer." 2) "Have you experienced any difficulty in achieving an erection?" 3) "Are you experiencing any side effects related to the medication?" 4) "Describe your exercise routine." 15) 4 Explanation: 1. This statement will provide information on the client’s recent changes in health. 2. This question will provide information on the client's past health history. 3. The side effects from medication will provide information on the internal environment. 4. This statement will elicit information on the client's health behaviour. Assessment Comprehension Objective 4 Page 431 and 432 Difficulty = 1
16) A nurse will be auscultating Mrs. Murray's carotid arteries. How should the nurse prepare the client for this assessment? 1) Have the client sit on the examination table 2) Ask the client to hold her breath for a few seconds 3) Have the client turn her head toward the side being examined 4) Adjust the head of the examination table to be at a 45 degree angle 16)2 Explanation: 1. The client needs to be supine for this assessment. 2. To decrease tracheal sounds while auscultating the carotid arteries the client should hold her breath. 3. The client should turn her head away from the side being examined. 4. The client should be positioned supine for this assessment. Assessment Application Objective 5 Page 436 Difficulty = 1 17) During the assessment of a client with a laceration of the left third finger, the nurse notes inflammation and swelling of the finger. What additional assessment data would the nurse anticipate finding? 1) 1cm, tender, soft, fixed, right brachial node 2) 1cm, tender, soft, mobile right brachial node 3) 2 cm, tender, firm, mobile right epitrochlear node 4) 2 cm, tender, firm, mobile right ulnar node 17)3 Explanation: 1. A lymph node will be greater than 1cm if infection is present, the node would feel firm not soft, the third finger drains into the epitrochlear lymph node not the brachial node, and the node involved would be on the left not the right.
2. The brachial node does not drain the third finger. 3. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. A node indicative of infection will be greater than 1 cm, tender and mobile. 4. The ulnar node does not drain the third finger and this infection is on the left not the right. Assessment Application Objective 10 Page 439 Difficulty = 2 18) A nurse notes that Mrs. Wu, 45 years old, has bilateral varicose veins. What information in the client's health history supports the nurse's observation? 1) Asian descent 2) Employed as hairdresser 3) Marathon runner 4) Nulliparous
18)2 Explanation: 1. Being of Irish or German descent increases the risk for various veins. 2. Occupations that require a person to stand all day increases the risk for varicose veins. 3. A sedentary lifestyle increases the risk for varicose veins. 4. The client has not had any children. Multiple pregnancies risk the risk for varicose veins. Assessment Analysis Objective 1 Page 429 Difficulty = 1 19) During the assessment of a client’s lower extremities, the nurse notes slight pitting edema. How should the nurse document this finding? 1) 1+ 2) 2+ 3) 3+ 4) 4+ 19)1 Explanation: 1. 1+ = Mild pitting that causes an indentation of approximately 2mm. 2. 2+ = Pitting edema indents to 4mm. 3. 3+ = The tissue will indent to 6mm. 4. 4+ = Pitting is severe and indents to 8mm. Diagnosis Application Objective 11 Page 447 (Figure 18.24) Difficulty = 1 20) A nurse is assessing an elderly client with atherosclerosis. What assessment findings would the nurse anticipate in this client?
1) 2) 3) 4)
Pitting edema Carotid bruit Blood pressure of 112/58 mm Hg Peripheral pulses 4+
20) 2 Explanation: 1. Pitting edema is consistent with venous insufficiency or right-sided heart failure. 2. A narrowing of the carotid artery, as occurs with atherosclerosis, will result in turbulent blood flow. This causes the swishing sound known as a bruit. 3. With atherosclerosis, you would expect the blood pressure to be high, rather than low. 4. The peripheral pulses would most likely be diminished and not increased. Assessment Application Objective 9 Page 436 Difficulty = 2 21) The arm blood pressures of a 4-year-old client are 108/65 left and 110/66 right. The nurse obtains a thigh pressure of 88/48. What condition would the nurse would suspect? 1) Normal in young children 2) Coarctation of the aorta 3) Atherosclerosis 4) Peripheral vascular disease 21) 2 Explanation: 1. This is not normal in young children. 2. Normally, a thigh pressure is always higher than the arm pressure. With coarctation of the aorta, the thigh pressure is lower as a result of the decreased blood supply below the constriction. Coarctation of the aorta is a congenital narrowing of the aorta and should be assessed for in young children with low thigh blood pressures. 3. Atherosclerosis occurs throughout the body in all the arteries and would not present in this manner. 4. Peripheral vascular disease will not result in a lower thigh pressure than the arms. Diagnosis Analysis Objective 9 Page 428 Difficulty = 2 22) A client is examined for concerns of bluish discolouration of the hands and fingers. The client states that spasms occur and the hands change colour from very red to blue. What situation would the nurse suspect? 1) Lymphedema 2) Raynaud’s Disease 3) Arterial insufficiency 4) Venous insufficiency 22)2 Explanation: 1. Lymphedema is unilateral swelling of the arm.
2. The findings described are consistent with Raynaud’s Disease, in which the arterioles in the fingers develop spasms, causing intermittent skin pallor or cyanosis, then redness. 3. Arterial insufficiency presents with a sharp, gnawing pain on exercise but dissipates with rest. 4. Venous insufficiency occurs in the legs and presents with edema and sensations of fullness, fatigue, and restlessness. Diagnosis Application Objective 10 Page 454 Difficulty = 2 23) A client presents with an enlargement of the inguinal lymph nodes and asks the nurse what these structures do for the body. How should the nurse respond? 1) “Your lymph nodes filter blood for your body.” 2) “They are responsible for the break down of old red blood cells.” 3) “They make antibodies for you.” 4) “Your lymph nodes help to remove infectious organisms.” 23)4 Explanation: 1. The spleen filters the blood not the lymph nodes. 2. Old red blood cells are broken down by the spleen and not the lymph nodes. 3. Lymph nodes do not make antibodies. Plasma cells a specialized division of B lymphocytes are responsible for antibody production. 4. Lymph nodes are small aggregates of specialized cells that assist the body’s immune system by removing foreign material, infectious organisms, and tumor cells from lymph. Diagnosis Application Objective 1 Page 427 Difficulty = 1 24) A nurse is assessing capillary refill on a client and notes colour return takes 4 seconds on each great toe. How should the nurse document this finding? 1) Normal 2) Brisk 3) Sluggish 4) Absent 24)3 Explanation: 1. Capillary refill is normal when colour returns in less than 1-2 seconds. 2. If the capillary refill is brisk this is within the normal range. 3. Longer time frames are documented as sluggish or delayed. 4. If the capillary refill was absent then the client is in serious trouble. Diagnosis Analysis Objective 11 Page 433 and 437 Difficulty = 1
25) A nurse has just completed a peripheral vascular assessment on Mr. McKenzie, who is several days postoperative for a fractured wrist. All assessment findings are normal except the capillary refill is delayed. This is a change from the previous assessment completed two hours ago. What should the nurse do next? 1) Notify the physician immediately 2) Ask the client if he just had a smoke 3) Reassess the client in 1 hour 4) Do nothing because all other assessments are normal 25) 2 Explanation: 1. This is not an emergent situation so it is inappropriate to contact the doctor. 2. Cigarette smoking can cause a delay in the capillary refill because the nicotine causes vasoconstriction. 3. The nurse may decide that this is necessary but first she needs to figure out why the change has occurred. 4. The nurse cannot ignore a change in an assessment finding. The nurse needs to do further investigation Assessment Analysis Objective 10 Page 437 Difficulty = 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
26) A client is being evaluated for lower extremity arterial insufficiency. What assessment findings would the nurse expect to observe in this client? (Select all that apply.) 1) Diminished pulses 2) Shiny skin 3) Redness on elevation 4) Pallor when dependent 5) Pain 26)1, 2, 5 Explanation: Arterial insufficiency may produce all these assessment with the exception of redness on elevation and pallor when dependent, which are actually reversed: the redness occurs with dependency and pallor occurs when elevated. Assessment Application Objective 10 Page 452 Difficulty = 2 27) A client is being evaluated for venous insufficiency. What assessment findings would the nurse expect to note in this client? (Select all that apply.) 1) Cool skin temperature 2) Edema 3) Thick and darkened skin 4) Pain with rest
27)1, 2, 3 Explanation: Venous insufficiency may produce all these assessment with the exception of pain with rest. Pain occurs with prolonged standing or sitting and is eventually relieved with rest. Assessment Application Objective 10 Page 453 Difficulty = 2 28) A nurse is preparing to assess a client’s peripheral vascular system. The nurse would use which of the following assessment techniques during this examination? (Select all that apply.) 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 28)1, 2, 4 Explanation: The techniques used to assess the peripheral vascular system include inspection of the skin for such changes as edema, ulcerations, or alterations in colour and temperature, auscultation of blood pressure, and palpation of the major pulse points of the body and lymph nodes. Assessment Application Objective 7 Page 433 Difficulty = 1 29) What are the risk factors for the development of varicose veins? (Select all that apply.) 1) Polish descent 2) Sedentary lifestyle 3) Multiple pregnancies 4) Obesity 29) 2, 3, 4 Explanation: Risk factors for varicose veins include Irish and German descent, a family history of varicosities, sedentary lifestyle, obesity, and multiple pregnancies. Diagnosis Analysis Objective 1 Page 429 Difficulty = 1
Chapter 19 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) What is the correct pattern for auscultating abdominal vascular sounds? 1) Begin in the right lower quadrant and then move to the other quadrants 2) Start midline below the xiphoid process and then side to side 3) The starting point is not important as long as the whole abdomen is assessed 4) Initiate the assessment from the right hypochondriac region 1) 2 Explanation: 1. This is the pattern for auscultating bowel sounds. 2. To auscultate vascular sounds the nurse begins midline below the xiphoid process for the aorta and then moves from side to side over renal, iliac, and femoral arteries. 3. Following a pattern ensures a consistent approach to assessment. 4. The right hypochondriac region is not the starting point for auscultating vascular sounds. Assessment Application Objective 7 Page 472 Difficulty = 2 2) A nurse is preparing to test a client for costovertebral tenderness. How should the nurse position the client for this assessment? 1) Place in supine position with the nurse's hand at a 90-degree angle to the abdominal wall 2) Position on either the right or left side while the nurse percusses the abdomen 3) Have the client raise the leg to cause flexion of the hip 4) Have the client seated while the nurse gently taps the area 2) 4 Explanation: 1. This is the position for assessing for the Blumberg's sign (rebound tenderness). 2. To assess for ascites the client is positioned on the right or left and the nurse percusses the abdomen. This technique is called shifting dullness. 3. To test for the psoas sign the client lies supine and lifts the leg to meet the nurse's hand. Flexion of the hip causes contraction of the psoas muscle. If there is pain associated with this movement it is an indication of peritoneal inflammation or appendicitis. 4. To test for costovertebral tenderness the client must be seated. The nurse will make a fist and gently tap the area overlying the posterior costovertebral angle on each side. Clients with pyelonephritis usually have extreme pain on slight percussion of these areas. Assessment Application Objective 5 Page 481 and 482 (Figure 19.26) Difficulty = 3
3) A nurse is performing an abdominal assessment on a client. While palpating the liver the client indicates a sharp pain in the abdomen. What term should be used to document this finding? 1) Blumberg’s sign
2) Rovsing's sign 3) Murphy’s sign 4) Psoas sign 3) 3 Explanation: 1. Blumberg’s sign is sharp pain occurring with the release of a compressed area and occurs in peritoneal irritation. 2. Pain on palpation of the left lower abdomen is Rovsing's sign, suggestive of peritoneal irritation in appendicitis. 3. Pain with palpation of the liver is indicative of cholecystitis and is noted as a positive Murphy’s sign. The examination should be halted. 4. Psoas sign is performed by the lifting the client’s leg to cause flexion of the hip. Pain with this move is indicative of appendicitis. Diagnosis Analysis Objective 11 Page 481 Difficulty =1 4) A nurse is assessing a client’s abdomen and notes dullness when percussing over the left lower quadrant. What would be the most appropriate question to ask the client? 1) “Do you take fiber tablets?” 2) “Do you have pain after eating?” 3) “When was your last bowel movement?” 4) “Have you ever had splenomegaly?” 4) 3 Explanation: 1. Diet preference or supplements should not affect what sound is produced with percussion unless the client has been constipated or has stool impaction. 2. The stomach is located left of midline in the upper quadrant not in the lower left quadrant. This question requires a yes or no response and isn't specific enough. 3. Percussion over the abdomen produces tympany and dullness is heard over the solid organs such as the liver and spleen. Dullness in the left lower quadrant may also indicate the presence of stool in the colon. 4. The spleen is in the left upper quadrant. Assessment Application Objective 10 Page 474 Difficulty =1 5) A nurse is percussing the liver and notes that the liver span is approximately 7 cm. How should the nurse document this finding? 1) Liver enlargement 2) Normal 3) Ascites 4) Liver displacement 5) 2
Explanation: 1. The liver in this situation is not enlarged because it is within a normal liver span. 2. The normal liver span, the distance between the lower and upper border of the liver, should be approximately 5 to 10 cm; therefore the liver span of 7 cm is within the normal range. 3. Ascites is the accumulation of fluid in the abdomen and there is no evidence that this situation exists based on a normal liver span. 4. There is no evidence of liver displacement because the liver span is within the normal range. Assessment Application Objective 11 Page 475 Difficulty = 1 6) A nurse is completing an abdominal assessment and is percussing over the stomach. What would the nurse expect to find? 1) Dullness 2) Flatness 3) Tympany 4) Resonance 6) 3 Explanation: 1. Dullness is a short, high-pitched sound heard over solid organs such as the liver. If heard over the stomach, dullness suggests a stomach mass or that the client just ate a large meal. 2. Flatness is short, abrupt sound heard over bone. 3. Tympany is a loud, drum-like sound heard over structures filled with air, such as the stomach or air in the intestines. 4. Resonance is hollow, moderate to loud sound heard over the lungs. Assessment Application Objective 8 Page 473 and 474 Difficulty = 1 7) What is the landmark for McBurney's point? 1) Midline below the xiphoid process 2) 3cm lateral to the right hypochondriac region 3) Midaxillary line between the sixth and tenth intercostal spaces 4) 2.5 to 5 cm above the anterosuperior iliac spine 7) 4 Explanation: 1. Incorrect. This is the starting point for auscultating abdominal vascular sounds. 2. The right hypochondriac region is the right upper quadrant of the abdomen and is not McBurney's point. 3. This is the landmark for assessing the spleen. 4. McBurney's point is 2.5 to 5 cm above the anterosuperior iliac spine on a line between the ileum and the umbilicus. Assessment Application Objective 2
Page 479 Difficulty = 2 8) During a health history interview the nurse wants to know more about a client's health behaviours. What question would elicit information on health behaviours? 1) "How much coffee do you consume in a 24-hour period?" 2) "Have you recently travelled to a developing country?" 3) "Have you experienced a change in bowel habits?" 4) "Does your illness affect your ability to carry out activities of daily living?" 8) 1 Explanation: 1. This question elicits information on health patterns that may affect the client's health. Caffeinated beverages can irritate the gastrointestinal system and contribute to ulcers and irritable bowel syndrome. 2. This question provides information on the client's external environment and whether the client was exposed to food-borne or water-borne microorganisms that can lead to disease such as hepatitis or gastroenteritis. 3. This question provides initial information about bowel functioning and whether there is a recent change to the client's health. 4. This question will elicit information on the client's past health history. Assessment Comprehension Objective 4 Page 467 Difficulty = 2 9) A nurse is preparing to assess a client’s abdomen. What assessment technique should be used last during this examination? 1) Inspection 2) Percussion 3) Palpation 4) Auscultation 9) 3 Explanation: 1. This is the first technique used in an abdominal assessment. 2. Percussion is the 3rd technique used in an abdominal assessment 3. When assessing the abdomen, use palpation last, as pressure on the abdominal wall and contents may interfere with bowel sounds and cause pain. 4. Auscultation is performed second after inspection and before percussion. Planning Application Objective 6 Page 469 Difficulty = 1 10) During the auscultation of a client’s abdomen the nurse notes a loud, long, consistent sound followed with several seconds of rumbling. What is the most accurate way to document this finding? 1) Borborygmi 2) Cheilosis
3) Bruit 4) Normal bowel sounds 10) 1 Explanation: 1. Normal bowel sounds occur 5 to 30 times per minute. Borborygmi (stomach growling) refers to more frequent sounds heard in clients who have not eaten in a few hours. 2. Cheilosis is cracking at the corners of the mouth and scaling of the lips associated with riboflavin deficiency. 3. A bruit is a blowing sound that is indicative of arterial stenosis. 4. Normal bowel sounds occur every 5 to 30 times per minute and the bowel sounds are more frequent than this based on the description provided. Assessment Application Objective 11 Page 472 Difficulty = 2 11) A nurse places a client with advanced metastatic cancer in the lateral position to begin percussion of the abdomen. What finding would the nurse expect in this situation? 1) Tympany at the superior level and dullness at lower levels 2) Tympany throughout the abdomen 3) Dullness over all abdominal organs 4) Dullness at superior level and tympany at lower levels 11) 1 Explanation: 1. Ascites is common in many types of cancer, especially with advanced metastasis. With the client in a side-lying position the fluid settles and produces tympany with percussion at the higher levels and dullness at lower levels. 2. Tympany will only occur above the fluid and dullness will occur where the fluid settles in the lower portion of the abdomen. 3. Dullness would still be heard over solid organs and any tumors present, but not over areas where fluid is present. 4. This is backwards because the tympany will occur at the superior level and dullness at the lower levels where the fluid has settled. Assessment Application Objective 8 Page 480 (Figure 19.22) and 487 Difficulty = 2 12) A nurse is teaching a pregnant client how to reduce nausea and vomiting. What information should be included in the teaching plan? 1) Eat fewer, small meals of vegetable soup 2) Limit intake of raw fruits and vegetables 3) Increase intake of dairy products 4) Eat frequent, small meals of dry foods 12) 4 Explanation:
1. A pregnant woman needs to ensure that she has an appropriate caloric and nutritional intake throughout the pregnancy and this suggestion will not support this goal or manage the nausea. 2. Meals of only vegetables provide little nutritional support and this does not manage the nausea. 3. Increasing the intake of dairy products will not manage the nausea and vomiting. 4. Frequent, small meals of dry foods are helpful in relieving the nausea and vomiting during pregnancy. Foods high in nutrients, including vitamins found in fresh vegetables and calcium found in dairy products, are important for a healthy pregnancy and baby and should not be limited. Implementation Application Objective 9 and 10 Page 462, 468 Difficulty = 1 13) During the auscultation of a client’s abdomen the client states “something must be wrong — you’ve been listening for an extremely long time!” How should the nurse respond? 1) “Shhhh, I am trying to listen.” 2) “I’m not sure what I’m listening to.” 3) “Now I have to start counting all over again.” 4) “I need to listen over all the major areas of your stomach area.” 13) 4 Explanation: 1. This is not an appropriate way to respond to a client concern. 2. This response by the nurse may cause the client more concern. 3. This response comes across as scolding and does not address the client concern. 4. Normal bowel sounds (gurgling or clicking) occur every 5 to 15 seconds. It is important for the nurse to listen for at least 5 minutes in each of the four quadrants to confirm the absence of bowel sounds. This response provides the client with a rationale as to why the nurse is taking time to listen to the abdomen. Assessment Application Objective 3 Page 472 Difficulty = 1 14) A nurse is conducting a health history on a client recently diagnosed with Hepatitis E (HEV). What piece of client health history is congruent with the diagnosis of HEV? 1) Intravenous drug use 2) Travel throughout Africa 3) Unprotected sexual intercourse 4) Numerous tattoos 14) 2 Explanation: 1. Needle sharing while using intravenous drugs is a common method of transmission for Hepatitis B and C but not for Hepatitis E. 2. Hepatitis E is transmitted enterically and is most common in people who travel to Asia, Africa, India, and Central America. 3. Hepatitis B is transmitted sexually. 4. Receiving a tattoo with unsterile needles can result in the transmission of Hepatitis C. Implementation
Application Objective 4 Page 490 Difficulty = 2 15) A nurse is palpating the spleen of a young adult male with infectious mononucleosis. How should the nurse approach this assessment? 1) Palpate under the lower portion of the eleven and twelve ribs 2) Must be done with light followed by deep palpation 3) Must be performed with the client’s breath held 4) This should be done carefully 15) 4 Explanation: 1. This is the hand placement for palpating the liver 2. Routinely in abdominal assessment the nurse will use a combination of light and deep palpation; however, in this situation deep palpation should be avoided due to the fragility of the spleen. 3. The client takes a slow, deep breath and as the diaphragm descends the spleen moves toward the left costal margin but it is unnecessary for the client to hold his breath. 4. It would be necessary to palpate the spleen to detect for enlargement, but excessive palpation must be avoided. Careful palpation is required because the spleen is fragile and sensitive. Assessment Application Objective 7 Page 478 Difficulty = 2
16) A nurse palpates the abdominal aorta of an adult client and finds that it measures approximately 5 cm in diameter. What should the nurse do next? 1) Discontinue palpation 2) Apply deep palpation inferiorly 3) Continue to palpate just under the xiphoid process 4) Auscultate for bruits 16) 1 Explanation: 1. The aorta is palpable in the upper abdomen to the left of midline below the xiphoid process, and the average adult aorta is 3 cm wide. A widened aorta may indicate the presence of an aneurysm and should not be palpated to avoid rupturing the aneurysm. 2. Deep palpation may result in rupture of the aneurysm and should not be done. 3. This is inappropriate due to the risk of rupturing the aneurysm. The nurse should stop palpating. 4. Auscultation of the abdomen occurs prior to palpation. Implementation Analysis Objective 10 Page 479 Difficulty = 2 17) A nurse is auscultating a client’s abdomen for bowel sounds, and no sounds have been detected for at least 2 minutes. What action should the nurse take?
1) 2) 3) 4)
Give the client something to eat or drink Document bowel sounds as absent Continue listening for an additional 3 minutes Document this finding as normal
17) 3 Explanation: 1. This is an inappropriate action if the client lacks bowel sounds. The nurse needs to complete the assessment by auscultating for another 3 minutes. 2. If bowel sounds are truly absent, this is not a normal finding, but cannot be determined after listening for only 2 minutes. Documenting bowel sounds as absent at this point would be premature. 3. It may be difficult for the nurse to hear bowel sounds in some clients, and all four quadrants should be auscultated for a total of at least 5 minutes before documenting absent bowel sounds. 4. This would be inaccurate documentation at this point because the assessment is incomplete. Assessment Application Objective 10 Page 472 Difficulty = 1 18) A nurse is assessing a client who reports a sudden onset of right lower quadrant pain. The nurse obtains a positive psoas sign. What condition should the nurse suspect based on this data? 1) Constipation 2) Appendicitis 3) Cholecystitis 4) Bowel obstruction 18) 2 Explanation: 1. Constipation typically does not cause pain of this nature 2. A positive psoas sign is indicative of irritation of the psoas muscle and is associated with peritoneal inflammation or appendicitis. 3. The pain of cholecystitis is in the right upper quadrant and radiates 4. A bowel obstruction causes varying types of pain depending on location but does not present with a positive psoas sign. Diagnosis Analysis Objective 10 Page 481 Difficulty = 2 19) A client asks the nurse, “What’s the purpose of my pancreas?” How should the nurse respond? 1) “You can’t live without one.” 2) “It increases your blood sugar when needed.” 3) “It produces digestive enzymes.” 4) “I am not sure.” 19) 3 Explanation: 1. This response does not answer the client's question about the purpose of the pancreas. 2. Incorrect response. The pancreas stores and secretes insulin to lower blood sugar.
3. The pancreas secretes pancreatic juices, which contain enzymes to digest proteins, fats, and carbohydrates. 4. This is not a useful response and the nurse should be able to explain the purpose of the pancreas. Implementation Application Objective 1 Page 458 Difficulty = 1 20) A nurse is conducting an educational session for a group of well seniors. What information would be appropriate to promote digestive health in this population? 1) Eating only soft foods 2) Decrease roughage 3) Increasing protein intake 4) Include daily exercise 20) 4 Explanation: 1. Chewing may be difficult for some older adults depending on their dental hygiene, but it would be incorrect to assume that all older adults have difficulty with mastication. 2. Selecting foods high in fiber will increase regularity in bowel elimination in older adults. 3. Increasing protein does not promote gastrointestinal function. 4. Regular exercise promotes and maintains the efficiency of gastrointestinal function. Implementation Application Objective 9 Page 463 Difficulty = 1 21) A nurse is assessing an infant and notes a bulging area in the umbilicus. What condition would the nurse suspect? 1) Infection 2) Umbilical hernia 3) Ventral hernia 4) Hiatal hernias 21) 2 Explanation: 1. This situation does not describe infection. 2. An umbilical hernia occurs at the umbilicus and allows the intestines or other abdominal structures to protrude through a separation in the abdominal rectus muscle. 3. Ventral hernias occur in previous incisional sites. 4. Hiatal hernias are not visible to the examiner. Assessment Application Objective 9 Page 488 Difficulty = 2 22) A nurse is assessing a client’s abdomen and notes loud, high-pitched, rushing, bowel sounds with auscultation. How should the nurse document these bowel sounds?
1) 2) 3) 4)
Hyperactive Bruits Boborygmi Normal
22) 1 Explanation: 1. Hyperactive bowel sounds are loud, high-pitched, and rushing, occurring more frequently with gastroenteritis or diarrhea. 2. Boborygmi is stomach growling and is heard in clients who have not eaten in a few hours. 3. A bruit indicates arterial stenosis and has blowing quality. 4. Normal bowel sounds are described as irregular, high-pitched but with a gurgling sound. Assessment Application Objective 8 Page 472 Difficulty = 2
23) A nurse is caring for a client in the first trimester of pregnancy. The client asks the nurse why she is experiencing nausea and vomiting. What is the most appropriate response by the nurse? 1) “You must not be eating correctly.” 2) “Your hormonal levels are changing.” 3) “The baby is pushing up on your stomach.” 4) “You need to ask your obstetrician.” 23) 2 Explanation: 1. This is not an appropriate response since the nurse does not have adequate information to make this inference and nausea is a normal physiologic response during the first trimester. 2. Pregnant females experience hormonal shifts that result in nausea, vomiting, and constipation. 3. This is an inaccurate statement when the client is in the first trimester of pregnancy. 4. Nausea is a normal physiologic response during the first trimester; therefore the nurse can answer the client's question without the need to refer to the obstetrician. Implementation Application Objective 9 Page 468 Difficulty = 1 24) A nurse is auscultating the abdomen of a client and notes a continuous hum around the umbilicus and epigastric area. What would the nurse suspect as the causative factor of this hum? 1) Gastroenteritis 2) Paralytic ileus 3) Portal hypertension 4) Aortic stenosis 24) 3 Explanation: 1. Hyperactive bowel sounds are associated with gastroenteritis not a venous hum.
2. A paralytic ileus will initially be associated with hyperactive bowel sounds followed by absence of sounds and not a venous hum. 3. Portal hypertension is a causative factor of a venous hum. 4. Aortic stenosis is associated with a bruit. Assessment Application Objective 10 Page 485 and 486 (Table 19.1) Difficulty = 2 25) A nurse is interviewing a client who reports abdominal pain and belching at bedtime. What priority question should the nurse ask in the interview? 1) “Do you eat fatty foods?” 2) “Do you take antacids?” 3) “How soon after eating do you go to bed?” 4) “Are you ever constipated at night?” 25) 3 Explanation: 1. Although fatty foods may contribute to gastric reflux it is overindulgence in general that leads to reflux. 2. Taking antacids will help neutralize the acids in the esophagus to diminish the burning sensation. This is an important question but not the priority question. 3. The client is describing the symptoms associated with gastrointestinal reflux disorder, which occurs with food intake, and lying down after meals. 4. Although important, this information is not immediately relevant to the issue therefore is not a priority question. Assessment Application Objective 4 Page 486 Difficulty = 2 26) A nurse is performing an abdominal assessment and notes ascites. What should the nurse do next? 1) Obtain a stool specimen for occult blood 2) Measure abdominal girth 3) Document 4) Notify the physician 26) 2 Explanation: 1. There is no need for stool testing. 2. When ascites is suspected, the abdominal girth should be measured to obtain a baseline for further evaluation. 3. It is premature to document without first completing the assessment. 4. The physician will need to know about the ascites but the nurse must first complete the assessment. Assessment Application Objective 10 Page 480 Difficulty 1
27) A nurse is assessing a toddler when the mother asks if the child’s abdomen should be so round and large. How should the nurse respond? 1) “There is no reason for you to be concerned.” 2) “How often does the child have a bowel movement?” 3) “What do your other children look like?” 4) “This is normal for children of this age.” 27) 4 Explanation: 1. This response is dismissive of the client's concern. 2. A rounded abdomen is normal in toddlers therefore this question is irrelevant. 3. This response does not answer the client's question. 4. Toddlers have “potbelly” appearances, and this is normal. Implementation Application Objective 9 Page 462 Difficulty = 1 28) Ms. Blomvist has esophageal cancer and reports pain with swallowing. How should the nurse document this information? 1) Dysphagia 2) Dysphasia 3) Odynophagia 4) Oligodactyly 28) 3 Explanation: 1. Dysphagia means difficulty swallowing 2. Dysphasia means difficulty speaking 3. Odynphagia means pain on swallowing 4. Oligodactyly means having fewer than the normal number of fingers or toes Diagnosis Analysis Objective 11 Page 490 Difficulty =2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 29) A nurse is completing discharge instructions on a client admitted with esophagitis. What are the triggers for esophagitis? (Select all that apply.) Smoking Alcohol Hot and cold fluids High fat foods 29)
X X X
Smoking Alcohol Hot and cold fluids
High fat foods Explanation: Smoking, alcohol, and fluids with extreme temperatures are causes of esophagitis. Implementation Comprehension Objective 10 Page 490 Difficulty 2 30) A nurse is planning an abdominal assessment for a client. Rank these assessment steps in the order the nurse would perform them. (Use numbers 1 through 5.) Percuss over the solid organs Auscultate for hyper or hypoactive bowel sounds Auscultate for bruits Visualize the abdominal quadrants Shine a light across the abdomen assessing for hernias 30)
5 Percuss over the solid organs 3 Auscultate for hyper- or hypoactive bowel sounds 4 Auscultate for bruits 1 Visualize the abdominal quadrants 2 Shine a light across the abdomen assessing for hernias Explanation: The order for assessment of the abdomen differs in that inspection is followed by auscultation, percussion, and palpation in order to prevent disturbance of the normal bowel sounds. By following an organized pattern of inspection and visualizing the abdomen in four quadrants, consistent mapping of the abdomen can occur. Visualization from various angles will allow the nurse to identify asymmetry, masses, and abnormal movement. Bruits should be auscultated with the bell of the stethoscope after bowel sounds have been assessed using the diaphragm of the stethoscope. Percussion occurs next in the sequence followed by palpation. Assessment Application Objective 6 Page 469, and 471- 473 Difficulty = 1 31) A nurse is palpating the right upper quadrant of a client’s abdomen. What structures would the nurse examine? (Select all that apply.) Liver Gallbladder Sigmoid colon Stomach Tail of pancreas 31)
X X
Explanation:
Liver Gallbladder Sigmoid colon Stomach Tail of pancreas
The liver and gallbladder are located in the right upper quadrant of the abdomen. The remaining structures are not. Assessment Application Objective 1 Page 461 Difficulty = 1 32) A nurse is mapping the client’s abdomen into four quadrants. What are the landmarks the nurse would
use to perform this assessment? (Select all that apply.) Xiphoid process Umbilicus Lower border of the left ribs Lower border of the right ribs 32)
X X
Xiphoid process Umbilicus Lower border of the left ribs Lower border of the right ribs
Explanation: To obtain four quadrants when mapping the abdomen, extend the midsternal line from the xiphoid process through the umbilicus to the pubic bone, then draw a horizontal line perpendicular to the first line. Assessment Application Objective 2 Page 459 Difficulty = 1
Chapter 20 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is interviewing an elderly client who reports having incontinence. Numerous attempts have been made in the recent past to help control the problem, with no success. What is a priority nursing diagnosis to consider for this client? 1) Skin integrity impairment 2) Self-care deficit 3) Self-esteem, low 4) Infection 1) 3 Explanation: 1. The client certainly has the potential for skin integrity impairment due to the incontinence but this is not an issue at this time. 2. There is no data to support a self-care deficit; the information available is that this client has tried to implement measures to treat the problem. 3. Clients suffering from incontinence are at increased risk for social isolation, self-esteem disturbance, and other psychosocial problems. 4. The client may be at risk for infection but this is not an issue at this time. Nursing Diagnosis Application Objective 9 Page 497 Difficulty 2 2) A nurse is collecting a urine specimen from a client and notes the urine is cloudy and has a strong odor. What situation would the nurse suspect? 1) Kidney stones 2) Renal failure 3) Urinary tract infection 4) Liver disease 2) 3 Explanation: 1. A client with kidney stones would present with intense pain and possible hematuria. 2. Renal failure results in oliguria and concentrated urine. 3. Urinary tract infections often result in cloudy, strong smelling urine. 4. Foamy, dark coloured urine may indicate the presence of liver disease. Diagnosis Application Objective 8 Page 513 Difficulty 2
3) A nurse is caring for an infant recently diagnosed with renal disease. What other body part will need to be evaluated? 1) Ears 2) Heart
3) Lungs 4) Joints 3) 1 Explanation: 1. The ears and kidneys develop at the same time in utero. Congenital deafness is associated with renal disease. Even though all other systems would be assessed to make sure their function is normal, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development. 2. The baby will have the heart assessed but congenital deafness is linked with renal disease. 3. The lungs will be assessed but it is the ears that are the primary concern with renal disease. 4. The joints would not be a primary concern because congenital deafness is associated with kidney disease in a baby. Assessment Application Objective 9 Page 502 Difficulty = 2
4) A nurse is admitting a client who has constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. What should the nurse do next? 1) Administer pain medication 2) Notify the physician immediately 3) Obtain a urine specimen for culture 4) Give an antiemetic 4) 2 Explanation: 1. The client may require analgesia to manage the pain but the priority nursing action is to get immediate medical assistance. 2. Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine. Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function, and medical care should be initiated immediately. 3. A urine culture is not appropriate because the client has hydroureter and not a urinary tract infection. 4. The client may require an antiemetic, however this client requires immediate medical attention so contacting the physician is the priority nursing action. Implementation Analysis Objective 10 Page 507 Difficulty 2
5) A nurse is palpating the flank area and feels a sharp edge with clearly delineated margins. What is the nurse palpating? 1) Spleen 2) Kidney 3) Colon
4) Bladder 5) 1 Explanation: 1. An enlarged spleen feels sharper with a well delineated edge. 2. Usually the kidneys are not palpable but, if enlarged, would feel smooth and rounded. 3. The colon should not be palpable. 4. The bladder is in the area over the symphysis pubis. Assessment Analysis Objective 8 Page 508 Difficulty 2 6) A nurse is assessing a client and needs to palpate the bladder. What instructions should the nurse provide the client? 1) “Please do not void prior to the examination.” 2) “Take a deep breath and hold it during the exam.” 3) “Inhale and exhale throughout the exam.” 4) “Please be sure to urinate prior to the examination.” 6) 1 Explanation: 1. The bladder, when empty, is usually not palpable. As the bladder fills, the fundus can reach the level of the umbilicus, and when the bladder is moderately full, it should be firm, smooth, symmetric, and non-tender. 2. Holding the breath will not assist the nurse in completing this exam. 3. Inhaling and exhaling during the exam are usually instructions given when assessing the client’s diaphragmatic excursion. 4. An empty bladder sits behind the pubic bone and is usually non-palpable. Implementation Application Objective 5 Page 510 Difficulty 1 7) A nurse is percussing over the client’s bladder and notes a dull tone. How should the nurse interpret this data? 1) An empty bladder 2) A full bladder 3) A bladder tumor 4) Air trapped in the intestines 7) 2 Explanation: 1. An empty bladder sits low in the pelvic cavity and would be difficult to percuss. 2. Percussion over a full bladder produces a dull tone. 3. Percussion over one of the kidneys would also produce a dull tone, but these organs lie laterally and anteriorly from the position of the bladder. 4. Air trapped in the intestines would produce tympany. Assessment
Application Objective 8 Page 510 Difficulty 2 8) A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, what client statement would prompt the nurse to do further teaching? 1) “I need to perform self-catheterization three times daily.” 2) “I know I cannot look to see if my bladder is full.” 3) “I need to avoid bladder distension.” 4) “I’ll drink adequate amounts of liquids.” 8) 1 Explanation: 1. Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distension causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distension by performing self-catheterization before this happens, most likely every 3 to 4 hrs. 2. By the time the client can see his abdomen expand or have a sense of bladder fullness — if able to have this sensation — it may be too late to avoid dysreflexia. 3. This statement demonstrates that the client does understand the connection between a distended bladder and dysreflexia. 4. Liquids are important in maintaining the urinary system. Implementation Analysis Objective 4 Page 513 Difficulty 2 9) A nurse is interviewing the parents of a toddler who state they are concerned about the child’s bedwetting. What is the best response by the nurse? 1) “Take your child to the bathroom once during the night.” 2) “Don’t worry; all children wet the bed.” 3) “We’ll run a specimen to check for a urinary tract infection.” 4) “This problem will be gone at the age of 4.” 9) 1 Explanation: 1. Most bedwetting ceases by the age of 6. If the parents are concerned enough to bring the problem to your attention, they’re interested in suggestions for help. Limiting fluid intake before bedtime or waking the child to void are methods to address the problem. 2. Dismissing their concerns is not therapeutic. 3. Ruling out a urinary tract infection may be appropriate but would have to be correlated with other symptomatology and assessment findings. 4. The nurse cannot make a definitive statement like this to the parents. For most children bedwetting will be gone by age 6 but there will be some children that this is not the case. Implementation Application Objective 3 Page 496 Difficulty 3
10) During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. What is the first body structure the nurse would assess? 1) Kidney 2) Ribs 3) Intestines 4) Bladder 10) 1 Explanation: 1. The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3, also termed the costovertebral angle. 2. The last posterior rib is used to landmark the kidneys but the majority of the ribs are located in the thoracic cavity. 3. The intestines are located in the abdominal cavity. 4. The bladder landmark is the symphysis pubis more so than the costovertebral angle. Assessment Application Objective 1 Page 495 (Figure 20.3A) Difficulty 1 11) A nurse is caring for a client admitted with an infection of the ureters. What other structure could be involved with this infection? 1) Capsule 2) Cortex 3) Medulla 4) Pelvis
11) 4 Explanation: 1. The capsule or Bowman's capsule filters the blood. 2. The outer portion of the kidney is called the cortex which is composed of the nephrons. 3. The inner portion of the kidney is called the medulla which is composed of structures called pyramids and calyces. 4. The renal pelvis is the funnel shaped superior end of the ureter. Assessment Application Objective 1 Page 492 Difficulty 2 12) A client has been diagnosed with azotemia. What assessment finding will the nurse anticipate being present? 1) Hematuria 2) Confusion 3) Increase urine output 4) Decreased sensation of thirst 12) 2
Explanation: 1. Hematuria is blood in the urine and this is not a usual symptom of renal failure and azotemia. 2. Due to the accumulation of nitrogenous waste products the client often experiences mental confusion. 3. Azotemia is associated with renal failure and urine output is low. 4. This is not an issue with azotemia. This is more an age-related physiologic change. Evaluation Application Objective 8 Page 504 Difficulty 2 13) A nurse is assessing an infant and notices that the urinary meatus is located on the top side of the penis. What term will the nurse use to document this finding? 1) Exstrophy 2) Epispadias 3) Hypospadias 4) Cryptorchidism 13) 2 Explanation: 1. Exstrophy is when the bladder is present outside the body. 2. Epispadias is the placement of the urinary meatus on the top side of the penis. 3. Hypospadias is when the urinary meatus is located on the underside of the penis. 4. Cryptorchidism literally means hidden testis. This condition is found in premature infants where the testes remain in the abdominal cavity. Assessment Application Objective 11 Page 502 Difficulty 2 14) What is a common urinary system change for postmenopausal women? 1) Decreased alkalinity of the urinary tract 2) Less urinary tract infections 3) Increase in nighttime urination 4) Increased urine leakage 14) 4 Explanation: 1. There is reduced acidity of the lower urinary tract (e.g. increased alkalinity) in postmenopausal women. 2. Postmenopausal women experience more urinary tract infections. 3. Nocturia, nighttime urination is more typical in older men. 4. Postmenopausal women have a decrease in estrogen which affects the strength of the pubic muscle leading to urine leakage. Diagnosis Analysis Objective 9 Page 496 Difficulty 3
15) A nurse is teaching a client in a bladder retraining program about the capacity of the bladder. How many milliliters of urine would the cause the bladder to rise above the symphysis pubis? 1) 100 2) 250 3) 375 4) 550 15) 4 Explanation: 1. 100 mls is too small a volume to cause the bladder to rise above the symphysis pubis. 2. This volume is too small to distend the bladder above the symphysis pubis. 3. 375 mls is still not enough to distend the bladder above the symphysis pubis. 4. When amounts larger than 500 mls are present in the bladder, it becomes distended and rises above the symphysis pubis. Implementation Analysis Objective1 Page 494 Difficulty 1 16) A nurse is preparing to catheterize a client after the client just independently voided. What is the purpose of this catheterization? 1) Serve as a urine output baseline. 2) Support the diagnosis of kidney stones. 3) Evaluate the ability of the bladder to empty urine. 4) Evaluate renal function. 16) 3 Explanation: 1. The baseline for urine output is 25-30mls/hr. 2. This is not the method used to diagnosis kidney stones. 3. A post-voiding residual urine test is done to evaluate the bladder’s ability to empty urine. 4. Renal function is evaluated through diagnostic tests such as creatinine and blood urea nitrogen. Implementation Application Objective 6 Page 499 Difficulty 1 17) Anne, 15 years old, visits the school nurse to ask why she is getting frequent urinary tract infections. What question would the nurse ask the client during this visit? 1) “Are you bathing enough?” 2) “Do you drink a lot of cokes?” 3) “Does the water in your area have a high mineral content?” 4) “What direction do you wipe after a bowel movement?” 17) 4 Explanation: 1. A more specific question that doesn't put the client on the defensive would be more useful. 2. This question is not relevant.
3. High mineral content in the water can be a risk factor for renal calculi but not urinary tract infections. 4. The most important teaching to provide females is to always wipe the perianal/genital area from front to back. E-coli is the most common microorganism responsible for urinary tract infections and can easily be dragged into the urethral orifice by wiping from the anus to the urethra after defecation. Females do have a shorter urethra compared to males and are more susceptible to urinary tract infections for this reason. Implementation Analysis Objective 3 Page 495 and 512 Difficulty 2 18) A postpartum client who had a difficult vaginal delivery 36 hours ago tells the nurse she has not needed to void much since delivery. How should the nurse respond? 1) “Your bladder is swollen, which makes you feel like you don’t have to urinate.” 2) “You must be overdoing it with your activity level so soon after delivery.” 3) “I need to catheterize you immediately.” 4) “The baby is no longer pressing on the bladder and thus it can hold more urine.” 18)1 Explanation: 1. During childbirth, the bladder mucosa may become edematous, causing decreased sensation and potential overdistension of the bladder. 2. Increased physical activity following childbirth would be an appropriate teaching item, but doesn’t affect bladder overdistension. 3. This may be necessary if the client is unable to void but at this point this is an unnecessary intervention. 4. This response does not relate to the issue of decreased sensation and overdistension of the bladder. Implementation Application Objective 9 Page 496 Difficulty 2 19) A nurse is educating a group of older adults on urinary health. What information would be important to provide to the participants? 1) Drink fluids even if you are not thirsty 2) Limit fluids throughout the day 3) Increase medication dosages 4) Eat foods high in potassium 19) 1 Explanation: 1. Older adults have decreased sensation of thirst consequently they drink less water. 2. Older adults should not limit fluids throughout the day because they are at risk for not taking in enough fluids due to their decreased sensation of thirst. 3. Medication dosages should not be adjusted without direction by the physician. 4. In general, older adults are at risk for hyperkalemia due to the diminished release of aldosterone. Implementation Application Objective 9
Page 496 Difficulty 1 20) During the assessment of a client’s urinary system, the nurse learns the client has painful urination. How should this information be documented? 1) Dysuria 2) Hematuria 3) Oliguria 4) Polyuria 20) 1 Explanation: 1. Painful urination is termed dysuria. 2. Hematuria is blood in the urine. 3. Oliguria is decreased urine output. 4. Polyuria is increased urine output. Diagnosis Application Objective 11 Page 499 Difficulty 1 21) A nurse is interviewing Mrs. Davis, who states she has urinary incontinence with coughing and sneezing. How should the nurse document this type of incontinence? 1) Functional 2) Reflex 3) Stress 4) Urge 21) 3 Explanation: 1. Functional incontinence results when there is an inability to reach the toilet in time. 2. Reflex incontinence occurs with spinal cord damage. 3. Stress incontinence is involuntary urination occurring with coughing, sneezing, or straining. 4. Urge incontinence may be due to excessive intake of fluids or diminished bladder capacity. Diagnosis Application Objective 11 Page 499 Difficulty 2 22) What is the landmark for palpating the kidneys through the abdominal wall? 1) Costoverterbral angle 2) Symphysis pubis 3) Iliac crests 4) Rectus abdominis 22) 4 Explanation: 1. The costovertebral angle is the area on the lower back formed by the vertebral column and the downward curve of the last posterior rib used to landmark the lower poles of the kidneys. 2. The symphysis pubis is the main landmark for palpating the bladder.
3. The iliac crests are not used to landmark the structures in the urinary system. 4. The rectus abdominis muscles are used as guidelines for positioning the hands when palpating the kidneys through the abdominal wall. Assessment Analysis Objective 2 Page 495 Difficulty 2 23) A nurse is auscultating the renal arteries on a 15-year-old client and hears a “whooshing." How should the nurse interpret this finding? 1) Nothing is abnormal 2) Polycystic kidney disease 3) Chronic renal failure 4) Renal artery stenosis 23) 1 Explanation: 1. An upper abdominal bruit is occasionally heard in young adults and is considered normal. 2. Polycystic kidney disease does not present in this manner. 3. Chronic renal failure is detected through abnormal diagnostic results. 4. Systolic bruits or “whooshing” sounds may indicate renal artery stenosis but due to the age of this client this is a normal finding particularly if all other assessments are normal. Diagnosis Application Objective 9 Page 505 Difficulty 2 24) During the assessment of a client’s renal system, the nurse is unable to palpate the kidneys. How would the nurse document this finding? 1) Inflammation 2) Acute renal disease 3) Normal 4) Polycystic kidney disease 24) 3 Explanation: 1. The kidneys are not normally palpable. If inflammation was present the area would be red, warm, and possibly swollen. 2. Renal failure is detected through diagnostic tests and not by palpating the kidney. 3. The kidneys are normally not palpable, this is a normal finding. 4. In polycystic kidney disease the kidneys are enlarged and may be palpable. Assessment Application Objective 11 Page 507 Difficulty 1 25) A nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area. How should the nurse interpret this finding?
1) 2) 3) 4)
Positive Grey Turner’s sign Costovertebral angle tenderness Possible clotting dysfunction Precursor to hematuria
25)1 Explanation: 1. The presence of ecchymosis in the flank area is a positive Grey Turner’s sign and must be correlated to signs of trauma such as blunt force trauma, penetrating wounds, or lacerations. 2. The costovertebral angle tenderness is likely but this does not describe the ecchymosis. 3. This is not possible to determine from the bruising alone. 4. This is not necessarily so. Diagnosis Application Objective 8 Page 506 Difficulty 1 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is interviewing a client regarding urinary health. Which questions would the nurse include during the collection of subjective data? (Select all that apply.) “Do you have difficulty starting your stream of urine?” “After you urinate, does your bladder feel full or empty?” “Do you ever have an accident or wet yourself when you sneeze?” “Do you have to hurry to the bathroom when you have to urinate?” X “Do you have difficulty starting your stream of urine?” X “After you urinate, does your bladder feel full or empty?” X “Do you ever have an accident or wet yourself when you sneeze?” X “Do you have to hurry to the bathroom when you have to urinate?” Explanation: Urinary retention or holding residual urine in the bladder after voiding creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Difficulty starting a stream usually indicates prostate disease in the male client. Stress incontinence and urgency occur when there is loss of muscle control over urination. Assessment Application Objective 4 Page 499 Difficulty 1 26)
27) A nurse is assessing a client admitted for oliguria of unknown origin. What factors affect urine output?
(Select all that apply.) Bladder size Bowel patterns Medications Anxiety Fluid intake
27)
X X
Bladder size Bowel patterns Medications Anxiety Fluid intake
X Explanation: Bowel patterns and anxiety are not usually related to the amount of urinary output. Implementation Application Objective 1 Page 499 Difficulty 1 28) A client presents with a medical diagnosis of uremia. What symptoms would the nurse anticipate finding? (Select all that apply.) Itching Weight loss Altered mental status Fluid retention Hyperkalemia Insomnia 28)
X X X X
Itching Weight loss Altered mental status Fluid retention Hyperkalemia Insomnia
Explanation: Hyperkalemia is a symptom of renal failure, and uremia predisposes the client to fatigue, not insomnia. Assessment Application Objective 8 Page 513 Difficulty 2 29) A nurse is preparing to assess the urinary system of a client. What assessment techniques would the
nurse use in this examination? (Select all that apply.) Inspection Palpation Percussion Auscultation 29)
X Inspection X Palpation X Percussion X Auscultation Explanation: The nurse uses each of the listed techniques in assessment of the urinary system. Assessment
Comprehension Objective 7 Page 503 Difficulty 1
30) An elderly female client is demonstrating signs of bladder dysfunction. What are the characteristics of age-related bladder changes? (Select all that apply.) 1) Decreased blood flow 2) Urinary retention is more common 3) Increase in urinary frequency 4) Increased risk of hyponatremia 30) 2, 3 Explanation: Age-related bladder changes include urinary retention, frequency, urgency, nocturia, larger amounts of residual urine present after voiding, and some stress incontinence, especially in women who have had several children. Evaluation Analysis Objective 9 Page 496 Difficulty 1
Chapter 21 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse has completed testicular self-examination teaching for a male client. Which statement if made by the client would indicate the need for further instruction? 1) “I should feel hardened areas where the testicles and epididymis are located.” 2) “I should perform this examination 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.” 1) 1 Explanation: 1. The testicle and epididymis are normally soft, without lumps or hardness. 2. Testicular self-examination should be performed monthly beginning in adolescence. 3. The scrotum will descend in a warm environment such as the bath or shower, allowing adequate palpation. 4. Gentle pressure should be applied to locate the testicle and epididymis. Evaluation Analysis Objective – 3 Page – 521 (Box 21.1) Difficulty – 1
2) A nurse is assessing a male infant and notes only one testis. The mother asks what effect this will have on the child. What would be a correct response by the nurse? 1) “There will be a need for testosterone replacement therapy.” 2) “He will be unable to father children.” 3) “He will do fine and have no problems”. 4) “There will be a normal level of sperm production.” 2) 1 Explanation: 1. The testes produce sperm and testosterone. With one testis, there will be a reduction in testosterone and sperm production. 2. Sterility should not be a problem. 3. There will be reduced sperm and testosterone production. 4. There will be less sperm with only one testis. Implementation Analysis Objective – 1 Page – 516 Difficulty – 2 3) A nurse is assessing a male client who has epididymitis. How should the nurse explain the diagnosis to the client? 1) “You will have a decrease in testosterone production.” 2) “Your sperm maturity may be affected.” 3) “There will be a decrease in blood flow to your penis.” 4) “There may be erectile difficulties.”
3) 2 Explanation: 1. The epididymis does not produce sperm. 2. The epididymis is the final area for the storage and maturation of sperm. 3. Blood flow to the penis will not be impacted. 4. The epididymis stores sperm and has no impact on achieving an erection. Implementation Analysis Objective – 3 Page – 516-517 Difficulty – 2
4) During the examination of an elderly male the nurse notes thin, gray pubic hairs and a scrotal sac that hangs significantly lower than the penis. What action should the nurse take? 1) Document the findings as normal 2) Inform the client that he is no longer fertile 3) Notify the physician of the findings 4) Ask the client about his sexual practices 4) 1 Explanation: 1. According to Tanner’s Maturation Stages in the male, the findings in this situation are appropriate for the elderly male client. 2. Although sperm production does decline during middle age, the presence of viable sperm in the elderly male contradicts infertility. 3. No further subjective information is required by the nurse. 4. The physician does not need notification. Assessment Analysis Objective – 9 Page – 520 Difficulty – 1
5) During the routine assessment on a two-year-old male the nurse notes that the testes are not descended. What action should the nurse take? 1) Report the finding to the physician 2) Ask the parents if the child plays with his genitals 3) Proceed with palpation of the scrotum 4) Inquire about the child’s voiding patterns 5) 1 Explanation: 1. Undescended testes, or cryptorchidism, is common in preterm infants, but should resolve spontaneously by one year of age. If unresolved, the condition can lead to infertility in the male and at risk for testicular cancer. This abnormal finding should be reported to the physician. 2. Playing with the genitals is not relevant. 3. Voiding patterns are not relevant to this situation. 4. Palpation will not be possible. Diagnosis/Analysis
Analysis Objective – 9 Page – 519 Difficulty – 1 6) During the examination of a male client’s scrotum the nurse detects a hardened area in the right side of the scrotal sac. What should the nurse do next? 1) Ask the client about voiding patterns 2) Notify the physician of this finding 3) Use a light to perform transillumination 4) Ask the client about a history of sexually transmitted infections 6) 3 Explanation: 1. The client’s voiding patterns are not relevant. 2. The nurse requires additional information prior to notification of the physician. 3. The scrotum contains the testes and the epididymitis, which should not feel hard upon palpation. Areas suggesting abnormalities may be detected using transillumination, or the use of light to examine the scrotum. 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. Sexually transmitted infections would not lead to these findings. Implementation Application Objective – 8 Page – 531-532 Difficulty – 2 7) 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 retracted. How should the nurse document this finding? 1) Urethral stricture 2) Paraphimosis 3) Urethritis 4) Phimosis 7) 4 Explanation: 1. A urethral stricture is suspected if the urinary meatus is pinpoint size. 2. Paraphimosis is a condition in which the foreskin cannot be moved back over the glans penis once retracted. 3. Signs of urethritis include redness and edema around the glans and foreskin, eversion of urethral mucosa, and drainage. 4. Phimosis is a condition in which the foreskin is too tight to retract over the glans penis. Diagnosis/Analysis Application Objective – 11 Page – 519, 530 Difficulty – 1
8) During the examination of a male child the nurse notes that the urinary meatus appears on the under side of the glans penis about 5 mm from the tip. How would the nurse document this finding? 1) Hypospadias 2) Normal finding 3) Epispadias 4) Paraphimosis 8) 1 Explanation: 1. When the opening is on the underside of the glans penis it is termed hypospadias. 2. The normal position of the urinary meatus in the male is in the center of the tip of the penis. 3. When the urinary opening on the upper surface of the glans penis it is termed epispadias. 4. Paraphimosis is a condition in which the foreskin of an uncircumcised male tightens around the glans penis. Diagnosis/Analysis Application Objective – 11 Page – 519, 530, 542 Difficulty – 2
9) During the examination of a male client, the nurse detects a bulge in the right inguinal area as the client is bearing down. How should the nurse interpret these findings? 1) Varicocele 2) Prostatitis 3) Cremasteric reflex 4) Hernia 9) 4 Explanation: 1. A varicocele is a distention of the spermatic cord and feels like “a bag of worms” rather than a mass. 2. Prostatitis is an inflammation of the prostate that will cause tenderness but not a bulge in the inguinal area. 3. The cremasteric reflex is a normal response of the testicles migrating toward the body. 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. Diagnosis/Analysis Analysis Objective – 8 Page – 518-519 (Table 21.1), 532-535 Difficulty – 1 10) A nurse is interviewing a male client who states “I feel like I have a bag of worms in my scrotum.” What conclusion can the nurse draw from this statement? 1) Orchitis 2) Varicocele 3) Epididymitis 4) Hernia 10) 2
Explanation: 1. Orchitis is an inflammation of the testicle and will result in pain and swelling. 2. A varicocele is a distention of the spermatic cord and often is described as “a bag of worms”. 3. Epididymitis is an inflammation of the epididymitis and results in pain and swelling. 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. Diagnosis/Analysis Analysis Objective – 8 Page – 534 Difficulty – 1 11) Mr. Barton, 52 years old, is scheduled for a prostatectomy. What assessment finding might the nurse observe in Mr. Barton? 1) Enlargement of the scrotal sac 2) Decrease in prostatic specific antigen (PSA) 3) Lower back pain 4) Difficulty in initiating urine stream 11) 4 Explanation: 1. There should be no enlargement of the scrotal sac. 2. There will be an increase in PSA. 3. Lower back pain may be seen with a kidney or prostate infection but not prostatic hyperplasia. 4. Symptoms of prostate problems include elevation of the PSA, dribbling of urine, difficulty initiating the urinary stream, and cystitis. The prostate may be enlarged, but is palpate via the rectum and not felt in the scrotum. Assessment Analysis Objective – 10 Page – 521 Difficulty – 2 12) The mother of a toddler expresses concern over her son “constantly playing with his penis and scrotum.” How should the nurse address the mother’s concern? 1) “These practices are normal for a toddler.” 2) “He has likely seen someone else doing this.” 3) “Does he know what it means to be a boy or a girl?” 4) “These bahaviours will go away once he gets older.” 12) 1 Explanation: 1. Children often display curiosity with their genitals throughout all age spans. Parents should be reassured that this is normal behaviour and part of the child’s growth and development. 2. This is a normal behaviour in the toddler and unrelated to what he has seen. 3. This is an incorrect response. 4. This does not address the mother’s concern. Implementation Application Objective – 3 Page – 519
Difficulty – 2 13) An elderly client tells the nurse that he has no desire to have sex. What should be the nurse’s initial response? 1) “What medications are you taking?” 2) “Are you happily married?” 3) “How often would you like to have sex?” 4) “Tell me how you view a satisfying sexual relationship.” 13) 4 Explanation: 1. Before asking about possible causes for the loss in sex drive the nurse should determine what a satisfying relationship means to the client. 2. The nurse is making an assumption that the client is married. Also, if married that the loss of sex drive is related to the marriage. 3. This is a closed question and does not address what the client sees as a satisfying sexual relationship. 4. Many factors can influence sexual drive and satisfaction in the older adult. However, the nurse must first determine what constitutes sexual satisfaction for the individual client, prior to asking more focused questions. This is an open-ended statement, allowing the client to describe his concerns openly. Assessment Application Objective – 9 Page – 520 Difficulty – 3
14) During the examination of an adult male the nurse notes thick, curly hair over the pubis area, a pearshaped scrotum, and slightly darkened skin on the penis. What action should the nurse take? 1) Ask the client about childhood illnesses 2) Inquire about the client’s sexual practices 3) Notify the physician of the findings 4) Document the findings as normal 14) 4 Explanation: 1. These are normal findings and not related to childhood illnesses. 2. These findings are normal and unrelated to sexual practices. 3. These are normal findings in an adult male and do not require notification of the physician. 4. According to Tanner’s Maturation Stages in the male, the findings in this situation are appropriate for the adult male client. Assessment Analysis Objective – 1 Page – 516, 520 (Table 21.2) Difficulty – 1
15) While performing prostate palpation, the nurse notes that the client expresses severe tenderness and discomfort during the procedure. What condition should the nurse suspect based on these findings? 1) Prostate cancer 2) Prostatitis 3) Enlargement of the prostate 4) Urinary tract infection 15) 2 Explanation: 1. The presence of extreme hardness or nodules is characteristic of prostate cancer. 2. The prostate examination should not cause tenderness, which is an indication of inflammation. 3. Enlargement of the prostate will cause urinary tract symptoms such as difficulty in starting a stream, or dribbling of urine. 4. Urinary tract infections will cause painful and frequent urination. Diagnosis/Analysis Analysis Objective – 10 Page – 537 Difficulty – 2
16) A couple is seeking infertility information from the nurse. What statement made by the couple would indicate the need for intervention by the nurse? 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.” 16) 4 Explanation: 1. The number of health-care providers the couple has been to is not relevant information in this situation. 2. Frequent intercourse is suggested when trying to conceive. 3. Temperature tracking for ovulation is suggested when trying to conceive. 4. Couples are not considered for infertility treatment until they have tried to conceive for at least one year. Implementation Analysis Objective – 3 Page – 525 Difficulty – 2 17) A nurse is examining a male client’s genitalia and notices the scrotum is asymmetric, with the left side hanging lower than the right side. What action should the nurse take? 1) Reassess after increasing the temperature in the room 2) Report the finding to the physician 3) Proceed with palpation of the scrotum 4) Ask if the client has sustained an injury to the scrotum 17) 3
Explanation: 1. Although the scrotum does drop away from the body in elevated temperatures, this will not change its asymmetrical appearance. 2. This finding does not need to be reported to the physician. 3. The male scrotum is normally asymmetric due to the longer length of the left spermatic cord. The nurse should continue with the examination. 4. This finding does not need further subjective data from the client. Assessment Analysis Objective – 1 Page – 528, 531 Difficulty – 2
18) Mr. VanBeek, 28 years old, tells the nurse he has decreased libido. The nurse tells him that the results of a semen analysis show a diminished sperm count. What question should the nurse ask Mr. VanBeek? 1) “How often do you masturbate?” 2) “Do you smoke?” 3) “How old is your present house?” 4) “Are you married?” 18) 3 Explanation: 1. Masturbation will not decrease sperm count. 2. Smoking can decrease sperm count, but will not affect libido. 3. Males exposed to lead may experience decreased libido, diminished sperm count, and abnormal sperm motility. Lead may be present in older homes. 4. This is an inappropriate question and is judgmental. Assessment Analysis Objective – 4 Page – 521, 526 Difficulty – 3 19) A nurse is interviewing a male client with an elevated prostate specific antigen level (PSA).What are the risk factors for prostate cancer? 1) A positive family history for prostate cancer 2) Masturbation 3) Frequent sexual intercourse 4) Drinking beer 19) 1 Explanation: 1. Risk factors for prostate cancer include positive family history and smoking. 2. Masturbation is not related to prostate cancer. 3. Frequent sexual intercourse does not increase the risk of prostate cancer. 4. Smoking is a risk factor not drinking beer or other forms of alcohol. Assessment Analysis Objective – 3 Page – 520, 521
Difficulty – 1
20) During the health history, a male client describes his erection and ejaculate in terms that are less than professional. What should the nurse do? 1) Ask the client to refrain from using offensive language. 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. 20) 3 Explanation: 1. The nurse should not be embarrassed by the terms used and it is inappropriate to tell the client to not use those terms. 2. This may further increase the embarrassment for the client. 3. The nurse should record the interview using the terms used by the client. 4. It is inappropriate to get another nurse to complete the history. Part of the process is building a rapport with the client and this would not build trust. Assessment Application Objective – 3 Page – 522 Difficulty – 2 21) A nurse is preparing to examine a male client’s reproductive organs. What should the nurse do in preparation for this examination? 1) Use clean hands for the examination 2) Ask the client to lie down on the examination table 3) Ensure the room’s temperature is cool and comfortable 4) Ask the client to empty his bladder
21) 4 Explanation: 1. Put on gloves before beginning and wear them throughout the examination. 2. The assessment may be done with the client sitting or standing. 3. Ensure that the examining room is warm and private. 4. Ask the client to empty his bladder, remove his clothing, and put on a gown or drape. Expose only those body parts being examined to preserve modesty. Planning Application Objective – 5 Page – 528 Difficulty – 2 22) A nurse is examining a male client and notes small clusters of vesicular lesions on the glans penis. The client states the area is painful and often reddened. How should the nurse interpret these findings? 1) Carcinoma 2) Genital warts 3) Syphilis 4) Genital herpes
22) 4 Explanation: 1. Carcinoma lesions are nodular or ulcerative. 2. In genital warts the lesions are papillar. 3. Syphilis produces non-painful ulcers called chancres. 4. The lesions described are those of genital herpes. Diagnosis Analysis Objective – 8 Page – 543 (Figure 21.24) Difficulty – 2
23) A nurse is examining a male adolescent with suspected spermatic cord torsion. What would be the nurse’s priority intervention? 1) Administer an analgesic as ordered 2) Prepare for surgery 3) Elevate the scrotum 4) Administer anti-inflammatory medication, if ordered 23) 2 Explanation: 1. Although medicating for pain may be indicated, torsion of the spermatic cord requires immediate surgical intervention, making this the priority for the nurse in this situation. 2. The client should be prepared for emergency surgery as this condition disrupts blood supply to the testicle. 3. Elevating the scrotum will not improve blood flow to the testicle. 4. Anti-inflammatory drugs will not improve blood flow to the testicle. Implementation Analysis Objective – 10 Page – 523, 545 (Figure 21.30) Difficulty – 3 24) A nurse is conducting a health history on an 18-year-old male. What would be an appropriate question for the nurse to ask? 1) “Do you and your girlfriend use birth control?” 2) “Are you sexually active?” 3) “Have you ever had measles?” 4) “What is you sexual relationship with your girlfriend?” 24) 2 Explanation 1. The nurse should ask questions that are gender neutral. 2. It is important to determine whether the client is sexually active to assess for Sexually Transmitted Infections. 3. Mumps not measles can cause sterility. 4. This question is not gender neutral and should not be asked. Assessment
Application Objective – 4 Page – 523, 527 Difficulty – 3 25) The mother of a 5-month-old male infant asks the nurse how to retract her son’s foreskin. What should the nurse tell the mother? 1) Demonstrate the procedure to the mother. 2) Explain the procedure to the mother as she retracts the foreskin. 3) Tell the mother it is too soon to retract the foreskin. 4) Suggest to the mother to have her husband do this. 25) 3 Explanation 1. The mother should be told it is too early to retract the foreskin. 2. The foreskin should not be retracted until age 2 or 3. 3. It is too early to retract the foreskin. The child should be at least 2 to 3 years of age. 4. The nurse is making an assumption that the mother is married, also it is too early to retract the foreskin. Implementation Analysis Objective – 1 Page – 519 Difficulty – 2 26) Simon, 7 years old, is developing pubic hair. His parents are concerned and ask the nurse for advice. How should the nurse respond? 1) “Some boys develop earlier than others.” 2) “Make an appointment with your physician as soon as possible.” 3) “Have you talked to your son about his sexual development.” 4) “How do his friends feel about these changes?” 26) 2 Explanation 1. A male normally develops adult male characteristics after age 10. 2. Precocious puberty is an endocrine disorder and the child needs to be seen by a physician and referred to an endocrinologist. 3. This is inappropriate for a 7 year old child. This child has an endocrine disorder that needs to be treated. 4. This question does not address the parents concerns. Assessment Application Objective – 9 Page – 519 Difficulty – 2
27) A nurse taught a group of adolescent males about sexually transmitted infections (STI). What response would indicate that additional teaching is required? 1) “I guess I better start using condoms.”
2) “So I just need to remember who I had sex with for the past month.” 3) “Gee, I have to wait another week to have sex after I finish being treated.” 4) “I guess I can’t double the dose of the medication to get better faster.” 27) 2 Explanation 1. This statement indicates that the male is aware of how to prevent the spread of STIs. 2. All sexual contacts need to be reported not just those for the past month. 3. It is recommended that individuals wait 1 week after the end of treatment before resuming sexual relations. 4. Medication needs to be taken as directed. Assessment Application Objective – 10 Page – 540 Difficulty – 3 28) What should be inspected in an assessment of the male reproductive system? 1) Epididymis 2) Bulbourethral Gland 3) Prostate Gland 4) Inguinal region 28) 4 Explanation 1. The nurse cannot see the epididymis. It has to be palpated. 2. The Bulbourethral Gland is located below the prostate and can only be palpated. 3. The prostate borders the urethra near the lower part of the bladder and cannot be inspected. 4. The nurse would inspect this area looking for herniations. Assessment Application Objective – 6 Page – 528-532 Difficulty 2 29) What equipment is normally required to assess the male reproductive system? 1) Sterile gloves 2) Flashlight 3) Measuring tape 4) Pubic hair comb 29) 2 Explanation 1. Clean gloves are used to assess the male reproductive system. 2. A flashlight may be used for transillumination. 3. The nurse would not require a measuring tape. 4. A pubic hair comb would be used in a suspected rape assessment. Assessment Application Objective – 7
Page – 528 Difficulty – 1 30) What is the landmark for palpating the spermatic cord? 1) Posterior side of each testicle 2) Anterior side of each testicle 3) Above each testicle 4) Between the base of the scrotal sac and the testicle 30) 3 Explanation 1. This is the landmark for palpating the epididymis. 2. This is not where the spermatic cord will be found. 3. The nurse slides fingertips up just above the testicle. The spermatic cord feels like a rope-like structure. 4. The spermatic cord is found above the testicle. Assessment Application Objective – 2 Page – 534 Difficulty – 1 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
31) The nurse is preparing a presentation on testicular cancer and wishes to target the age group most frequently affected. Which group (s) should the nurse schedule for this presentation? (Select all that apply.) 1) Elementary schools 2) Post-secondary institutions 3) Senior Action Centers 4) High schools 31) 2, 4 Explanation: Testicular cancer is the most common type of cancer in males between the ages of 15 and 49. It is recommended that adolescent males perform testicular self-examination monthly. Planning Application Objective – 3 Page – 521 Difficulty – 1
32) What assessment techniques would the nurse use to examine the male reproductive system? (Select all that apply.) 1) Inspection 2) Palpation 3) Percussion 4) Transillumination
32) 1, 2, 4 Explanation: The physical assessment techniques of inspection and palpation are used in the examination of the male reproductive system. Transillumination of the scrotum may be used if a mass is palpated. Planning Application Objective – 6 Page – 528, 531 Difficulty – 1
Chapter 22 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules. What conclusion can the nurse make based on these findings? 1) Genital warts 2) Herpes infection 3) Bartholin’s abscess 4) Contact dermatitis 1) 1 Explanation: 1. Genital warts produce the lesions described. 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. Diagnosis/Analysis Analysis Objective – 8 Page – 564 Difficulty – 2
2) A nurse suspects a gonorrheal infection in a client during an examination. What is the priority nursing action? 1) Counsel regarding safe sex practices 2) Obtain history of sexual contacts 3) Take a swab for culture and sensitivity 4) Document the findings 2) 3 Explanation: 1. Although the nurse should do this teaching it is not the priority action. 2. If the diagnosis is confirmed following a swab for culture the nurse should obtain a history of all sexual contacts. 3. The priority for the nurse in this situation is to obtain a culture of any discharge present so a definitive diagnosis can be made. 4. The nurse should take a swab for culture and then document the findings. Implementation Analysis Objective – 6 Page – 566 Difficulty – 3
3) A nurse is providing education on menopause to a group of female clients. What statement made by a client would indicate the need for further instruction? 1) “I will have gone through menopause once I have not had a period for 2 years.” 2) “Night sweats and hot flashes are commonly experienced.”
3) “My mood changes are a normal part of menopause.” 4) “I should consider using a vaginal lubricant.” 3) 1 Explanation: 1. Menopause is said to have occurred when the female has not experienced a period in over one year. 2. As estrogen levels decline, symptoms include night sweats and hot flashes. 3. Mood changes are common during menopause. 4. Vaginal dryness occurs with menopause and a vaginal lubricant may be helpful. Evaluation Analysis Objective – 9 Page – 554 Difficulty – 2
4) While examining a female client, a nurse notes reddened areas on the labia and a discharge that is white and curd-like in the vaginal canal. What should the nurse suspect based on these findings? 1) Chlamydia 2) Candidiasis 3) Herpes infection 4) Trichomoniasis 4) 2 Explanation: 1. Chlamydia will result in purulent discharge and tenderness when the cervix is moved. 2. Candidiasis or yeast infections are the most common female genital infection and can produce redness, pruritus, and cheese-like discharge. 3. Herpes infection causes small red, painful ulcerations. 4. Trichomoniasis results in painful urination, vulvular itching, and purulent, yellow, foul smelling vaginal discharge. Diagnosis/Analysis Analysis Objective – 10 Page – 582 (Figure 22.27) Difficulty – 2 5) What statement made by an elderly client would require intervention by the nurse? 1) “I use a lubricant for sex to help with dryness.” 2) “I take hormone pills to help with my hot flashes.” 3) “At times it hurts when I have intercourse.” 4) “I don’t have a desire for sex very often, but neither does my partner.” 5) 2 Explanation: 1. The use of lubrication for sexual intimacy is normal due to vaginal dryness. 2. The use of estrogen replacement therapy is no longer recommended and is a risk factor for cancer. 3. Dyspareunia, or pain during intercourse, may occur in the elderly female client. 4. Libido may be diminished in both the male and female. Diagnosis/Analysis Analysis Objective – 9 Page – 554, 581 Difficulty – 3
6) A nurse reads in the client’s history and physical the presence of a nontender protrusion into the anterior vaginal wall. What condition would the nurse suspect? 1) Skene’s infection 2) Prolapsed uterus 3) Rectocele 4) Cystocele 6) 4 Explanation: 1. Skene’s 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 vaginal wall. Diagnosis/Analysis Analysis Objective – 8 Page – 565 Difficulty – 1
7) During an inspection of the perineum the nurse notices a protrusion from the vagina. What conclusion can the nurse make from this observation? 1) Uterine prolapse 2) Bartholin’s gland infection 3) Cystocele 4) Rectocele 7) 1 Explanation: 1. The uterus may protrude from the vaginal wall, with or without straining. 2. The Bartholin’s 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 Diagnosis/Analysis Analysis Objective – 10 Page – 565 (Figure 22.6) Difficulty – 2
8) A female client reports a grayish discharge with a fishy odor. What condition should the nurse suspect? 1) Bacterial vaginosis 2) Chlamydia 3) Genital warts 4) Gonorrhea 8) 1 Explanation:
1. Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odour. 2. A yellow discharge can be seen in chlamydial infection. 3. Genital warts are raised, moist, cauliflower-shaped papules. 4. Green discharge that has a foul smell is associated with gonorrhea. Diagnosis/Analysis Analysis Objective – 9 Page – 569 Difficulty – 2
9) Annette, 17 years old, tells the nurse that she has a frothy, yellow-green discharge. What condition should the nurse suspect? 1) Vaginitis 2) Trichomoniasis 3) Gonorrhea 4) Chlamydia 9) 2 Explanation: 1. Vaginitis indicates a nonspecific inflammation of the vagina. 2. Frothy yellow-green discharge is seen in trichomoniasis. 3. Green discharge that has a foul smell is associated with gonorrhea. 4. A yellow discharge can be seen in a chlamydial infection. Diagnosis/Analysis Analysis Objective – 9 Page – 569, 583 (Figure 22.29) Difficulty – 2
10) A nurse is performing a bimanual examination on an extremely obese client and is unable to palpate the uterus. What action should the nurse take? 1) Defer the examination 2) Ask another nurse to perform the examination. 3) Discuss obtaining an ultrasound with the physician 4) Ask the client if they have had recent problems 10) 3 Explanation: 1. The examination should not be deferred. 2. It may be difficult to palpate the uterus and ovaries in obese women and asking another nurse to perform the examination is not indicated. 3. In the obese female, it may be difficult to clearly differentiate the uterine structures and an ultrasound may be needed. 4. Although a history is important, the area should still be examined. Implementation Application Objective – 10 Page – 574 Difficulty – 2
11) A nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful. What conclusion should the nurse make from these findings? 1) Genital warts 2) Herpes infection 3) Bartholin’s abscess 4) Contact dermatitis 11) 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. Diagnosis/Analysis Analysis Objective – 9 Page – 558, 579 (Figure 22.19) Difficulty – 2
12) A nurse is examining the external genitalia of a female client and notes a nontender papule. The nurse would suspect which condition in this situation? 1) Human papillomavirus 2) Syphilitic lesion 3) Herpes infection 4) Contact dermatitis 12) 2 Explanation: 1. Human papillomavirus appear as wartlike, painless growths appear in clusters. 2. Syphilitic lesions produce the findings described. 3. Herpes infection produces red, painful vesicles with localized swelling. 4. Contact dermatitis produces red, weepy rashes. Diagnosis/Analysis Analysis Objective – 10 Page – 558, 579 (Figure 22.20) Difficulty – 2
13) Ms. LaRosa, 28 years old, reports a greenish discharge with a foul odor. She is guarding her abdomen. What condition should the nurse suspect in Ms. LaRosa? 1) Trichomoniasis 2) Herpes infection 3) Gonorrhea 4) Bacterial vaginosis 13) 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. Diagnosis/Analysis Analysis Objective – 10 Page – 569 Difficulty – 3
14) A nurse notes a forward tilted uterus with a downward tilted cervix when examining a female client. What term should the nurse use to document this finding? 1) Anteflexion 2) Retroflexion 3) Anteversion 4) Uterine descensus 14) 3 Explanation: 1. Anteflexion (the uterus is folded forward at 90 degree angle, the cervix is tilted downward) is not the normal position for the uterus. 2. An abnormal variation of uterine position includes retroflexion (the uterus is folded backward at 90 degree angle, the cervix is tilted upward). 3. Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward). 4. Uterine descensus or prolapsed is not consistent with the findings. Diagnosis/Analysis Application Objective – 11 Page – 572, 573 Difficulty – 2
15) Ms. Horton, 35 years old, tells the nurse that she has a very heavy flow during her menses. She also states she has urinary frequency. Upon examination the nurse finds that the uterus is slightly enlarged. What conclusion should the nurse draw from these findings? 1) Pregnancy 2) Bladder infection 3) Fibroids 4) Ovarian cancer 15) 3 Explanation: 1. Pregnancy would be incorrect as Ms. Horton has heavy menstrual flow. 2. A bladder infection may cause frequency but would not account for the heavy bleeding and enlarged uterus.
3. Fibroids may cause excessive bleeding during menses, enlarged uterus and frequent urination. Other symptoms may include abdominal distension, pain, intestinal obstruction, and constipation.
4. Ovarian cancer may cause frequency but the other findings would not be seen. Ovarian cancer presents with gastrointestinal symptoms, abdominal pressure and bloating. Diagnosis/Analysis Application Objective – 10 Page – 580-581 Difficulty – 3
16) A nurse is examining an elderly client and palpates a mobile, smooth, round-shaped area in the left lower abdominal quadrant. What action should the nurse do next? 1) Ask the client if she is menstruating 2) Report the findings to the physician 3) Re-examine the area using a vaginal speculum 4) Ask the client if she could be pregnant 16) 2 Explanation: 1. Menstruation is not relevant to this situation. 2. In women that have been postmenopausal for more than 2.5 years, palpable ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen. 3. The ovary cannot be viewed with a vaginal speculum. 4. A pregnant uterus would not be palpated in this area. Diagnosis/Analysis Analysis Objective – 9 Page – 574 Difficulty – 2 17) Aime, 15 years old, is having a physical examination. The nurse notes Aime has no pubic hair. What should the nurse do first? 1) Ask Aime if she is taking the birth control pill 2) Examine the client for breast buds 3) Report the findings to the physician 4) Document the findings 17) 2 Explanation: 1. The absence of pubic hair is likely related to an endocrine disorder and not birth control pills. 2. According to Tanner’s Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis. This abnormality may be indicative of endocrine pathology and needs to be reported to the physician for follow-up. Examination of the chest for the presence or absence of breast buds is indicated. 3. The nurse would report this to the physician but after she has determined whether other adult female sexual characteristics are present or absent. 4. The finding would be documented, but not before determined whether other adult female sexual characteristics are present or absent. Diagnosis/Analysis Analysis
Objective – 10 Page – 553 Difficulty – 3
18) A nurse is examining an adult female and notes thick, course, pubic hair covering the pubis and extending to the thighs. What action should the nurse take? 1) Ask the client if she has started menstruation 2) Report the findings to the physician 3) Document the findings as normal 4) Ask the client if she is sexually active 18) 3 Explanation: 1. This is a normal finding and required no further investigation. 2. There is no need to report these findings. 3. According to Tanner’s Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. 4. This is an inappropriate question. Diagnosis/Analysis Analysis Objective – 1 Page – 553 (Table 22.1) Difficulty – 1
19) A nurse is examining a pregnant client and notes the cervix is soft in texture and nontender. How would the nurse document this finding? 1) Nabothian cyst 2) Chadwick’s sign 3) Cervical cancer 4) Goodell’s sign 19) 4 Explanation: 1. Nabothian cysts are benign, yellow and nodular areas that may appear after childbirth. 2. Chadwick’s sign, occurring during pregnancy, is the appearance of a bluish-purple colouration of the cervix due to vascular congestion. 3. Ulcerations with vaginal discharge, postmenopausal bleeding or spotting, or bleeding between menstrual periods are characteristics of cervical carcinoma. 4. During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Diagnosis/Analysis Application Objective – 9 Page – 554, 571 Difficulty - 2 20) What landmark should the nurse use when assessing the Skene’s glands? 1) Posterior to the urethra 2) Beside the vaginal opening
3) Between the clitoris and urethra 4) Posterior to the vaginal opening 20) 1 Explanation: 1. The Skene’s glands are located posterior to the urethra. 2. The Skene’s glands are not beside the vaginal orifice. 3. The Skene’s glands are posterior to the urethra. 4. The Skene’s glands are not located near the vaginal orifice. Diagnosis/Analysis Application Objective – 2 Page – 551 Difficulty – 2
21) A nurse is performing a gynecological examination and is ready to insert the speculum into the vagina. How should the nurse insert the speculum? 1) 90 degree angle 2) 45 degree angle 3) Straight down 4) Straight up 21) 2 Explanation: 1. A 45 degree angle should be used. 2. The speculum should be inserted at a 45 degree downward angle. This angle matches the downward slope of the vagina when the client is in lithotomy position. 3. The speculum is not inserted in this manner. 4. This is incorrect. Assessment Application Objective – 7 Page – 568 Difficulty – 1
22) A nurse is performing a vaginal examination, which includes a cervical scrape, on a client who has had a hysterectomy. What should the nurse do in this situation? 1) Inform the client cervical scrapes will no longer be required 2) Scrape the vaginal wall to obtain a specimen 3) Tell the client she will not need a vaginal examination in the future 4) Use the surgical stump for the cervical scrape 22) 4 Explanation: 1. This scrape may still be required depending on the type and the reason for the hysterectomy. The nurse would not have this information. 2. The vaginal wall should not be used for the specimen. 3. A vaginal examination is still required for women who have had a hysterectomy to detect other problems.
4. Clients that have had hysterectomies should have the surgical stump scraped as part of the examination. Implementation Application Objective – 10 Page – 570 Difficulty – 3 23) What factor may increase a woman’s risk for cervical cancer? 1) Obesity 2) Family history of cancer 3) History of gonorrhea 4) Having only 6 to 10 sexual partners in a lifetime 23) 4 Explanation 1. Obesity is related to an increased risk for uterine cancer. 2. Family history is not a risk factor in cervical cancer. 3. There is increased risk with human papillomavirus but not gonorrhea. 4. A woman who has more than 4 sexual partners during her lifetime is at increased risk for cervical cancer. Assessment Application Objective – 4 Page – 555 Difficulty – 3 24) A nurse is teaching a women’s group about ovarian cancer. What risk factor should the nurse include in the presentation? 1) Having more than 2 children 2) History of birth control use 3) Using baby powder in the perineal area 4) Having cervical cancer 24) 3 Explanation 1. There is a decreased risk if a woman has children. 2. History of fertility drug use will increase a woman risk. 3. The use of talcum powder and baby powder in the perineal area will increase a woman’s risk. 4. A history of breast and colon cancer will increase a woman’s risk. Assessment Application Objective – 4 Page – 581 Difficulty – 2 25) Ms. O’Hara, 26 years old, is to have her first Papanicolaou test (Pap test) in the morning. What should the nurse tell Ms. O’Hara to help her prepare for the test? 1) Ask Ms. O’Hara to douche before going to bed
2) A gel like lubricant will be used to make insertion easier 3) Teach relaxation exercises to help Ms. O’Hara deal with the pain 4) Ask Ms. O’Hara if her vagina is inflamed 25) 4 Explanation 1. Douching and having sexual relations within 24 hours of a Pap test will impact the accuracy of the results. 2. A lubricant will impact the results and would not be used. 3. A Pap test may be uncomfortable but should not be painful. 4. A Pap test will be deferred if Ms. O’Hara has vaginitis. Assessment Application Objective – 5 Page – 567, 568 Difficulty – 3
26) Kaitlyn, 17 years old, is having a vaginal examination. The nurse notes that the cervix is soft and the cervix and vagina has a bluish discolouration. What should the nurse do next? 1) Take a culture for sexually transmitted infections 2) Ask Kaitlyn if she has had rough sexual relations in the past 24 hours 3) Discuss with Kaitlyn the possibility of pregnancy 4) Inquire whether Kaitlyn’s mother used diethylstilbestrol when pregnant 26) 3 Explanation 1. There is no evidence that Kaitlyn has an STI. 2. The bluish discolouration is not related to bruising. 3. The softened cervix and bluish discolouration of the vagina and cervix suggest pregnancy. 4. Diethylstilbestrol may result in granular epithelial patchiness extending from the cervix to the vaginal walls. Diagnosis/Analysis Application Objective – 1, 9 Page – 554 Difficulty – 3
27) A nurse is asked to teach a group of women about Pelvic Inflammatory Disease (PID). What risk factors for PID should the nurse include in her presentation? 1) Use of condoms 2) Frequent douching 3) Limiting the number of partners. 4) Using the birth control pill 27) 2 Explanation 1. Condom use will decrease the risk of PID.
2. Frequent douching may mask the symptoms and push organisms up into the uterus. 3. This may help but it does not prevent having a partner who has had multiple partners. 4. Birth control pill will prevent an unplanned pregnancy but will not prevent sexually transmitted infections. Diagnosis/Analysis Application Objective – 4 Page – 577 Difficulty – 2 28) A nurse is completing a health history on a 21-year-old female client. What is the best question to ask about health practices and health behaviours? 1) “Do you use birth control?” 2) “Have you ever been forced to have sexual relations?” 3) “How do you protect yourself from sexual transmitted infections?” 4) “Do you drink or use drugs?” 28) 3 Explanation 1. This question is about health practices but is a closed question and not the best question to ask. 2. This question deals with the environment. It is also a closed question. 3. This question is about health practices and is an open-ended question that will encourage discussion. 4. This question is closed and not the best type of question to ask. Assessment Application Objective – 3 Page – 555, 559 Difficulty – 2
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 29) A nurse is preparing to assess a female client’s external genitalia. What structures would be included in this examination? (Select all that apply.) 1) Vagina 2) Cervix 3) Clitoris 4) Labia majora 5) Labia minora 29) 3, 4, 5 Explanation: The external genitalia collectively are called the vulva. They include the mons pubis, the labia, the clitoris, the vaginal and urethral openings, and glands. Assessment Application Objective – 1 Page – 550, 551 Difficulty – 1
30) A nurse is preparing to examine the reproductive system of a female client. The nurse would anticipate using which assessment techniques? (Select all that apply.) 1) Inspection 2) Palpation 3) Percussion 4) Auscultation 30) 1, 2 Explanation: The physical assessment techniques of inspection and palpation are used in the examination of the female reproductive system. Planning Application Objective – 6 Page – 562 Difficulty – 1 31) A nurse is preparing to perform an endocervical swab. What equipment will the nurse require to collect this specimen. (Select all that apply.) 1) Microscopic slides 2) Saline 3) Cytobrush 4) Cotton applicator 31) 1, 2, 3 Explanation: The nurse may have all of the equipment listed, but should choose to use the cytobrush rather than the cotton applicator because more endocervical cells adhere to it, thus yielding more accurate results. Planning Application Objective – 7 Page – 569-570 Difficulty – 1
Chapter 23 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) Ms. Delmonte, 30 years old, tells the nurse she has a non-painful lump on her left wrist. The nurse notes a round mass on the back of the wrist. What condition should the nurse suspect? 1) Rheumatoid arthritis 2) Osteoarthritis 3) Ganglion 4) Carpal tunnel syndrome 1) 3 Explanation: 1. In acute rheumatoid arthritis, the wrist, proximal interphalangeal, and metacarpophalangeal joints are likely to be swollen, tender, and stiff. 2. In osteoarthritis the joint cartilage erodes, resulting in pain and stiffness. 3. The findings describe a ganglion, a painless, round, fluid-filled mass that arises from the tendon sheaths on the dorsum of the wrist and hand. 4. Carpal tunnel syndrome is a nerve disorder in which an inflammation of tissues in the wrist causes pressure on the median nerve (which innervates the hand). Diagnosis Analysis Objective – 8 Page – 614 Difficulty – 2 2) What technique is used in assessing the musculoskeletal system? 1) Inspection 2) Conduction 3) Percussion 4) Transillumination 2) 1 Explanation: 1. Physical assessment of the musculoskeletal system requires the use of inspection, palpation and ballottement. 2. Conduction is not used in assessing the musculoskeletal system. 3. Percussion is not used in assessing the musculoskeletal system. 4. Transillumination is used to assess the sinuses. Planning Application Objective – 6 Page – 605, 622 Difficulty – 1
3) Jeremy, 17 years old, is admitted with a dislocated shoulder. He asks the nurse what this diagnosis means. How should the nurse respond? 1) “I cannot tell you without your doctor’s permission.” 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.” 3) 3 Explanation: 1. The nurse does not require permission to answer this question. 2. This is not a muscle tear. 3. Dislocation is a displacement of the bone from its usual anatomical location in the joint. 4. This is an incorrect response as the bone is not fractured. Diagnosis Analysis Objective - 3 Page – 633 (Table 23.5) Difficulty – 2 4) What instruction should the nurse provide the client in order to perform this assessment? 1) Sit down, then stand as the nurse looks from the front of the client 2) Stand, bend forward slowly, then to the right and left while the nurse looks from the back 3) Bend over, stand tall, and stretch arms over the head 4) Lie down on the abdomen so the nurse can look at the back more carefully 4) 2 Explanation: 1. This position will not allow the nurse to see the spine. 2. The spine should appear straight when viewed from the back. The cervical and lumbar spine should appear concave, and the thoracic spine should appear convex. 3. This will not provide the nurse with a full assessment of the spine. 4. This will show the placement of the spine but not movement. Assessment Application Objective – 5 Page – 627, 628 Difficulty – 3 5) A nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. How should the nurse document this finding? 1) Grating 2) Grinding 3) Crepitation 4) Joint noise 5) 3 Explanation: 1. Although this describes the sound it is important to use proper terminology when reporting findings. 2. Grinding does not describe the sounds heard. 3. Crepitation is the proper term when a grating sound is present in a joint. Crepitation results when the joint articulating surfaces have lost their cartilage. 4. The nurse should use medical terminology when charting. Assessment Application Objective – 11
Page – 627 Difficulty – 1 6) A nurse notes a child sitting in reverse tailor position during a well-child examination. What action should the nurse take? 1) Notify the physician so that x-rays can be obtained 2) Explain to the parent that this can cause joint stress 3) Continue with the examination 4) Ask the child if this is a comfortable position 6) 2 Explanation: 1. This position does not indicate a deformity what would require an x-ray. 2. The reverse tailor position stresses the hip, knee, and ankle joints of the growing child. Children should be encouraged to try other sitting positions to prevent these problems, and teaching the parent and the child regarding this is best done at the time the position is noted. 3. This position can place stress on the hip, knee and ankle joins and the nurse should do teaching to the parents. 4. This does not address the fact that this position creates stress on joints. Implementation Analysis Objective – 9 Page – 598, 599 (Figure 23.15) Difficulty – 2 7) A 38-week pregnant client is complaining of lower back pain. The nurse notes a slight lordosis. What action should the nurse take? 1) Tell the client to go on bedrest 2) Notify the physician 3) Document the finding as normal 4) Ask the client if she has been lifting 7) 3 Explanation: 1. The initiation of bedrest is not required for lordosis which is normal in pregnancy. 2. This is a normal occurrence in pregnancy and does not require notification of the physician. 3. During pregnancy estrogen and other hormones soften the cartilage in the pelvis and increase the mobility of the joints. Lordosis is due to compensation for the enlarging uterus, and as the women’s center of gravity shifts forward, her weight shifts farther back on the lower extremities, causing lower back pain. 4. The lordosis is related to a shift in gravity due to the enlarging uterus and not related to lifting. Implementation Analysis Objective – 9 Page – 599 Difficulty – 1
8) What musculoskeletal change would a nurse expect in an elderly client? 1) Difficulty with dexterity 2) Increased bone production 3) Risk for fractures 4) Pain when ambulating
8) 3 Explanation: 1. Difficulty with dexterity is not age related. 2. The elderly have a loss of bone density. 3. Elderly clients are at risk for fractures due to decreased calcium absorption and loss of done density. 4. Pain on ambulation is not age related. Planning Comprehension Objective – 9 Page – 599, 600 Difficulty – 1 9) The client’s chief complaint is numbness and tingling in the hands when interviewed by the nurse. The nurse performs a Phalen’s test which is positive for pain and numbness. What would the nurse conclude from these findings? 1) Arthritis of the wrists 2) Carpal tunnel syndrome 3) Crepitus of the wrists 4) Dupuytren’s contracture 9) 2 Explanation: 1. Arthritis typically causes pain and limitations in movement, but not numbness and tingling. 2. A Phalen’s test is used on individuals with carpel tunnel syndrome. 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’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. Diagnosis/Analysis Analysis Objective – 10 Page – 616, 636 Difficulty – 3 10) A nurse notes a grating sound when examining the knee joint. How should the nurse correctly document this finding? 1) Crepitus 2) Limited motion 3) Knee deformity 4) Atrophy 10) 1 Explanation: 1. Crepitus is a grating sound caused by bone fragments in joints and is suggestive of degenerative disease, trauma, or inflammatory conditions. 2. Limited motion would be documented by describing the inability of the joint to move in the normal ranges. 3. A knee deformity is not conclusive with this information.
4. Atrophy is not conclusive with this information. Assessment Application Objective – 11 Page – 608 Difficulty – 1 11) A nurse notes full range of motion against gravity with full resistance when assessing muscle strength of the upper extremities in a client. How should the nurse document this finding? 1) Poor 2) Normal 3) Fair 4) Good 11) 2 Explanation: 1. Full range of motion without gravity (passive motion) is a 2 or a rating of poor. 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. Assessment Application Objective – 11 Page – 610 (Table 23.3) Difficulty – 2 12) A nurse notes swelling and tenderness of the olecranon process during palpation. The client’s chief complaint is pain upon movement of the forearm and wrist. What conclusion can the nurse draw from these findings? 1) Arthritis 2) Bursitis 3) Epicondylitis 4) Crepitus 12) 3 Explanation: 1. Arthritis will typically produce nontender nodules along the extensor surface of the ulna. The nodules are firm, nontender, and not attached to the overlying skin. 2. Bursitis is the inflammation of the bursae (fluid-filled sacs) that surround joints. The pain of bursitis may limit range of motion of the affected 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. Diagnosis/Analysis Analysis Objective – 8
Page – 611 Difficulty – 2 13) A nurse is palpating the knee of a client and uses firm pressure to stroke the medial aspect of the knee upward while applying pressure to the lateral side and observing the medial side. The client has expressed pain and immobility in the area. What test has the nurse performed? 1) Inspection 2) Ballottement 3) Bulge sign 4) McMurray 13) 3 Explanation: 1. Inspection is a general physical assessment technique, not a specific test. 2. Ballottement is a technique used to detect fluid or detect a floating body. The examiner displaces body fluid and then palpates the return impact of fluid to the structure. 3. The bulge sign is used to detect the presence of small amounts of fluid in the suprapatellar bursa. If there is fluid in the joint, the medial aspect of the knee bulges. 4. The McMurray test is used to assess for tears in the meniscus. With the client supine, flex the knee. With one hand on the medial aspect of the joint and the other on the palmar surface of the foot, rotate the leg externally and fully extend the knee. Assessment Application Objective – 7 Page – 621, 622 Difficulty – 2 14) The client’s chief complaint is pain in the foot. The nurse notes a deviation of the great toe from the midline and crowding of the remaining toes. There is enlargement and inflammation noted in the area. What conclusion can the nurse make from these findings? 1) Pes planus 2) Gouty arthritis 3) Hammertoe 4) Hallux valgus 14) 4 Explanation: 1. In pes planus, or flat foot, the arch of the foot is flattened, sometimes coming in contact with the floor. 2. In gouty arthritis the metatarsophalangeal joint of the great toe is swollen, hot, red, and extremely painful. 3. Hammertoe produces flexion of the proximal interphalangeal joint of a toe, while 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. The metatarsophalangeal joint and bursa become enlarged and inflamed. Diagnosis/Analysis Analysis Objective – 8 Page – 623 Difficulty – 2
15) A nurse asks the client to pull the toes up towards the nose during an examination of the lower extremities. What movement is the nurse assessing? 1) Inversion 2) Plantar flexion 3) Eversion 4) Dorsiflexion 15) 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. Assessment Application Objective – 7 Page – 624 Difficulty – 1 16) A nurse notes an exaggerated lumbar curve while inspecting the spine of a client. How would the nurse document this finding? 1) Lordosis 2) Spinal list 3) Kyphosis 4) Flattened curve 16) 1 Explanation: 1. Lordosis is an exaggerated lumbar curve and is often present in pregnancy, obesity, or other skeletal changes. 2. The spine leans to the left or right in a list, and a line drawn from the T1 vertebrae does not fall between the gluteal cleft. This condition may occur with spasms in the paravertebral muscles or a herniated disc. 3. Kyphosis is an exaggerated thoracic dorsal curve that causes 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. Diagnosis/Analysis Analysis Objective – 11 Page – 625, 634 Difficulty – 1 17) A nurse notes asymmetry of the iliac crests and gluteal folds while inspecting the spine of a client. The client’s spine has a slight curvature to the right, but denies complaints of pain. How should the nurse document these findings? 1) Compression fracture 2) Scoliosis 3) Spinal list 4) Kyphosis
17) 2 Explanation: 1. Compression fractures cause pain, tenderness, and restricted movement. 2. In scoliosis the spine curves to the right or left, causing an exaggerated thoracic convexity on that side. 3. The spine leans to the left or right in a list, and a line drawn from the thoracic one vertebrae does not fall between the gluteal cleft. This condition may occur with spasms in the paravertebral muscles or a herniated disc. 4. Kyphosis is an exaggerated thoracic dorsal curve that causes asymmetry between the sides of the posterior thorax. Diagnosis/Analysis Analysis Objective – 11 Page – 626, 634 Difficulty – 1 18) A nurse asks the client to touch the chest with the chin during the examination. What movement is the nurse assessing? 1) Flexion 2) Hyperextension 3) Lateral flexion 4) Rotation 18) 1 Explanation: 1. Flexion causes a decrease in the angle from the chin to the chest. 2. Hyperextension would cause an increase in this angle, such as looking up toward the ceiling. 3. Attempting to touch each shoulder with the ear on that side would be lateral flexion. 4. Turning the head to face each shoulder would be rotation. Assessment Application Objective – 7 Page – 627 Difficulty – 1 19) What type of bone is the ilium? 1) Short 2) Hollow 3) Flat 4) Irregular 19) 4 Explanation: 1. Short bones include the carpals and tarsals. 2. Bones are not classified as hollow. 3. Flat bones include the parietal skull bone and sternum. 4. Irregular bones include the vertebrae and hips. Assessment Comprehension Objective – 1
Page – 585 Difficulty – 1
20) What bone changes might occur in the elderly client? 1) No bone changes should be noted 2) Increased osteoblastic activity 3) Decreased calcium absorption 4) Increase in bone density 20) 3 Explanation: 1. There are bone changes that occur due to aging. 2. The elderly client will experience reduced, not increased, osteoblastic activity. 3. The elderly will experience decreased calcium absorption. 4. Bone density decreases, not increases, in the elderly. Assessment Application Objective – 9 Page –599, 600 Difficulty – 2
21) A client tells the nurse of pain in the right great toe. The nurse notes hardened nodules on the lateral aspect of the toe, as well as redness and swelling. What conclusion can the nurse make from these findings? 1) Bunion 2) Synovitis 3) Hammertoe 4) Gout 21) 4 Explanation: 1. A bunion is a thickening and inflammation of the bursa of the joint of the great toe causes enlargement of the joint. 2. Synovitis occurs in the knee. 3. Hammertoe results in a flexion of the proximal interphalangeal joint of a toe, while the distal metatarsophalangeal joint hyperextends. 4. The findings describe tophi, which are the hardened nodules associated with the altered purine metabolism of gout. Diagnosis Analysis Objective – 10 Page – 623, 624, 638 (Figure23.64) Difficulty – 2 22) What type of joint is the knee? 1) Saddle 2) Hinge 3) Pivot 4) Plane
22) 2 Explanation: 1. The thumbs are saddle joints. 2. The knee and elbows are hinge joints. 3. The neck is a pivot joint. 4. The intercarpals and intertarsals are plane joints. Assessment Comprehension Objective – 1 Page – 591 (Table 23.1) Difficulty – 1 23) Mr. Grassie tells the nurse he is unable to move his fourth and fifth fingers. The nurse notes severe flexion in both of the affected fingers but there are no complaints of pain from Mr. Grassie. What condition might the nurse suspect based on these findings? 1) Dupuytren’s contracture 2) Carpel tunnel syndrome 3) Bursitis 4) Osteoarthritis 23) 1 Explanation: 1. Dupuytren’s contracture involves inability to extend the fourth and fifth fingers, but is a painless, inherited disorder. 2. In carpel tunnel syndrome the client feels numbness, tingling, and pain in the hands and wrists. 3. Bursitis refers to inflammation of the bursae (fluid-filled sacs) that surround joints. The pain of bursitis may limit range of motion of the affected area. 4. Arthritis typically causes pain and limitations in movement, but not numbness and tingling. Diagnosis/Analysis Analysis Objective – 8 Page – 616, 636 (Figure 23.58) Difficulty – 2 24) Upon inspection of a client’s knee, the nurse notes swelling, heat, and redness of the anterior aspect of the knee. The client reports pain in the area. What condition might the nurse suspect? 1) Degenerative disease 2) Torn meniscus 3) Osteoarthritis 4) Prepatellar bursitis 24) 4 Explanation: 1. Painless swelling frequently occurs in degenerative joint disease. 2. A torn meniscus indicates damage to the structure and produces marked immobility. 3. Osteoarthritis often produces bony ridges or prominences in the outer aspects of the joint. 4. A painful localized area of swelling, heat, and redness in the knee is caused by inflammation of the bursa, or bursitis. Diagnosis/Analysis Analysis
Objective – 10 Page – 620 Difficulty – 2 25) A nurse is completing a health history on a client. What question relates to health behaviours? 1) “Have you ever broken your arm?” 2) “Have you gained any weight in the last year?” 3) “Are you lactose intolerant?” 4) “How many hours a day do you spend on the computer?” 25) 2 Explanation: 1. This question relates to past history. 2. Healthcare behaviours include both health practices and health patterns. Health practices consist of following recommendations for disease prevention, including screening for risks, screening for early detection of problems, and immunization. Health patterns are habits or acts that affect the client’s health. An increase in weight places greater stress on the musculoskeletal system. 3. This question relates to the internal environment. 4. This question relates to work or play – the external environment. Planning Application Objective – 4 Page – 603 Difficulty – 2 26) A nurse is assessing shoulder movement of a client expressing pain. The nurse notes that the client is unable to abduct the right arm without lifting the shoulder. The deltoid muscle of the affected arm appears smaller than that of the other arm. What conclusion can the nurse draw from these findings? 1) Shoulder strain 2) Bursitis 3) Tendinitis 4) Rotator cuff injury 26) 4 Explanation: 1. Shoulder strain may result from overstretching or overuse of the muscle. This may result in pain on movement but will not account for all the findings. 2. The pain of bursitis may limit range of motion of the affected area but will not cause the shoulder to lift when abducting the arm. 3. The inflammation of the tendon results in pain and limitation in movement but will not result in lifting of the shoulders when abducting the arm. 4. The signs, symptoms, and mobility limitations described are those associated with rotator cuff tears. Diagnosis Analysis Objective – 10 Page – 608, 635 (Figure 23.53) Difficulty – 3
27) A nurse is assessing a client who is experiencing wrist pain. Upon examination the pain occurs when resistance is produced against the wrist. What condition can the nurse suspect based on these findings?
1) 2) 3) 4)
Rheumatoid arthritis Bursitis Medial epicondylitis Crepitus
27) 3 Explanation: 1. Rheumatoid arthritis does not yield the symptoms described. 2. Bursitis refers to inflammation of the bursae. The pain may limit range of motion of the affected area. 3. Medial epicondylitis, also called pitcher’s or golfer’s elbow, results from constant, repetitive flexion of the 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. Diagnosis Analysis Objective – 10 Page – 611 Difficulty – 2 28) Daniel, 16 years old, has a possible fractured femur. What finding would support this diagnosis? 1) External rotation of the lower leg and foot 2) Internal rotation of the lower leg and foot 3) Limited hip internal rotation 4) Limited hip external rotation 28) 1 Explanation: 1. External rotation, not internal rotation, of the lower leg and foot is a classic sign of a fractured femur. 2. The foot and leg rotate externally. 3. Limitations of internal rotation in the hip signify inflammatory or degenerative joint diseases. 4. Limitations of external rotation in the hip signify inflammatory or degenerative joint diseases. Diagnosis Analysis Objective – 8 Page – 617 Difficulty – 1
29) A nurse is assessing a client with complaints of back pain, possibly related to sciatic nerve involvement. When would the client experience pain with this diagnosis? 1) Sitting 2) Leg raises 3) Abduction 4) Adduction 29) 2 Explanation: 1. Pain when sitting is not related to sciatic nerve problems.
2. Raising each leg straight up off the bed or table will produce back and leg pain in clients with sciatic nerve disorders, particularly disk herniation. 3. Pain on abduction is not related to sciatic nerve problems. 4. Pain on adduction is not related to sciatic nerve problems. Diagnosis Analysis Objective – 7 Page – 617 Difficulty – 1
30) A nurse is assessing the musculoskeletal system of a client and notes hard knots along the back muscles bilaterally. What would the nurse suspect? 1) Spasmodic torticollis 2) Muscle spasms 3) Scoliosis 4) Compression fracture 30) 2 Explanation: 1. Muscle spasms associated with temporomandibular joint dysfunction may cause spasmodic torticollis, a disorder in which the spasms cause the head to be pulled to one side. 2. Muscle spasms feel like hardened or knot-like formations. 3. The findings described do not support scoliosis. 4. The findings described do not support a compression fracture. Diagnosis Analysis Objective – 10 Page – 627 Difficulty – 2
31) Maddox, 1 week old, is assessed by the nurse. What is a normal finding in Maddox? 1) Forefeet are turned outward 2) Positive Ortolani’s sign 3) Arches in both feet 4) Tibial torsion 31) 4 Explanation 1. The forefeet are turned inward due to position in utero. 2. A positive Ortolani’s manoeuvre indicates Maddox has a dislocated hip. 3. Arches develop during the preschool years. 4. Tibial torsion, a curving apart of the tibias is normal in infants. Diagnosis Analysis Objective – 9 Page – 598 Difficulty – 3 32) What landmark is used to assess the hips?
1) Lesser trochanter 2) Anterior inferior iliac spine 3) Symphysis pubis 4) Ischial tuberosity 32) 2 Explanation 1. The greater trochanter is the landmark used. 2. Landmarks include the iliac crest, the greater trochanter, and the anterior inferior iliac spine. 3. This is not one of the landmarks used. 4. The ischial tuberosity is the rounded bone at the base of the ischium. Assessment Application Objective – 2 Page – 588 Difficulty – 1
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 33) A nurse is preparing to examine the musculoskeletal system of a client. In what order would the nurse conduct this assessment properly? 1) Assess joints for deformities or pain 2) Inspect and palpate the bones 3) Compare the extremities for length and circumference 4) Assess gait and posture 33) 4, 2, 3, 1 Explanation: All are appropriate techniques that need to be performed in the sequence stated. Assessment Application Objective – 7 Page – 605 Difficulty – 3 34) A nurse is assessing a client with suspected rheumatoid arthritis. What musculoskeletal changes would contribute to a positive diagnosis? (Select all that apply.) 1) Ulnar deviation 2) Bouchard’s nodes 3) Heberden’s nodes 4) Swan-Neck deformity 34) 1, 4 Explanation: Ulnar deviation and flexion contractures that include Swan-Neck and Boutonnière deformities are associated with rheumatoid arthritis. Bouchard’s and Heberden’s nodes are associated with osteoarthritis. Diagnosis Analysis Objective – 8
Page – 633 (Table 23-6), 637 (Figure 23.59) Difficulty – 2
35) What should be included in the teaching plan for a client with osteoarthritis? (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 35) 1, 2, 3 Explanation: Smoking and alcohol contribute to the development of osteoporosis, not osteoarthritis. Planning Application Objective – 3 Page – 631, 633 (Table 23-6) Difficulty – 2 36) What is the function of the skeletal muscles? (Select all that apply.) 1) Provide a body framework 2) Provide movement 3) Maintain posture 4) Generate heat 36) 2, 3, 4 Explanation: Skeletal muscle maintains all the functions listed except providing a body framework; bones have this function. Assessment Comprehension Objective – 1 Page – 585 Difficulty –1
Chapter 24 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is assessing a client with Parkinson’s disease. What type of tremors would the nurse observe? 1) Fasciculations 2) Chorea 3) Rhythmic shaking 4) Athetoid movements 1)3 Explanation: 1. Fasciculations are involuntary local muscle twitches. 2. Chorea is the uncontrollable jerking associated with Huntington’s disease. 3. The tremors noted with Parkinson’s disease produce rhythmic shaking of the hands. 4. Athetoid movements are continuous, repetitive, "wormlike" muscular movement seen with cerebral palsy. Assessment Application Objective 10 Page 681 (Table 24.3) and 683 Difficulty = 2 2) A nurse notes that a client has difficulty with ambulation due to an unsteady gait. The client uses a wide base to walk, has uneven steps, and tends to sway. What is the correct term to document this finding? 1) Steppage 2) Scissors 3) Festination 4) Ataxia 2) 4 Explanation: 1. A steppage gait is also called "foot drop" walk. The gait is characterized by a higher-than-usual knee lift resulting in a flopping of the foot. 2. Scissors gait is noted for the stiff, jerky movement where the knees come together and then the legs cross in front of one another. 3. Festination gait is characterized by the stooped posture, small steps, slow to initiate the walk but results in accelerated steps. 4. A walk characterized by a wide base, uneven steps, feet slapping, and a tendency to sway is called an ataxic gait. Assessment Application Objective 10 Page 681 (Table 24.3) Difficulty = 3 3) A nurse is performing the Romberg test on a client. The nurse notes the findings are normal. What client response occurred in this situation? 1) Swayed from side to side 2) Had minimal swaying
3) Gait is smooth 4) Complete loss of balance 3) 2 Explanation: 1. A positive test would indicate the client sways from side to side and may be a sign of disease of the posterior columns of the spinal cord. 2. With a Romberg test slight swaying is expected when the eyes are closed. This is a normal finding and would indicate a negative test. 3. Gait should be smooth but the Romberg test assesses equilibrium not gait. 4. If the client falls or has a complete loss of balance this is not a normal finding and indicates a positive Romberg test. Assessment Application Objective 7 Page 665 Difficulty = 2 4) A nurse is performing a neurological assessment and needs to test cranial nerves. The nurse asks Mr. Li to close both eyes and to report when he feels a wisp of cotton touch his face. What cranial nerve is the nurse assessing? 1) Trigeminal,V 2) Abducens, VI 3) Facial, VII 4) Optic, II 4) 1 Explanation: 1. The trigeminal nerve (V) controls the sensation of pain and touch for the head and face. The cotton wisp is used to assess light touch on the face. 2. The abducens nerve (VI) allows the eyes to move away from the midline of the face. 3. The facial nerve (VII) controls motor function of the face. 4. The optic nerve (II) is responsible for vision. Assessment Analysis Objective 7 Page 657 (Figure 24.9), 644 (Table 24.1), and 681(Table 24.4) Difficulty = 3 5) A client reports that he has hearing loss. A nurse suspects that the client has conductive hearing dysfunction. What test is required? 1) Otoscopy 2) Weber test 3) Rinne test 4) Audiometry 5) 3 Explanation: 1. An otoscope is used to look into the ear canal. It is not used to assess hearing. 2. The Weber test is used to evaluate hearing in a person who hears better in one ear than the other. 3. The Rinne test is used to evaluate conductive (e.g. bone conduction of sound) versus perceptive (e.g. air conduction of sound) hearing loss.
4. Audiometry is the testing of hearing ability. It will determine the client's ability to discriminate between different sounds. Diagnosis Application Objective 6 Page 660 Difficulty = 2 6) A nurse is examining a client experiencing vertigo and wants to perform the Romberg test. What instructions 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, then on your toes again.” 4) “Stand with your feet together, arms at sides, and eyes open.” 6) 4 Explanation: 1. “Touch your finger to your nose alternating hands” is called the finger-to-nose test and is used to assess coordination and equilibrium but is not the Romberg test. 2. “Walk across the room by placing one foot in front of the other, heel to toes” describes tandem walking, which is used to observe gait. 3. “Walk on your toes, then on your heels” is used to observe coordination, balance, and equilibrium. 4. “Stand with your feet together, arms at sides, and eyes open” describes the Romberg test, which is used to determine coordination and equilibrium. Assessment Application Objective 5 Page 665 Difficulty = 2 7) A nurse is reviewing the history and physical on a client and notes a history of syncope. What intervention would the nurse implement for this client? 1) Soft diet 2) Seizure precautions 3) Fall precautions 4) Move from lying to standing slowly 7) 3 Explanation: 1. This intervention will not manage the issues related to syncope. 2. A client with syncope does not have seizures; therefore, this intervention is not applicable. 3. Syncope is a sudden, brief loss of consciousness, and the nurse would need to provide safety for a client experiencing this condition. Fall precautions are important to client safety. 4. This intervention is more appropriate for the client experiencing orthostatic hypotension. Implementation Analysis Objective 10 Page 676 Difficulty = 1
8) A nurse is interviewing a client with suspected Lyme disease. What question would be a priority in this situation? 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?” 8) 2 Explanation: 1. Not applicable in Lyme disease. 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. In Lyme disease a person will experience flulike symptoms and may have a low grade fever but this is not the priority question. 4. This information may be helpful but is not a priority question. Assessment Application Question 4 Page 682 Difficulty = 1 9) A nurse is admitting a client with suspected meningitis. During the assessment, the nurse asks the client to flex the chin down towards the chest. The client verbalizes pain and stiffness during this action. How would the nurse document this finding? 1) Positive Brudzinski's sign 2) Neck strain 3) Nuchal rigidity 4) Decorticate posturing 9) 3 Explanation: 1. A positive Brudzinski's sign occurs when neck flexion causes flexion of the legs and thighs. 2. Neck strain would not present in this particular manner. 3. Nuchal rigidity occurs with meningeal irritation, which will cause pain and neck stiffness. 4. Decorticate posturing is an involuntary flexion or extension of the arms and legs associated with severe brain injury. Assessment Application Objective 11 Page 676 Difficulty = 2 10) A nurse needs to conduct an interview to assess the cognitive status of a client. What would be the most appropriate assessment tool to use? 1) Addenbrooke's Cognitive Examination 2) Dementia Signs and Symptoms Scale 3) Confusion Assessment Method 4) Mini-Mental State Examination 10) 4 Explanation: 1. This tool detects early dementia.
2. This tool assesses behavioural problems. 3. Tests for delirium. 4. This tool is used to assess cognitive status. Assessment Application Objective 4 Page 653 (Table 24.2) Difficulty = 3 11) A nurse is assessing the patellar reflex on a client and obtains no reflexive activity. The client is alert and oriented. What should the nurse do first? 1) Document the findings as normal 2) Notify the physician immediately 3) Look at the medication records for central nervous system depressants 4) Retest the reflex but use a distraction technique with the client 11) 4 Explanation: 1. This is not normal in an alert client. The nurse needs to retest the reflex. 2. Inappropriate action for an alert and oriented client. The nurse needs to redo this test. 3. Most medications will not affect the reflex testing. 4. When absent reflexes are noted in an alert client, the use of distraction may be needed. Assessment Application Objective 8 Page 672 and 674 (Figure 24.39) Difficulty = 1 12) A nurse is interviewing Ms. Davis, who states that she does not have any feeling on the right side of her body. After confirmation of this subjective data, how should the nurse document this finding? 1) Anaesthesia 2) Analgesia 3) Hypalgesia 4) Hypoesthesia 12) 1 Explanation: 1. Anaesthesia is the inability to perceive the sense of touch. 2. Analgesia is the absence of painful stimuli. 3. Hypalgesia is a decreased pain sensation. 4. Hypoesthesia is a decreased, but not absent, sensation. Diagnosis Application Objective 11 Page 668 Difficulty = 1 13) A nurse is performing a neurological assessment on a client and needs to use stereognosis. What instructions should the nurse provide 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.” 13) 2 Explanation: 1. These instructions are for the two-point discrimination test. 2. These instructions are appropriate for assessing stereognosis, the ability to identify an object without seeing it. 3. These instructions are for graphesthesia, the ability to perceive writing on the skin. 4. These instructions could be used to assess how well a client follows commands. Assessment Application Objective 5 Page 670 and 671 Difficulty = 2 14) A nurse performing reflex testing on a client uses the reflex hammer to gently strike the forearm about five centimeters above the wrist. What reflex is being tested? 1) Brachioradialis 2) Biceps 3) Triceps 4) Achilles 14) 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 nurse's nondominant thumb that is placed over the client's bicep tendon. 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. Assessment Application Objective 1 Page 673 (Figure 24.36) Difficulty = 1 15) A nurse has assessed a client and notes diminished reflexes. How should the nurse document this finding? 1) 4+ 2) 3+ 3) 2+ 4) 1+ 15) 4 Explanation: 1. Evaluation of reflex responses uses a scale from 0 to 4+ and a 4+ = hyperactive. 2. 3+ = brisk, above normal 3. 2+ = normal 4. 1+ = diminished Assessment Application
Objective 8 Page 672 Difficulty = 1 16) A nurse notes fanning of the toes when the sole of the foot is stimulated during assessment of the plantar reflex. What is the correct way to chart this finding? 1) Hyperreflexia 2) Babinski response 3) Brudzinski's sign 4) Nuchal rigidity 16) 2 Explanation: 1. Hyperreflexia is an overactive or over responsive reflexes that often indicates upper motor neuron disease. 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. The Brudzinski's sign, flexion of the legs and thighs when the neck is flexed, is used for assessing meningitis. 4. Nuchal rigidity or stiffness of the neck is often present with meningitis. Diagnosis Analysis Objective 11 Page 675 (Figure 24.42) Difficulty = 2 17) A nurse is interviewing a client that reports a loss of smell. How should the nurse document this information? 1) Nystagmus 2) Presbyopia 3) Anosmia 4) Polyneuritis 17) 3 Explanation: 1. Nystagmus is involuntary eye movement. 2. Presbyopia is the diminished ability to focus on near objects that develops with age. 3. Anosmia is the absence of the sense of smell. 4. Neuritis is nerve inflammation. Diagnosis Application Objective 11 Page 655 Difficulty = 1 18) A nurse is performing a neurological assessment on a client experiencing anosmia. What cranial nerve is involved in this problem? 1) Trochlear, IV 2) Trigeminal, V 3) Olfactory, I 4) Oculomotor, III
18) 3 Explanation: 1. Trochlear nerve (IV) controls eye movement. 2. Trigeminal nerve (V) provides sensation to the head and face. 3. Anosmia is the absence of the sense of smell and can be indicative of problems with the olfactory nerve (I). 4. The oculomotor nerve (III) controls eye movement and constricts the pupil. Diagnosis Analysis Objective 1 Page 681(Table 24.4) and 655 Difficulty = 1 19) A nurse is interviewing a client and notes that the left eyelid is drooping. What term should be used to document this finding? 1) Ptosis 2) Nystagmus 3) Strabismus 4) Myopia 19) 1 Explanation: 1. Ptosis, or a dropped lid, is usually related to weakness of the muscles. 2. Nystagmus is the constant 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. Diagnosis Application Objective 11 Page 656 and 683 Difficulty = 2 20) A nurse is assessing a 3-month-old infant and performs the Babinski reflex. The result was dorsiflexion of the great toe and fanning of other toes. What should the nurse do? 1) Nothing this is a normal response until around 2 years of age 2) Call the physician to report this finding 3) Document that the infant has a Babinski reflex 4) Retest the reflex because this is an abnormal result in a healthy infant 20) 3 Explanation: 1. Although this is a normal response the nurse still needs to document the findings of the assessment. 2. Since a Babinski reflex is normal in a 3-month-old infant there is no need to contact the physician. 3. This is a normal response in a young infant and the nurse needs to document the findings of the assessment. 4. Retesting the reflex is unnecessary since the original result was normal for a 3 month old infant. Assessment Application Objective 9 Page 645 and 675 Difficulty = 1
21) A nurse is assessing cranial nerve XI (accessory). What instructions should the nurse provide the client? 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.” 21) 1 Explanation: 1. This is how to correctly assess cranial nerve XI which controls movement of the trapezius muscle (shoulders) and sternocleidomastoid muscle (neck muscle used to flex and rotate the head). 2. This is how to assess the hypoglossal, cranial nerve XII. 3. This is not a technique used to assess cranial nerve function. 4. This is how to assess the olfactory, cranial nerve I. Assessment Application Objective 5 Page 661 (Figure 24.14) and 681(Table 24.4) 22) What piece of equipment is required to assess the abdominal reflexes? 1) Reflex hammer 2) Tongue blade 3) Tuning fork 4) Safety pin 22) 2 Explanation: 1. Although a reflex hammer is used to assess most reflexes it is not used to assess the abdominal reflexes. 2. The tongue blade is used to briskly stroke the abdomen from the lateral aspect toward the umbilicus. 3. The tuning fork is not used to assess the abdominal reflexes. 4. A safety pin would be an inappropriate to use for this reflex examination. Assessment Knowledge Objective 7 Page 676 Difficulty = 1 23) A nurse instructs a client to walk heel-to-toe, then on toes, and finally on the heels. What area of the brain is the nurse assessing? 1) Cerebellum 2) Cerebrum 3) Midbrain 4) Brainstem 23) 1 Explanation: 1. The cerebellum controls coordination, smooth movements, muscle tone, and maintaining equilibrium. The gait assessment provides information on balance, coordination, and smooth movements.
2. The cerebrum is responsible for all conscious behavior and enables the individual to perceive, remember, communicate, and initiate voluntary movements. 3. The midbrain is part of the brainstem. 4. The brainstem controls blood pressure and regulates respiratory rate, depth, and rhythm, as well as vomiting, hiccupping, swallowing, coughing, and sneezing. Assessment Application Objective 1 Page 663 and 664 Difficulty = 1 24) A nurse is completing a health history on an older adult and wants to gather information on health behaviours. What question would elicit this information? 1) "What factors seem to precipitate your headaches?" 2) "Do you require more time to perform tasks today than perhaps 2 years ago?" 3) "Do you use or have you ever used recreational drugs?" 4) "When were you diagnosed with Parkinson's disease?" 24) 3 Explanation: 1. This question provides information on a health concern rather than a health behavior. 2. This question provides information on age related physiologic changes the client may be experiencing. 3. This question will elicit information about the use of illicit drugs and/or social use of drugs and alcohol. This question provides insight into the client's health behaviours. 4. This question elicits information on the client's past health history and not about health behaviours. Assessment Application Objective 4 Page 649 to 650 Difficulty = 2 25) A nurse is observing a client’s ambulation abilities and notes a scissors gait. What disorder should the nurse suspect based on this gait? 1) Parkinson’s disease 2) Multiple sclerosis 3) Alcoholic neuritis 4) Muscular dystrophy 25) 2 Explanation: 1. Festinating gait is typical in Parkinson's disease. 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. Steppage gait is seen in individuals with alcoholic neuritis. 4. Wadding gait is characteristic in advanced muscular dystrophy. Assessment Application Objective 8 Page 681 (Table 24.3)
Difficulty = 3 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is interviewing a client with dysphagia after a recent cerebral vascular accident. How would the nurse assess the function of cranial nerves IX and X? (Select all that apply). 1) Ask client to protrude the tongue 2) Use tongue blade to depress tongue 3) Test gag reflex 4) Observe voice for hoarseness 26) 3, 4 Explanation: 1. This action will test the function of cranial nerve XII (hypoglossal). Although the hypoglossal nerve is used in swallowing and would be assessed in a client with dysphagia this was not asked for in the question. 2. This action would allow the nurse to look more easily into the back of the throat but it will not provide information on the function of cranial nerves IX and X. If the tongue was depressed and the client was asked to say "ah" then this would be an appropriate method for assessing cranial nerves IX and X. 3. Dysphagia, or difficulty swallowing, may be related to dysfunction in the glossopharyngeal (IX) and vagus (X) cranial nerves. Testing the gag reflex provides information on the sensory function of cranial nerve IX and motor function of cranial nerve X. 4. The quality of the voice or hoarseness of the voice is a standard assessment technique used to assess the function of both the IX and X cranial nerves. Diagnosis Analysis Objective 6 Page 660, 661, and 681 (Table 24.4) Difficulty = 3 27) A nurse is assessing a client that experienced a head injury and assigns a Glasgow Coma Scale rating of 3. What would be the client responses to have a score of 3? (Select all that apply.) 1) No response to eye opening 2) No verbal response 3) Pupil response sluggish 4) No motor movement 27) 1, 2, 4 Explanation: The Glasgow Coma Scale (GCS) assesses level of consciousness on a continuum from alertness to coma. The scale tests verbal, eye, and motor responses. The GCS has a maximum score of 15 and lowest possible score is 3. Pupil response is assessed as part of the neurologic assessment with head trauma but is not assessed in the Glasgow Coma Scale. Assessment Application Objective 8 Page 676 and 677(Figure 24.44) Difficulty =1
28) A nurse is caring for an elderly client and has performed a neurological assessment. What age related physiologic change(s) would the nurse anticipate with this client? (Select all that apply.) 1) Total loss of coordination 2) Diminished reflexes 3) Slower movements 4) Decrease in sense of touch 28) 2, 3, 4 Explanation: In general the aging process causes subtle, slow, but steady decrease in neurologic function. Typical aged related physiologic changes are: diminished reflexes, slow movements, muscle mass decreases and senses become less acute. An elderly client should not experience total loss of coordination as part of the normal aging process. Assessment Application Objective 9 Page 645 and 646 Difficulty = 1 29) A nurse is preparing a seminar on Alzheimer’s disease for a group of seniors. What information should be included in this session? (Select all that apply.) 1) Incidence increases with age 2) Causes memory loss and disorientation 3) Occurs more commonly in men 4) May be caused by a virus 29) 1, 2 Explanation: Alzheimer’s disease incidence does increase with age, but women have higher rates of Alzheimer's disease than men do. It is thought to be caused by a mutation in four genes and does produce memory loss, confusion, and disorientation. Planning Application Objective 9 Page 647 and 682 Difficulty = 1 30) A nurse is interviewing a client with a history of seizures. What subjective data would the nurse collect about the origin of the seizures? (Select all that apply.) 1) Alcohol withdrawal 2) Traumatic injury 3) Cerebral vascular accident 4) Infections 30) 1, 2, 3, 4 Explanation: All of the items listed are potential causes of seizures disorders. Assessment Application Objective 4 Page 681 Difficulty = 1
Chapter 25 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is preparing to examine a 13-year-old client brought in by the mother. The child appears uncomfortable throughout the interview and the mother intermittently answers questions directed at the child. What should the nurse do? 1) Ask the child if they would prefer to be examined without the mother present 2) Request the mother to refrain from answering the questions 3) Complete the examination with the mother present 4) Insist that the mother leave the room during the exam 1) 1 Explanation: 1. Children who are at least ten years of age should be given the option of being examined without their parents present. The client is the child, not the parent, and the nurse’s legal and ethical responsibility is first to the child. 2. It is inappropriate to ask the mother to refrain from speaking. She may be able to answer questions the child is unable to. 3. The child has the option whether the mother is present or not. 4. The nurse should not have the mother leave the room unless the child wants her to leave. Implementation Analysis Objective – 5 Page – 699 Difficulty – 2 2) The mother of a 5-year-old child reports “lumps in the child’s neck.” The nurse notes enlarged, nontender, cervical lymph nodes. What action should the nurse take? 1) Obtain a temperature to see if the child is febrile 2) Take a throat culture 3) Explain to the mother this is normal 4) Ask the child if the throat is sore 2) 3 Explanation: 1. This is a normal finding and it is not necessary to take the child’s temperature. 2. There is no evidence to support taking a throat culture. 3. “Shotty” lymph nodes are a normal variant in preschool and school-age children, and are noninfected, non-tender, enlarged nodes that move when palpated. 4. There is no need to ask if the throat is sore. Assessment Application Objective – 1 and 6 Page – 691, 705 Difficulty – 2
3) A nurse needs to assess a child’s gait and range of motion of extremities. What should the nurse ask the child to do? 1) “Would you please do some jumping jacks for me?” 2) “Please hop across the room on one foot, then come back by hopping on the other foot.” 3) “I need you to be a duck; squat and move forward while flapping your arms.” 4) “Let me see you jump in place on both feet.” 3) 3 Explanation: 1. This does not assess gait. 2. This does not assess range of motion. 3. The duck walk involves squatting and moving forward while flapping the upper arms and can be used to evaluate normal range of motion, muscle strength and coordination in a child. 4. This does not assess gait and all aspects of range of motion. Assessment Application Objective – 3 Page – 711 Difficulty – 2 4) A nurse is assessing a newborn and notes that there are six fingers on the left hand. What term would the nurse use to document this? 1) Syndactyly 2) Arachnodactyly 3) Polydactyly 4) Brachydactyly 4) 3 Explanation: 1. Syndactyly is webbed fingers. 2. Arachnodactyly is abnormally long, slender fingers. 3. Polydactyly is the presence of extra fingers. 4. Brachydactyly is shortness of the fingers and toes. Diagnosis Analysis Objective – 9 Page – 711 Difficulty – 2 5) A nurse is assessing a newborn and abducts the hips and palpates the greater and lesser trochanter while flexing the hips and knees at a 90-degree angle. What manoeuvre is the nurse performing? 1) Barlow’s 2) Gower’s 3) Galeazzi’s 4) Ortolani’s 5) 4 Explanation: 1. Barlow’s manoeuvre is performed by adducting the hip while pushing each femur posteriorly. It will assess if the hip will dislocate.
2. Gower’s manoeuvre is the inability to get up from a seated or squatting position without pushing up with the arms. 3. Galeazzi’s manoeuvre compares the length of the left and right femur. The child is supine and the hips and knees flexed and the feet flat on the table. The 4. The procedure described is called Ortolani’s manoeuvre and is used to assess dysplasia of the hip. Diagnosis Application Objective – 4 Page – 712, 713 (Figure 25.18) Difficulty – 3 6) A nurse is examining a newborn and notes that the lateral edges of the eyes are below the level of the ear tops. What action should the nurse take? 1) Perform an otoscopic exam 2) Complete an opthalmoscopic exam 3) Obtain a plastic surgery referral 4) Document and report the findings 6) 4 Explanation: 1. There is no need to assess the ears. 2. There is no indication that an eye examination is required. 3. The nurse would not get a consult with a plastic surgeon. 4. Normally the lateral edge of the eyes should be even with or slightly higher than the upper margin of the ears. Low-set ears are associated with various genetic disorders, including Down’s syndrome, and this finding should be noted and reported. Diagnosis Analysis Objective – 6 Page – 705, 706 Difficulty – 2 7) A nurse is assessing a newborn when the mother asks about the tiny white areas on the forehead and nose. How should the nurse respond? 1) “That is a Morbilliform rash.” 2) “Those are Mongolian spots.” 3) “Those are salmon patches.” 4) “Those are milia.” 7) 4 Explanation: 1. Morbilliform rash, a measles-like rash, is seen in toddlers. 2. Mongolian spots are areas of dark bluish pigmentation and are most commonly found at the base of the spine. 3. Salmon patches, also known as stork bites, are small macules and patches caused by visible intradermal capillaries and are found on the forehead, eyelids, upper lip, nasal bridge, and nape of the neck. 4. Milia are tiny (less than 0.5 mm), smooth, white cysts of the hair follicle found commonly on the forehead and nose at birth. Assessment Application
Objective – 6 Page – 689 Difficulty – 1
8) A nurse notes a bluish discolouration of the hands and feet when examining a newborn infant. What should the nurse do first? 1) Assess the oral mucosa 2) Assess capillary refill 3) Applying a warm blanket 4) Obtain a temperature 8) 1 Explanation: 1. Acrocyanosis, or a bluish discolouration of the hands and feet, is a common finding in newborns and infants during times of stress and exposure to cold environments. The nurse must differentiate this benign finding from true cyanosis by examining the oral mucosa, which is also blue in true cyanosis. 2. Assessing capillary refill is indicated in the event of true cyanosis. 3. Covering the newborn with a blanket does not allow for additional assessments. 4. Taking a temperature would not be indicated as the next action. Assessment Application Objective – 8 Page – 689 Difficulty – 3
9) The mother of a five-year-old child states that the child has to urinate at least twice during a ten-hour night of sleep. What response should the nurse give the mother? 1) “Does the child complain about any urinary discomfort?” 2) “As long as the bed stays dry, don’t worry about it.” 3) “Does the child wear pull-ups, and is the bed padded?” 4) “A five-year-old’s bladder can only hold 90 mL to 210 mL.” 9) 4 Explanation: 1. This is not indicative of urinary dysfunction. 2. The mother needs to be reassured that this is normal. 3. A five-year-old should not need to wear pull-ups. 4. The mother requires reassurance that this is a normal finding for a child of this age. Estimation of a child’s bladder capacity can be done with the following formula: the child’s age (in years) plus or minus 60 mL (2 fl.oz.). Diagnosis Analysis Objective – 1 Page – 694 Difficulty – 3
10) A nurse is interviewing the mother of a healthy six-month-old. The mother reports a continuous watery drainage from the outer aspect of the left eye. How would the nurse document this? 1) Nystagmus
2) Dacryostenosis 3) Strabismus 4) Esotropia 10) 2 Explanation: 1. Nystagmus is an abnormal eye deviation. 2. Dacryostenosis is the congenital blockage of the tear ducts and is a normal variant until nine months of age. It presents with unilateral tearing and non-purulent crusting. 3. Strabismus is a deviation of the eyes. 4. Esotropia is an inward gaze of the eyes. Diagnosis Application Objective – 6 Page – 705 Difficulty – 2
11) A nurse is performing an otoscopic examination of a three-year-old child. What technique would the nurse use while inserting the otoscope? 1) Pull the auricle down and back 2) Pull the tragus down and back 3) Pull the auricle up and back 4) Pull the tragus up and back 11) 2 Explanation: 1. The tragus, not auricle is pulled down and back. 2. In children under the age of four years, the tragus should be pulled down and back while the otoscope is inserted. This allows for the speculum to follow the curve of the auditory canal. 3. The auricle is not manipulated in an otoscopic examination. 4. The tragus is pulled down, not up. Assessment Application Objective – 4 Page – 706 Difficulty – 1 12) A nurse is performing an otoscopic examination in a child and notes the child expressing pain when the tragus is pulled. What should the nurse suspect? 1) Ruptured tympanic membrane 2) Otitis media 3) Otitis media with effusion 4) Otitis externa 12) 4 Explanation: 1. A ruptured tympanic membrane would reveal a small puncture-size hole in an otherwise intact membrane. 2. Otitis media causes an orange-yellow colour change in a normally dull gray tympanic membrane and a decrease in membrane motility.
3. Otitis media with effusion appears with non-purulent fluid in the middle ear space, causing edema in the eustachian tubes. 4. Otitis externa results in pain with pinna manipulation and red, edematous ear canals without purulent discharge. Diagnosis Analysis Objective – 8 Page – 706 Difficulty – 2
13) A nurse is examining a child and notes an erythematous, edematous pharynx, tonsillar exudate, and a reddened tongue with prominent taste buds. There are also petechial hemorrhages on the soft palate. What order should the nurse anticipate? 1) Saline mouth rinses 2) Dental referral 3) Throat culture 4) Aspirin for pain 13) 3 Explanation: 1. Saline mouth rinses will only treat the symptoms and not identify the cause. 2. A dental referral is not indicated. 3. Strep throat infection may cause these symptoms. Confirmation would be obtained by a rapid strep test and culture. 4. Children should not be given aspirin due to the potential risk of Reye’s syndrome. Implementation Analysis Objective – 8 Page – 707 Difficulty – 3
14) A nurse is assessing a child when the mother points out a depression in the lower part of the sternum. How would the nurse correctly document this finding? 1) Pectus carinatum 2) Pectus excavatum 3) Barrel chest 4) Normal sternal border 14) 2 Explanation: 1. Pectus carinatum, also called pigeon chest, causes a bowing of the sternum. 2. Pectus excavatum, also called funnel chest, causes a depression in the lower part of the sternum. 3. Barrel chest, or an increased anterioposterior chest diameter, is seen in infancy, with chronic respiratory disorders and normal aging. 4. A normal sternum does not contain depressions or bowing. Diagnosis Analysis Objective – 9 Page – 707
Difficulty – 1 15) A nurse is assessing heart sounds in a three-year-old child and notes a split S2 sound throughout the cardiac cycle. What action should the nurse take? 1) Auscultate for a bruit 2) Document the findings as normal 3) Palpate the point of maximal impulse 4) Notify the physician 15) 4 Explanation: 1. Auscultation for a bruit is not necessary at this time. 2. Any split S2 sound that persists throughout the cardiac cycle merits further evaluation. A physiological S2 split present with inspiration but that disappears with expiration is often a normal variant in children under age six. 3. Palpating the point of maximal impulse is not necessary. 4. The physician should be notified as the S2 split should not occur throughout the cardiac cycle. Implementation Analysis Objective – 8 Page – 693 Difficulty – 3 16) When discussing the current growth and development expectations with the mother of a 6-month-old infant, the mother states: “We have bought him toys to push and walk behind so it will help him walk sooner.” What should the nurse include in her response? 1) Children develop fine motor skills prior to developing gross motor skills. 2) Children who are encouraged with toys are usually able to walk earlier than expected. 3) Language skills are going to develop prior to physical abilities. 4) Physical abilities follow an expected pattern of growth and development. 16) 4 Explanation: 1. Young children develop in a cephalocaudal growth pattern. They grow and develop physically proximally, then distally. They are able to accomplish fine motor skills only after gross motor skills are mastered. 2. Walking is considered to be a fine motor skill as coordination, balance and muscle strength are needed. Providing toys that are beyond the child’s growth and development range will not produce earlier than normal results. 3. Physical development will advance rapidly in the first year of life, before language skills. 4. The physical growth and development of a child progresses in a set pattern and the child will learn to walk after mastering crawling and cruising. Implementation Analysis Objective – 1 Page – 697 (Table 25-4) Difficulty – 2 17) A nurse determines that nutritional teaching is needed with a family of an 8-month- old infant after the history reveals: the infant is drinking whole milk 3 times a day from a bottle, has table food such as hot dogs with the 2-year-old sibling, and is allowed chunks of fresh unpeeled apple as a reward for good
behaviour. Which part of the data would the nurse be able to support as being correct for a child of this age? 1) Eating the same foods as the sibling. 2) Consumption of whole milk. 3) Is rewarded for good behaviour. 4) Drinking from a bottle. 17) 4 Explanation: 1. The child should not be consuming hot dogs, as they are a choking hazard, even for the 2-year-old sibling. 2. An infant of this age should be consuming commercial, iron-fortified formula or breast milk. Whole milk is introduced, usually in a cup, at one year of age. 3. Rewarding an 8-month-old infant for good behaviour is not typically necessary, especially with a choking hazard such as chunks of fresh, unpeeled apple. 4. The best data reported about this child’s nutritional consumption is that they continue to drink from a bottle. It is unlikely that a child of this age would be able to drink effectively from a cup. Assessment Analysis Objective – 8 Page – 686 (Box 25-1) Difficulty – 3
18) A 13-month-old child is brought to the well-child clinic for a routine exam. After the height and weight are measured, the nurse documents the findings on a growth chart. The child is at the 25th percentile for height and weight. The nurse shares the findings with the mother who asks what treatments are needed for her child. How should the nurse respond? 1) “I will need to look at your child’s height and weight since birth before we can decide if any treatment is needed. “ 2) “Each child needs to be assessed to see if they are growing like everyone else their age.” 3) “When a child’s information is plotted on these charts, we are able to see if they have any nutritional problems.” 4) “We like to measure children at this clinic to see if they have specific health needs.” 18) 1 Explanation: 1. The goal is to utilize the tool to assess growth over time. Growth charts are used to plot many types of objective data such as height, weight, head circumference (up to 36 months) and BMI. This allows a healthcare provider to assess a child’s overall physical growth. The progression of the specific child can be followed with this tool. Standardized growth charts also allow comparison to other children of the same age. 2. The nurse should not compare the child to other children of the same age, because not all children should grow the same. 3. The data revealed by the use of growth charts cannot reveal specific health needs, but an overall growth concern. 4. This response does not address the mother’s concern. Implementation Analysis Objective – 1 Page – 687 Difficulty – 2
19) The parents of a 3-year-old with a history of otitis media ask the nurse why their child continues to have this issue. How should the nurse respond to the parent’s concerns? 1) Children of this age have more frequent colds and upper respiratory infections. 2) The Eustachian tube is longer at this age. 3) This child needs further evaluation of a hearing problem that is causing this. 4) Children of this age often put things in their ears. 19) 1 Explanation: 1. Frequent colds and upper respiratory infections; contribute to the increased incidence of ear infections. Children under 4 years of age are more prone to otitis media, or ear infections, due to several factors. Their external ear canal is narrower and less straight than that of an adult. This allows for bacteria to get trapped more easily. 2. The Eustachian tubes of young children are shorter, straighter and more level than in older children. 3. A hearing problem would not cause the otitis media, but frequent ear infections may result in a hearing problem. 4. Putting objects in the ear is possible, but not typical of children of this age. Planning Application Objective – 2 Page – 691, 716 Difficulty – 2
20) A 2-month-old infant is hospitalized for a severe viral upper respiratory infection. The pulse oximeter is reading 85% and the child is pale. While the nurse is suctioning the nose of the infant with a bulb syringe, the father enters the hospital room and states: “You need to stop that! You are just making him upset!” What information should the nurse discuss with the father? 1) Suctioning nasally will keep the infant from coughing and sneezing as much. 2) The infant should be suctioned nasally and then orally before each feeding. 3) Infants of this age only breathe through their nose, so it must be free of blockage. 4) The infant is in need of oxygen therapy and the nose needs to be free of any discharge. 20) 3 Explanation: 1. Nasal suctioning is not done to decrease coughing. 2. Suctioning prior to each feeding is not required. The need would be assessed individually with each feeding. 3. Infants under the age of 6months are obligate nose breathers, breathing only through their nose, and not their mouth. If an infant with an upper respiratory infection has nasal passages that are blocked, the infant is unable to breathe effectively and respiratory distress may result. The infant with a pulse oximeter reading of 85% and pale skin is in need of intervention to prevent further respiratory distress. Infants do not like to be suctioned with bulb syringes, so they often cry. 4. A determination of the need for supplemental oxygen should be made after the nasal passages are cleared. Implementation Analysis Objective – 2, 8 Page – 692, 707 Difficulty – 3
21) A nurse is performing a complete assessment on a 6-year-old child who was admitted for abdominal pain. When asking about pain, which statement would be expected to elicit the most detailed information? 1) “Can you tell me about your abdominal pain?” 2) “Tell me where your tummy hurts right now.” 3) “Can I feel your tummy and see where it hurts?” 4) “Does your abdomen hurt anywhere right now?” 21) 2 Explanation: 1. The word “abdomen” is unfamiliar to most 6-year-old children. 2. This is an open-ended question and will elicit information on the pain. 3. Asking permission to feel where it hurts may be denied by a child if given this option. 4. This is a close-ended question and does not elicit more detailed information. Assessment Application Objective – 4 Page – 699, 701 Difficulty – 2
22) The nurse has assessed a 7-year-old female. The child has a moderate amount of pubic and axillary hair. The mother states: “I just think she is going through puberty early. I was 10 when I had these changes.” The nurse’s best response would be: 1) “Are her friends experiencing the same changes?” 2) “Your daughter is very young to be having these changes.” 3) “The doctor will probably want you to bring her back for visits every 3 months to monitor these changes.” 4) “You are probably right, since you had these changes early.” 22) 2 Explanation: 1. Whether or not her friends are experiencing the same changes does not address this specific child’s issues. 2. The presence of pubic, facial or axillary hair in a prepubescent child is indicative of endocrinologic disease. The nurse should not give any diagnosis, but alert the mother that this is not a normal finding in a child of this age. 3. It would not be appropriate to simply suggest future monitoring without a current evaluation of the situation. 4. The mother was not necessarily “early” to begin changes at 10 years of age. Implementation Analysis Objective – 6 Page – 694, 704 Difficulty – 2
23) An 18-month-old child is brought to the emergency room with difficulty breathing. The nurse notes the child has stridor, retractions, increased respiratory rate, drooling, and pale, hot skin. What should the nurse do first? 1) Perform a complete physical exam as quickly as possible. 2) Apply oxygen by mask to ease work of breathing. 3) Notify the physician. 4) Apply a pulse oximeter probe to assess saturation level. 23) 3 Explanation: 1. The physical assessment would take time and the child is in respiratory distress. 2. Application of oxygen will not help if the airway is closing. Anything that may upset the child may lead to respiratory arrest. 3. Remaining with the child and notifying the physician is the appropriate initial intervention. This child is exhibiting signs and symptoms of epiglottitis. This is an acute, life-threatening bacterial infection in which the epiglottis is edematous. If the child is agitated and begins to cough, gag or cry, acute respiratory failure may result due to airway occlusion. 4. A pulse oximeter will show a level below the ideal range with the presence of the other signs and symptoms. The physician should be called as respiratory arrest is a possibility. Implementation Analysis Objective – 8 Page – 693, 707 Difficulty – 3 24) Cherise, 15 years old, has been examined by the nurse. Her weight is in the 25th percentile, her teeth are eroding and she has scarring on the dorsal surface on her hands. What action should the nurse take? 1) Ask if she is cutting her hands 2) Inquire about her dental hygiene 3) Ask how Cherise feels about her weight 4) Discuss nutrition to help gain weight 24) 3 Explanation 1. The scarring on the dorsal surface of the hands is due to her teeth when purging. 2. The erosion of the teeth is related to the gastric acid when purging. 3. The findings listed are consistent with bulimia and purging. A discussion about weight may further show that Cherise has an eating disorder. 4. Teaching about nutrition will not be helpful for someone with an eating disorder. Implementation Analysis Objective – 7 Page – 688 (Box 25.2) Difficulty – 3 25) A nurse is teaching a group of new mothers about best practices for bottle feeding. What should the nurse include in the presentation? 1) Sweeten the formula using honey rather than sugar 2) Give no solids until 4 to 6 months 3) Start cow’s milk at 9 months
4) At 1 month start adding cereal to the bottle
25) 2 Explanation 1. Honey before age 1 increase the risk of botulism. 2. Solids should be avoided until after 4 to 6 months of age. 3. Cow’s milk should not be started until after age 1. 4. Solids, like cereal, should not be added to the bottle. Assessment Application Objective – 7 Page – 686 (Box 25-1) Difficulty – 2 26) Julio, 6 months old, is having a physical examination. The nurse notes he grasps a finger when placed in his hand and he turns his head to the side his cheek is stroked on. What conclusion can the nurse make based on these findings? 1) Normal Palmar and Moro reflexes 2) Normal Plantar and Rooting reflexes 3) Palmar and Rooting reflexes should have disappeared 4) Plantar and Moro reflexes should disappear soon 26) 3 Explanation 1. The Moro reflex is also called the startle reflex. 2. The Planter reflex is the curling of the toes when the base of the toes is touched. 3. The Palmar and Rooting reflexes should disappear by 3 to 4 months of age. Persistent primitive reflexes are associated with possible brain trauma. 4. The Moro reflex will disappear by 6 months and the Plantar reflex will disappear by 6 to 8 months. However they are not the reflexes the nurse observed. Assessment Analysis Objective – 8 Page – 696 (Table 25.3) Difficulty – 2 27) Tyler, 5 years old, weighs 15 kg and has a body mass index (BMI) at the 25th percentile. He has a urinary output of 45 mL over the past two hours. What can the nurse conclude from these finding? 1) Normal output for his age 2) Reduced urinary output 3) Normal bladder capacity 4) Underweight 27) 2 Explanation 1. Tyler has a reduced output. 2. Tyler should have an hourly output of at least 60 mL. Normal output in children is 2 mL/kg/h. 3. Tyler’s bladder capacity is 90 to 210 mL (age in years time 30 mL, plus or minus 60 mL).
4. Underweight children would be below the 5th percentile. Assessment Analysis Objective – 7 and 8 Page – 694, 703 Difficulty – 3
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 28) A 6-year-old child is brought to the emergency room after being in a motor vehicle accident. What assessment data, collected in the first 5 minutes of admission to the ER, should be of concern to the nurse? (Select all that apply) 1) Hypotension 2) Occasional heart murmur 3) Bradycardia 4) Continuous crying 28) 1, 3 Explanation: Bradycardia in a child can cause a rapid state of decompensation. The cardiac output would be reduced as it is more dependent on heart rate than stroke volume in a child. Hypotension is a late sign of decompensation in a child and indicates shock. This child is experiencing a life-threatening situation. Crying is a good sign of consciousness. The presence of an occasional heart murmur could be related to injury or could be a pre-injury problem. The fact that it is occasional does not indicate an emergent problem. Assessment Analysis Objective – 8 Page – 693 Difficulty – 2
29) A nurse who is orienting for the first week on pediatrics is ready to do a full assessment and initiation of an intravenous line on a 4-year-old child. What interventions by the nurse would provide a positive outcome? (Select all that apply) 1) Asking the parents to remain with the child 2) Allowing the child to see the intravenous catheter 3) Leaving the child in their hospital room bed to perform the interventions 4) Allowing the child to see the stethoscope and blood pressure cuff 29) 1, 4 Explanation: Allowing a child to see and touch any equipment possible helps to secure cooperation by addressing curiosity and fear of the unknown. The child should not be shown the intravenous catheter in case the first attempt is not successful and the child would see it again. The interventions, when pain is anticipated, should be performed in a place, such as a special procedure room, so that the hospital room and bed can be considered a “safe” and comforting environment. The child will be most comfortable with the parents with them instead of asking them to leave during any situation that is new or painful to the child. Implementation
Application Objective – 3 and 7 Page – 697, 698, 702 Difficulty – 2
Chapter 26 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse is interviewing a primigravida client who is 14 weeks pregnant and reports she has not felt the baby move yet. How should the nurse respond?? 1) “You need an ultrasound.” 2) “Have you lost a baby before?” 3) “We will listen for the heartbeat today.” 4) “Fetal movement does not occur until the 18th week.” 1) 4 Explanation: 1. There is no indication that an ultrasound is required as it is too early for the client to feel fetal movement. 2. This is a closed question and will also increase the client’s anxiety. 3. This does not address the client’s concern. 4. Quickening, the fluttery initial sensations of fetal movement perceived by the mother, usually occurs at approximately 18 weeks. Giving the client this factual information will reduce her anxiety. Implementation Analysis Objective – 3 and 9 Page – 724 Difficulty – 2 2) A nurse is examining a client who is 37 weeks pregnant. What finding requires immediate intervention by the nurse? 1) Patellar reflex +4/+4 bilaterally 2) Weight gain of 1 kg in two months 3) Blood pressure of 124/82 mm/Hg 4) Mild glycosuria 2) 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; 4+ = hyperactive. 2. Weight gain in the second and third trimester is 0.5 kg per month. 3. This is a normal blood pressure. 4. Occasional mild glycosuria is normal in pregnancy. There is not enough information to show this is a problem. Diagnosis Analysis Objective – 8 Page – 747, 749 Difficulty – 2
3) A nurse is preparing a teaching plan for a group of pregnant clients. What should the nurse include in this teaching session?
1) 2) 3) 4)
Double the daily intake of Vitamin A Do not take iron supplements due to constipation Limit salt intake Eat four servings of dairy products daily
3) 4 Explanation: 1. Pregnant women should not double the intake of Vitamin A. 2. Iron is required to prevent anemia. 3. Salt is important for pregnant women and they should salt food to taste. 4. Pregnant women should have 4 or more servings of milk or milk products a day. Evaluation Application Objective – 9 Page – 732, 733 (Table 26-3), 744 Difficulty – 2
4) A nurse is interviewing a female client who reports no menstrual periods for two months and breast soreness. What classification of signs of pregnancy would the nurse document? 1) Objective 2) Positive 3) Presumptive 4) Probable 4) 3 Explanation: 1. Objective is not a classification of signs of pregnancy. 2. Positive signs of pregnancy have no other possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology 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. Probable signs include positive pregnancy test, abdominal enlargement, Piskacek’s sign, Hegar’s sign, Goodell’s sign, Chadwick’s sign, and Braxton Hicks contractions. Diagnosis Application Objective – 7 Page – 735 Difficulty – 2 5) The client reports her last menstrual period (LMP) started on Sept. 28, 2011. What is the EDB using Naegele’s Rule? 1) June 21, 2012 2) July 28, 2012 3) June 5, 2012 4) July 5, 2012 5) 4
Explanation: 1. This date is incorrect. 2. Do not subtract 7 days, they are added. 3. Add the 7 days and then subtract the 3 months) 4. Using Naegele’s Rule to determine EDB, add seven days to the day of the month of the first day of the LMP; then subtract three from the number of the month; then add one year to the year of the LPM if January 1 is passed during the pregnancy. In the situation above: LMP Sept. 28, 2011: Day - 28 + 7 = 35 (or Oct. 5); Month - Oct.(10) - 3 = July (7) ; Year - + 1 = 12 for an EDB of July 5, 2012. Diagnosis Analysis Objective – 4 Page – 736 Difficulty – 3
6) A nurse is examining a client in her third trimester. What finding would require immediate intervention by the nurse? 1) Blood pressure of 148/94 2) Respiratory rate of 26 per minute 3) Pulse of 98 beats per minute 4) Weight gain of .75 kg in a month 6) 1 Explanation: 1. 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. 2. A pregnant client’s respiratory rate will increase slightly due to a decrease in intrathoracic space. 3. The pregnant client’s heart and will increase slightly due to an increased circulatory volume. 4. Weight gain should be .5 kg per month in the second and third trimesters. Diagnosis Analysis Objective – 8 Page – 747 Difficulty – 2 7) A nurse is monitoring a pregnant client in labour and wants to determine the length of time from the beginning of the contraction until the end of the contraction. What is the nurse assessing? 1) Period between contractions 2) Contraction frequency 3) Contraction intensity 4) Contraction duration 7) 4 Explanation: 1. The period between contractions is timed from the end of one contraction to the start of the next. 2. The frequency of the contractions is determined by measuring the interval from the beginning of one contraction to the beginning of the next contraction. 3. Assessing the intensity or strength of contractions is done by palpation. 4. The duration of contractions is measured from the beginning of the contraction until the end of the contraction.
Assessment Application Objective – 6 and 7 Page – 749 Difficulty – 1
8) A nurse is interviewing a client who is 36-weeks pregnant. What statement, if made by the client, would require immediate intervention by the nurse? 1) “I have to use Tylenol for my backaches.” 2) “I am leaking a yellowish fluid from my breasts.” 3) “I have to get up during the night to void.” 4) “I have not felt the baby move today.” 8) 4 Explanation: 1. Tylenol is appropriate for the back pain that accompanies third trimester pregnancy. 2. Leaking of breast fluid is colostrum, a normal finding. 3. Due to the pregnant uterus crowding the bladder, urinary frequency is also common. 4. The fetal alarm signal occurs when no fetal movement has been noted in the past eight hours, there are fewer than ten movements in twelve 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. Immediate evaluation of the fetus should take place. Diagnosis Analysis Objective – 10 Page – 750 Difficulty – 3
9) A nurse is performing a pelvic examination on a client who is 20 weeks pregnant and notes a white, odourless discharge from the vagina. What action should the nurse take? 1) Document the findings as normal 2) Obtain a culture of the discharge 3) Ask the client about vaginal discomfort 4) Inquire about recent sexual intercourse 9) 1 Explanation: 1. During pregnancy it is normal for vaginal secretions to be increased, white, and odourless, also called leukorrhea. 2. This is a normal finding and does not require a culture of the discharge. 3. Leukorrhea is normal in pregnancy. 4. Recent sexual intercourse did not cause this discharge. Diagnosis Application Objective – 8 Page – 725, 754 Difficulty – 2
10) A nurse is assessing a postpartum client and notes the perineal pad has whitish-yellow discharge. How would the nurse document this? 1) Lochia rubra 2) Lochia serosa 3) Lochia blanca 4) Lochia alba 10) 4 Explanation: 1. The initial lochia rubra is dark red and has a fleshy odour. 2. Next the discharge becomes pinkish and is called lochia serosa. 3. There is no lochia blanca. 4. When the discharge becomes whitish-yellow and is called lochia alba. Diagnosis Application Objective – 11 Page – 734 Difficulty – 1
11) A nurse examines a client and notes the cervix is soft in texture and nontender during the pelvic examination. What term would the nurse use to document this finding? 1) Chadwick’s sign 2) Piskacek’s sign 3) Hegar’s sign 4) Goodell’s sign 11) 4 Explanation: 1. Chadwick’s sign is the appearance of a bluish-purple colouration of the cervix due to vascular congestion. 2. Piskacek’s sign is when the shape of the uterus becomes irregular due to the implantation of the ovum. 3. Hegar’s sign occurs throughout pregnancy and is the softening of the region that connects the body of the uterus and the cervix. 4. During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodell’s sign. Diagnosis Application Objective – 11 Page – 725, 758 Difficulty – 1 12) A nurse is assessing the fundal height of a pregnant client and notes the fundus is halfway between the symphysis pubis and the umbilicus. How many weeks is the client pregnant? 1) 12 2) 16 3) 20 4) 24
12) 2 Explanation: 1. At 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. At about 20 weeks the fundus reaches the umbilicus. 4. At 24 weeks it is above the umbilicus. Diagnosis Application Objective – 8 Page – 724 Difficulty – 2 13) A nurse is assessing a client in the third trimester of pregnancy and notes a yellowish discharge from both breasts. What action should the nurse take? 1) Document the findings as normal 2) Obtain a culture of the discharge immediately 3) Notify the physician 4) Ask the client if she is pumping her breasts 13) 1 Explanation: 1. Colostrum, a yellowish, specialized form of early breast milk, is produced starting in the second trimester. This is a normal finding. 2. The discharge is colostrum and does not need to be cultured. 3. It is not necessary to notify the physician. 4. A client in the third trimester would not be pumping her breasts. Diagnosis Application Objective –7 and 8 Page – 726, 748 Difficulty – 1
14) A nurse is performing a vaginal examination on a female client and notes the cervix is a bluish-purple colour. How should the nurse document this finding? 1) Chadwick’s sign 2) Hegar’s sign 3) Goodell’s sign 4) Leukorrhea 14) 1 Explanation: 1. Chadwick’s sign appears is the bluish-purple colouration of the cervix due to vascular congestion. 2. Hegar’s sign is the softening of the region that connects the body of the uterus and the cervix. 3. Vascularity of the cervix contributes to the softening of the cervix, and is called Goodell’s sign. 4. Leukorrhea is a profuse, non-odourous, non-painful, vaginal discharge. Diagnosis Application Objective – 11 Page – 725, 754 Difficulty – 1
15) A postpartum client tells the nurse she has an ugly mass of red streaks all over her abdomen. How should the nurse respond? 1) “Over time they will become silvery in colour and be less noticeable.” 2) “They will disappear in a few weeks.” 3) “I am sure they are not so bad.” 4) “That is the price you pay for having a baby.” 15) 1 Explanation: 1. Striae gravidarum, stretch marks, will fade and become silvery in colour. 2. Stretch marks do not disappear. They fade to a silvery colour. 3. This is not addressing the clients concern. 4. This does not address the client concern about the streaks. Implementation Analysis Objective – 1 and 3 Page – 728 Difficulty – 2
16) Alana, 15 years old, is 28 weeks gestation. She tells the nurse she is worried about gaining 6.5 kg to this point in her pregnancy. How should the nurse respond? 1) “I understand why you feel that way.” 2) “Your weight gain is slightly less than recommended for this stage in your pregnancy.” 3) “Perhaps you should begin to watch your intake more closely.” 4) “Your weight gain is somewhat more than we recommend.” 16) 2 Explanation: 1. The nurse should not confirm having the same feelings as Alana. 2. Alana is presenting with a weight gain less than recommended for this stage of gestation. 3. This is not an empathetic response. 4. The weight gain is less than recommended. Implementation Analysis Objective – 3 and 10 Page – 747 Difficulty – 2
17) A client, 11 weeks gestation, a hemoglobin level of 110 g/L. What action should the nurse take? 1) Contact the physician to assess the client’s need for additional prenatal vitamin supplements. 2) Record the results as required by agency policy. 3) Make a dietary consultation to provide education geared toward improving intake to meet the nutritional demands of the pregnancy. 4) Call the client and remind her to take the prenatal vitamin supplements are prescribed. 17) 2 Explanation: 1. There is no need to contact the physician.
2. As a result of hemodilution in early pregnancy, the woman’s hemoglobin level is decreased in the first trimester. 3. There is no evidence that the client is eating inappropriately. 4. There are no indications the client is not taking the prescribed iron supplements. Implementation Application Objective – 1 and 8 Page – 723 (Table 26-2), 732 (Table 26-3) Difficulty – 2
18) While completing a health history, a pregnant client reports taking daily herbal supplements. What initial action is indicated by the nurse? 1) Encourage the client to speak with the physician about the herbal supplements. 2) Record the client’s reports on the permanent medical record. 3) Advise the client to reduce the amount of supplements taken to allot for the prescribed prenatal vitamins being taken. 4) Instruct the client to increase the supplements to promote nutritional wellbeing. 18) 1 Explanation: 1. Herbal supplements are not regulated. They should be avoided during the pregnancy. If taken, it should only be under the recommendation of the physician. 2. Although the client’s reports are to be noted in the medical record, it is not the initial action by the nurse. The nurse’s documentation must also include the client’s response and type of supplements being ingested. 3. It would not be appropriate to condone the use of herbal supplements during pregnancy. 4. Increasing the supplementations may endanger the fetus. Implementation Analysis Objective – 4 Page – 745 Difficulty – 2
19) A client who is 38 weeks pregnant reports she has been experiencing urinary frequency. How should the nurse respond? 1) “I will need to check your blood sugar as polyuria is associated with gestational diabetes.” 2) “We will notify the physician.” 3) “This is normal.” 4) “You likely have a urinary tract infection.” 19) 3 Explanation: 1. Urinary frequency is seen in late pregnancy. There is no other indication that the client has gestational diabetes. 2. It is unnecessary to notify the physician of a normal finding. 3. The pressure of the pregnant uterus results in frequent urination during the third trimester. In the absence of other information, this is the most correct response. 4. There are no indications the client has an infection or a urinary tract infection. Implementation
Application Objective – 10 Page – 730 Difficulty – 2 20) A nurse has completed the health history of a pregnant client. The nurse documents that the client is multigravida. What does this term mean? 1) Pregnant with twins 2) Was pregnant previously 3) Had a previous delivery 4) Pregnant for the second time 20) 2 Explanation 1. Multigravida does not refer to multiple gestation. 2. A multigravida is a woman who is pregnant with her second or subsequent pregnancy. 3. Gravida refers to number of pregnancies and does not provide information about the outcome. 4. There is not enough information to support this answer. Diagnosis Application Objective – 7 Page – 724 Difficulty – 1 21) A client at 33 weeks gestation calls the clinic and reports she was attempting to nap when she became dizzy and felt faint. What assessment data should be collected by the nurse first? 1) The position the client was in during the nap period 2) Dietary intake prior to the episode 3) No additional data as this appears to be an isolated incident 4) History of gestational hypertension 21) 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 are not indicated. 3. The nurse must investigate the complaints to ensure client safety 4. These symptoms are due to hypotension. Assessment Application Objective – 10 Page – 728 Difficulty – 2 22) A 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 amount of empty calories and of red meat consumed while significantly increasing intake of fish, poultry and fresh fruits and vegetables. What action is indicated by the nurse? 1) Notify the physician about the client’s risky dietary choices.
2) Refer the client to a dietitian for counseling. 3) Investigate the specific types of meats being eaten. 4) Take no action as the client’s actions are healthful. 22) 3 Explanation: 1. Dietary education is within the scope of nursing practice and the client’s behaviors do not warrant further action at this time. 2. It is premature to consult with the dietitian. 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. 4. 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. Evaluation Analysis Objective – 4 Page – 744 Difficulty – 3 23) Ms. Pasichnyk is 24 weeks pregnant. What test needs to be done in the next month? 1) 50 gm glucose test 2) Maternal serum triple screen 3) Ultrasound 4) Group B Streptococcus 23) 1 Explanation 1. This test is done between 24 and 28 weeks gestation. 2. This test should have been done between 15 and 20 weeks gestation. 3. An ultrasound is normally done at 16 to 40 weeks. 4. This test is done at 35 to 37 weeks gestation. Assessment Application Objective – 3 Page – 732, 733 (Table 26.3) Difficulty -2
24) A client has been diagnosed with Group B Streptococcus at 33 weeks gestation. The client becomes tearful when the diagnosis is discussed. She asks what will be done next. What information should be provided to the client? 1) IM antibiotic treatment to facilitate a rapid cure 2) Treatment will begin after delivery 3) Oral antibiotics to be taken over the next 7 weeks. 4) IV antibiotics when in active labour. 24) 4 Explanation: 1. Intramuscular antibiotics are not indicated for this infection.
2. Treatment after delivery is too late. 3. Oral antibiotics are not indicated for this infection. 4. Group B Streptococcus is treated when the client goes into active labour. The treatment involves IV antibiotics. Implementation Application Objective – 1 and 3 Page – 732, 733 (Table 26.3) Difficulty – 1 25) During a prenatal counseling session a client indicates concern about her potential HIV positive status. The client states she does not want to “jinx” the pregnancy by getting tested because if she is positive so is the baby. How should the nurse respond? 1) “Even if you do test HIV positive, preventative treatments have a good chance of providing protection for your baby.” 2) “You are right to avoid the stress of finding out you are HIV positive during the pregnancy.” 3) “As long as you do not breastfeed and have a cesarean section, your baby will be protected.” 4) “If you are HIV positive, your baby will also have HIV.” 25) 1 Explanation: 1. 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. 2. If the client is positive treatment will protect the baby. 3. Although breastfeeding and a cesarean section delivery will reduce the rate of transmission, they are not 100% effective tools of prevention. 4. A client who is HIV positive does not mean the baby will be positive if the client receives treatment during pregnancy. Analysis Objective – 3 Page – 732, 733 (Table 26.3), 740 Difficulty – 2 26) The client who is 5 weeks gestation is seen in the Emergency Room with severe abdominal and pelvic pain. A vaginal examination reveals tenderness and a palpable mass near the uterus. What can the nurse anticipate will take place first? 1) The client will be sent home on bed rest. 2) An ultrasound will be ordered. 3) The client will be evaluated in the labour and delivery department with a nonstress test. 4) The client will be admitted to the acute care facility for observation. 26) 2 Explanation: 1. Sending the client home without a thorough evaluation could result in rupture of the ectopic and place the client at great risk. 2. The client is presenting with manifestations consistent with an ectopic pregnancy. The ultrasound will be used to assist in confirming the diagnosis. 3. The client’s gestational age is not yet advanced enough to utilize a nonstress test for evaluation. 4. Observation may be indicated if the ectopic pregnancy is ruled out.
Assessment Analysis Objective – 10 Page – 764 (Table 26.6) Difficulty – 2
27) A nurse is completing the health history on a client who is pregnant with her second child. What question should the nurse ask about her previous pregnancy? 1) “Was your labour over 3 hours long?” 2) “What method of birth control have you used?” 3) “How did you feel about your first pregnancy?” 4) “Did your mother have problems with her blood pressure when pregnant?” 27) 3 Explanation: 1. This is a close-ended question related to the previous pregnancy but does not open conversation. 2. This question relates to past gynecological history. 3. This is an open-ended question that will encourage the client to talk about her first pregnancy. 4. This question relates to family history. Assessment Application Objective – 4 Page – 738 Difficulty – 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 28) A pregnant client reports concern about the development of reddish marks on her abdomen and breasts. The client asks about having a cream prescribed to help them disappear. What information should be included in the teaching provided to the client regarding this inquiry? (Select all that apply.) 1) The stretch marks will fade but not disappear. 2) The marks will lighten to a silvery tone after pregnancy. 3) Cocoa butter lotions and creams will clear the marks completely. 4) The cream will help the skin stay supple. 28) 1, 2, 4 Explanation: Striae gravidarum are known as stretch marks. They commonly occur during pregnancy. They 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. There is no need for a prescription cream. Over the counter preparations can be used to keep the skin soft and supple. Planning Application Objective – 1 Page – 728 Difficulty – 2 29) A nurse is preparing to assist the physician perform an abdominal and fetal assessment on a client who is pregnant. Identify in order the correct steps that will be included in the process. 1. Assess fundal height
2. Allow the client to void 3. Inspect the abdomen 4. Palpate the abdomen 29) 2, 3, 4, 1 Explanation: The client must be allowed to void. Performing the abdominal examination will be uncomfortable if the bladder is distended. Further, the findings will be inaccurate. During an abdominal assessment, visual inspection is completed before palpation. Palpation is the initial means to determine fundal height. Assessment Analysis Objective – 5 Page – 746 Difficulty – 1 30) What are the landmarks used to determine fundal height in a pregnant client in the last trimester of pregnancy? (Select all the apply) 1) Inferior edge of the symphysis pubis 2) Fundus 3) Umbilicus 4) Superior edge of the symphysis pubis 30) 2, 4 Explanation After 20 weeks gestation the distance from the superior edge of the symphysis pubis to the top of the fundus is a way to estimate to gestational age of the fetus. The fundal height in centimeters should equal the gestational age in weeks. Assessment Application Objective – 2 Page – 725, 727 (Figure 26.5), 749 Difficulty – 1 31) What shunts are seen in the fetus? (Select all that apply) 1. Umbilical artery 2. Ductus Arteriosus 3. Foramen ovale 4. Umbilical vein 5. Ductus venosus 6. Ventricular septal shunt 31) 2, 3, 5 Explanation The foramen ovale, ductus arteriosus and ductus venosus are three shunts that allow the fetus to maximize the oxygenated blood received from the mother. The umbilical vessels are not shunts within the fetus. A ventricular septal defect is a heart anomaly. Assessment Application Objective – 1 Page – 724, 726 (Figure 26.4) Difficulty – 1
Chapter 27 MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) A nurse notes edema in bilateral knees in an elderly client. The client has complaints of joint stiffness and pain upon awakening. What disorder would the nurse suspect based on this data? 1) Rheumatoid arthritis 2) Osteoarthritis 3) Gouty arthritis 4) Tendonitis 1) 2 Explanation: 1. Rheumatoid arthritis produces the same symptoms, but is more likely to be seen in younger adults. 2. Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain. 3. Heat, redness, swelling, and pain on movement of joints is an indication of gouty arthritis. 4. These symptoms are not related to tendonitis. Diagnosis Analysis Objective 8 Page 790 Difficulty 2 2) A nurse is assessing deep tendon reflexes in an elderly client and notes that the brachial and patellar reflexes are 2+ bilaterally on the 0 to 4+ scale. What would the nurse do next? 1) Document the findings as normal 2) Perform additional neurological assessments 3) Inquire about the client’s medication regimen 4) Check past medical history 2) 1 Explanation: 1. Reflexes normally diminish with aging; therefore no additional subjective or objective data is required at this time. 2. This is not necessary because diminished reflexes are part of the normal aging process. 3. The diminished reflexes are a normal finding; therefore a review of the medications is not required. 4. Unnecessary with a normal assessment finding Assessment Application Objective 7 Page 792 Difficulty 1 3) A nurse is interviewing an elderly client who is concerned about “bumps on my body.” Moist, brownish, wart-like lesions are noted on the client's neck and chest. What condition would the nurse suspect? 1) Actinic keratoses 2) Acrochordons
3) Seborrheic keratoses 4) Cherry angiomas 3) 3 Explanation: 1. Actinic keratoses are normal aging growths that are red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp. 2. Acrochordons, also called skin tags, are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids. 3. Seborrheic keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back. 4. Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk. Diagnosis Analysis Objective 6 Page 796 Difficulty 2 4) A nurse is examining the oral cavity of an elderly client with concerns of mouth soreness. Red, cracked skin is noted at each corner of the mouth. How should the nurse document this finding? 1) Periodontal disease 2) Herpes infection 3) Cheilitis 4) Dehydration 4) 3 Explanation: 1. Periodontal disease presents with redness, spongy swelling of the gums, and recession of the gums from the teeth. 2. Herpetic infections cause vesicular lesions. 3. Cheilitis, also called angular stomatitis, is seen in persons with poorly fitting dentures, or persons who are not swallowing saliva well due to stroke or muscular weakness, and can also be caused by candida infection. 4. A dry, red tongue with longitudinal furrows indicates dehydration. Diagnosis Analysis Objective 9 Page 796 Difficulty 1
5) A nurse is presenting information on the wear -and -tear theory of aging to her colleagues. What statement is consistent with this theory? 1) "Longevity and healthy aging is due to the chromosomal differences between people." 2) "Strands of DNA that should remain separate are linked together causing cell death." 3) "Highly reactive molecules damage cellular components but antioxidants can neutralize these effects." 4) "Healthy behaviours have a positive effect by protecting cells and allowing cells to repair themselves." 5) 4
Explanation: 1. This is the genetic theory of aging. 2. This is the cross-linkage theory. 3. This describes the free radical theory. 4. This is the wear-and-tear theory. Assessment Knowledge Objective 1 Page 768 Difficulty 2 6) A nurse is interviewing Mr. Douglas, 78 years old, who reports painful sores that start on the left side of his back and cross over to the left side of his abdomen. What condition would the nurse suspect? 1) Ecchymoses 2) Purpura 3) Petechiae 4) Herpes zoster 6) 4 Explanation: 1. Ecchymoses is bruising. 2. Purpura is latin for purple. Purpura is caused by bleeding underneath the skin resulting in red or purple discolourations on the skin. 3. Petechiae are small pin point bruises. 4. Herpes zoster, also commonly called shingles, yields painful, red, vesicular or pustular lesions that may be in a line or in patches on the thorax, front or back. Diagnosis Analysis Objective 6 Page 782 Difficulty 1 7) A nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and straight in appearance. What would the nurse do next? 1) Document the findings as normal 2) Observe the red reflex 3) Repeat the visual screening test 4) Obtain an ophthalmology referral 7) 1 Explanation: 1. Age related changes in the eyes include narrower and straighter vessels, which should be documented as normal. 2. No additional assessments are required because this is a normal finding in the elderly. 3. The vessels of the eye are normal; therefore, vision screening is unnecessary. 4. A physician referral is not necessary at this time. Diagnosis Application Objective 7 Page 785 Difficulty 2
8) A nurse is examining the eyes of an elderly client using the ophthalmoscope. The vessels of the eyes are narrow and tapered in appearance. What would the nurse do next? 1) Inquire about a history of diabetes 2) Document the findings as normal 3) Check for past history of hypertension 4) Assess PERRLA 8) 3 Explanation: 1. The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages. 2. This finding is not a normal finding. 3. Narrowing and tapering of the arterioles are abnormal findings and are seen in hypertensive disease; thus the nurse must obtain additional information about previous disease and/or compliance with prescribed regimen. 4. The assessment of PERRLA is used to evaluate changes in intracranial pressure; therefore, this is unnecessary at this time. Diagnosis Analysis Objective 6 Page 785 Difficulty 2 9) The daughter of an elderly client reports that her father has a decrease in hearing ability. The nurse suspects a conductive hearing loss due to the presence of dried cerumen in the ear canal. How would the nurse validate this finding? 1) Examine the external ear 2) Perform the Weber test 3) Perform the Rinne test 4) Complete the whisper test
9) 2 Explanation: 1. Cerumen cannot always be visualized by external ear examination. 2. Excessive cerumen may cause a conductive hearing loss in the elderly due to dryness and inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the good ear or equal in both ears if hearing is diminished bilaterally. 3. The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction. 4. Performing the whisper test is not a relevant action at this time. Diagnosis Analysis Objective 5 Page 785 and 786 Difficulty 3 10) A nurse is interviewing an elderly client who reports mouth dryness and “tunnels” on the tongue. What condition would the nurse suspect? 1) Fungal infection
2) Vitamin deficiency 3) Leukoplakia 4) Dehydration 10) 4 Explanation: 1. A dark red, swollen tongue with white or yellow patches is a sign of a fungal infection, commonly experienced after antibiotic administration in the elderly. 2. A bright red tongue may be indicative of vitamin B1 or C deficiency. 3. Leukoplakia, thickened white patches in the mouth, is caused by irritations, such as poor-fitting dentures or tobacco products. 4. A dry red tongue with longitudinal furrows may indicate dehydration in the elderly. Diagnosis Analysis Objective 6 Page 783 Difficulty 3 11) A nurse is interviewing an elderly client and notes several soft, yellow plaques on the eyelids at the inner canthus. What term would be used to document this finding? 1) Xanthelasma 2) Pterygium 3) Presbyopia 4) Pingueculae 11) 1 Explanation: 1. Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems. 2. Pterygium is an opacity of the bulbar conjunctiva that can grow over the cornea and block vision. 3. Presbyopia is nearsighted vision due to lens changes. 4. Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. Diagnosis Application Objective 9 Page 770 and 796 Difficulty 2 12) A client, 68 years old, tells a nurse that he is experiencing erectile dysfunction since starting on a new medication. The nurse reviews the client's medication profile. What drug classification has the most potential to cause this problem? 1) Antidepressant 2) Analgesic 3) Antiarrhythmic 4) Anti-inflammatory 12) 1 Explanation: 1. Antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants all have erectile dysfunction as a side effect.
2. Analgesics are not known to have this side effect. 3. A beta blocker, antihypertensive can cause erectile dysfunction but antiarrhythmics do not. 4. Anti-inflammatory medications do not have this side effect. Evaluation Analysis Objective 8 Page 774 Difficulty 2 13) A nurse is assessing the vital signs of an elderly client and obtains a temperature of 36 degrees celsius. What action would the nurse take? 1) Provide warm fluids to the client 2) Ask the client if the room is too cold 3) Document the finding as normal 4) Apply warm blankets to the client 13) 3 Explanation: 1. The client's temperature is normal so this is an unnecessary action. 2. The nurse wants to ensure that the examination room temperature is comfortable but the client' body temperature is normal so there is no need to alter the room temperature. 3. The body temperature in older adults is lower than those of younger clients. The mean temperature is 36.2 degrees celsius. The temperature described is within normal limits for an elderly client and requires no further assessments or interventions by the nurse. 4. The client does not require blankets because the temperature is normal. Diagnosis Application Objective 3 Page 781 Difficulty 1 14) A nurse hears a bruit when auscultating the right carotid artery of an elderly client. What would the nurse do next? 1) Obtain a surgical consult 2) Assess for jugular vein distention 3) Document the findings as normal 4) Auscultate the heart for murmurs 14) 4 Explanation: 1. Further assessment is not required and a physician is responsible for making referrals to medical specialists. 2. Assessment of jugular vein distention is not relevant at this time 3. A bruit is not a normal finding. 4. Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. Diagnosis Analysis Objective 6 Page 784
Difficulty 1 15) A nurse is assessing an elderly client who reports a chronic cough. Upon auscultation, crackles are detected bilaterally in both lower lobes. These sounds do not clear when asked to cough. What condition would the nurse suspect? 1) Pneumonia 2) Emphysema 3) Pulmonary fibrosis 4) Pulmonary edema 15) 4 Explanation: 1. Scattered or discrete rales can be due to alveolar or small airway exudates. 2. Emphysema produces diminished breath sounds. 3. Course, loud rales may be signs of pulmonary fibrosis, seen in people with long-standing lung disease. 4. Crackles that extend upward and do not clear with cough suggest pulmonary edema. Diagnosis Analysis Objective 6 Page 786 Difficulty 2
16) A nurse is performing an assessment on a 70-year-old client. The nurse notes that there is "cupping" of the optic disc and the eyeballs are rock hard. What condition would the nurse suspect? 1) Cataracts 2) Glaucoma 3) Hypertension 4) Diabetic retinopathy 16) 2 Explanation: 1. Cataracts would present with black spots in the red reflex and cloudiness over the iris and pupil. 2. Cupping of the disc and rock hard orbits are indicators of glaucoma. 3. Narrowing and tapering of the arterioles occurs with hypertensive disease. 4. Small red spots (punctate hemorrhages) or creamy round lesions (exudate) are seen in diabetic retinopathy. Assessment Application Objective 6 Page 785 Difficulty 2 17) During a health teaching session with Mrs. Samuelsson, who has no natural teeth, the nurse recommends that the client make an appointment with a dentist for a routine check up. The client asks the nurse why this is important since she has no teeth. What statement by the nurse is most appropriate? 1) “It is important to assess you for mouth cancer.” 2) “Although you do not have natural teeth, you are still at risk for disorders affecting the gums.” 3) “You will need to be evaluated for dentures.” 4) “You are probably right, no dental care is needed.”
17) 2 Explanation: 1. There are no indications the client is at a heightened risk of oral cancer. 2. The client without natural teeth is still at risk for gingivitis and periodontal disease. It is important for clients without teeth to have regular dental care. 3. Although the client may benefit from dentures, it is not the primary reason for recommending dental care. 4. This is an inappropriate response because the client does need to see a dentist. Implementation Analysis Objective 4 Page 770 Difficulty 1 18) During a routine physical examination, a 66-year-old client reports feeling tired. She asks what is wrong with her. What is the best initial action by the nurse? 1) Encourage the client to alter their evening routine to reduce stressors. 2) Encourage the client to begin to take a short nap each day. 3) Assess the client’s sleep patterns. 4) Ask the physician to prescribe a sleeping pill. 18) 3 Explanation: 1. Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation. 2. Not all clients are candidates for napping. 3. The client’s sleep habits will need to be investigated. If they are inadequate, action will be warranted. 4. It is inappropriate for the nurse to make recommendations to the physician concerning a prescription when the nurse has not completed an assessment of the client's sleep habits.. Assessment Analysis Objective 4 Page 773 Difficulty 1 20) Mr. Basso who has a lengthy history of arthritis, reports to the physician’s office for a routine physical examination. Mr. Basso reports his skin has become fragile and has experienced skin tears with little trauma inflicted. Which statement by the nurse is most appropriate? 1) “Tell me what medications you are taking.” 2) “There is nothing you can do for this problem.” 3) “You may not have been aware of the amount of stress the skin was under when it became injured.” 4) “The skin changes you report are a normal part of aging.” 20) 1 Explanation: 1. The elderly client who has a history of arthritis may be taking corticosteroids. Long term use of corticosteroids is associated with tearing and bruising of the skin. 2. It is not appropriate for the nurse to dismiss the client’s concerns. 3. It is not appropriate for the nurse to dismiss the client’s concerns.
4. Although the skin becomes increasingly fragile with aging, the client’s complaints must still be evaluated. Diagnosis Analysis Objective 6 Page 782 Difficulty 2 21) A 76-year-old client presents to the ambulatory care clinic with concerns consistent with influenza. During the interaction, the nurse notes the client appears unkempt. The client’s hair is uncombed and the clothing appears too large. What would the nurse do next? 1) Document the findings. 2) Engage the client in a discussion regarding dietary practices. 3) Contact social services. 4) Report the findings to the physician. 21) 2 Explanation: 1. The findings must be documented but should be done after the interaction is finished. 2. The client who appears dishevelled may be experiencing periods of altered cognition. Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for these problems can best be assessed by conversation between the client and nurse. 3. There is no evidence at this point that social services needs to be involved. 4. There is no need to consult with the physician at this juncture of the interaction. Assessment Analysis Objective 4 Page 771 and 782 Difficulty 1 22) A 76-year-old client, presents with a tremor associated with Parkinson's disease. How would the nurse document this tremor? 1) Head bobbing consistent with a senile tremor 2) A resting tremor 3) Dystonia 4) A pin-rolling tremor of the hand 22) 4 Explanation: 1. This is not a tremor associated with Parkinson's disease. 2. A resting tremor diminishes with a willed movement whereas in Parkinson’s disease the tremor worsens with purposeful movement. 3. Dystonia has sustained muscle contractions that cause twisting and repetitive movements or postures. 4. The classic tremor in Parkinson’s is called pin-rolling. Assessment Analysis Objective 9 Page 791 Difficulty 2
23) A client reports to the Emergency Room with concerns consistent with a fractured hip. The client reports sitting down on the toilet seat and feeling the bone snap. The client asks how this could have happened. What information can be provided by the nurse? 1) “You should discuss this with your physician.” 2) “There is no good explanation for what has happened to you.” 3) “Unfortunately, this may signal a serious underlying health problem.” 4) “The body’s bones become increasingly brittle and lose density with aging.” 23) 4 Explanation: 1. Although the client should be encouraged to speak with the physician, the nurse should attempt to meet the client’s needs for immediate education. 2. This is not a helpful statement and may increase the client's anxiety about what happened. 3. The client’s fracture may simply be a normal adverse effect associated with aging. 4. The body’s bones have an increasing loss of density with aging. It is related in part to hormone levels. Fractures can result with little stress. Implementation Application Objective 2 Page 774 Difficulty 1 24) A client who is seen in the clinic for a routine blood pressure assessment states they have been experiencing the normal pain associated with aging. What statement by the nurse is most therapeutic? 1) “Normal aging can be quite painful.” 2) “Tell me more about your pain and discomfort.” 3) “Do you take medications for the discomfort you are experiencing?” 4) “You must have osteoarthritis.” 24) 2 Explanation: 1. Normal aging does not have to be filled with pain 2. Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated. The nurse will need to ask an open-ended question to obtain additional assessment data. 3. Asking about pharmacological therapies being utilized to manage a condition is a part of the assessment; however, it is closed-ended question and will not provide the most information. 4. It is inappropriate and beyond the scope of practice of the nurse to make a diagnosis. Assessment Analysis Objective 4 Page 775 and 778 Difficulty 1 25) A nurse notes a faint murmur while auscultating Mr. Carlson's apical pulse. He is 66 years old and reports no history of heart problems. Which statement is most correct? 1) Mr. Carlson is presenting with the normal changes of aging 2) The client had an underlying heart disorder 3) The client has clinical manifestations associated with aortic calcifications 4) The client is demonstrating mitral calcifications
25) 1 Explanation: 1. Faint murmurs are common in older clients. They are related to decreased cardiac muscle tone. 2. Loud murmurs are associated with underlying cardiac disease. 3. Clicks and snaps are associated with aortic calcifications. 4. When a calcified mitral valve opens the nurse will hear a click or snap not a murmur. Diagnosis Analysis Objective 3 Page 787 Difficulty 2 SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question. 26) A nurse is discharging a client with stress incontinence. The nurse would correctly include which of the following management techniques in the teaching plan? (Select all that apply.) 1) Perform pelvic muscle exercises 2) Limit fluid intake to four glasses a day 3) Void on a regular schedule 4) Maintain an ideal body weight 5) 1, 3, 4 Explanation: 1. Loss of muscle tone and stretching of the perineal muscles through childbirth are contributing factors to stress incontinence. Performing pelvic muscle exercises will help to improve muscle tone. 2. Fluid intake should include eight to ten glasses of non-caffeinated fluid a day, limiting intake only in the evening hours. 3. Voiding on a regular schedule will help to keep the bladder empty and prevent urine leakage. 4. Obesity is a contributing factor to stress incontinence. Implementation Analysis Objective 2 Page 773 Difficulty 1 27) A nurse is planning an educational program for new nurses regarding health care needs for the elderly. What should be included in the nurse’s planning? (Select all that apply.) 1) Depression is a common problem for the elderly. 2) Pneumonia is a significant health issue for older adults. 3) Falls are the most common type of injuries experienced by older adults. 4) Influenza vaccines should be given to most elderly clients. 27) 1, 2, 3, 4 Explanation: 1. Depression is often related to the presence of serious health disorders, financial concerns, and isolation. Depression is a major concern with older adults 2. Pneumonia has a significant impact on morbidity and mortality in the older adult. 3. Falls are the most common injuries for older adults and represents a significant safety issue 4. Influenza vaccines are recommended for the majority of older adults. Planning Application
Objective 2 Page 778, 774, and 770 Difficulty 1