Test Bank for Nursing Health Assessment A Clinical Judgement Approach 4th Edition.

Test Bank For Nursing Health Assessment A Clinical Judgment Approach 4th Edition

by SHARON JENSEN

Chapter 01: The Nurse's Role in Health Assessment 1. What is one of the broad goals within nursing?

A. To provide cost effective care B. To form broad nursing diagnoses C. To promote self-care D. To treat human responses ANS: D Feedback: Four broad goals are within nursing: (1) to promote health (state of optimal functioning or well-being with physical, social, and mental components); (2) to prevent illness; (3) to treat human responses to health or illness; and (4) to advocate for individuals, families, communities, and populations. The other options listed are not broad goals. Nursing, focuses on promoting health; while cost-effective care is strived for, is not a part of the broad goal, therefore, this is not a broad goal within nursing.

Nursing looks to develop specific nursing diagnoses, not broad. Promoting self-care is important, but does not correctly answer the question.

PTS: 1 REF: p. 4 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What do nursing activities that promote health and prevent disease accomplish? (Select all that apply.)

A. Reduce the risk of disease B. Maintain optimal functioning C. Reinforce good habits D. Optimize self-care abilities E. Create home care safety ANS: A, B, C Feedback: Nursing activities that promote health and prevent illness reduce the risk of disease, reinforce good habits, and maintain optimal functioning. They do not optimize self-care abilities or create home care safety.

PTS: 1 REF: p. 4 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Select 3. The purpose of a health assessment includes what? (Select all that apply.)

A. Identifying the client's major disease process B. Collecting information about the health status of the client C. Clarifying the client's ability to pay for health care D. Evaluating client outcomes E. Synthesizing collected data

ANS: B, D, E Feedback: Health assessment is "gathering information about the health status of the client, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating client care outcomes" (AACN, 2008).

While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are not to identify the client's major disease process or ability to pay.

PTS: 1 REF: p. 6 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 4. The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

A. How much time the nurse has B. The seriousness of a client's condition C. The client's cooperation D. Onset of current symptoms ANS: B Feedback: Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms. The data collected during a physical assessment do not depend on how much time the nurse has, how cooperative the client is, or the onset of the current symptoms.

PTS: 1 REF: p. 7 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

A. To establish a database against which subsequent assessments can be measured B. To establish rapport with the client and family C. To gather information for specialists to whom the client might be referred D. To quantify the degree of pain a client may be experiencing ANS: A Feedback: A health assessment is performed to gain further insight into the current condition and to establish a database that subsequent assessments can be measured against.

PTS: 1 REF: p. 7 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. How do nurses facilitate the achievement of high-level wellness with a client?

A. Encouraging the client to keep appointments B. Providing the client information on alternative treatments C. Promoting health in the client D. Providing good client care ANS: C Feedback: High-level wellness is a process by which people maintain balance and direction in the most favorable environment. The role of nurses is to facilitate this achievement through health promotion and teaching. Nurses do not facilitate the achievement of high-level wellness by encouraging clients to keep appointments, providing information on alternative treatments, or providing "good" client care.

PTS: 1 REF: p. 6 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Choice 7. The nurse is caring for a client who, on the continuum between wellness and illness, is moving toward illness and premature death. How would the nurse know this to be true?

A. The client stops doing wellness-promoting activities B. The client develops signs and symptoms C. The client begins exercising D. The client verbalizes anxiety over the cost of medications ANS: B Feedback: The person who moves toward illness and premature death develops signs, symptoms, and disability, which, unfortunately, is when most treatment occurs in the current health care system. The client may stop doing wellness-promoting activities and not tell the nurse of this fact, which makes "The client stops doing wellness-promoting activities" incorrect. "The client begins exercising" is incorrect because a client who begins exercising is moving toward wellness, not illness. "The client verbalizes anxiety over the cost of medications" is incorrect because the verbalization of anxiety over financial matters is not an indication of illness.

PTS: 1 REF: p. 6 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Choice 8. A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?

A. Rationale B. American Nurses Association recommendations C. Physical assessment skills D. Diagnostic reasoning

ANS: D Feedback: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.

PTS: 1 REF: p. 16 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

A. Diagnostic reasoning B. Physical assessment C. Critical thinking D. Nursing care plan ANS: C Feedback: Nurses are frequently involved in complex situations with multiple responsibilities. They are required to think through the analysis, develop alternatives, and implement the best interventions. Critical thinking is the key to resolving problems.

Diagnostic reasoning is important in developing diagnostic statements, not in caring for multiple clients with complex care needs. Physical assessment is important in the building the foundation of the nursing care plan. The nursing care plan directs the care that will be provided for the individual client, but does not address the needs of caring for multiple clients.

PTS: 1 REF: p. 8-9 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?

A. Nursing process B. Diagnostic reasoning C. Critical thinking D. Community care map ANS: A Feedback: The nursing process serves as a framework for providing individualized care not only to individuals but also to families and communities. Diagnostic reasoning, critical thinking, and community care maps are not frameworks for providing individualized care to a community.

PTS: 1 REF: p. 7 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 11. What are the types of nursing assessments? (Select all that apply.)

A. Physical B. Focused C. Mental D. Emergency E. Comprehensive ANS: B, D, E Feedback: Three types of nursing assessments are common: emergency, focused, and comprehensive. Physical and mental assessments are areas addressed in the various types of nursing assessments.

PTS: 1 REF: p. 9 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Select 12. A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment?

A. Circulatory assessment B. Assessment of the airway C. Complete health history D. Disability assessment ANS: C Feedback: The comprehensive assessment includes a complete health history and physical assessment. It is done annually on an outpatient basis, following admission to a hospital or long-term care facility, or as defined in a facility's standards of care in the acute care setting. Circulatory assessment, assessment of the airway, and disability assessment are part of an emergency assessment.

PTS: 1 REF: p. 10 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A. A focused assessment covers the body head to toe, unlike a comprehensive assessment B. A focused assessment occurs only in the clinic area, unlike a comprehensive

assessment C. A focused assessment involves all body systems, unlike a comprehensive assessment D. A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment ANS: D Feedback: A focused assessment is based on the client's issues. This type of assessment can occur in all settings, including the clinic, hospital, and home health. It usually involves one or two body systems and is smaller in scope than the comprehensive assessment but is more in-depth on the specific issue(s). The comprehensive assessment includes a head-to-toe evaluation.

PTS: 1 REF: p. 10 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 14. A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?

A. Patient centered B. Subjective C. Unconfirmed D. Objective ANS: D Feedback: The physical assessment follows the history and focused interview and includes objective data, which are measurable. Subjective data are gathered during the health history and generally provided by the client. All data collected regardless of method should be client centered. Unconfirmed data is common and will be evaluated through diagnostic studies regardless of how it was obtained.

PTS: 1 REF: p. 13 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 15. The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?

A. Functional status B. Data focusing on the client complaint C. A focused assessment of the client complaint D. Family history for the past three generations ANS: A

Feedback: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Data must be included information other than the client complaint. Family histories generally go back only to grandparents, not great-grandparents.

PTS: 1 REF: p. 12 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. What does the Health Insurance Portability and Accountability Act (HIPAA, 1996) regulate?

A. Who will provide client care B. Privacy of information C. How insurance information is obtained D. Where a chart can be stored ANS: B Feedback: HIPAA regulates the security and privacy of information. It does not regulate who will provide client care, how insurance information is obtained, or where a chart is stored.

PTS: 1 REF: p. 13 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 17. The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

A. Body systems B. Head to toe C. Functional D. Focused ANS: C Feedback: A functional assessment focuses on the patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, coping and stress tolerance, sexuality and reproduction, and values and beliefs (Gordon, 1987). The body systems, the focused nor the head to toe assessment addresses the holistic needs of the client. The roles and relationships of the client would not be included in these assessment PTS: 1 REF: p. 13 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process

BLM: Cognitive Level: Apply

NOT: Multiple Choice

18. A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data. The instructor is teaching about which type of assessment?

A. Body systems B. Comprehensive C. Head to toe D. Emergency ANS: A Feedback: A body systems approach is a logical tool for organizing data when documenting and communicating findings. This method promotes critical thinking and allows nurses to analyze findings as they cluster similar data. The comprehensive assessment is more encompassing in nature, including more aspects that the body systems approach. The head-to-toe assessment does not look at promoting critical thinking and clustering, rather going through a process to organize data in a logical fashion. The emergency assessment involves a life-threatening or unstable situation PTS: 1 REF: p. 15 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?

A. Body systems B. Functional C. Focused D. Head to toe ANS: D Feedback: The head-to-toe method is efficient and provides more modesty for clients.

The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client.

PTS: 1 REF: p. 14 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

20.

The nurse has completed a client's health history and physical assessment. Which of the above assessment findings will require follow-up?

A. abdomen B. oral mucosa C. bowel sounds D. level of consciousness ANS: A Feedback: Nurses constantly make treatment decisions to manage and coordinate care.

The nurse must be able to communicate findings and refer clients to other health care providers after appropriate assessments are made. In this case, the radial pulse, oral mucosa, bowel sounds, and level of consciousness are expected findings, while the distended abdomen will require follow-up.

PTS: 1 REF: p. 4 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 1: The Nurse's Role in Health Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

Chapter 02: Health History and Interview 1. A nursing instructor is talking about nonverbal communication with the nursing class.

The instructor explains that facial expressions should be what?

A. Happy B. Inquisitive C. Relaxed D. Detached ANS: C Feedback: Facial expressions should be relaxed, caring, and interested. Facial expressions that are happy, inquisitive, or detached can interfere with the therapeutic communication process.

PTS: 1 REF: p. 24 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 2. A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

A. Seated in a chair at eye level with the client B. Sitting on the side of the bed, looking down at the client C. Leaning on the nightstand at eye level with the client D. Standing beside the bed, looking down at the client ANS: A Feedback: To facilitate optimal eye contact, the nurse needs to be at eye level with the client. Those who stand while clients are in bed will be taller than clients, assuming a position of power. Thus, the nurse should be seated in a chair at eye level with clients who are in bed during interviews. Leaning on the nightstand and sitting on the bed do not promote therapeutic communication or professionalism.

PTS: 1 REF: p. 24 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 3. A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate phrase for the nurse to use to clarify the expression's meaning from the client?

A. "Tell me what you mean by ________?"

B. "I think that expression means ____________."

C. "That expression is unclear to me."

D. "Where did you hear that expression?"

ANS: A

Feedback: Clarification is important when the client's word choice or ideas are unclear.

For example, the nurse states, "Tell me what you mean by _____." Another way to clarify is to ask, "What happens when you _____?" Such questions prompt clients to identify other symptoms or give more information so that the nurse better understands.

The nurse can also use clarification when the client's history of illness is confusing.

Asking where the client heard the expression is not an appropriate response to help clarify the expression. The nurse thinking or believing the expression means something does not clarify the true meaning of the expression with the client. The nurse stating that the expression is unclear does not clarify the meaning with the client.

PTS: 1 REF: p. 26 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 4. The client tells the nurse that he is sorry he fell off the roof and broke his leg. The nurse responds by saying, "Oh, you poor thing! I am sorry you fell off the roof and broke your leg, too." What type of response is this?

A. Empathetic B. Therapeutic C. Sympathetic D. Supportive ANS: C Feedback: Sympathy is feeling what a client feels from the viewpoint of the nurse. When the nurse is being sympathetic, the nurse is interpreting the situation as the nurse perceives it. The nurse's response is incorrect to the situation. The nurse should be supportive, therapeutic, and empathetic in response to the client's situation.

PTS: 1 REF: p. 26 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A nurse is preparing to admit a new client to the unit and is reviewing the client record chronologically. In what phase of the interview process are the nurse and the client?

A. Pre-interaction B. Beginning C. Working D. Closing ANS: A

Feedback: In the pre-interaction phase, the nurse reviews the record chronologically to detect patterns of illness, such as declining functional status, and to identify how things fit together. Beginning, working and closing are all phases in the interview process. The beginning phase occurs when introductions are exchanged, creating a safe and relaxed environment for the interview to occur. The working phase is the phase where data, both subjective and objective, are collected. The closing phase is when a summary of the interview session occurs, allowing the client to ask any questions or verbalize any concerns.

PTS: 1 REF: p. 31 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment.

Why would it be inappropriate to use the sister as an interpreter for this client?

A. The sister may not tell the client exactly what the nurse says B. The client's sister may not understand medical terminology C. The sister may not be there every time the nurse needs to talk to the client D. The client may not want the sister to know their private information ANS: D Feedback: Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because clients may not want to share personal information with others. HIPAA guidelines address privacy issues such as this scenario. Even when the client gives permission for the family member to be present, an official interpreter should be present per facility policy. The other options could be true in some situations, but the priority answer addresses privacy, both the client's right to privacy, and the facility's handling of private information.

PTS: 1 REF: p. 30 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 7. A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

A. "Is your spouse living with you?"

B. "Are you living with your spouse?"

C. "Do you live alone or with someone?"

D. "Are you married, divorced, or widowed?"

ANS: C

Feedback: An inclusive, sensitive, and ultimately better question by which to determine the client's marital status is, "Do you live alone or with someone?" This phrasing provides a more direct avenue for finding out about support at home. The other options list questions that would not be the most appropriate question to ask the client about their marital status since they make assumptions or limit possible answers.

PTS: 1 REF: p. 31 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. A pediatric nurse, working in a community health clinic, is about to start an interview with a school aged child. What is the most appropriate way to address this child and the accompanying adults?

A. Call the child by their legal name and refer to the parents as Mr. and Mrs. B. Call the child by their first name and ask the parents how they prefer to be addressed C. Call the child by their first name and refer to the parents as Mr. and Mrs. D. Call the child by their full name and refer to the parents as "mom" and "dad" ANS: B Feedback: The nurse should refer to children by their first names and ask the adults what name they prefer for address. The nurse avoids calling parents "mom" or "dad" to maintain professional communication. Referring to the adults as Mr. and Mrs. is making an assumption that may not be correct.

PTS: 1 REF: p. 42 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. When dealing with a client who has impaired hearing, what interventions should the nurse implement to facilitate lip reading?

A. Speak louder than usual B. Exaggerate your lip movement C. Sit closer than normally to the client D. Speak much more slowly than usual ANS: C Feedback: The nurse sits closer to the client with hearing impairment to facilitate a setting for lip reading. The nurse uses regular speech volume and lip movement but may speak slightly more slowly.

PTS: 1 REF: p. 43 OBJ: 1 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice

10. Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do?

A. Assess the degree to which the client perceives the cultural beliefs B. Assess how acculturated the client is C. Know the mores of the culture D. Know his or her own cultural beliefs ANS: A Feedback: The nurse should avoid assuming clients follow cultural beliefs and assess the degree to which each individual perceives those beliefs. Knowing the mores of the culture and the nurse's own cultural beliefs are important, but do not answer the question at hand. The nurse would have difficulty assessing how acculturated the client is within the client's cultural beliefs.

PTS: 1 REF: p. 29 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 11. In what way would a nurse indicate to a client that the client's concerns are not worth discussing?

A. By being empathetic B. By providing false reassurance C. By being sympathetic D. By giving unwanted advice ANS: B Feedback: Providing reassurance is not a therapeutic response, because by providing reassurance the nurse unconsciously indicates to clients that their concerns are not worth discussing. Empathy is a therapeutic response to a client and is a positive interaction.

Being sympathetic and giving unwanted advice are nontherapeutic responses, but they do not tend to imply that the client's concerns are not worth discussing.

PTS: 1 REF: p. 26 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze NOT: Multiple Choice 12. The nurse is gathering a complete history of the client's present illness. The nurse knows that the most appropriate way to begin to gather this information is what?

A. Assessing the client's vital signs B. Gathering a complete list of the client's medications C. Asking open-ended questions D. Asking focused questions ANS: C

Feedback: The nurse collects information about the present illness by beginning with open-ended questions and having the client explain symptoms. The most appropriate way to collect data about the present illness is not to assess the client's vital signs, gather a complete list of the client's medications, or ask focused questions.

PTS: 1 REF: p. 33 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. A clinical instructor is discussing with a clinical group how to take a history of the client's present illness. A student asks how to best guide the interview. What would be the instructor's most appropriate answer?

A. Follow the cues of the client during the interview B. Use a written checklist to make sure you cover all necessary areas C. Use a head-to-toe approach to make sure you do not miss anything D. Use a focused approach, asking only about symptoms of the present illness ANS: A Feedback: Regardless of the order of data, the nurse guides the conversation following the cues of the client and uses a mental checklist to ensure that he or she has assessed all categories before the end of history taking. The nurse would not use a written checklist during the interview, and the nurse would not use a head-to-toe approach when eliciting information about the present illness. The nurse also would not focus only on the symptoms of the present illness.

PTS: 1 REF: p. 33 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 14. When using Gordon's framework for a functional health assessment, the nurse asks a client, "Have you made any changes in your environment because of vision, hearing, or memory decrease?" What functional health pattern is the nurse assessing?

A. Vision B. Hearing C. Coping D. Cognition ANS: D Feedback: A question to include in review of cognition and perception is whether the client has made any environmental changes because of vision, hearing, or memory decrease. The options of vision or hearing individually would not be complete as a response. The option of coping is not addressed in the question posed by the nurse.

PTS: 1 REF: p. 36 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview

KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. The nurse is caring for an older adult client and is reviewing information obtained in the health history assessment. The nurse knows that it is important to identify the pattern of illnesses and recognize how they might be related because of what factor?

A. Client is hospitalized B. Client presents as being stoic C. Client is of advanced age D. Client is chronically ill ANS: C Feedback: It is important to identify the pattern of the illnesses and recognize how they might be related as the client is an older adult. The question does not state that the client is in the hospital, stoic, or chronically ill.

PTS: 1 REF: p. 43 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 16. The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?

A. To remember the elements that are important to assess with a symptom B. To remember the parts of a focused assessment C. To remember the order of the assessment D. To remember how to document assessment findings ANS: A Feedback: Some providers use a mnemonic to remember the elements that are important to assess for the presenting symptom. OLDCARTS is one example and stands for onset, location, duration, character, associated/aggravating factors, relieving factors, timing, and severity. OLDCARTS does not help a nurse remember the parts of a focused assessment, order of assessment, or how to document findings.

PTS: 1 REF: p. 33 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 17. During the admission process, the client states, "I am allergic to sulfa drugs." How would the nurse verify this information?

A. Ask family members B. Ask the physician C. Ask the client about the response to the allergen D. Compare against the client's medical records

ANS: D Feedback: Allergies are verified with clients and compared against their medical records.

When asking about allergies, the nurse notes the type of response such as rash, throat swelling, difficulty breathing, or anaphylactic shock. It is not appropriate to ask either family members or the physician about allergies that the client may have. Asking the client about reactions to an allergen is part of the assessment; it is not to verify the allergy information.

PTS: 1 REF: p. 35 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 18. A new client is admitted to the clinic. The nurse assesses how the effects of health or illness affect the client's quality of life. What type of assessment is this nurse performing?

A. Comprehensive B. Functional C. Emergency D. Focused ANS: B Feedback: Functional health patterns are especially important to nursing because they focus on the effects of health or illness on a client's quality of life. The emergency assessment is urgent in nature, addressing an emergent issue at hand. The comprehensive assessment is detailed in nature, not focusing specifically on the impact of the illness on the client's quality of life. The focused assessment addresses a particular issue or concern, not looking at the impact of the issue or concern on the client's quality of life.

PTS: 1 REF: p. 35 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 19. When a client responds to a question with a "yes" or "no" answer, what appropriate responses by the nurse encourage the client to elaborate? (Select all that apply.)

A. Yes B. I see C. Um hum D. Go on E. Okay ANS: A, C, D Feedback: These responses encourage clients to say more and continue the conversation.

They show clients that the nurse is interested. The nurse may nod the head or say "Um hum," "Yes," or "Go on" to cue clients to keep talking. Responses of "I see" and "Okay" do not encourage elaboration by the client and are therefore incorrect.

PTS: 1 REF: p. 26 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Select 20. What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

A. Asking the client if they are wearing a hearing aide B. Using pre-written cards that state the interview questions C. Closing the door may help to limit background noise.

D. Introducing hand gestures whenever it is appropriate ANS: C Feedback: Closing the door may help to limit background noise, making it easier for the client to hear. Not all clients with minimal hearing loss wear hearing aids. Pre-written questions and hand gestures are interventions reserved for those diagnosed with severe hearing limitations.

PTS: 1 REF: p. 43 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 21. Student nurses are practicing taking comprehensive health histories from one another.

Which statement(s) by the pretend client should be included as data in the comprehensive health history? (Select all that apply.)

A. "I started coughing a week ago."

B. "My right upper abdomen hurts."

C. "The pain has lasted for more than six days."

D. "The pain is sharp."

E. "I've followed my normal diet all week."

ANS: A, B, C, D Feedback: Location, duration, intensity, description, aggravating factors, alleviating factors, and functional impairment are components of a comprehensive health history.

What was eaten for the last several days does not fall into the definition of a comprehensive health history.

PTS: 1 REF: p. 33 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Select 22. The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?

A. Works in the service industry

B. Lives in a high-income household C. Has a history of low blood pressure D. Eats a diet low in carbohydrates ANS: A Feedback: Health disparities that came to the forefront during the COVID-19 pandemic included underrepresented groups and people living in low-income households who were more likely to work in the service industries that remained open during the pandemic.

Having high income, low blood pressure, and a diet low in carbohydrates are not factors associated with increased risk for COVID-19.

PTS: 1 REF: p. 228-231 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 2: The Health History and Interview KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 03: Assessment Techniques, Safety, and Infection Control 1. What tool does the nurse use to auscultate the client's abdomen?

A. None B. Fetoscope C. Otoscope D. Stethoscope ANS: D Feedback: The nurse uses a stethoscope to perform auscultation, in which movements of air or fluid are heard in the body over the lungs and abdomen. A fetoscope is used to hear the fetal heartbeat. An otoscope is used to view portions of the ear.

PTS: 1 REF: p. 61 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. When caring for clients in any health care environment, what is the most important technique for preventing infection?

A. Sterile technique B. Standard precautions C. Hand hygiene D. Use of gloves ANS: C Feedback: The single most important action to prevent infection is hand hygiene. Sterile technique is important in preventing infection in invasive procedures, but the questions does not address the specific situation of invasive procedures, only infection in general.

Standard precautions and the use of gloves prevent a healthcare provider from being exposed to blood and body fluid while caring for a client. This is important in the infection cycle, but is not the most important technique.

PTS: 1 REF: p. 52 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. What steps are involved in the client-to-client transmission of pathogens? (Select all that apply.)

A. The nurse uses an alcohol-based hand sanitizer for hand hygiene B. Organisms are transferred from the client to the nurse's hands C. Organisms survive on the nurse's hands for less than 1 minute D. The nurse's contaminated hands come into direct contact with another client E. Organisms are present in the client's immediate environment ANS: B, D, E

Feedback: Patient-to-client transmission of pathogens requires five sequential steps: (1) Organisms are present on a client's skin or immediate environment; (2) Organisms are transferred from the client to the nurse's hands; (3) Organisms survive on the nurse's hands for at least several minutes; (4) The nurse omits or performs inadequate or inappropriate hand hygiene; (5) The nurse's contaminated hands come into direct contact with another client or environment in direct contact with the client. The use of alcohol-based hand sanitizer breaks the five-step process. Organisms can live on the nurse's hands for more than 1 minute if not cleansed appropriately.

PTS: 1 REF: p. 52 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 4. According to the guidelines from the Centers for Disease Control and Prevention (CDC), why are nurses supposed to wear gloves? (Select all that apply.)

A. To help maintain a sterile environment B. To reduce transient contamination of the hands C. To reduce the risk of infecting healthcare personnel D. To prevent the transmission of bacteria from nurses to clients E. To reduce the number of bacteria in the health care environment ANS: B, C, D Feedback: The CDC recommends that nurses wear gloves to (1) reduce the risk of personnel acquiring infections from clients, (2) prevent the transmission of flora from health care workers to clients, and (3) reduce transient contamination of the hands of healthcare personnel by flora that can be transmitted from one client to another. Gloves do not help to maintain a sterile environment, nor do they reduce the number of bacteria in the health care environment.

PTS: 1 REF: p. 53 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 5. A nursing instructor is discussing techniques used in the inspection of a client. What would the instructor note as a priority when inspecting a client?

A. Adequate exposure of the body part B. Dim lighting in the examination room C. Use of therapeutic touch when assessing the client D. Use of therapeutic communication when assessing the client ANS: A

Feedback: During inspection, adequate exposure of each body part is necessary.

Concurrently, nurses take measures to maintain the privacy of clients through appropriate draping, especially over the breasts in women and genitalia in both men and women. Adequate lighting is essential to observe color, texture, and mobility.

Therapeutic touch and therapeutic communication are important but not the priority when inspecting the client.

PTS: 1 REF: p. 58 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 6. The nurse is assessing a client who is new to the unit. During inspection of the client, what will the nurse do?

A. Tell the client that modesty is not necessary B. Make sure that the client is covered C. Look for internal abnormalities D. Smell for odors ANS: D Feedback: Nurses perform inspection by consciously observing clients for physical characteristics and behaviors and smelling for odors. The nurse would explain to the client that every measure will be taken to protect modesty, the client will have to be uncovered for inspection, and internal abnormalities cannot be seen during inspection.

PTS: 1 REF: p. 58 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. A new graduate nurse is inspecting a client. What is a challenge the nurse will face?

A. Maintaining client modesty B. Learning how to perform inspection C. Identifying subtle differences D. Documenting what is normal ANS: C Feedback: One challenge that beginners face is identifying details and subtle differences.

Maintaining client modesty, learning how to inspect, and documenting normal findings are skills that nurses learn before they graduate from nursing school.

PTS: 1 REF: p. 58 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 8. For what is light palpation appropriate? (Select all that apply.)

A. Inflamed areas of skin B. Internal organs C. Skin texture D. Deep pain E. Surface lesions ANS: A, C, E Feedback: Light palpation is appropriate for the assessment of surface characteristics, such as texture, surface lesions or lumps, or inflamed areas of skin (e.g., over an intravenous site). Light palpation is not appropriate for assessing internal organs or deep pain.

PTS: 1 REF: p. 59 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 9. Nursing students are in the laboratory practicing palpation. What would they learn about the best depth for moderate palpation?

A. 1/2 to 1 cm B. 1 to 2 cm C. 1 to 2 1/2 cm D. 2 to 3 cm ANS: B Feedback: Pressure during moderate palpation is firm enough to depress approximately 1 to 2 cm. Other options above would be either not deep enough or too deep to correctly demonstrate moderate palpation.

PTS: 1 REF: p. 59 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 10. When percussing a client, where would the nurse expect to find the loudest tones?

A. Over the liver B. Over the bladder C. Over the spleen D. Over the lungs ANS: D Feedback: The loudest percussion tones are over the lungs and hollow stomach; the quietest tones are over bone. Solid organs such as the spleen and liver would not have loud tones when percussed. The bladder, if positioned to be percussed, would be full of fluid, which would not have a loud tone.

PTS: 1 REF: p. 59 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 11. A client presents at the clinic reporting a possible sinus infection. How would the nurse assess the sinuses in this client?

A. Indirect percussion B. Palpation C. Direct percussion D. Auscultation ANS: C Feedback: An example of direct percussion is percussion of the sinuses in clients with sinus infections or percussion of the thorax in newborns to assess the air-filled lungs.

The nurse would push or tap directly on the sinus area of the face with 1 to 2 fingers to assess pain or tenderness to the client. The nurse would not auscultate or palpate to assess the sinuses. The nurse would not use indirect percussion on the sinuses. With indirect percussion, the nurse assesses the density of the underlying tissue or organs to determine the perimeter or outline of the underlying structure. The indirect percussion method uses two hands to tap over the surface area to be assessed.

PTS: 1 REF: p. 59 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. A student nurse is spending clinical hours on the medical-surgical unit with an experienced nurse. The student is assessing a client using indirect percussion. The student hears what sound while percussing the center of the client's abdomen?

A. Resonance B. Tympany C. Dullness D. Damping ANS: B Feedback: During indirect percussion, it is easiest to go from the center of the abdomen with tympany and move upward to the liver where dullness is percussed. Tympany would be described as loud in intensity, with a high pitch. Dullness would be described as soft to moderate in intensity with a high pitch. Resonance would be described as a moderate to loud intensity with a low pitch. Damping is not a term used to describe percussion sounds.

PTS: 1 REF: p. 60 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

13. When auscultating the client's lungs, how should the nurse position the earpieces of the stethoscope?

A. Pointed slightly forward toward the nose B. Pointed slightly downward toward the occiput C. At a 90° angle from the nose D. At a 45° angle to the occiput ANS: A Feedback: The nurse should tilt the earpieces slightly forward so that the point on the earpiece is forward in the same direction as the nose. The other options are incorrect.

Not positioning the earpieces correctly can lead to a less than optimal auscultation of the client's lungs.

PTS: 1 REF: p. 61 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 14. While beginning the assessment of a client's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

A. The bell B. The small side of the chestpiece C. The earpieces D. The diaphragm ANS: D Feedback: Most stethoscopes have a diaphragm and bell on the chestpiece. The bell is used with light skin contact to hear low-frequency sounds, while the diaphragm is used with firm skin contact to hear high-frequency sounds. The earpieces do not provide sound, and the small side of the chestpiece is the bell.

PTS: 1 REF: p. 61 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. Student nurses are in the laboratory learning auscultation techniques. How would they be instructed to hold the chestpiece on the client?

A. Place the endpiece between the thumb and the index finger B. Place the index and middle fingers on top of the stethoscope C. Place the endpiece between the index and the middle fingers D. Place the thumb and index finger on top of the stethoscope ANS: C Feedback: When holding the chest piece, the nurse places the endpiece between the index and the middle finger, not on top of the stethoscope, which would distort the sound.

PTS: 1 REF: p. 62 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 16. When assessing a client, the first skill used is inspection. What purpose does inspection serve?

A. Gathering information B. Feeling abnormalities C. Observing modesty D. Identifying internal abnormalities ANS: A Feedback: Inspection is the first technique of the overall general survey and for each body part, because it provides so much general information. Inspection is the one technique that is performed for every body part and body system. During inspection, the nurse does not use the hands to feel anything. Inspection is not to observe the client's modesty or to identify anything internal. Feeling some abnormalities and identifying some internal abnormalities would not be inspection but rather palpation. Inspection does not help with observing modesty.

PTS: 1 REF: p. 58 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 17. The instructor asks the student why percussion is performed on a client. What would be the student's most accurate response?

A. To identify resonance B. To hear bowel sounds C. To elicit tenderness D. To produce tympany ANS: C Feedback: The third technique of physical assessment is percussion to produce sound or elicit tenderness. Percussion produces sounds that can be described using resonance and tympany, but that is not the most accurate response the student can give. Percussion is not used to hear bowel sounds.

PTS: 1 REF: p. 59 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 18. It is necessary for the nurse to accurately describe the sounds heard while percussing a client. Which of the following is a subjective description of percussion sound?

A. quality B. intensity C. duration D. pitch ANS: A Feedback: Quality refers to the subjective description of the percussion sound, such as a low-pitched thud of short duration versus a drum-like sound with high pitch and long duration. The intensity of the sound is its loudness, the duration is how long the sound lasts, and the pitch of the sound is the frequency or how soon the sound oscillates.

Intensity, duration, and pitch are objective, not subjective, in nature.

PTS: 1 REF: p. 60 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. A nurse who suffers from a respiratory infection is preparing to perform a shift assessment on a client when the urge to cough occurs. What is the nurse's best action?

A. Cough into the inner aspect of the elbow.

B. Cough into the air away from the client toward the hallway.

C. Cover the mouth and nose with her hands while coughing.

D. Perform hand hygiene before coughing into hands.

ANS: A Feedback: Patients and other people with symptoms of a respiratory infection are asked to cover their mouths and noses with a tissue when coughing or sneezing; covering with a tissue is better than covering with the hands. Additionally, clients should dispose of tissues directly into receptacles and perform hand hygiene after, not before, hands have been in contact with respiratory secretions. If a tissue is not available, according to the CDC a person should cough into the inner aspect of the elbow.

PTS: 1 REF: p. 54 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 20. A nurse in the emergency department is assessing a client admitted with suspected appendicitis. The nurse would avoid using which kind of palpation over the right lower quadrant of this client?

A. None B. Light palpation C. Deep palpation D. Moderate palpation ANS: C Feedback: Deep palpation should not be used over areas that pose a risk of injuring clients, such as over a suspected enlarged spleen or inflamed appendix.

PTS: 1 REF: p. 59 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 3: Techniques, Safety, and Infection Control KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 04: Documentation and Interprofessional Communication 1. The medical record serves many purposes. What are they? (Select all that apply.)

A. Framework for medical information B. Means for financial reimbursement C. Research D. Care planning E. Information for the family ANS: A, B, C, D Feedback: The medical record serves multiple purposes. In addition to being a legal document, the medical record is used for communication among health team members, care planning, quality assurance, financial reimbursement, education, and research. The purpose of the medical record is not for information for the family.

PTS: 1 REF: p. 72 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Select 2. A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?

A. To provide a record of the nurse's activities B. To provide a record of the actual events C. To provide a record of how the client was harmed D. To provide a record of the physician's activities ANS: B Feedback: The client record serves as a legal document recording the client's health status and any care the client receives. While all answers are correct, the best answer is providing a record of the actual events.

PTS: 1 REF: p. 72 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. Students are learning about the many uses of the medical record. One of these uses is to perform an internal audit. What is the goal of an internal audit?

A. The evaluation of financial reimbursement B. The evaluation of client nutrition C. The evaluation of care for continual improvement D. The evaluation of timely documentation of pain ANS: C Feedback: During an internal audit, the goal is to evaluate the care provided for continual improvement. Other types of audits are conducted for information on financial reimbursement, client nutrition, and timely documentation of care provided.

PTS: 1 REF: p. 72 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 4. Why do nursing students review medical records? (Select all that apply.)

A. To enhance clinical learning B. To compare nursing care provided to clients C. To evaluate the plan of care for a specific client D. To verify that laboratory results are accurate E. To better understand complex clinical situations ANS: A, E Feedback: Students in various health care disciplines review client records to enhance clinical learning and to better understand complex clinical situations. They can access and review records during care delivery. Nursing students do not use medical records to compare nursing care provided to a client population, evaluate the care plan, or verify that laboratory results are accurate.

PTS: 1 REF: p. 73 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Select 5. The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?

A. Safety among client populations decreases B. Pharmacy orders are electronically verified C. Physician notes are more secure D. Client safety increases ANS: D Feedback: Although implementing a computerized system is expensive and requires much planning and education, such systems significantly increase client safety.

Computerized medical records do not decrease client safety, make physician notes more secure, or verify pharmacy orders.

PTS: 1 REF: p. 74 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 6. A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

A. To have up-to-date information on which to base clinical decisions

B. To be able to verify what care has been given C. To communicate with other health care providers D. To be able to update the plan of care ANS: A Feedback: All the responses are correct; however, the best answer is that prompt documentation allows health team members to use up-to-date assessment information to make clinical decisions.

PTS: 1 REF: p. 77 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 7. The Joint Commission developed a National Patient Safety Goal. What is a requirement of this goal?

A. Health care agencies need to standardize their charting B. Health care agencies need to develop a standardized approach to hand off communications C. Health care agencies need to conform to Joint Commission communication templates D. Health care agencies need to computerize medical records ANS: B Feedback: In 2006, the Joint Commission developed a National Patient Safety Goal that required agencies to develop a standardized approach to hand off communications, including the opportunity to ask and respond to questions. The Joint Commission does not have communication templates or mandate computerized medical records or standardized charting.

PTS: 1 REF: p. 82 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 8. One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?

A. By accurately charting client care B. By continually assessing client laboratory values C. By continual communication with all members of the health care team D. By giving client care conferences including all members of the health care team ANS: C Feedback: Nurses perform all these functions for clients. Nevertheless, the best way to provide safe client care is to continually communicate with all members of the health care team.

PTS:

1

REF: p. 82

OBJ: 2

NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. A new graduate nurse has just started working. The new nurse asks a more experienced nurse to explain SOAP charting. What would the experienced nurse explain that the A in SOAP stands for?

A. Analysis of data to identify a problem B. Assessment of subjective data C. Assessment of objective data D. Articulation of the plan of treatment ANS: A Feedback: The SOAP format focuses on a single problem and includes subjective (S) assessment findings, objective (O) assessment findings, analysis (A) of the assessment data to identify a problem or indicate whether the problem is improving or worsening, and plan (P) for treating or improving the problem. Assessment and articulation would be incorrect.

PTS: 1 REF: p. 80 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 10. When an agency has policies that require nurses to write notes using the DAR (Data, Action, Response) system, the nursing documentation can include what?

A. Areas of personal accomplishments B. Areas of personal weakness C. Social networks D. Family concerns ANS: D Feedback: Documentation can focus on areas of strengths as well as medical problems, family concerns, or nursing diagnoses. Focus notes do not generally include areas of personal accomplishments, personal weaknesses, or the client's social networks.

PTS: 1 REF: p. 81 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 11. When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what?

A. Medical diagnoses B. Client needs C. Standardized norms D. Joint Commission standards

ANS: C Feedback: A group may develop the standard of what it considers "normal" in each area of assessment (e.g., respiratory, mobility, psychosocial). These norms structure the client assessment. Client assessments are not structured by Joint Commission standards, client needs, or medical diagnoses.

PTS: 1 REF: p. 76 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 12. When charting by exception is used in a health care agency, the most important aspect of this method is what?

A. Organizing new forms for the nursing staff B. Identifying the standards and norms for the institution C. Training new nurses in writing charting by exception notes D. Pulling together a group of experts to teach agency staff ANS: B Feedback: Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.

PTS: 1 REF: p. 81 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. Nursing students are learning about different methods of charting in the clinical laboratory. What method would they learn that is a shared mental model for improving communication between and among clinicians?

A. SBAR B. CBE C. SOAP D. PIE ANS: A Feedback: SBAR, first developed by Kaiser Permanente in Denver and supported by the Institute for Healthcare Improvement (IHI), is a shared mental model for improving communication between and among clinicians. SOAP, PIE, and CBE are not shared mental models.

PTS: 1 REF: p. 84 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation

BLM: Cognitive Level: Understand

NOT: Multiple Choice

14. The nursing instructor is explaining SBAR documentation to students before taking them into the clinical area. What would the instructor explain that the situation, background, and assessment are based on in SBAR charting?

A. The client's background B. Information that the nurse obtains from the family C. Complete and accurate assessment data D. Data in old medical records ANS: C Feedback: This model organizes communication around Situation, Background, Assessment, and Recommendations. Note that situation, background, and assessment are all based on the collection of complete and accurate assessment data. Situation, background, and assessment are not based entirely on the client's background, what family has to say, or what is in the old medical records.

PTS: 1 REF: p. 83 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 15. What is the most common use of SBAR? A. Contacting a provider regarding a client issue B. Structuring communications during handoff C. Delegating care to nursing assistants D. Expressing concern about a client's condition to the charge nurse ANS: A Feedback: Nurses most commonly use SBAR when contacting a provider regarding a client issue. SBAR also can serve as a method for structuring communication during handoffs, when delegating care to nursing assistants, or when expressing concern regarding a client's condition to the charge nurse or manager; however, none of these is the most common use.

PTS: 1 REF: p. 84 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 16. A nurse has assessed that a client's condition is worsening. The nurse is telephoning the primary care provider and providing an SBAR report about the client's condition. What would be important for the nurse to document? (Select all that apply.)

A. The time B. Information from the previous shift C. The information received D. Specialists to whom the client is referred E. The name of the provider

ANS: A, C, E Feedback: It is important to document the call, including the time, who was called, what information the nurse gave to the provider, and what information the nurse received. It is not important to document assessment data from the previous shift or specialists to whom the client has been referred.

PTS: 1 REF: p. 85 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Select 17. A nurse has been called to testify in a lawsuit brought by a client against his employer.

This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

A. The charting format is not ethical B. Details are often missing C. Subjective information is often missing D. It reflects poor assessment skills on the part of the nurse ANS: B Feedback: CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.

PTS: 1 REF: p. 80 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 18. How does computerized documentation enhance communication? (Select all that apply.)

A. It is more complete than handwritten charting B. It is legible and time dated C. It permits multiple simultaneous users D. It increases compliance E. It verifies telephone communication ANS: B, C, D Feedback: The computerized client record helps ensure client safety and enhances communication, because computerized documentation is legible and time dated, increases compliance, permits multiple simultaneous users, and permits surveillance of client data to identify clients at risk. Computerized client records are not more complete nor do they verify telephone communications.

PTS: 1 REF: p. 74 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation

BLM: Cognitive Level: Understand

NOT: Multiple Select

19. To make a legal entry into the medical record, the nurse must document what?

A. Laboratory tests ordered B. Attending physician C. Time of the assessment D. Nature of the assessment ANS: C Feedback: The nurse must record normal assessment data, abnormal assessment data, and the time of the assessment. The nurse does not have to document laboratory tests ordered, the attending physician, or the nature of the assessment.

PTS: 1 REF: p. 72 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 20. HIPAA gives clients greater control over their medical records. What else does HIPAA provide?

A. Copying of medical records B. Education of lay people about medical records C. Client recourse if privacy protections are violated D. Legal use of medical records ANS: C Feedback: HIPAA provides for client education on privacy protection, client access to medical records, client consent prior to disclosing information from the record, and client recourse if privacy protections are violated. HIPAA does not address copying of medical records, education of lay people about medical records, or legal use of medical records.

PTS: 1 REF: p. 75 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 4: Documentation and Interprofessional Communication KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice

Chapter 05: Vital Signs and General Survey 1. The nurse is caring for a newly admitted adult client. When performing the general survey of this client, the nurse knows that accurate anthropometric measurements provide critical information about what?

A. safety B. state of health C. growth pattern D. past surgeries ANS: B Feedback: Anthropometric measurements are the various measurements of the human body, including height and weight. They provide critical information about the adult's state of health. Accurate measurements do not provide critical information about safety, past surgeries, or growth pattern in the adult client.

PTS: 1 REF: p. 99 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What is the importance of assessing vital signs? (Select all that apply.)

A. To carry out orders from the healthcare provider B. To plan how to improve a client's condition C. To establish a baseline D. To monitor risks for alterations in health E. To evaluate the client's responses to treatment ANS: C, D, E Feedback: Assessment of vital signs helps nurses to establish a baseline, monitor a client's condition, evaluate responses to treatment, identify problems, and monitor risks for alterations in health. Vital signs are not assessed to carry out orders from the healthcare provider or to plan how to improve a client's condition.

PTS: 1 REF: p. 94 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 3. The nurse aide reports to the nurse that an older adult client has abnormal vital signs.

What is important to remember in this type of situation?

A. At client's age, abnormal vital signs are an indication of something serious B. Normal readings get lower with advanced age C. Normal readings get higher with advanced age D. Normal readings vary according to age ANS: D

Feedback: When encountering an abnormal value, the nurse should obtain the vital sign(s) again to assess accuracy. The nurse should also consider whether the client appears to be in distress, noting skin color, respiratory effort, and behavior. Normal readings vary according to age.

PTS: 1 REF: p. 102 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 4. How does the nurse use critical thinking when accurately assessing vital signs?

A. Evaluating assessment techniques B. Developing nursing diagnoses C. Monitoring evaluations D. Planning assessment techniques ANS: B Feedback: Several nursing diagnoses can be addressed under vital sign assessment. The nurse would not evaluate assessment techniques, monitor evaluations, or plan assessment techniques when assessing vital signs.

PTS: 1 REF: p. 120 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A client arrives at the emergency department by ambulance after an accident while playing softball. The client's left leg is swollen and deformed. The client describes the pain as a 9 on a 10-point scale. When the nurse assesses the client's blood pressure, what would the nurse expect to find?

A. The blood pressure is lower than normal B. There would be no need to assess the blood pressure C. The blood pressure is elevated D. The blood pressure is within normal limits ANS: C Feedback: Many variables affect vital signs, including pain, stress, anxiety, and activity.

Pain and anxiety can contribute to increased blood pressure. The nurse would not expect to find the blood pressure lower than normal or within normal limits with the client's report of pain as a 9 on a 10-point scale. It would be expected that the nurse would assess the blood pressure upon arrival to the emergency department for this client.

PTS: 1 REF: p. 102 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. The paramedics are called to a gym to see an individual who has been exercising and developed pain in the upper right quadrant of the abdomen. The initial vital sign reading indicates a pulse of 175 beats per minute. This pulse would be considered what? (Select all that apply.)

A. Elevated due to pain B. Elevated due to dehydration C. Elevated due to anxiety D. Elevated due to activity E. Elevated due to weight ANS: A, C, D Feedback: Variables that can affect vital signs include pain, stress, anxiety, and activity.

The individual's weight is not mentioned in the scenario, nor is that the individual is dehydrated.

PTS: 1 REF: p. 102 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 7. An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what?

A. Higher than normal B. Lower than normal C. Within normal limits D. The nurse would not routinely take this client's vital signs ANS: A Feedback: Many variables can lead to increased vital signs, including pain, stress, anxiety, activity, and chronic disease processes. It is imperative that nurses measure vital signs correctly and accurately, understand the data, and communicate the findings appropriately. COPD is often a result of smoking and likely result in an increase in vital signs. The client's vital signs would be assessed at each clinic visit.

PTS: 1 REF: p. 102 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. What does the nurse knows about normal blood pressure?

A. Stays level throughout the day B. Follows a diurnal rhythm C. Rises with the early morning fall of blood glucose D. Follows the same cycle as the sun ANS: B

Feedback: A daily, circadian (diurnal) cycle of blood pressure occurs, with it increasing late in the afternoon and decreasing in the early morning. Blood pressure does not stay level throughout the day. Blood pressure does not rise with the early morning fall of blood glucose. Blood pressure does not follow the same cycle as the sun.

PTS: 1 REF: p. 112 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 9. A student nurse studying hypertension would learn that the risk factors include what?

A. Family history, obesity, vegetarian diet B. Cigarette smoking, heavy alcohol consumption, hepatic disease C. Prolonged stress, renal disease, heavy alcohol consumption D. High cholesterol and triglyceride levels, family history, hepatic disease ANS: C Feedback: Risk factors for hypertension include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Neither hepatic disease nor vegetarian diet are risk factors for hypertension.

PTS: 1 REF: p. 94 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 10. A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

A. Quitting cigarette smoking 5 years ago B. Loss of 50 pounds within the last 12 months C. High cholesterol and low triglyceride levels D. Family history ANS: D Feedback: Clients should be educated about the risks of hypertension. Risk factors include obesity, cigarette smoking, heavy alcohol consumption, prolonged stress, high cholesterol and triglyceride levels, family history, and renal disease. Weight loss, low triglyceride level, and smoking cessation are not risk factors for hypertension.

PTS: 1 REF: p. 94 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

11. While assessing respirations and heart rate in a school aged client, the nurse finds that the client's heart rate increases during inspiration and decreases during expiration. What would be the most correct way to document this finding?

A. The client has an abnormal heart rate B. The client has a sinus arrhythmia C. The client's heart rate speeds up and slows down in a cyclical pattern D. The client has a cardiopulmonary disorder ANS: B Feedback: Rhythm may vary with respirations, speeding up during inspiration and slowing down with expiration. This finding, common in children and young adults, is called a sinus dysrhythmia or sinus arrhythmia. This condition is not an abnormal heart rate or a cardiopulmonary disorder. Describing the finding as the heart speeding up and slowing down is not correct terminology to describe the finding.

PTS: 1 REF: p. 107 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 12. General survey of an adult client reveals that the client is wearing eccentric makeup and clothes. For what would the nurse perform further assessments?

A. Inadequate finances B. Depression C. Poor hygiene D. Mania ANS: D Feedback: Eccentric makeup or dress may indicate mania. Previously well-groomed clients who are now disheveled may have depression. Worn or disheveled clothes may indicate inadequate finances, disinterest in appearance, or problems with self-care.

PTS: 1 REF: p. 98 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. Student nurses are doing clinical hours on the medical-surgical unit. What additional assessment should the student nurses make when they take client vital signs?

A. Oxygen saturation B. Blood pressure C. Heart rate D. Mobility ANS: A Feedback: Oxygen saturation is assessed in hospitalized clients. Assessing blood pressure and heart rate is a regular vital sign assessment, not an additional assessment.

Mobility is a distracter for this question.

PTS: 1 REF: p. 97 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. An ICU nurse is caring for a client in shock. To obtain an accurate set of vital signs, the nurse uses a Doppler to obtain pulse and blood pressure. What would be the best technique for the use of the Doppler on this client? (Select all that apply.)

A. Hold the probe firmly against the skin at the expected pulse site B. Hold the probe perpendicular to the skin at the expected pulse site C. Moisten the skin with water prior to using the probe D. Mark the location of the loudest sound E. Move the probe slowly over the area of the expected pulse site ANS: B, D, E Feedback: The procedure for assessment of the pulse using a Doppler is as follows: (1) Apply the gel that is specific for the Doppler to the transducer probe. (2) Turn the Doppler on. (3) Adjust the volume. (4) Touch the probe lightly to the skin at the expected pulse site. (5) Hold the probe perpendicular to the skin and move it slowly where you anticipate that the pulse should be until it is located. (6) Wipe off the gel and mark the location of the loudest sound with indelible ink. Water cannot be used to moisten the skin prior to using the probe. An accurate reading will not be collected if the probe is pressed firmly against the skin.

PTS: 1 REF: p. 119 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 15. The nurse is caring for four clients on the short-stay unit. Which client would cause the nurse greatest concern?

A. A 10-year-old client with a BP of 103/62 B. A 7-year-old client with a sinus dysrhythmia C. A 77-year-old client with a resting heart rate of 69 beats/min D. An 82-year-old client with a temperature of 37.2°C (99°F) ANS: D Feedback: Temperatures considered normal for younger adults may constitute fever in older adults. The three other options represent normal findings for the clients described.

PTS: 1 REF: p. 119 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

16. The nurse is performing assessments on several male clients. The first client is 52 years old and African American. The second client is 54 years old and Mexican American.

The third client is 50 years old and Native American. The fourth client is 60 years old and Caucasian. Which client would the nurse expect to be tallest?

A. Caucasian B. African American C. Mexican American D. Native American ANS: A Feedback: Height varies little among racial groups compared to other anthropometric measures. Height results from genetics, nutrition, and stressors. Mean height varies by gender. In men, Caucasians as a group are usually tallest, followed by African Americans, and then Mexican Americans.

PTS: 1 REF: p. 120 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 17. Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

A. Systolic pressure 180 mm Hg. B. Apical pulse 70 beats/minute.

C. Respirations 12 breaths/minute.

D. Oxygen saturation 95% on room air.

ANS: A Feedback: The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg. PTS: 1 REF: p. 123 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. A student nurse is teaching a group of peers about vital sign changes in older adults. The nursing instructor should intervene when the student nurse states: A. "As a person ages, their pulse rate will naturally increase."

B. "Respirations per minute may increase with age. " C. "Older adults have less subcutaneous fat, making their body temperature lower."

D. "Elevated blood pressure is not a normal sign of aging."

ANS: A

Feedback: The pulse rate of older adults takes longer to rise to meet sudden increases in demand, takes longer to return to resting state, and tends to be lower than that of younger adults. Hypertension is not considered a normal age-related finding. Typically, older adults have less subcutaneous adipose tissue, which results in a decrease in body temperature. Respiration rate typically does not change with age.

PTS: 1 REF: p. 119 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 19. Student nurses are taking vital signs at a community screening clinic. The nursing instructor should intervene when the student nurse performs which of the following actions?

A. Applies the cuff to the right arm above the client's shunt location.

B. Places the arm on the table below the level of the heart.

C. Obtains a larger blood pressure cuff for an obese client.

D. Asks the client to sit quietly while performing the blood pressure.

ANS: A Feedback: The extremity with a shunt should not be used for obtaining blood pressure.

The client should sit quietly and calmly, the arm should be at arm level, and an appropriately sized cuff should always be used when obtaining blood pressure readings.

PTS: 1 REF: p. 114 OBJ: 2 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

The nurse obtains the client's vital signs (see above). What should be the nurse's next action?

A. Contact rapid response team.

B. Administer prescribed acetaminophen for fever.

C. Document the findings.

D. Reassess pulse in one hour.

ANS: A Feedback: The nurse may call a rapid response team if the client's vital signs are abnormal in urgent, acute, or ongoing care. A pulse less than 55 or greater than 120 beats/minute and decreased oxygen saturation levels warrant a call to rapid response in this scenario. The client's blood pressure, temperature, and respirations are not clinically significant at this time.

PTS: 1 REF: p. 123 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 5: Vital Signs and General Survey KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

Chapter 06: Pain Assessment 1. What is the most commonly accepted theory of pain?

A. Pain stimulus theory B. Gate control theory C. Pain transmission theory D. Gatekeeper theory ANS: B Feedback: Currently, the theory of pain with the widest acceptance is the gate control theory. The other three options do not represent a theory of pain.

PTS: 1 REF: p. 131 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What is the current focus of pain research?

A. Elements that can affect the intensity of pain B. Stopping the cause of pain C. Elements that can affect pain inhibition D. Stopping the sensation of pain ANS: C Feedback: Current research focuses on those elements that can affect pain inhibition and stop the pain stimulus. The other options listed are not where current research on pain is focusing.

PTS: 1 REF: p. 131 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. What is the element of pain transmission that causes nociceptors to perceive a nerve impulse?

A. Transduction B. Transmission C. Perception D. Modulation ANS: A Feedback: In transduction, noxious stimuli create enough of an energy potential to cause nociceptors (free nerve endings) to perceive a nerve impulse. Transmission is when the neuronal signal moves from the periphery to the spinal cord and up to the brain.

Perception is when higher areas of the brain perceive the impulse being transmitted as pain. Modulation is the action of inhibitory and facilitating input from the brain modulating or influencing sensory transmission at the level of the spinal cord.

PTS: 1 REF: p. 132 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 4. Both the peripheral and the central nervous systems are involved in the transmission of a pain stimulus. When there is continued input from the peripheral nervous system, what can develop?

A. Fibromyalgia B. A peripherally mediated pain syndrome C. Neuronal plasticity D. A centrally mediated pain syndrome ANS: D Feedback: Transmission of a pain stimulus uses two separate but continuous systems: the peripheral nervous system and the central nervous system. Continued input from the peripheral nervous system can create a centrally mediated pain syndrome, in which pain occurs without a pain stimulus. Fibromyalgia is chronic pain syndrome. Neuronal plasticity is the term for changes in the transmission of the pain stimulus.

PTS: 1 REF: p. 132 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 5. The nursing instructor is discussing the different types of pain with the nursing class.

What type of pain would the instructor explain originates from a specific site, yet the client feels the pain at another site?

A. Chronic pain B. Cutaneous pain C. Referred pain D. Somatic pain ANS: C Feedback: Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve. Chronic pain is pain referred to as persistent. Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues and is felt at its origination. Somatic pain originates from skin, muscles, bones, and joints and is felt at its origination.

PTS: 1 REF: p. 132 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 6. A nurse is caring for a client who reports constant pain. The nurse knows that constant pain can lead to the modification of the function of the nervous system, which can, in turn, lead to what?

A. Neuronal windup B. Peripheral sensitization C. Neuronal plasticity D. Chronic pain ANS: B Feedback: Once pain becomes a constant stimulus, the nervous system can modify its function (neuronal plasticity). In turn, this can lead to another phenomenon called peripheral sensitization, by which peripheral nociceptors are sensitized to pain stimuli.

Neuronal windup is produced when repeated assaults on the afferent neurons create enhanced response and increased activity in the central nervous system. Chronic pain is referred to as persistent pain.

PTS: 1 REF: p. 133 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. Pain is often untreated or undertreated; when this occurs, chronic pain may result. What can be the outcome?

A. Chronic sensitization syndrome B. Peripheral sensitization syndrome C. Complex regional pain syndrome D. Fibromyalgia pain syndrome ANS: C Feedback: Untreated or undertreated acute pain may lead to chronic pain syndromes, such as complex regional pain syndrome (CRPS), which are difficult to treat. Chronic sensitization is an excitatory process involving spinal nerves produced by continued pain stimuli that can persist even after peripheral stimulation is no longer present. Peripheral sensitization is the result of an inflammatory process that creates hypersensitivity to touch or pressure. Fibromyalgia pain syndrome is a complex disorder characterized by widespread musculoskeletal pain, as well as various other disorders that could possibly include mood, sleep, and fatigue issues.

PTS: 1 REF: p. 132 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 8. What is an excitatory process caused by pain stimuli that involves the spinal nerves and can persist when there is no longer stimulation?

A. Central sensitization B. Neuronal windup C. Peripheral sensitization D. Neuronal plasticity ANS: A

Feedback: Central sensitization is an excitatory process involving the spinal nerves and produced by continued pain stimuli that can persist even after peripheral stimulation is no longer present. Neuronal windup is produced when repeated assaults on the afferent neurons create enhanced response and increased activity in the central nervous system.

Peripheral sensitization is when peripheral nociceptors are sensitized to pain stimuli.

Neuronal plasticity means the ability of the nervous system to change or alter its function.

PTS: 1 REF: p. 133 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 9. An older adult comes to the clinic reporting pain in the right lower quadrant. When assessing the client's pain, what elements would the nurse include? (Select all that apply.)

A. Aggressiveness B. Intensity C. Quality D. Location E. Quantity ANS: B, C, D Feedback: Basic elements of pain assessment include intensity, quality, and location.

Other basic elements are location, duration, quality/description, alleviating/aggravating factors, pain management goal, and functional goal. Aggressiveness and quantity are not identified aspects of pain.

PTS: 1 REF: p. 136 OBJ: 5 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 10. The nurse is assessing a client with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this client?

A. Gathering information that the client wants to share about his pain B. Using in-depth questions to collect significant data about the client's pain C. Collecting objective data that the client chooses to share D. Collecting subjective data that the nurse notes during assessment ANS: B Feedback: Use of in-depth questions to collect all the significant data from the pain assessment will be the biggest help in determining what types of interventions will be most beneficial for providing adequate pain relief to the client. Objective data are not shared by the client, and subjective data are not what the nurse notes during the assessment-these are what the client shares about the pain. While assessing a client's pain, the nurse needs to gather more information than is freely shared by the client.

PTS:

1

REF: p. 135

OBJ: 7

NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 11. A nurse in the emergency department is caring for a nonverbal client. What would be the best way for the nurse to assess this client's level of pain?

A. Ask the client to draw a picture of the pain B. Ask the paramedics what they think is the client's pain level C. Ask the client to describe the pain D. Ask the family if they have noticed any changes in the client's behavior ANS: D Feedback: When attempting to perform a pain assessment on a client who cannot self-report pain, the nurse should try to identify any potential causes for pain, observe client behaviors, ask the family or other caregivers if they have noticed any changes in the client's behavior, and attempt an analgesic trial. A nonverbal client cannot describe the pain in spoken words. Asking the client to draw a picture of pain while in the emergency department would not be the best way to assess the client's level of pain, nor would asking paramedics what they think about the client's pain.

PTS: 1 REF: p. 143 OBJ: 7 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 12. When a client with opioid tolerance has an altered physiologic response to pain stimuli, the client develops a form of pain sensitivity called what?

A. Opioid hyperalgesia B. Pain hyperactivity C. Opioid hypoalgesia D. Pain hypoactivity ANS: A Feedback: Clients with a history of opioid tolerance pose difficult challenges to nurses for pain assessment. They have an altered physiologic response to the pain stimulus, and the repeated use of opioids causes their bodies to become more sensitive to pain. This sensitivity is called opioid hyperalgesia and can occur as soon as 1 month after opioid use begins. The other options are not terms used to describe pain sensitivity.

PTS: 1 REF: p. 143 OBJ: 7 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 13. What are the steps for pain transmission in the gate control theory? (Select all that apply.)

A. Unrelieved painful stimulus on a peripheral neuron causes the "gate" to open B. The gate opens through repolarization of the nerve fiber

C. The brain stem recognizes the stimulus as pain D. The pain stimulus passes down the afferent pathway E. The pain stimulus crosses the dorsal horn of the spine to the limbic system ANS: A, E Feedback: The steps for pain transmission in the gate control theory are as follows: (1) Continued painful stimulus on a peripheral neuron causes the "gate" to open through depolarization of the nerve fiber. This is accomplished by ion influx and outflow. (2) The pain stimulus then passes from the peripheral nervous system at a synaptic junction to the central nervous system up the afferent nerve pathways. (3) The pain stimulus passes up through and across the dorsal horn of the spine to the structures of the limbic system and the cerebral cortex. (4) In the cerebral cortex, the stimulus is identified as pain and a response is created. The response, once generated, passes down the efferent pathways where reaction to the pain is created. The distractors listed all have an incorrect component in the option which was noted above in the explanation.

PTS: 1 REF: p. 131 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Select 14. The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

A. The research supporting intravenous medications given for pain take half as long to work as oral medications B. The time it takes a pain medication to decrease pain intensity C. The time it takes a pain medication to block pain in a client D. The median half-life of an intravenous pain medication ANS: B Feedback: Most healthcare facilities have a standard time frame for reassessment, such as 1 hour for oral medication and 30 minutes for pain medication given intravenously.

Standards are based on the time it takes a pain medication to provide a noticeable decrease in pain intensity. The mandate from The Joint Commission does not look at the half-life of the pain medication, because the half-life would differ from drug to drug, and no drug is listed in the question. The pain medication does not block pain, but decreases the pain intensity. Research does not support that intravenous medication take half as long to work as oral medication, because this information depends on the individual drug and the chemical makeup of the drug.

PTS: 1 REF: p. 144 OBJ: 8 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 15. What phrase describes the pain phenomena felt in rheumatoid arthritis and osteoarthritis?

A. Neuronal windup B. Neuronal plasticity C. Peripheral sensitization

D. Central sensitization ANS: A Feedback: Neuronal windup is produced when repeated assaults on the afferent neurons create enhanced response and increased activity in the central nervous system. Windup can cause tissues in the affected area to become extremely sensitive to pressure in areas not identified usually as painful. Examples of windup include rheumatoid arthritis and osteoarthritis. Neuronal plasticity is the ability of the nervous system to change or alter its function. Peripheral sensitization is the result of inflammatory process that creates hypersensitivity to touch or pressure. Central sensitization is the excitatory process involving spinal nerves produced by continued pain stimuli that can persist even after peripheral stimulation is no longer present.

PTS: 1 REF: p. 133 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 16. The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the client's pain?

A. Sleep patterns B. Family history C. Genetic history D. Elimination pattern ANS: A Feedback: When assessing pain in older adults, the nurse should be sure to also review the effects of pain on diet, sleep, and mood. Unrelieved pain may lead to insomnia or depression and seriously affect the client's quality of life. It would not be necessary to assess the family history, genetic history, or elimination pattern to gain insight into the client's pain level.

PTS: 1 REF: p. 142 OBJ: 9 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. An older adult is admitted to the unit with abdominal pain. The nurse doing the admission assessment knows what about pain in older adults?

A. Older adults have fewer nerve fibers; therefore, they feel less pain B. Older adults may be reluctant to report pain C. Older adults are always in chronic pain D. Older adults are stoic and expect to be in pain ANS: B

Feedback: Although pain is prevalent in older clients, some of them see pain as just part of natural aging. They may be reluctant to report pain, because they want their providers to consider them "good clients," or they may fear that complaints of pain may lead to costly tests or expensive medications that they cannot afford. Older adults do not have fewer nerve fibers, they are not always in chronic pain, and they are not always stoic or expecting to be in pain.

PTS: 1 REF: p. 142 OBJ: 9 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. An adult is recovering from sinus surgery. The client reports being in "a lot" of pain. The physician has ordered morphine every 3 hours. What intervention would be most appropriate?

A. Give morphine every 3 hours B. Reassess the client before giving morphine as ordered C. Use nonpharmacologic pain relief prior to giving morphine D. Wait until the client asks for pain medication before administering morphine ANS: A Feedback: In a client recovering from surgery, pain control is of utmost importance. Pain medication should be given as ordered for the first 24 hours unless the client refuses it.

The other options are distracters for the question.

PTS: 1 REF: p. 143 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 19. The charge nurse on a geriatric unit should further educate a new staff nurse who makes which statement?

A. Transmission of pain along A-delta and C fibers may be altered in older adults.

B. There is little information about the effects of increased age on pain.

C. Pain sensation is diminished in older adults.

D. Older adults tend to be undertreated for pain.

ANS: C Feedback: Little is known about the effect of increased age on pain perception. No evidence suggests that pain sensation is diminished in older adults, which is a common misperception. Transmission along the A-delta and C fibers may become altered with aging, but it is not clear how this change affects the pain experience. Studies of sensitivity and pain tolerance have indicated that changes in pain perception are probably not clinically significant. Because older people are likely to experience more adverse effects from analgesia, especially from opiates, health care providers may undertreat pain in older adults.

PTS: 1 REF: p. 134 OBJ: 9 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Caring

BLM: Cognitive Level: Apply

NOT: Multiple Choice

20. The nurse is using the Brief Pain Inventory to help assess pain in a client. Which of the following clients will benefit from this assessment?

A. client admitted with bone cancer B. client who had a recent appendectomy C. client who fell at home and now has a hip fracture D. client who had local anesthesia for a lumpectomy ANS: A Feedback: The Brief Pain Inventory was first developed to measure pain in clients with cancer and has been found effective for use with those who have chronic pain. Pain following a lumpectomy, pain associated with a hip fracture, and pain following an appendectomy are representative of acute pain.

PTS: 1 REF: p. 139 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 6: Pain Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 07: Nutrition Assessment 1. A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer?

A. "Hair consists mostly of carbohydrates."

B. "Hair consists mostly of protein."

C. "Hair consists mostly of inorganic matter."

D. "Hair consists mostly of cellular waste."

ANS: B Feedback: Body tissues such as muscles, bones, teeth, skin, and hair primarily consist of protein. This information makes carbohydrates, inorganic matter and cellular waste incorrect answers to the client's question.

PTS: 1 REF: p. 153 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 2. A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

A. Decreased intake of grains B. Weight loss C. Variety D. Increased intake of meats ANS: C Feedback: Emphasis of nutritional guidelines is on variety; increased intake of vegetables, fruits, lentils, and grains, particularly from plant sources; and meeting individual nutritional needs while avoiding either deficiencies or excesses in nutrient intake.

PTS: 1 REF: p. 156 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. A nurse is caring for a client who belongs to the Mormon faith. What would be the best breakfast for this client?

A. Coffee, scrambled eggs, and sausage B. Tea, pancakes, and a grapefruit C. Coffee, oatmeal, sausage, and an English muffin D. Orange juice, French toast, and bacon ANS: D Feedback: Food practices may be based on religious beliefs, such as fasting or abstaining from eating certain foods. Mormons avoid coffee, tea, alcohol, and tobacco.

PTS: 1 REF: p. 158 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Analyze NOT: Multiple Choice 4. A college football player has been hospitalized with knee surgery. When discussing dietary choices, what nutrient would the nurse encourage increasing to promote muscle healing?

A. Protein B. Carbohydrates C. Grains D. Fats ANS: A Feedback: Athletes may require additional protein for muscle building and maintenance; this client also requires protein for muscle repair. Hospitalized athletes and post-surgical clients do not generally require extra servings of carbohydrates, grains, or fats.

PTS: 1 REF: p. 153 OBJ: 1 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A nursing instructor is discussing nutrition screening and assessment with a clinical group. What would this instructor identify for the students as parts of a complete nutrition screening assessment? (Select all that apply.)

A. Physical examination B. Dietary log C. Calorie count D. Focused history of common symptoms E. Serial laboratory values ANS: A, D, E Feedback: Parameters for a complete nutrition screening assessment include a risk assessment, focused history of common symptoms, comprehensive nutritional history, physical examination, calculated measurements, and serial laboratory values (especially during times of high metabolic demand, such as fever, pain, or infection or during limited nutritional intake). Generally speaking, a complete nutrition screening assessment does not include a dietary log or calorie count.

PTS: 1 REF: p. 159 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Select 6. When taking a dietary assessment on a newly admitted client who has had a mild myocardial infarction and is a vegetarian, what would the nurse identify as being important to include in dietary teaching?

A. Food/drug interaction with chlorophyll B. Food/drug interaction with melatonin C. Food/drug interaction with green leafy vegetables D. Food/drug interaction with grapefruit ANS: C Feedback: Diet and food intake affect medications. Dark green leafy foods can decrease the effect of some anticoagulants, and many clients who have had a myocardial infarction usually take some kind of anticoagulant. Grapefruit, melatonin, and chlorophyll do not generally react with anticoagulants.

PTS: 1 REF: p. 161 OBJ: 4 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 7. A client with alcoholism is on a detoxification unit. What nutritional deficit would the nurse expect in this client?

A. Vitamin C B. Vitamin A C. Vitamin K D. Vitamin D ANS: C Feedback: It is common for clients with a high alcohol intake to be deficient in the B vitamins and vitamin K. These clients are not generally expected to be deficient in vitamins C, A, and D. PTS: 1 REF: p. 155 OBJ: 4 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 8. Friends bring a young adult client to the emergency department after a fall down a flight of stairs at a party. The nurse notes that the client has very little muscle mass or fat stores on the client's body. What syndrome should the nurse suspect the client has?

A. Ascites B. Cachexia C. Dehydration D. Bulimia ANS: B Feedback: Cachexia means a highly catabolic state with accelerated muscle loss and a chronic inflammatory response. It is a distinct syndrome separate from bulimia with the production of proinflammatory cytokines that contribute to the breakdown of fat and muscle protein, causing loss of both muscle mass and fat stores. Ascites, bulimia, and dehydration are not syndromes and are therefore incorrect responses.

PTS:

1

REF: p. 166

OBJ: 8

NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. The triage nurse suspects malnutrition in an older adult with altered mental status who has been brought to the emergency department by family members. What visible signs might the nurse have noticed that would lead to the suspicion of malnutrition? (Select all that apply.)

A. Atrophied tongue B. Temporal muscle wasting C. Generalized muscle weakness D. Dry eyes E. Productive cough ANS: A, B, C, D Feedback: Clinical findings of malnutrition can occur throughout the body. Visible signs include muscle wasting, particularly in the temporal area; muscle weakness and decreased muscle size; tongue atrophy; and bleeding or changes in the integrity or hydration status of the skin, hair, teeth, gums, lips, tongue, eyes, and, in men, genitalia.

A productive cough is not a visible sign of malnutrition.

PTS: 1 REF: p. 159 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 10. What is the most common indication of nutritional status in infants and children?

A. Appetite B. Number of wet diapers/day C. Growth D. Sleep pattern ANS: C Feedback: Growth charts are commonly used to indicate nutritional status. As an indication of nutritional status, appetite, number of wet diapers/day, and sleep pattern are generally not used.

PTS: 1 REF: p. 166 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 11. What amount of weight loss over 36 months is associated with increased mortality among older adults living in the community?

A. 1% B. 3% C. 5% D. 10% ANS: C

Feedback: A loss of as little as 5% of weight over a 3-year period is associated with increased mortality among older adults living in the community. This information makes the remaining options incorrect.

PTS: 1 REF: p. 158 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 12. After assessing a new client, the nurse documents findings in the medical record. What is the best example of documenting normal findings?

A. Clothing appears too large B. Nails are strong C. Hair is thin and appears oily D. Oral mucosa is pink with white patches ANS: B Feedback: Nails are strong; is the documentation that represents a normal finding.

Clothing that is too large might indicate weight loss. Thin, oily hair is not generally a normal finding, nor are white patches on the oral mucosa.

PTS: 1 REF: p. 163 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. What is the use of dietary assessment data gathered from a client by a nurse?

A. Initiate social service consult B. Evaluate an adequate diet C. Identify client outcomes D. Identify areas that are not of concern ANS: C Feedback: Nurses use assessment information to identify client outcomes. The other options are distractors for the question.

PTS: 1 REF: p. 175 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A middle aged client is admitted to the observation unit with right lower quadrant pain.

The client has not kept down any food or drink for 24 hours. The client's temperature is 38.6°C orally (101.5°F). The client describes the pain as "achy with periods of sharp, stabbing sensations." What would be the most appropriate nutritional nursing diagnosis for a client with these assessment data?

A. Deficient knowledge related to disease process B. Pain related to an inability to tolerate food

C. Potential for malnutrition (deficit) related to an inability to tolerate food D. Fluid volume less than body requirements related to an inability to tolerate fluids ANS: D Feedback: Fluid volume is generally affected faster than anything else when a client cannot keep fluids down. A knowledge deficit can only occur once a medical diagnosis is established. Pain is not a nutrition-related nursing diagnosis. Malnutrition does not occur during a hospitalization but over a long period.

PTS: 1 REF: p. 158 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. A male client who was transferred from intensive care and extubated less than 24 hours ago exhibits drooling and a weak voice. At meal time, what is the nurse's priority action?

A. Delegate feeding the client to a nursing assistant.

B. Place the client in semi-Fowler's position for feeding.

C. Call the healthcare provider to request a liquid diet.

D. Explain to the client why he should not eat anything by mouth yet.

ANS: D Feedback: If the client exhibits drooling with a weak voice and has a history of recent intubation he should be kept on nothing by mouth and a swallowing evaluation should be performed before any type of oral feeding. The client should also be placed on aspiration precautions and remain in a fully upright position.

PTS: 1 REF: p. 167 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. The nurse instructor is helping student nurses to better understand the body's main source of energy, carbohydrates. The nurse instructor determines that further education is needed when a student lists which of the following as simple carbohydrate(s)? (Select all that apply.)

A. glycogen B. fiber C. glucose D. dextrose E. fructose ANS: A, B Feedback: Simple carbohydrates include glucose, dextrose, fructose, galactose, sucrose, maltose, and lactose. Examples of simple carbohydrates include candy, sugary drinks, syrups, and table sugar. Complex carbohydrates include starch, glycogen, and fiber.

Examples of complex carbohydrates include whole grains, legumes, vegetables, and fruits.

PTS:

1

REF: p. 153

OBJ: 1

NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 17. The nurse in a long-term care facility is caring for an older adult client who had a 7% weight loss over a two-year period. Which is an expected intervention based on the information?

A. Assess the client's dentures for proper fit.

B. Place the client on fall risk precautions.

C. Ask the client to eat in their room to avoid distractions at mealtime.

D. Teach the client to choose food low in protein.

ANS: A Feedback: Poor-fitting dentures can detract from the enjoyment of meals, and unless the situation is remedied there can be a further decrease in weight. Losing weight doesn't automatically cause an older adult to be at risk for falls. If the client is having difficulty with maintaining proper fluid status, they will be at risk for falls. Older adults need to consume diets high in protein. Mealtimes should be as enjoyable as possible.

PTS: 1 REF: p. 157 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is conducting a 24-hour dietary recall with a client. Which of the following questions are appropriate to ask? (Select all that apply.)

A. "When was the first time you ate or drank anything yesterday?"

B. "What was the next thing you had to eat or drink?"

C. "What foods did you eat that you might have put condiments on?"

D. "Did you eat three large meals yesterday?"

E. "Were you hungry in the late afternoon?"

ANS: A, B, C Feedback: When conducting a 24-hour recall, the nurse should ask open-ended questions to obtain complete and accurate results. Closed-ended questions don't allow for elaboration or additional details.

PTS: 1 REF: p. 164 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 19. The charge nurse is prioritizing the review of intake and output records. Which client's records should be reviewed first?

A. a client who has burns to 60% of their body B. a client who underwent hip arthroscopy two days ago C. a client who was admitted with malignant hypertension D. a client who was admitted with acute pain caused by gout

ANS: A Feedback: Patients with burns, drains, wounds, or severe diarrhea need to have outputs closely monitored. Chronic conditions such as hypertension, gout, and hip arthroplasty do not place a client at high risk for alterations in hydration and nutrition status. These conditions aren't associated with large fluid shifts, swallowing problems, or inability to eat and drink.

PTS: 1 REF: p. 165 OBJ: 3 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 20.

After reading the documented notes above, what is the priority action for the nurse to take?

A. Complete a nutritional assessment.

B. Monitor white blood cell count.

C. Continually monitor pain.

D. Place the injured leg in a dependent position.

ANS: A

Feedback: The nurse should recognize that the client's BMI is extremely low and that the client expressed concern over not being able to exercise. In addition, the client appears to be thin in structure and has not had a regular menses cycle in the last six months. These findings should indicate the need for a nutritional assessment. The injured ankle should be elevated and not placed in a dependent position. The client's injury does not require frequent assessment of pain level. The white blood cell count would not be altered in this scenario.

PTS: 1 REF: p. 167 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 7: Nutritional Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 08: Assessment of Developmental Stages 1. What term refers to the drive to establish and guide the next generation?

A. Ego integrity B. Despair C. Generativity D. Stagnation ANS: C Feedback: The essence of generativity is that people need to be needed. With maturity comes satisfaction from what has been produced. Generativity is principally the drive to establish and guide the next generation. The three distractors are also terms from Erikson's Model of Individual Development. In the late adulthood stage ego integrity versus despair is paired. Ego integrity is when one comes to terms with one's life choices. When one does not reach this developmental mark, despair can result. In the middle adult stage generativity is paired with stagnation. Stagnation results when one does not meet generativity as described above.

PTS: 1 REF: p. 182 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. Piaget differentiates young adulthood from middle adulthood by the use of what function?

A. Expertise B. Fluid intelligence C. Wisdom D. Cognitive pragmatics ANS: A Feedback: Because expertise requires years of experience, learning, and work, middle adults are far more likely to have it compared to young adults. Therefore, the other options are distractors.

PTS: 1 REF: p. 185 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 3. Wisdom, as defined by Piaget, has many characteristics. What are they? (Select all that apply.)

A. Focuses on important and moderately easy matters B. Involves superior knowledge, judgment, and advice C. Applies only to nonspecific situations D. Is easily recognized by most people E. Is employed for personal well-being

ANS: A, B, D, E Feedback: Wisdom refers to an expert knowledge system that appears to focus on important and difficult matters often associated with the meaning of life and the human condition; requires a superior level of knowledge, judgment, and advice; is associated with knowledge that has extraordinary scope, depth, and balance; and is applicable to specific situations. Wisdom combines mind and virtue (character) and is employed for personal well-being as well as for the benefit of humankind. Although difficult to achieve, wisdom is easily recognized by most people, and it represents the capstone of human intelligence.

PTS: 1 REF: p. 186 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 4. What is egocentrism?

A. Internalized sets of actions that permit children to do mentally what they once did physically B. Centering attention on one aspect of a problem and failing to consider other dimensions C. The belief that inanimate objects are capable of action and have lifelike qualities D. The inability to distinguish one's own perspective from another person's ANS: D Feedback: Egocentrism is the inability to distinguish one's own perspective from another person's. Animism is the belief that inanimate objects are capable of action and have lifelike qualities. Centration is the child centering attention on one aspect of a problem and failing to consider other dimensions. Piaget defined operations as internalized sets of actions that permit children to do mentally what they once did physically.

PTS: 1 REF: p. 184 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A nurse is caring for an older adult who reports that he is becoming "forgetful." The nurse explains that some parts of memory decrease with aging, and some do not. What would the nurse identify happens with aging to the type of memory that corresponds with the retrieval of facts, vocabulary, and general knowledge?

A. Decreases minimally B. Decreases, but may be from slower processing speed C. Decreases, but the client may use better strategies to minimize the effects D. Shows slight or no decrease ANS: A

Feedback: Semantic long-term memory involves the retrieval of facts, vocabulary, and general knowledge and decreases minimally with aging. Option C is active processing of information while it is held in short-term memory. Option D is memory for things the person is presently and actively thinking about; option B is the recollection of past events and personally relevant information.

PTS: 1 REF: p. 187 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. The nurse is presenting a class for new mothers and explains that from ages 4 to 8 months infants perform secondary circular reactions. This occurs when A. The infant reproduces an event that initially happened by chance B. The infant coordinates schemes and intentionality C. The infant becomes more object-oriented, moving beyond being preoccupied with the body D. The infant experiments with new behavior ANS: C Feedback: Between ages 4 and 8 months, infants engage in secondary circular reactions, by which they become more object-oriented and move beyond being preoccupied with the body. The infant coordinates schemes and intentionality occurs during coordination of secondary circular reactions. The infant reproduces an event that initially happened by chance represents primary circular reactions. The infant experiments with new behavior occurs during tertiary circular reactions.

PTS: 1 REF: p. 184 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. Erikson theorizes that the school-aged child faces the task of industry vs. inferiority.

What is the danger in this stage of development?

A. The child will separate himself or herself from others to avoid commitment to intimacy B. The child will not be able to learn to use adult tools C. The child will struggle to choose an occupational identity D. The child will overmanipulate self and work to repossess the environment in a repetitive fashion ANS: B

Feedback: The danger in this stage is that the child will not be able to learn to use the adult tools and will feel a sense of inferiority and inadequacy. It is difficult for the child to be admitted to an adult role in society without the tools to deal with the technology and economy of the culture. "The child will separate himself or herself from others to avoid commitment to intimacy" represents the danger of the young adult stage of development. "The child will overmanipulate self and work to repossess the environment in a repetitive fashion" represents the danger of the toddler developmental stage.

PTS: 1 REF: p. 182 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 8. If A is greater than B, and B is greater than C, then it must be true that A is greater than C. This is called what?

A. Transitivity B. Seriation C. Formality D. Hypothetical-deductive reasoning ANS: A Feedback: Piaget's concept of transitivity refers to the child's ability to consider such problems as if A is greater than B, and B is greater than C, then it must be true that A is greater than C. Seriation refers to the ability to arrange objects by quantitative dimensions. Formality is the rigid observance of rules of convention or etiquette.

Hypothetical-deductive reasoning is a very important method for testing theories or hypotheses.

PTS: 1 REF: p. 184 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A nurse is presenting an educational event for a local community group. What form of knowing would the nurse tell the group is learned and influenced by the individual person's culture?

A. Pragmatic mechanics B. Cognitive mechanics C. Fluid intelligence D. Crystallized intelligence ANS: D Feedback: Crystallized intelligence is "accumulated knowledge and skills based on education and life experiences." Fluid intelligence, also known as cognitive mechanics, looks at the ability for the brain to learn new skills or tasks. Pragmatic mechanics is not a term used to describe this type of knowledge.

PTS:

1

REF: p. 185

OBJ: 3

NAT: Client Needs: Psychosocial Integrity TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 10. A couple adopts an 8-month-old infant. The clinic nurse writes a care plan that includes the diagnosis of risk for delayed child development related to recent adoption. What would be an appropriate nursing intervention for this infant/family?

A. Consider visits by a home health nurse to assess the environment for safety and comfort B. Teach parents to discipline the infant C. Teach parents to stimulate the infant as needed D. Consider a visit by a home health nurse to assess parenting skills ANS: A Feedback: The most appropriate intervention for risk for delayed child development related to recent adoption is to consider a home health nurse visit to assess the environment for safety and comfort. Infants are too young for discipline, and this has no connection to the nursing diagnosis. All children need stimulation. Nothing in the scenario indicates that the couple's parenting skills are in question.

PTS: 1 REF: p. 200 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. In some countries, the transition to adulthood is a long process. Why is this?

A. These countries value parenting more than in other countries B. These countries have no rites of passage C. These countries have higher education opportunities D. These countries do not value independence ANS: C Feedback: The transition to adulthood is a long process for some cultures (particularly those with higher education opportunities) and a very short one for others. The process is not related to how much a country values parenting or embraces rites of passage.

Countries that value independence would be equated with shortened, not prolonged, transitions to adulthood.

PTS: 1 REF: p. 189 OBJ: 4 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 12. When Erikson published his theory in 1963, he predicted that childhood ended when?

A. At the end of grammar school B. Puberty C. When the person gets his or her first job

D. Teenage years ANS: B Feedback: In Erikson's 1963 model, puberty signals the end of childhood. Therefore, the other options are incorrect. End of grammar school and teenage years are not specific enough. Employment does not correlate with the end of childhood.

PTS: 1 REF: p. 182 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 13. In what life stage, defined by Erikson, is group identity important?

A. Early adulthood B. School age C. Adolescence D. Young adult ANS: C Feedback: Adolescents tend to cling together in cliques and crowds. Doing so helps to protect against the loss of identity through the assumption of a group identity that temporarily defines for the adolescent how to dress, act, and belong. Erikson explained that this behavior will eventually fall away as the individual defines his or her own identity. The other options are distractors for this question.

PTS: 1 REF: p. 182 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 14. According to Piaget, which child activities are indicative of the preoperational stage of development? (Select all that apply.)

A. Recalls visiting the zoo several days after the visit.

B. Participates in pretend play.

C. Recognizes equal volume in different shaped containers.

D. Scribbles pictures of pets, clouds, and cars.

E. Engages in hypothetical-deductive reasoning.

ANS: A, B, D Feedback: Piaget divided the preoperational stage into two substages: (1) symbolic function and (2) intuitive thought. The child in the symbolic function substage, which lasts roughly from ages 2 to 4 years of age, can now mentally represent an absent object.

For example, he or she can talk about a grandparent's house for many days after a visit.

Scribbled designs represent people, houses, cars, clouds, and other objects (Santrock, 2012). Using language and pretend play (Fig. 8.2) are other characteristics of this substage. Children understand defined operations, such as recognizing equal volume in different shaped containers, in the concrete operations stage. Formal operations stage encompasses hypothetical-deductive thinking.

PTS: 1 REF: p. 184 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 15. The nurse is estimating potential adult height of a female child. The father's height is 69 inches and the mother's height is 68 inches. What is the child's potential adult height in inches?

ANS: 66 inches Feedback: There are formulas for estimating potential adult height for children (Leifer & Fleck 2013). For girls, the formula is father's height (inches) + mother's height (inches) 5 inches/2.

PTS: 1 REF: p. 197 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Fill In the Blank 16. The clinic nurse is educating a caregiver about promoting the development of a 2-year-old child. Which statement should be included in the teaching?

A. "Allow the child to make choices when possible."

B. "Engage the child in goal-setting activities."

C. "Pick the child up when crying."

D. "Encourage the child to play in large groups of children."

ANS: A Feedback: According to Erikson, caregivers must help toddlers learn how to discriminate and choose appropriately. Goal setting and learning to work with others are not priorities during the toddler years. Comforting a crying child to help that child develop trust is associated with infancy.

PTS: 1 REF: p. 181 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 17. The nurse is caring for a young child. The child draws a picture of their home and gives it to the nurse. Which is the correct documentation?

A. The child is in the preoperational stage according to Piaget.

B. The child is establishing trust versus mistrust per Erikson.

C. The child has reached the concrete operation stage according to Piaget.

D. The child is demonstrating generativity as described by Erikson.

ANS: A

Feedback: According to Piaget, from ages 2 to 4 years, the child develops the ability to mentally represent an absent object. For example, the child can scribble designs that represent people, houses, cars, etc. At this developmental stage the child has reached the preoperational (not concrete) stage. The concrete stage generally occurs between ages 7 to 11 and is characterized by logical reasoning and understanding logical operations and being able to reverse or classify items. According to Erikson, trust versus mistrust is established in infants. The infant either comes to view others as trustworthy or develops a fundamental distrust of the environment. Also according to Erikson, generativity and intimacy versus isolation are associated with adults. These stages relate to establishing a concern for the next generation (generativity) and developing intimate and loving relationships with other people (intimacy).

PTS: 1 REF: p. 184 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. The nurse is developing a plan of care for an older adult who lives independently. Which of the following should the nurse include?

A. Allow additional time for the client to perform activities of daily living.

B. Develop educational materials for the client's family instead of the client.

C. Repeat the directions for each task multiple times.

D. Provide all written educational materials in large text.

ANS: A Feedback: Older adults take longer to perform simple tasks such as activities of daily living. The client should be given additional time to complete regular tasks. Despite age, older adults still have the ability to learn and teaching should be directed toward the client. Teaching may need to be slowed down but repeating the same thing over and over may not be necessary and can frustrate the client. In addition, the client may not teaching related to each task. What needs to be taught should be assessed and not assumed. In addition, not all older adults require print to be in large text; that is an assumption the nurse should avoid making.

PTS: 1 REF: p. 186 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is teaching the family member of an older adult about changes associated with the body and aging. Which statement by the family member indicates a need for additional education?

A. "Limited exercise is recommended due to decreased vital organ capacity."

B. "The ability learn new things will remain intact."

C. "Taking multiple medications from various health care providers can cause delirium."

D. "Older adults are more likely to get pneumonia."

ANS: A Feedback: It is important for older adults to maintain function by keeping a healthy weight, exercising, and treating conditions that arise before they cause serious health effects. Older adults are more likely to get pneumonia because the immune system weakens with age, and older adults may have additional chronic illnesses such as chronic obstructive pulmonary disorder, making them more susceptible to pneumonia. Older adults are at a higher risk for taking too many medications, also called polypharmacy.

Polypharmacy symptoms can be psychological including delirium, apathy, delusions, and agitation. Although it may take older adults longer to learn new materials or tasks, the ability to learn new things remains present.

PTS: 1 REF: p. 188 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Create NOT: Multiple Choice 20.

The nurse reviews the notes (above) for the client. Which of Erikson's developmental stages is the client experiencing?

A. Generativity B. Intimacy C. Stagnation D. Integrity ANS: A

Feedback: The nurse should recognize that the client is achieving generativity according to Erikson. This can be identified by the client's age and the activity of coaching youth sports. Generativity is principally the drive to establish and guide the next generation.

Generativity is the opposite of stagnation in which the client would likely not feel motivated to coach a youth sports team. Although the scenario mentions the client has a significant other, there is nothing else to indicate that the client is unable to build a committed relationship. Integrity is a developmental task associated with older adults when their pace of life slows down and they assess all that they have achieved. There is nothing in the scenario to indicate the client is concerned with the satisfaction of their life.

PTS: 1 REF: p. 182 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 8: Assessment of Developmental Stages KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 09: Mental Health, Violence, and Substance Use Disorder 1. A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

A. Age B. Occupation C. Environment D. Support systems ANS: A Feedback: Factors that cannot be changed include family history, age, and gender.

Occupation, environment, and support systems are all, to some degree, modifiable.

PTS: 1 REF: p. 215 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 2. The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life?

A. MMPI B. ABCT C. CAGE D. HOPE ANS: C Feedback: If alcohol use might be a problem, the CAGE is a quick first-step questionnaire to use as an assessment tool. The MMPI is the Minnesota Multiphasic Personality Inventory used to aide in diagnosing psychological problems. The ABCT is used for assessment of mental status. It includes Appearance (posture, movement, hygiene, and dress), Behavior (level of consciousness, eye contact, facial expressions, speech), Cognitive function (orientation, attention span, memory, judgment), and Thought processes and is not a tool. The HOPE tool is used for assessing spirituality.

PTS: 1 REF: p. 228 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. The nurse suspects substance abuse in an adult client who has been admitted to the emergency department following a motor vehicle collision. What is the reason the nurse would administer the CAGE tool to this client?

A. The CAGE tool tracks patterns over time B. The CAGE tool addresses problems at work C. The CAGE tool tracks the progress of the client's disease

D. The CAGE tool addresses the client's denial ANS: D Feedback: When screening for substance abuse, the client will most likely deny a problem. The CAGE tool is valuable because it addresses this denial. The CAGE tool does not address problems at work; it does not track the progress of the client's disease nor does it track patterns over time.

PTS: 1 REF: p. 215 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 4. When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

A. Suicide attempts B. Suicide means C. Suicide risk D. Suicide plan ANS: C Feedback: Suicide risk is assessed by asking, "Do you have any thoughts of wanting to harm or kill yourself?" This question does not assess attempts at suicide, means of suicide, or plans of suicide.

PTS: 1 REF: p. 217 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 5. While assessing a new client in the clinic area, the nurse administers the SAD PERSONAS. For what is the nurse most likely assessing?

A. Risk of depression B. Risk of self-mutilation C. Risk of violence D. Risk of suicide ANS: D Feedback: SAD PERSONAS suicide risk assessment: Sex, Age, Depression, Previous attempt, Ethanol abuse, Rational thought loss, Social supports lacking, Organized plan, No spouse, Access to lethal means, Sickness. The presence of each factor is given a point value of one. Total scores range from 0 to 10. Higher scores indicate greater client suicide risk. The assessment tool does not assess depression, self-mutilation, or violence.

PTS: 1 REF: p. 217 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process

BLM: Cognitive Level: Apply

NOT: Multiple Choice

6. The nurse is assessing a client in the clinic who reports hearing "voices." What would be the most important assessment to make?

A. The nature of the voices B. How the voices affect the client C. If the client also sees things D. Whether others hear the voices ANS: A Feedback: If the client confirms auditory hallucinations, it is important to ask about their nature. Are they hostile or critical? Do they "command" or tell the client to do things such as harm self or others? The other options are appropriate, but not the most important since they are not directly associated with client safety.

PTS: 1 REF: p. 219 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 7. What collection of factors are the most common causes for visual hallucinations?

A. Multiple sclerosis, alcohol withdrawal, and medication side effects B. Medication side effects, alcohol withdrawal, and Parkinson's disease C. Parkinson's disease, medication side effects, and amphetamine withdrawal D. Narcotic withdrawal, multiple sclerosis, and head injury ANS: B Feedback: Common causes of visual hallucinations include side effects from medications, alcohol withdrawal, and Parkinson's disease. Generally, multiple sclerosis, amphetamine withdrawal, narcotic withdrawal, and head injury do not cause visual hallucinations.

PTS: 1 REF: p. 219 OBJ: 1 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 8. The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face.

The instructor explains that this may be an indication of long-term lack of care because of what disorder?

A. Depression B. Bipolar disorder C. Violence D. Schizophrenia ANS: D

Feedback: Cradle cap around the face of adults indicates long-term lack of care and is often seen in clients with schizophrenia. None of the other options are associated with this assessment finding.

PTS: 1 REF: p. 222 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. An adult arrives at the psychiatric clinic in an unkempt state. An assessment notes clubbed fingers and nicotine stained fingertips. The client's history includes emphysema.

What nursing diagnosis might the nurse use in this client's plan of care?

A. Poor cognition related to poor oxygenation B. Poor cognition related to primary disease process C. Poor cognition related to drug withdrawal D. Poor cognition related to side effects of medication ANS: A Feedback: Hands may be indicators of health problems, smoking status, drug withdrawal, low blood glucose level, or side effects of medications. Clubbing is seen in clients with emphysema or who use recreational drugs with talc in them; poor oxygenation affects cognition. The primary disease process for this client at this time would be psychiatric; the scenario does not mention drug withdrawal or medications with side effects that might cause poor cognition.

PTS: 1 REF: p. 223 OBJ: 8 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Create NOT: Multiple Choice 10. A nurse is conducting a mini-Cog examination (MMSE) on an older adult client. What is this nurse assessing for? (Select all that apply.)

A. Disorientation B. Violence C. Recall D. Language E. Registration ANS: C, D, E Feedback: The MMSE is used with adults to assess for cognitive impairment and its severity in orientation, registration, attention, calculation, recall, and language. Neither of disorientation and violence are assessed by the MMSE. PTS: 1 REF: p. 227 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select

11. When administering a mini-Cog examination (MMSE), what score would indicate cognitive impairment?

A. 38 or less B. 33 or less C. 28 or less D. 23 or less ANS: D Feedback: A score of 23 or lower on the MMSE indicates cognitive impairment. The other options represent scores too high to indicate cognitive impairment.

PTS: 1 REF: p. 227 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 12. The nurse notes an acute change in an adult client's mental status. The client has gone from being coherent and oriented to person, place, and time to having very disorganized thought processes. The client has become delirious. What are the possible effects of delirium on the client?

A. Visual hallucinations B. Depression C. Increased risk for suicide D. Stomach pains ANS: C Feedback: Delirium usually has an acute onset, and disorganized thoughts can place the client at risk for injury or suicide. Delirium generally does not cause visual hallucinations, depression, or stomach pains.

PTS: 1 REF: p. 216 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. The nurse notes that a client's conversation is often incoherent and wandering, with thoughts that seem illogical and inconsistent. What would these abnormal indications signify to the nurse?

A. The client is thinking less efficiently B. The client is delusional C. The client is hallucinating D. The client has schizophrenia ANS: A

Feedback: Illogical, incoherent, irrelevant, wandering, inconsistent, or concrete thought processes are abnormal indications that the client is thinking less efficiently. Nothing in the scenario indicates that the client has delusions or hallucinations. Schizophrenia is a psychiatric diagnosis that a nurse would not identify a client as having.

PTS: 1 REF: p. 225 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A client reports, "bugs are crawling under my skin." The nurse knows that this tactile hallucination is usually associated with what?

A. Medication side effect B. Methamphetamine use C. Brain tumor D. Parkinson's disease ANS: B Feedback: Hallucinogen and methamphetamine use is associated with tactile hallucinations. The other options do not describe situations or disease processes where the client would report tactile hallucinations.

PTS: 1 REF: p. 219 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 15. What type of family violence is among the most common type that children experience?

A. Financial abuse B. Sibling violence C. Munchausen's syndrome D. Traumatic stress ANS: B Feedback: Sibling violence is among the most common type of violence that children experience. The other options may be experienced by children but do not describe the most common type of family violence that children experience.

PTS: 1 REF: p. 207 OBJ: 7 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice

16. A woman comes to the emergency department with a broken humerus. The client lives in an area with a high crime rate and low socioeconomic demographic. During the examination, the client states, "I was fighting with my husband. He pushed me and I fell, landing on the coffee table. That is how I broke my arm." Why might this client be so forthcoming in her disclosure of violence?

A. Decreased social stigma about violence B. Low ethnic rate of acceptance of violence C. Increased cultural statistics on violence D. Decreased environmental pressure for violence ANS: A Feedback: The social stigma attached to human violence may vary among cultures. For example, a client from a neighborhood with a high rate of violent crime may feel less stigmatized because it is a common occurrence.

PTS: 1 REF: p. 206 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 17. What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

A. "What can I tell you about abuse?"

B. "I know you have been abused. Please tell me about it."

C. "Abuse is more prevalent than most people think."

D. "What would you like me to know?"

ANS: D Feedback: Open-ended questions, such as "What would you like to know?" "How can I help you understand?" or "What would you like me to know?" are especially helpful if a client appears uncomfortable. It would be inappropriate for the nurse to ask what she can tell the client about abuse or to tell the client that the nurse knows the client has been abused. While discussing the prevalence of abuse might help increase the client's knowledge, it might not make her feel any more comfortable about the situation or ready to share information.

PTS: 1 REF: p. 211 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. During the assessment of an adult woman at the clinic, the nurse finds indications that the client is a victim of abuse. When documenting findings, the nurse knows that it is important to be what? (Select all that apply.)

A. Sympathetic B. Consoling C. Descriptive D. Non-biased

E. Detailed ANS: C, D, E Feedback: When documenting objective data, it is important to be detailed, be descriptive, and note findings without bias. Documentation should not be sympathetic or consoling.

PTS: 1 REF: p. 211 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Select 19. An older adult client confined to a wheelchair is admitted to the hospital after a fall down a flight of stairs. The client is found to have multiple abrasions and bruises in various stages of healing. Abuse is suspected, and an Elder Assessment Inventory is performed. For what risk factors is the nurse assessing? (Select all that apply.)

A. Strained mental health of caregiver B. Financial issues C. Cognitive decline D. Independence E. Optimal physical health of caregiver ANS: A, B, C Feedback: Factors that put older adults at risk include dependency, cognitive decline, strained mental or physical health of caregivers, and financial issues. A commonly used tool to screen for maltreatment in older adults is the Elder Assessment Inventory.

Independence and optimal physical health of caregiver are issues not addressed by the assessment tool.

PTS: 1 REF: p. 207 OBJ: 7 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 20. A caregiver brings a handicapped client to the ED reporting the presence of an altered level of consciousness and the client's refusal to eat. When the client is found to be severely dehydrated, the nurse suspects neglect and asks the caregiver several questions regarding the client's activities, diet, and care. The caregiver states, "I didn't know it could hurt him if he didn't drink anything." This is an example of what kind of abuse?

A. Psychological B. Intentional C. Unintentional D. Direct ANS: C Feedback: Physical, sexual, psychological, and financial abuse and neglect may be intentional or unintentional. The scenario does not describe psychological abuse or intentional abuse. Direct is not a term commonly used to describe abuse.

PTS: 1 REF: p. 207 OBJ: 7 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 21. Nursing students are learning about human violence. The instructor is explaining key differences among various forms and how the differences affect assessment and intervention. What would the instructor explain is a key difference between violence against older adults and intimate partner violence?

A. Perpetrator B. Age C. Support people D. Family involvement ANS: A Feedback: Violence against older adults is intentional or unintentional acts such as physical, sexual, psychological, and financial abuse and neglect. Intimate partner violence is between spouses or nonmarital partners, threatened or actual physical or sexual violence or psychological/emotional abuse, coercive tactics, or both when there has been prior physical and/or sexual violence. Violence against an older adult can be perpetrated by someone other than the intimate partner. The other options are distractors for the question.

PTS: 1 REF: p. 206 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 22. Who are the major perpetrators of human trafficking?

A. Individuals who own and manage sweatshops B. Individuals who kidnap children to sell for adoption C. Individuals who own and manage commercial "sex trade" businesses D. Individuals who sell people for cheap labor ANS: C Feedback: Reasons people are trafficked include sexual exploitation, forced marriage, and cheap labor for domestic or commercial purposes. Those who own and manage commercial "sex trade" businesses (i.e., forced prostitution, stripping, pornography, live-sex shows) are the major perpetrators of human trafficking. None of the other options pose the risk presented by the "sex trade."

PTS: 1 REF: p. 207 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice

23. What qualities does the type of aggression called "punking" or "bullying" have? (Select all that apply.)

A. It is usually perpetrated by a male upon a female.

B. The behavior is intended to shame the victim.

C. The behavior can be both physically and verbally abuse.

D. The behavior occurs in public.

E. Is common in middle school and high school.

ANS: B, C, D, E Feedback: Punking and bullying are common among middle and high school males, usually resulting in the victim's shame, humiliation, and anger. Similar to bullying and sometimes used interchangeably, punking is a practice of verbal and physical violence, humiliation, and shaming, usually done in public or with an audience. Punking and bullying do not always involve opposite-gender relationships and do not represent humorous behaviors.

PTS: 1 REF: p. 207 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 9: Mental Health, Violence, and Substance Use Disorder KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select

Chapter 10: Cultural Assessment 1. What was the primary reason that the American Nurses Association and other accrediting agencies developed the National Standards for Culturally and Linguistically Appropriate Services in Health Care?

A. The composition of the United States is multicultural.

B. Ethnicity in nursing is part of the holistic process.

C. Unless cultural differences are addressed, many clients do not respond well to nurses.

D. Nurses need to understand every aspect of various cultures to provide good care to all clients.

ANS: A Feedback: The American Nurses Association, Joint Commission, American Psychological Association, and other accrediting agencies direct nurses to acknowledge and address the biopsychosocial and spiritual needs of clients. This is because the composition of the United States is multicultural. Ethnicity is not part of the holistic process. Clients may not respond well to nurses even when cultural differences are addressed. It is necessary to understand cultural differences when providing nursing care to specific cultures, but no nurse can know every aspect of all the different cultural groups encountered.

PTS: 1 REF: p. 237 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Remember NOT: Multiple Choice 2. A nursing student is caring for an older adult from a different cultural background. The nurse's preceptor asks the student what would be an important assessment to make to provide quality nursing care for this client. What would be the student's most appropriate response?

A. transcultural assessment B. respiratory assessment C. mobility assessment D. family assessment ANS: A Feedback: A specific example of a comprehensive nursing assessment that attends to both social and cultural dimensions is the transcultural assessment. A respiratory assessment would be important if the client had a respiratory problem. Mobility and family assessments could be useful, but these aspects can also be addressed through a transcultural assessment.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply NOT: Multiple Choice

3. The nurse begins the community assessment process for a small town with an assessment of what relationship?

A. The community's social support and marriage rates B. The community's level of education and rates of chronic illness C. The community's living conditions and divorce rate D. The community's median family income and high school graduation rate ANS: B Feedback: Ideally, the process of community assessment begins with an assessment of various social, economic, environmental, and quality-of-life health indicators and their relationship with the community's health concerns. Examples of findings from a community social assessment include the relationship between social determinants of health (family income, level of education, social support, and living conditions) and chronic illness. None of the other options focus on health-related issues.

PTS: 1 REF: p. 249 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 4. What is a mandated goal included in Anderson and McFarlane's Community as Partner Assessment Model?

A. Transcultural assessment of community allies B. Social assessment of community leaders as individuals C. Systemic evaluation to identify the effects of interventions D. Community evaluation to identify interventions in communities ANS: C Feedback: Anderson and McFarlane's model mandates that every community assessment and intervention include systematic evaluation to identify the effects of interventions.

None of the other statements accurately describe a mandated goal.

PTS: 1 REF: p. 250 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 5. A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what term?

A. society B. community C. system D. culture ANS: D

Feedback: At the most basic level, culture can be defined as a shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world. Society is defined as a group of people bound by a common culture. Community is defined as a group of people having a common interest. System is defined as a group of interrelated elements forming a complex whole.

PTS: 1 REF: p. 238 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Remember NOT: Multiple Choice 6. A new graduate nurse, attending a hospital orientation, is asked to explain the goals of a cultural assessment. What would be the graduate nurse's best answer?

A. Developing and implementing a culturally congruent plan of care B. Comparing social care needs of the specific person C. Acquiring knowledge about the community's cultural beliefs and practices D. Comparing social and health beliefs of public health agencies ANS: A Feedback: The specific aim of cultural assessment is to provide an all-inclusive picture of the client's culture-based health care needs by (1) gaining knowledge about the client's cultural beliefs and practices; (2) comparing culture care needs of the specific person with the general themes of those of a similar cultural background; (3) identifying similarities and differences among the cultural beliefs of the client, health care agency, and nurse; and (4) generating a holistic picture of the client's care needs, upon which a culturally congruent nursing care plan is developed and implemented. The remaining options are associated with components of an effective cultural assessment.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 7. Madeline Leininger identified attributes and behaviors that a nurse practicing effective care across cultures must have. What statement is reflective of Leininger's theory?

A. The nurse's own beliefs always interfere with cultural sensitive care.

B. Use of active listening by the nurse is fundamental to effective care.

C. Awareness of meanings behind the client's social communications is of minor importance.

D. Use of body language is not recommended when providing cultural sensitive nursing care.

ANS: B

Feedback: Leininger suggests that the attributes and behaviors of a nurse practicing effective care within the client's cultural context include genuine interest in a client's culture and personal life experiences, active listening, and awareness of meanings behind the client's verbal communication (storytelling); nonverbal communication (body language, eye contact, facial expressions, interpersonal space, and preferences regarding touch); and acknowledgement that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 8. When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care?

A. To enhance the client's social system B. To enhance cultural connectedness C. Improvement of the client's health outcomes D. Improvement of communication with the client and family ANS: C Feedback: Consideration of the client's cultural background and incorporating health beliefs and practices in care plans contribute to enhanced client experiences with health care and improve health outcomes. Incorporating the client's health beliefs and practices will not enhance this client's social system or cultural connectiveness, nor will it improve communication with the family.

PTS: 1 REF: p. 238 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. Matters of the human soul are referred to as what?

A. culture B. ethnicity C. values and beliefs D. spirituality ANS: D Feedback: Spirituality, in the most fundamental sense, pertains to matters of the human soul, be it a state of mind, a state of being in the world, a journey of self-discovery, or a place outside the five senses. Culture can be defined as a shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world. Ethnicity is one's self-defined race. Values and beliefs are those things that a person or culture sees as having worth.

PTS: 1 REF: p. 245 OBJ: 3 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process:

Teaching/Learning BLM: Cognitive Level: Remember

NOT: Multiple Choice

10. A hospice nurse is admitting a new client who states, "I'm not religious but consider myself spiritual." What change in attitude has been noted when illness stresses such a client's beliefs and values?

A. Religious activities may lose importance.

B. Religious activities may take a central position in life.

C. Religious activities may blend with national identity.

D. Religious activities may become formalized.

ANS: B Feedback: Even when daily prayers or other religious practices are not a routine part of a client's life, they often take a central position during life transitions, such as loss of a loved one, an accident, or serious illness. None of the other options are as likely to occur.

PTS: 1 REF: p. 246 OBJ: 4 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 11. A nursing student is helping with a group presentation on social assessment. What would be a foundational concept for the student to include in the group presentation?

A. Social assessment emphasizes the interconnectedness of physical, physiologic, and educational dimensions of health.

B. Social assessment emphasizes the interconnectedness of physical, family, and social dimensions of health.

C. Social assessment emphasizes the interconnectedness of physical, spiritual, and psychic dimensions of health.

D. Social assessment emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health.

ANS: D Feedback: Social assessment, integral to quality nursing care at every level, emphasizes the interconnectedness of physical, psychosocial, and spiritual dimensions of health for individuals, communities, and populations studied. Psychic, social, and educational dimensions are not dimensions of health emphasized in the social assessment.

PTS: 1 REF: p. 248 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 12. The nurse is participating in a group assignment on performing a social assessment on the Hmong society. What would be important to include in this assessment?

A. Societal trends and relationships B. Spiritual architecture C. Individuals in the society D. Occupational relationships

ANS: A Feedback: At the societal level, social assessment is intended to generate information about societal trends and relationships among social variables and prevalent health concerns. The other options are incorrect because an assessment of a society does not include spiritual architecture, the individuals in the society, or their occupational relationships.

PTS: 1 REF: p. 249 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Understand NOT: Multiple Choice 13. A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

A. Assessing if the client speaks and understands English B. Realizing that some women are not allowed an education in their home country C. Requesting a professional translator fluent in the woman's language D. Directing assessment questions only to the client's partner or family members ANS: A Feedback: To best address individualization during a transcultural assessment with this client, the nurse must determine the degree to which the client effectively speaks and understands English. The nurse would need this information prior to asking for a translator, assuming the client was not allowed an education, or talking only with the partner or family members.

PTS: 1 REF: p. 239 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 14. Madeline Leininger formulated a theory that highlights what information?

A. Social behaviors in a community B. Nursing behaviors necessary to carry out an effective cultural assessment C. Nursing behaviors that compare personal philosophies of life and spiritual beliefs D. Behaviors and skills necessary to carry out a community social assessment ANS: B Feedback: Leininger's theory identifies the relationships between cultural variables and health and highlights the nursing behaviors and skills necessary to carry out effective cultural assessment. None of the other options accurately describe Leininger's theory.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Teaching/Learning

BLM: Cognitive Level: Analyze

NOT: Multiple Choice

15. The nurse is caring for a hospitalized client from a culture that believes that a diet low in fruit and vegetables and high in fat is healthiest. While writing the plan of care for this client, it would be important to include which of the following nursing diagnoses?

A. Emotional distress related to hospital diet B. Spiritual distress related to prescribed diet C. Nutritional deficiency related to beliefs in societal diet D. Nutritional excess related to societal diet ANS: A Feedback: In many cultures, ideal body weight is higher than medical experts recommend. Such cultures may not consider "dieting" healthy. People may prefer to consume foods high in fat, salt, and cholesterol and low in fruit and vegetables because they believe that it is best for their health. The most appropriate nursing diagnosis in this case involves the emotional distress the client will likely experience following the hospital diet. Regardless of the client's potential beliefs, the hospital diet would not pose a risk for a nutritional deficiency. While the client's diet may be excessive in certain nutrients, the nurse or a dietitian would have to do more extensive nutritional assessment to arrive at specific conclusions.

PTS: 1 REF: p. 243 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. The nurse can best practice effective care by exhibiting which behavior during a cultural assessment?

A. Set a focused time limit for collecting data.

B. Stay focused on the computer screen to remain neutral.

C. De-emphasize nonverbal communication cues.

D. Acknowledge own prejudices that might create barriers to care.

ANS: D Feedback: Acknowledge that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care. Leininger suggests that the attributes and behaviors of a nurse practicing effective care within the client's cultural context include the following: - Genuine interest in a client's culture and personal life experiences - Active listening and awareness of meanings behind the client's verbal communication (storytelling) - Nonverbal communication (body language, eye contact, facial expressions, interpersonal space, and preferences regarding touch) - Acknowledgement that the nurse's own beliefs and prejudices might create barriers to providing culturally sensitive care.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Choice

17. The nurse is assessing a client in the emergency department who appears to be confused and unable to follow commands. When obtaining the client's social history, which of the following questions should the nurse ask first?

A. "Have you consumed any alcohol today?"

B. "Do you live in low-income housing?"

C. "Are you able to afford your medications?"

D. "Are you married?"

ANS: A Feedback: Nurses should use their judgement regarding the appropriate timing of a social assessment considering the health encounter, and only ask the questions that are essential. Asking about drug and alcohol use is a priority as the client is confused and unable to follow commands. Determining housing status, ability to purchase medications, and marital status are not immediately essential questions to ask.

PTS: 1 REF: p. 249 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is reviewing the chart of an 87-year-old female French-speaking client admitted to the hospital with abdominal pain. What should the nurse do prior to beginning a cultural assessment?

A. Determine if a translator is needed.

B. Request an order for pain medication.

C. Apply personal protective equipment.

D. Ensure the client is placed on fall precautions.

ANS: A Feedback: Without adequate communication, it is difficult to develop rapport or trust.

The nurse should first determine what kind of language assistance will be required to effectively communicate with the client and family. The other options can be determined, if necessary, after completing a physical assessment. Being able to properly communicate takes priority in conducting a cultural assessment, especially in this non-emergent situation.

PTS: 1 REF: p. 242 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply NOT: Multiple Choice

19.

The nurse is reviewing the chart notes (see above) for a client newly admitted to the hospital. Which of the following is a priority for the nurse when first meeting this client?

A. Ask for more information about the client's treatment preference.

B. Obtain the client's blood glucose level.

C. Offer to speak with the client's adult child as an intermediary.

D. Obtain assistance from an interpreter.

ANS: A Feedback: When first meeting a client, establishing a positive nurse-client relationship is essential. Attributes and behaviors of a nurse practicing effective care within the client's cultural context include taking a genuine interest in a patient's culture and treatment preferences. The client's vital signs were within normal limits and there is no indication that the blood glucose is not managed. Because the client can speak English, obtaining assistance from an interpreter is not a priority, unless the client were to request one. The nurse should speak directly to the client and not the adult child, as there is no indication that the client wants or needs a family member to act as an intermediary.

PTS: 1 REF: p. 238 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

After reviewing the nursing notes (above), the nurse should do which of the following?

A. Provide education related to infant formula consumption and overfeeding.

B. Demonstrate for the parents how to weigh diapers.

C. Demonstrate for the parents how to burp the infant to reduce vomiting.

D. Provide education related to preventing constipation in infants.

ANS: A Feedback: Some people believe that a fat infant is a healthy infant, and the parents may not understand that bottle feeding after breastfeeding may not be necessary and can lead to excessive weight gain and additional health risks. Based on the scenario there is no evidence that the infant is constipated, needs diapers weighed to assess for dehydration, or that needing to burp is the cause for the infant vomiting.

PTS: 1 REF: p. 244 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 10: Cultural Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 11: Skin, Hair, and Nails Assessment 1. The nursing instructor is discussing the function of sebaceous glands in the body. What would the teacher explain as the purpose of sebum to the students?

A. Assists in keeping the skin intact B. Assists in friction protection C. Assists in protection from infection D. Assists in keeping skin dry ANS: B Feedback: Sebum, an oil-like substance, assists the skin in moisture retention and friction protection. Sebum does not assist in keeping the skin intact, protecting from infection, or helping to keep the skin dry.

PTS: 1 REF: p. 264 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. A client has been prescribed tetracycline for acne. What is the most important point the nurse should make in client teaching about this medication?

A. The client may experience phototoxicity B. The medication may interfere with the menstrual cycle C. The client may experience photosensitivity D. The medication may be inactivated by antacids ANS: C Feedback: Tetracycline can lead to photosensitivity reactions, which usually present as a rash after exposure to the sun. Other medications stimulate phototoxicity, a reaction caused by the drug's molecules absorbing energy from a particular UV wavelength and then damaging surrounding tissues. The result is marked and severely tender sunburn.

Tetracycline does not interfere with the menstrual cycle and is not inactivated by antacids.

PTS: 1 REF: p. 269 OBJ: 2 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. A female teenager comes to the clinic reporting excessive hair growth. She tells the nurse that she is teased a lot because of hair growing on her shoulders and back; the client also reports that hair is growing on her upper inner thighs. What would the nurse suspect?

A. Endocrine disorder B. Ovarian dysfunction C. Hepatic dysfunction D. Chronic nephrosis

ANS: B Feedback: Ovarian dysfunction may be characterized by the presence of hair in the beard area, abdomen, upper back, shoulders, sternum, and inner upper thighs on female clients.

Body hair is not a sign of endocrine, hepatic, or kidney disorders.

PTS: 1 REF: p. 279 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 4. The nurse in the dermatology clinic is assessing an adult who has presented at the clinic with a lesion on the left inner thigh. The client tells the nurse that the lesion was discovered one month ago and no changes in the color or size of the lesion have been noted. What would be the most appropriate teaching subject for this client?

A. Skin self-examination B. Signs and symptoms of melanoma C. Recognizing different types of lesions D. Protection from sun damage ANS: B Feedback: A simple method is to use the ABCDEs of melanoma detection: Asymmetry, Border irregularity, Color, Diameter of more than 6 mm, Evolution of lesion over time.

The other given options are correct, but the most appropriate response is teaching about melanoma.

PTS: 1 REF: p. 267 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 5. A first-time mother calls the clinic to talk to the nurse. The mother is very upset, saying that her newborn's fingernails dip in the middle, appearing spoon-like. What would be the nurse's best response?

A. "Take the newborn to the emergency room to be evaluated."

B. "Bring your newborn to the clinic immediately."

C. "This may be normal in newborns."

D. "This is a sign of a nutritional deficiency. What are you feeding your newborn?"

ANS: C Feedback: With koilonychia (spoon nails), the nails may have transverse and longitudinal concavity, with the appearance of a spoon. This sign may be normal in newborns and usually resolves in few months. The nurse would not tell the mother to take the newborn to the emergency room or clinic. The nurse would not tell the mother that the finding was a sign of a nutritional deficiency.

PTS: 1 REF: p. 309 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Skin, Hair, and Nails Assessment

KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 6. A pediatric nurse is doing the initial shift assessments on assigned clients. One of the clients is a toddler with pneumonia. How would the nurse assess this client's skin turgor?

A. Pinch a fold of skin on the client's abdomen.

B. Pinch a fold of skin on the client's cheek.

C. Pinch a fold of skin on the client's upper thigh.

D. Pinch a fold of skin on the client's forearm.

ANS: D Feedback: To assess skin turgor in a toddler, the nurse would gently grasp a fold of the client's skin between the fingers and pull up. Then, the nurse would release the fold of skin. This is easiest performed on the dorsal surface of the client's hand or lower arm.

The most accurate reflection of turgor in the adult is on the anterior chest, just below the midclavicular area. The nurse would not assess for skin turgor on a fold of skin on the client's abdomen, cheek, or upper thigh.

PTS: 1 REF: p. 280 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 7. When inspecting the hair, what would the nurse note? (Select all that apply.)

A. Color B. Condition of hair shaft C. Length of hair D. Hair breakage of more than 6 hairs E. Hair shafts that are shiny ANS: A, B, E Feedback: During hair inspection, the nurse notes color, consistency, distribution, areas of hair loss, and condition of the hair shaft. Length of hair and hair breakage of more than 6 hairs are not things the nurse typically inspects.

PTS: 1 REF: p. 279 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Select 8. The nurse is performing a generalized assessment of an older adult. The nurse notes that the client's skin is thin and rough with abrasions. The client tells the nurse that it seems to take "forever" for scratches to heal, "a lot longer than when I was younger.". How would the nurse note these findings in the client's medical record?

A. The client has abnormal thinning of skin B. The client's integumentary system is within normal limits C. The client states that wounds are taking longer to heal D. The client has an abnormal inability to maintain temperature

ANS: C Feedback: Replacement of the epidermal layer decreases with aging, resulting in rougher skin texture and prolonged time for wound healing. It would be incorrect to state that the client has abnormal thinning of skin from the information given in the question. The nurse would not document that the integumentary system is within normal limits if the client states the wounds take an excessive time to heal. There is no information in the question that addresses the client have an abnormal inability to maintain temperature.

PTS: 1 REF: p. 264-265 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A newborn has a hemangioma on the face. What would be important for the nurse to include in client teaching?

A. Will need surgery to remove B. Will become smaller over the first year of life C. Is made of epithelial cells that form caverns and fill with blood D. Will usually resolve by age 9 years ANS: D Feedback: Hemangiomas are vascular lesions, present at birth, that rapidly develop and evolve into larger lesions but spontaneously resolve by age 9 years. The other options do not provide accurate information.

PTS: 1 REF: p. 304 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 10. An older adult client hospitalized with pancreatitis is having problems performing ADLs. The nurse's aide brushes the client's hair and tells the nurse that the client is losing an excessive amount of hair. The hair has the hair bulb intact. What might this indicate to the nurse?

A. Abnormal endocrine function B. Abnormal ovarian function C. Abnormal hepatic function D. Abnormal integumentary function ANS: A Feedback: Absent hair bulb may indicate chemical damage to the hair shaft (excessive coloration). Presence of hair bulb may indicate abnormal endocrine function. There is no indication of abnormal ovarian, hepatic, or integumentary function with the loss of hair with the hair bulb intact.

PTS: 1 REF: p. 280 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 11. An older adult client presents at the clinic with a painful ulcer on the left big toe. The client states that the ulcer is very painful and never seems to heal. An assessment of the ulcer shows a lesion with well-defined wound edges. When dependent, the base of the lesion is ruddy in appearance and exhibits signs of infection. What would the nurse suspect?

A. Infected spider bite B. Arterial ulcer C. Infected tick bite D. Venous ulcer ANS: B Feedback: Arterial ulcers are usually located distally, such as at the ends of the toes or fingers. Wound edges are sharply defined; the base is pale when elevated and appears ruddy when dependent. These ulcers may be deep, frequently infected, and painful; they exhibit minimal granulation tissue. Venous ulcers occur when chronic pooling of blood happens in the extremities. The wound bed is beefy red with profuse exudate noted.

Venous ulcers are generally painless. A spider bite usually presents as erythematous and papular with a visible small puncture opening at the center. A tick bite often presents as a erythematous target-like lesion that appears at the site of the bite.

PTS: 1 REF: p. 308 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 12. Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales.

What would the nurse practitioner chart?

A. Seborrhea B. Contact dermatitis C. Eczema D. Psoriasis ANS: D Feedback: Psoriasis is characterized by reddish-pink lesions covered with silvery scales.

It commonly occurs on extensor surfaces such as the elbows and knees but can appear anywhere on the body. Seborrhea is an inflammatory skin disorder characterized by macular lesions that may be pink, red, or orange-yellow and may or may not have a fine scale. Distribution is usually on the face, scalp, and ears. Contact dermatitis is an inflammatory response to an antigen that has contact with exposed skin. Initial contact causes stimulation of the histamine receptors, which results in the classic erythematous and pruritic lesions. Eczema, also known as atopic dermatitis, is characterized by itchy, pink macular or papular lesions, commonly located on flexural areas such as the inner elbows or posterior knees. Eczema can occur anywhere on the body.

PTS: 1 REF: p. 300 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. The ICU nurse is caring for a trauma victim whose status is critical. On assessment, the nurse notes uremic frost along the client's hairline. What would this indicate to the nurse?

A. Renal failure B. Cardiovascular failure C. Hepatic failure D. Respiratory failure ANS: A Feedback: Uremic frost is a sign of marked renal failure. This appearance results from precipitation of renal urea and nitrogen waste products through sweat onto the skin.

Uremic frost is not related to cardiovascular failure, hepatic failure, or respiratory failure.

PTS: 1 REF: p. 288 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 14. The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

A. The client exhibits no signs or symptoms of infection B. The client changes position every 2 hours C. The client keeps the area clean and dry D. The client knows prevention measures for pressure ulcers ANS: A Feedback: All options are appropriate outcomes for this client, but the most important outcome is that the client exhibits no signs or symptoms of infection since infection is a risk for additional injury.

PTS: 1 REF: p. 282 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. An obese adult client is undergoing a preoperative examination prior to having bariatric surgery. The client tells the nurse that he has a red sore in the groin area that appears to be spreading. The nurse assesses the lesion and finds a macular erythematous lesion with satellite pustules. What would the nurse suspect?

A. Roseola B. Candida

C. Pityriasis rosea D. Herpes simplex ANS: B Feedback: Candida is a fungal infection commonly found in skin folds or generally warm and moist areas. Affected sites are the axillae, inframammary areas, and groin.

Satellite pustules are commonly found surrounding the erythematous macular lesion.

Roseola is a viral illness with a rash that presents as discrete macules and papules, with an area of pallor surrounding each lesion. Pityriasis rosea is a viral infection initially presenting with a herald patch described as a large oval hyperpigmented lesion with a fine scale. Smaller lesions appear in subsequent days. Herpes simplex are cold sores and present as vesicles on an erythematous base.

PTS: 1 REF: p. 299 OBJ: 9 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 16. An older adult client is admitted to the hospital with pneumonia. While performing the admission assessment, the nurse finds a reddened area on the client's coccyx. What would the nurse include about this finding in notes? (Select all that apply.)

A. Depth B. Location C. Other lesions on body D. Size E. Texture ANS: B, D, E Feedback: A wound is assessed for location, size, color, texture, drainage, wound margins, surrounding skin, and healing status. When documenting a lesion, the nurse would not address other lesions on the body or the depth of the lesion.

PTS: 1 REF: p. 279 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Select 17. A woman and her teenager have come to the clinic. The teenager has acne lesions and says that the lesions are not well controlled. The mother asks the nurse what causes acne.

What would be the nurse's best response?

A. Acne is caused by the apocrine glands B. Acne is caused by decreased activity of the sebaceous glands C. Acne is caused by the impedance of sebum secretion onto the skin's surface D. Acne is caused by enlarged apocrine glands ANS: C

Feedback: As children approach puberty, the apocrine glands enlarge and become active.

At puberty, sebaceous glands increase activity, resulting in large amounts of sebum secreted into the hair follicles of the face, neck, chest, and back. Anything impeding sebum secretion onto the skin's surface may result in the formation of closed comedones and ultimately acne.

PTS: 1 REF: p. 264 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 18. The nurse is teaching an older adult diagnosed with diabetes about the skin. Which of the following should be emphasized?

A. A neuropathic ulcer can develop without feeling it.

B. Skin collagen decreases with age.

C. Wound healing becomes prolonged with age.

D. Hydration alters skin turgor.

ANS: A Feedback: While all options are true of older adults' skin, it is most important to emphasize to a client with diabetes that a neuropathic ulcer can develop without the client feeling it. People with diabetes are more likely to experience decreased sensation in the feet. The slowing of the healing process that comes with aging is also exacerbated by diabetes, as circulation may be slowed and the rate in which nutrients are delivered to wounds becomes decreased. Therefore, to reduce the risk of client injury, the nurse should emphasize that the client with diabetes checks their feet on a regular basis.

PTS: 1 REF: p. 308 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is caring for a female client with hormone disorder producing excessive testosterone. Which of the following is an expected finding when assessing this client?

A. Hirsutism B. Rapid heart rate C. Sensitivity to cold D. Muscle cramps ANS: A Feedback: Excessive androgenic hormones in a female client can increase testosterone levels and cause masculinization changes, including hair in male distribution patterns.

This hair growth is called hirsutism. Muscle cramps and cold sensitivity are associated with decreased thyroid hormone levels, and a rapid heart rate is associated with increased thyroid hormone levels.

PTS: 1 REF: p. 310 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 20. The nurse is conducting a skin assessment on a client and notices the client has bilateral patches on tops of both feet with no color. The nurse should document this finding as: A. vitiligo.

B. erythema.

C. pallor.

D. tinea corporis.

ANS: A Feedback: Vitiligo is characterized by areas of no pigmentation. Erythema is redness from inflammation. Pallor is a generalized paleness in skin color often caused by anemia. Tinea corporis is characterized by a ring-like rash on the body.

PTS: 1 REF: p. 275 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 11: Skin, Hair, and Nails Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 12: Head and Neck, with Vision and Hearing Basics 1. During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

A. Just above the thyroid cartilage B. Between the thyroid and the cricoid cartilages C. Just below the cricoid cartilage D. In front of the sternocleidomastoid muscle ANS: C Feedback: Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. The other options do not accurately describe the location of the isthmus.

PTS: 1 REF: p. 324 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What structure is found midline in the tracheal area just beneath the mandible?

A. Cricoid cartilage B. Hyoid bone C. Thyroid cartilage D. Adam's apple ANS: B Feedback: Important landmarks for the head and neck region are in the tracheal area.

The usually palpable U-shaped hyoid bone is located midline just beneath the mandible.

The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.

PTS: 1 REF: p. 314 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. When considering the head and neck, what screening should be included as a component of a pregnant woman's regular examinations?

A. B12 B. folic acid C. thyroid D. amniocentesis ANS: C

Feedback: A focus area for pregnant women is the need for regular examinations that include thyroid screening. Such prenatal care helps to ensure that thyroid levels remain within normal limits, protecting both the mother and the fetus. It is not generally recommended that pregnant women schedule screenings for B12 or folic acid.

Amniocentesis is not a regular screening procedure.

PTS: 1 REF: p. 318 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 4. A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

A. Ask the doctor for an order for an MRI B. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment ANS: B Feedback: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.

PTS: 1 REF: p. 319 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 5. A client brought to the emergency department after a diving accident tells the nurse, "I think I hit a rock, and now I can't feel my arms or legs." A rapid physical assessment shows no other apparent injuries. What initial nursing intervention is essential to the safety of this client?

A. Send for a CT scan immediately.

B. Draw a basic metabolic panel to check for infection.

C. Maintain immobilization of the spine until it is cleared of injury.

D. Log roll the client to remove backboard, reducing pressure on the spine.

ANS: C Feedback: It is essential to keep the spine immobilized to prevent spinal cord injury, so immobilization devices should not be removed until the spine is cleared of injury. A CT scan is not appropriate for this client; he or she would have an MRI ordered. Blood work on this client would not be essential to this client's care. Log rolling the client to remove the backboard would be contraindicated until the spine is cleared.

PTS:

1

REF: p. 316

OBJ: 6

NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck?

A. Signs of a strain B. Indications of a vertebral injury C. Lymph node enlargement D. Limitations in movement ANS: D Feedback: During inspection of the neck, the nurse observes for lesions and limitations in movement. The nurse cannot assess strain, vertebral injury, or lymph node enlargement by inspection. The other options are incorrect because they are related to a focused inspection assessment.

PTS: 1 REF: p. 321 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. What physical characteristics should the nurse describe when discussing the characteristics of fetal alcohol syndrome? (Select all that apply.)

A. Microcephaly B. Small eyes C. Flattened upper lip D. Prominent cheekbones E. Macrocephaly ANS: A, B, C Feedback: Physical manifestations of fetal alcohol syndrome include microcephaly, flattened cheekbones, small eyes, and a flattened upper lip. Children with fetal alcohol syndrome have multiple developmental and learning disabilities. Prominent cheekbones and macrocephaly are not associated with fetal alcohol syndrome.

PTS: 1 REF: p. 334 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 8. When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

A. Myxedema B. Cushing's syndrome C. Scleroderma

D. Bell's palsy ANS: B Feedback: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigracans). The scenario does not describe signs and symptoms demonstrated by a client with myxedema, scleroderma, or Bell's palsy.

PTS: 1 REF: p. 336 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 9. A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

A. Work with medical team to evaluate possible surgery.

B. Discuss pharmacologic interventions.

C. Educate the client regarding cervical spine pain.

D. Assess the client regarding characteristics of the pain.

ANS: D Feedback: The first step would be for the nurse to assess characteristics of the pain.

Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.

PTS: 1 REF: p. 319 OBJ: 4 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. An adult woman presents with overwhelming fatigue, reporting "It seems like I sleep all the time and yet I am still tired" and "I never seem to have the energy to clean my house or cook dinner." Diagnostic studies show a TSH of 6.2 mU/L and a T3 of 65 ng/dL. What outcome might the nurse identify for this client?

A. The client verbalizes increased energy B. The client participates in activities with no change in vital signs C. The client verbalizes desire to participate in physical activities D. The client sleeps 12 hours daily ANS: A Feedback: The client verbalizes increased energy, and well-being would be the most appropriate outcome. Nothing in the scenario indicates that the client is having a problem related to her vital signs. The client is not having a problem with desire to participate in activities; the problem is her energy level. Twelve hours of sleep daily for an adult is excessive.

PTS: 1 REF: p. 329 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch.

The area seems to have several nodes matted together. How would the nurse chart this last finding?

A. Nodes feel matted together on palpation B. Nodes are delimited on palpation C. Nodes appear grown together on palpation D. Nodes are demarcated on palpation ANS: B Feedback: Usually, no lymph nodes are palpable in the adult. If a node is palpable, it is important to describe the following characteristics: location-which lymphatic chain and where along that chain is the node; size-in mm or cm; consistency-how hard or soft is the node; mobility-it should be freely movable; delimitation-there should not be any matting together of lymph nodes. The other options do not demonstrate accurate documentation.

PTS: 1 REF: p. 325 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 12. The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland.

Identification of what sound would tend to confirm a diagnosis of a toxic goiter?

A. Rush B. Gurgle C. Murmur D. Bruit ANS: D Feedback: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. A murmur is assessed during a cardiac assessment.

PTS: 1 REF: p. 326 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice

13. Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?

A. Educating them about not drinking and driving B. Teaching them how to turn these clients every 2 hours C. Fulfilling the court requirements D. Keeping the shelves restocked ANS: A Feedback: Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these clients would not spend time with the teenagers teaching them how to turn the clients, fulfilling court requirements, or keeping the shelves restocked.

PTS: 1 REF: p. 318 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 14. Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

A. Shape of the ears B. Shape of the chin C. Shape of the lips D. Shape of the nose E. Shape of the eyes ANS: C, D, E Feedback: The most noticeable difference among racial groups is skin color. Shape of the eyes, nose, and lips also varies based on background and genetics. Variations in skull or neck shape or size relate more to height and weight than to specific racial or cultural background. Shape of the chin and ears is not related to cultural differences.

PTS: 1 REF: p. 316 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Select 15. An infant is born with microcephaly. The infant also has a depressed nasal bridge, low-set ears, and a protruding tongue. What nursing diagnosis would be appropriate for this client and the parents?

A. Inability to suck related to protruding tongue B. Knowledge deficit related to trisomy 21 C. Impaired hearing related to low-set ears D. Altered breathing related to depressed nasal bridge

ANS: B Feedback: Down's syndrome (trisomy 21) is a congenital condition that results from either an extra chromosome 21 or a translocation of chromosome 14 or 15 with 21 or 22.

Manifestations in the head and neck region include microcephaly, a flattened occipital bone, slanted small eyes, a depressed nasal bridge, low-set ears, and a protruding tongue.

The scenario described does not indicate that the infant has difficulty hearing, breathing, or feeding.

PTS: 1 REF: p. 334 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 16. An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

A. Impaired skin integrity related to bed rest B. Impaired range of motion related to injury C. Immobility related to bed rest D. Impaired comfort related to possible neck injury ANS: D Feedback: Diagnosis of a cervical spine injury is challenging and, in many cases, goes undiagnosed, especially in those lacking adequate health insurance. Clients at risk include those following a fall or collision and those with osteoporosis, advanced arthritis, cancer, or degenerative bone disease. The scenario does not indicate that the client is on bed rest or that the client has a limited range of motion.

PTS: 1 REF: p. 320 OBJ: 9 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 17. A client presents at the emergency room reporting "the worst headache I have ever had."

What are the critical initial nursing interventions for this client? (Select all that apply.)

A. Scheduling a magnetic resonance imaging (MRI) scan B. Physical examination for neurologic changes C. Scheduling a computerized tomography (CT) scan D. Conducting a focused history interview E. Scheduling an electroencephalography (EEG) ANS: B, D Feedback: A client with severe headaches may be unable to provide a complete history, but a focused history and physical examination looking for neurologic changes are critical nursing interventions. Nursing interventions do not include scheduling MRIs, CT scans, or EEGs without a prescription.

PTS: 1 REF: p. 319 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 18. What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.)

A. Female gender B. Male gender C. Coffee drinker D. Tobacco use E. Age older than 50 years ANS: B, D, E Feedback: Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For clients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include female gender or being a coffee drinker.

PTS: 1 REF: p. 318 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 19. The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?

A. "Loss of sensation in the toes is an age-related change."

B. "Standing up slowly is important because dizziness can cause falls."

C. "Certain medications can cause muscle weakness."

D. "Changes in vision such as decreased accommodation happen with aging."

ANS: A Feedback: Numbness, tingling, or loss of sensation in the toes are not normal age-related findings and should be assessed immediately. Older adults are more prone to having their blood pressure drop briefly upon standing. This drop in blood pressure may lead to dizziness and places the client at increased risk for falling. Older adults are often prescribed several medications and should be monitored for side effects such as muscle weakness. Vision changes such as a decline of accommodative ability are common in older adults and can also contribute to falls.

PTS: 1 REF: p. 320 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

The nurse reviews the laboratory report in the chart (above). Which nursing intervention should the nurse complete?

A. Offer to provide the client with extra blankets.

B. Assess the client for excessive facial hair growth.

C. Encourage the client to stop using body lotion.

D. Offer the client high carbohydrate foods.

ANS: A Feedback: The elevated TSH, low Free T4, T3, and T4 are all lab values associated with hypothyroidism. Clients with hypothyroid disorders often develop an intolerance to cold, and offering the client extra blankets may help the client feel more comfortable. Hair loss, not growth, is associated with hypothyroidism. Hypothyroidism often causes dry skin and the need for lotion. Hypothyroidism often causes constipation, so the client should be offered a diet high in fiber, not carbohydrates.

PTS: 1 REF: p. 329 OBJ: 3 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 12: Head and Neck Assessment, With Vision and Hearing Basics KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 13: Eye Assessment for Advanced and Specialty Practice 1. What is the open space between the eyelids called?

A. The palpebral fissure B. The limbus C. The lacrimal apparatus D. The eyeball ANS: A Feedback: The palpebral fissure is the almond-shaped open space between the eyelids.

The limbus is the border of the cornea and the sclera. The eyeball is the round part of the eye within the eyelids and socket. The lacrimal apparatus protects and lubricates the cornea and conjunctiva by producing and draining tears.

PTS: 1 REF: p. 339 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. The nursing instructor is discussing the eye with the nursing students. What would the instructor cite as part of the lacrimal apparatus? (Select all that apply.)

A. Punctum B. Lacrimal sac C. Lacrimal gland D. Limbus E. Nasolacrimal duct ANS: A, B, C, E Feedback: The lacrimal apparatus, which consists of the lacrimal gland, punctum, lacrimal sac, and nasolacrimal duct, protects and lubricates the cornea and conjunctiva by producing and draining tears. The limbus is the border between the cornea and the sclera.

PTS: 1 REF: p. 339 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 3. A student nurse asks the nursing instructor what blood vessels go to the eye. What would be the instructor's best answer?

A. The optic vein B. The optic plexus C. The choroids D. The coronal vein ANS: C Feedback: The choroids, which cover the recessed portion of the eye, are a network of blood vessels to the eye. The other options are distracters for this question.

PTS: 1 REF: p. 340 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 4. What is the largest chamber of the eye?

A. anterior B. posterior C. corneal D. vitreous ANS: D Feedback: The interior eye has three chambers: anterior, posterior, and vitreous. The largest, the vitreous chamber, is adjacent to the inner retinal layer and lens. This chamber is filled with vitreous humor, which is gel-like, holds the retina in place, and maintains the shape of the eyeball. The anterior chamber is the space between the cornea in the front and the iris and lens in the back. It contains aqueous humor, produced by the ciliary body; the amount varies to maintain pressure in the eye. The posterior chamber starts behind the iris and goes to the lens. It is also filled with aqueous humor that helps to nourish the cornea and lens. Corneal is not a chamber of the eye.

PTS: 1 REF: p. 340 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. The nursing instructor should include what information regarding the effects of mydriatic drops on glaucoma?

A. Mydriatic drops do not specifically affect glaucoma.

B. Mydriatic drops may precipitate acute angle-closure glaucoma.

C. Mydriatic drops constrict the pupils in clients with glaucoma.

D. Mydriatic drops may cause a crisis in clients with open-angle glaucoma.

ANS: B Feedback: Mydriatic drops may precipitate acute angle-closure glaucoma. Those at risk include clients with a history of glaucoma and extremely farsighted clients. Mydriatic drops do affect clients with glaucoma, they do not constrict the pupils in clients with glaucoma, and they are not known to cause a crisis in clients with open-angle glaucoma.

PTS: 1 REF: p. 357 OBJ: 3 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 6. What test would the nurse use to assess the boundaries of the client's peripheral vision?

A. Static confrontation

B. Allen C. Kinetic confrontation D. Cover ANS: C Feedback: Static and kinetic confrontation tests measure peripheral vision. The static confrontation test assesses peripheral vision in all four quadrants. The kinetic confrontation test assesses the boundaries of peripheral vision. The Allen test is for visual acuity of toddlers. The cover test is for accommodation.

PTS: 1 REF: p. 347 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. A client shares that a first-degree relative has an eye problem, but they not sure what the diagnosis is. What major eye problem will the nurse suggest screening the client for?

A. Retinoblastoma B. Strabismus C. Retinitis pigmentosa D. Glaucoma ANS: D Feedback: Glaucoma in a first-degree relative increases the client's risk for the same problem two to three times. Retinoblastoma can be inherited from either parent but does not have increased incidence if a first-degree relative has the disease. Retinitis pigmentosa is also a genetic disease, but a client's risk of the disease is not increased if a first-degree relative is affected. Strabismus is not genetic in nature.

PTS: 1 REF: p. 344 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. A teenager is brought to the clinic for a sports physical examination. The client states plans to play goalie on the community soccer team. What is the most important teaching opportunity presented for this client?

A. Use of safety equipment B. Prevention of knee injuries C. Prevention of head injuries D. Use of correct foot gear ANS: A Feedback: The nurse should assess with each client the use of safety equipment when playing sports. Proper eye protection can prevent many sports-related eye injuries. All options are points for client teaching for this client; however, the most important opportunity involves the use of safety equipment.

PTS: 1 REF: p. 343 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other."

What test would be most appropriate for the nurse to use to assess this client?

A. Cover B. Kinetic confrontation C. Cardinal fields D. Static confrontation ANS: C Feedback: The cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation.

PTS: 1 REF: p. 347 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. The cup-disc ratio is assessed using the ophthalmoscope. What should the nurse practitioner know about the cup-disc ratio? (Select all that apply.)

A. It should be 1:1.

B. It occurs only in females.

C. It is genetically determined.

D. It is equal in both eyes.

E. It is found only in older adults.

ANS: C, D Feedback: Cup-disc ratio is genetically determined and normally equal in both eyes. It is not found only in females or only in older adults.

PTS: 1 REF: p. 358 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 11. The nurse practitioner is assessing the eyes of a client with long-standing uncontrolled hypertension. What might the nurse practitioner visualize during an assessment with an ophthalmoscope?

A. AV nicking B. Dilated veins C. Dilated arteries D. Brass wiring

ANS: A Feedback: AV nicking results from high blood pressure and retinal hemorrhages in the form of dot-blot spots or flame hemorrhages. Dilated arterioles and venules may be seen, not dilated arteries and veins. Brass wiring is not an assessment finding.

PTS: 1 REF: p. 358 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 12. A client presents at the ophthalmologist's office after being referred by his family health care provider. The referral was made after a benign growth of the conjunctiva was found growing from the nasal side of the sclera to the limbus in the client's right eye. The client asks the nurse what this growth is. What is the best answer the nurse can give?

A. "It is called hypertrophied conjunctiva."

B. "It is called a pterygium."

C. "It is called hypertrophied sclera."

D. "It is called a pterygota."

ANS: B Feedback: An abnormal thickening of the conjunctiva from the limbus over the cornea is known as a pterygium. It is not known as hypertrophied conjunctiva or sclera. A pterygota is a class of insects.

PTS: 1 REF: p. 354 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. When assessing visual acuity in children, what would be the expected normal vision in a school-aged child?

A. 20/50 bilaterally B. 20/100 bilaterally C. 20/150 bilaterally D. 20/20 bilaterally ANS: D Feedback: Normal vision findings in school-aged kids are 20/20 bilaterally using the Snellen eye chart. This means the child can clearly see at 20 feet of distance what should be seen at that distance. The other three options would be outside of normal range and require follow-up.

PTS: 1 REF: p. 349 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

14. What test would the nurse perform to test for strabismus?

A. Corneal light reflex B. Cover C. Allen D. Static ANS: A Feedback: The corneal light reflex tests for strabismus. The cover test is for presence and amount of ocular deviation. A low light level with no direct light sources shining in the client's eyes is ideal. At rest, the extraocular muscles have very little activity. The assessment referred to as cardinal fields of gaze allows nurses to detect muscle defects that cause misalignment or uncoordinated eye movements. The static test can help the nurse detect gross differences in all four quadrants of the visual field. The Allen test tests a toddler's visual acuity.

PTS: 1 REF: p. 348 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 15. A client who uses a computer for most of the day at work presents at the clinic with painful eyes, blurred vision, and headaches. After a generalized assessment with no abnormal findings, the nurse should use what term to document the possible cause of the symptomology?

A. presbyopia B. asthenopia C. myopia D. hyperopia ANS: B Feedback: Asthenopia (eyestrain) develops after reading, computer work, or other visually tedious tasks. The eye muscles tighten after maintaining a constant focal distance. Symptoms include fatigue, red eyes, eyestrain, pain in or around the eyes, blurred vision, headaches, and, rarely, double vision. Presbyopia is considered a normal part of aging. This condition affects near vision and is corrected with a convex lens in front of the eye in the form of half-glass, or as the bottom of a bifocal or multifocal lens if other correction is needed for distance viewing. Hyperopia is farsightedness. Myopia is nearsightedness.

PTS: 1 REF: p. 365 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 16. Normal movement of the eye involves what cranial nerves? (Select all that apply.)

A. II B. III

C. IV D. V E. VI ANS: A, B, C, E Feedback: As the nurse inspects and palpates the eye, he or she assesses for the sensory and motor functions of four cranial nerves: Cranial nerve II, optic nerve, visual acuity, visual fields, fundoscopic examination; cranial nerve III, oculomotor, cardinal fields of gaze, eyelid inspection, pupil reaction (direct/consensual/ accommodation); cranial nerve IV, trochlear, cardinal fields of gaze; and cranial nerve VI, abducens, cardinal fields of gaze. Cranial nerve V, known as the trigeminal nerve, is a nerve responsible for sensation in the face and certain motor functions such as biting and chewing.

PTS: 1 REF: p. 347 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 17. The nurse is performing visual acuity testing on an older adult who has fallen and fractured their femur. What finding would be considered normal for this client? (Select all that apply.)

A. Arcus senilis B. Increased tear production C. Small cataract D. Decreased central vision E. Increased pupillary response ANS: A, C, D Feedback: Findings related to aging include loss of central vision, decreased tear production, and decreased pupillary response. Arcus senilis, a gray/white circle that circumscribes the limbus and results from the deposition of lipid, is a common cloudiness that appears around the corneas of older adults. Cataracts are common in the older adult.

PTS: 1 REF: p. 342 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 18. What notation demonstrates the nurses understanding of effective documentation when the assessment findings identify thick, purulent drainage in both eyes of a client?

A. Thick, purulent drainage is noted at inner corner of OD. B. Thick, purulent drainage is noted at inner corner of OS. C. Thick, purulent drainage is noted at inner corner of OU. D. Thick, purulent drainage is noted at inner corner of both eyes.

ANS: D

Feedback: The abbreviations OD (right eye), OS (left eye), and OU (both eyes) are no longer used due to the potential for order errors. Instead, it is recommended to use "right eye," "left eye," or "both eyes."

PTS: 1 REF: p. 349 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 19. A client presents to the clinic reporting sudden visual loss in the left eye. What is the nurse's priority action?

A. Assess cranial nerve function.

B. Notify the healthcare provider immediately.

C. Ask the client if protective eyewear was worn.

D. Perform the Allen test and report the findings urgently.

ANS: B Feedback: Sudden visual loss is an emergency and should be immediately reported to the healthcare provider. Wearing protective eyewear is not a priority, though whether the client wore protective eyewear is relevant information. Assessing cranial nerve function and vision testing are not realistically possible when the client suffers sudden visual loss.

PTS: 1 REF: p. 345 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. A school nurse is reviewing charts of school-age children. Which visual impairment is most common in this population?

A. amblyopia B. presbyopia C. glaucoma D. nystagmus ANS: A Feedback: The most common type of visual problem in children is amblyopia (lazy eye).

If not treated it can lead to monocular visual impairment in adulthood. Presbyopia is vision loss associated with older adults; nystagmus causes repetitive eye movements and would be cause for concern; and optic nerve damage such as glaucoma is uncommon in school-age children.

PTS: 1 REF: p. 369 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 13: Eye Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

Chapter 14: Ear Assessment for Advanced and Specialty Practice 1. The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

A. Helps to regulate pressure in the middle ear B. Protects the middle ear C. Allows for drainage of fluid from the middle ear D. Maintains fluid in the middle ear ANS: A Feedback: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options do not accurately describe the function of the eustachian tube.

PTS: 1 REF: p. 376 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What components of sound does the cochlea interpret? (Select all that apply.)

A. Tone B. Direction C. Amplitude D. Decibel E. Frequency ANS: C, E Feedback: The cochlea interprets two components of sound: amplitude (volume) and frequency (pitch). The cochlea does not interpret tone, direction, or decibel.

PTS: 1 REF: p. 377 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Select 3. When assessing the tympanic membrane, where would the nurse expect to visualize the malleus?

A. In the anterior aspect B. In the area of the cone of light C. Near the center D. To the left of the cone of light ANS: C Feedback: The tympanic membrane adheres through its concave shape to the malleus near the center. The other options do not accurately describe the location of the malleus.

PTS: 1 REF: p. 376 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 4. When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?

A. Anterior proximal quadrant B. Anterior superior quadrant C. Anterior medial quadrant D. Anterior inferior quadrant ANS: D Feedback: The healthy tympanic membrane is intact and translucent and allows visualization of the short process of the malleus. The cone of light is visible in the anterior inferior quadrant. The other options do not accurately describe the location of the cone of light.

PTS: 1 REF: p. 387 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A nurse practitioner is working in a clinic with a client who reports that drainage from her ear is no better despite finishing three courses of prescribed antibiotics. After reviewing the client's records, what would be the nurse's most appropriate action?

A. Prescribe a different antibiotic B. Refer the client to an otolaryngologist C. Reassess the client's ear D. Perform the Rinne test.

ANS: B Feedback: A client with a chronically draining ear unresponsive to treatment with antibiotics requires referral to an otolaryngologist. The greatest concern with chronically draining ears is cholesteatoma, an abnormal accumulation of squamous epithelium within the middle ear. The growth can erode the auditory ossicles and cause great damage to the client's hearing. The nurse practitioner would have assessed the client's ear prior to reviewing the client's records. It would be inappropriate to perform Rinne test at this time or to prescribe a different antibiotic without a culture and sensitivity being run.

PTS: 1 REF: p. 378 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. When assessing the client's risk for hearing loss, it is important to ask about the history of exposure to noise. What related client teaching would be important? (Select all that apply.)

A. Types of noise to avoid B. Types of protective equipment used C. Instructions for the use of protective ear equipment D. Length of time to limit protective equipment E. Effectiveness of protective equipment ANS: B, C, E Feedback: Clients need to be asked about their exposure to noise and what protective equipment they use. Educating clients on the types, effectiveness, and instructions for the use of protective ear equipment allows them to make decisions based on their needs.

The other options do not address the history of exposure to noise noted in the question.

PTS: 1 REF: p. 381 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 7. When providing client teaching about the ears, what should the nurse be sure to include?

A. How the client cleans the ears B. Basic anatomy and physiology of the ears C. How to use cotton-tipped applicators safely D. Potential infection from self-cleaning of ears ANS: A Feedback: It is important to address how the client cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, clients think that cotton-tipped applicators are for this purpose. This self-care behavior is unsafe, placing clients at risk for cerumen impaction. Nurses should reinforce proper cleaning techniques. Since cleaning with cotton-tipped applicators is not correct, the nurse would not teach the client how to use the applicators to clear the ears.

The nurse would not teach the client about basic anatomy and physiology of the ears.

The option of potential infection from self-cleaning of ears is not correct.

PTS: 1 REF: p. 381 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 8. An objective assessment of a client's ears reveals small, painless nodules on the left helix. How would the nurse note this finding in the client's medical record?

A. Left external ear abnormal; Darwin's tubercle noted at the midpoint of helix B. Left external ear within normal limits C. Small nodules on the left helix indicating inflammation of the external ear D. Small, painless nodules on the left helix; further evaluation for carcinoma indicated ANS: B

Feedback: Small, painless nodules on the helix are a variation of normal anatomy known as Darwin's tubercle. The other options do not accurately describe the relevance of the nodules.

PTS: 1 REF: p. 385 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A nurse is preparing to perform a general assessment of an adult client who is new to the clinic. How would the nurse prepare to obtain objective data about the client's ears?

(Select all that apply.)

A. Have the client sit on the examination table B. Place the client in semi-Fowler's position on the examination table C. Make sure the client is comfortable in a quiet room D. Perform the whisper, Weber, and Rinne tests before inspection E. Place the client's ears at the nurse's eye level ANS: A, C, D, E Feedback: To obtain objective data about the ears, it is best to make sure the client is comfortable and the room is quiet. It is ideal for the client's ears to be at the nurse's eye level to facilitate inspection that does not cause discomfort for the client. For adults and older children, nurses can perform the examination with the client sitting on the examination table. The nurse would inspect before performing the whisper, Weber, and Rinne tests. The client would sit in the upright position, not semi-Fowler's position for the exam.

PTS: 1 REF: p. 384 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 10. While performing an otoscopic examination of a client's ear, the nurse finds white patches on the tympanic membrane. How would the nurse note this finding in the chart?

A. Tympanic membrane abnormal; white, patchy areas noted.

B. Tympanic membrane scarred, indicating loss of hearing.

C. Tympanic membrane visualized with areas of sclerosis noted.

D. Tympanic membrane within normal limits.

ANS: C Feedback: A variation of normal for the tympanic membrane is sclerosis, or white areas that are visible scars from repeated ear infections. The other options do not accurately document the described white patches.

PTS: 1 REF: p. 387 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Communication and Documentation

BLM: Cognitive Level: Apply

NOT: Multiple Choice

11. The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding?

A. Tenderness of the mastoid process B. Atrophied lymph nodes C. Tenderness of the apex D. Sclerotic tympanic membrane ANS: A Feedback: Normal ear findings on physical assessment are firm auricles without lumps, nonpalpable lymph tissue, nontender ears, and no pain elicited during palpation or manipulation of the auricle. No pain should occur with palpation of the mastoid process.

Enlarged lymph nodes indicate pathology or inflammation. Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. Sclerosis of the tympanic membrane is a variation of normal ear findings. Atrophied lymph nodes and tenderness of the apex are not assessment findings for the ear.

PTS: 1 REF: p. 385 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

A. The arm of the stapes B. The short process of the malleus C. The head of the incus D. The long process of the stapes ANS: B Feedback: During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

PTS: 1 REF: p. 387 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. Student nurses are spending time in the laboratory learning the proper use of an otoscope. What technique would these students learn for best visualization of the tympanic membrane in an adolescent?

A. Hold the ear at the tragus and lift up and back B. Hold the ear at the pinna and pull down and back C. Hold the ear at the auricle and pull down and back D. Hold the ear at the helix and lift up and back

ANS: D Feedback: Hold the adolescent's ear at the helix and lift up and back to align the canal for best visualization of the tympanic membrane. In children younger than 3 years, the nurse would pull down and back to visualize the tympanic membrane. The nurse always lifts from the helix, not the auricle (pinna) and never from the tragus.

PTS: 1 REF: p. 386 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A nurse is admitting a client to the hospital. When reviewing the client's medical record, the nurse notes that this client had abnormal findings during the Weber test. What would the nurse know this means?

A. The client has unilateral hearing loss B. The client has loss of high-frequency sounds C. The client has loss of low-frequency sounds D. The client has bilateral hearing loss ANS: A Feedback: The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC). Remember AC has less resistance than BC. Option D is a distracter for this question.

PTS: 1 REF: p. 386 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 15. The nurse practitioner is assessing the tympanic membrane of a client. Once the tympanic membrane has been visualized, the nurse practitioner uses the bulb insufflator to observe the movement of the tympanic membrane. When forcing air into the ear canal, what would the nurse practitioner expect to note?

A. Negative pressure pulling the tympanic membrane B. Positive pressure pushing down the tympanic membrane C. Negative pressure pushing down the tympanic membrane D. Positive pressure pulling the tympanic membrane ANS: B Feedback: Positive pressure forces air into the external auditory canal and pushes down the tympanic membrane. The tympanic membrane moves inward when inflated and outward with release. The three other options do not accurately describe the normal response to the bulb insufflator.

PTS: 1 REF: p. 388 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 16. A client comes to the Emergency Department with excruciating pain in the left ear. On assessment, the nurse notes that the client experiences extreme pain during palpation of the tragus. Which factor would the nurse suspect has triggered the pain?

A. Otitis media B. Furuncle C. Foreign body D. Impacted cerumen ANS: B Feedback: Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. It does not indicate otitis media, foreign body, or impacted cerumen.

PTS: 1 REF: p. 385 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. A nurse practitioner is assessing the ears of a toddler who has had tympanostomy tubes in place for 6 months. Where in the tympanic membrane would the nurse practitioner expect to find the tympanostomy tubes?

A. Inferior portion B. Superior portion C. Medial portion D. Upper right quadrant ANS: A Feedback: Tympanostomy tubes placed to treat recurrent or persistent otitis media should be inserted in the inferior portion of the tympanic membrane with the lumen of the tube patent. The other options are distracters for the question.

PTS: 1 REF: p. 400 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 18. An older adult client presents at the clinic, reporting otalgia in the right ear. Physical assessment reveals cerumen impacted in the client's ear. Removing this mechanical blockage may have what outcome for this client? (Select all that apply.)

A. Increase the size of ear canal B. Provide less rigidity in outer ear C. Improve hearing D. Enhance socialization

E. Prevent injury ANS: C, D, E Feedback: Removing a mechanical blockage can improve hearing and enhance socialization. It also helps to prevent injury by preserving the sense of hearing.

Removing the mechanical blockage will not increase the size of the ear canal or provide less rigidity in the outer ear.

PTS: 1 REF: p. 378 OBJ: 9 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 19. A client reports, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

A. Dizziness B. Tinnitus C. Vertigo D. Otalgia ANS: C Feedback: Vertigo, the sensation of the room spinning, indicates dysfunction of the bony labyrinth in the inner ear. Dizziness indicates that the client feels like he/she is spinning in the room. Tinnitus, a sensation of buzzing in the ear, is thought to be an inability to filter internal noise from the external input of sound. Otalgia is ear pain.

PTS: 1 REF: p. 382 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 20. A client presents to the primary care provider's office reporting right ear pain and otorrhea. What does the nurse suspect?

A. infection B. presbycusis C. intracranial bleed D. basilar skull fracture ANS: A Feedback: Foul-smelling ear drainage and pain are symptoms of infection. A culture of the fluid for testing will identify the pathogen and help determine the proper antibiotic treatment. Presbycusis is hearing loss associated with aging and is not associated with otorrhea. A basilar skull fracture and intracranial bleed are not associated with unilateral ear pain.

PTS: 1 REF: p. 378 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential

TOP: Chapter 14: Ear Assessment for Advanced and Specialty Practice KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment 1. A student nurse is taking a nursing test and is asked a question about the columella.

What is the best description of the term columella?

A. The structure that divides the nares B. The lining of the nares C. The lining of lymphatic ducts D. The mound of tissue just posterior to the eustachian tube ANS: A Feedback: The midline columella divides the oval nares (nostrils), which are openings that lead into the internal nose and are lined with skin and ciliated mucosa. That lining is known as the vestibule. Just posterior to the eustachian tube opening is a mound of tissue known as the torus tubarius.

PTS: 1 REF: p. 403 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. An oncology nurse is caring for a client newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?

A. Osteomeatal complex B. Rosenmuller's fossa C. Kiesselbach's plexus D. Wharton's ducts ANS: B Feedback: Posterior to the torus region is the pharyngeal recess or Rosenmuller's fossa, which is a common site of occult nasopharyngeal malignancies. The middle turbinate and middle meatus area are known collectively as the osteomeatal complex, which is also the most anatomically significant area involved in chronic sinusitis. The anterior portion of the nasal septum has a rich vascular supply known as Kiesselbach's plexus.

The submandibular gland is beneath the body of the mandible. Its Wharton's ducts run deep to the floor of the mouth and open on both sides of the frenulum.

PTS: 1 REF: p. 405 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 3. A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

A. Rosenmuller's fossa B. Wharton's ducts C. Kiesselbach's plexus

D. Stensen's duct ANS: C Feedback: The anterior portion of the nasal septum has a rich vascular supply known as Kiesselbach's plexus. It is often the site of origination for nosebleeds. The other options are distracters for the question.

PTS: 1 REF: p. 404 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 4. A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.)

A. Tobacco use B. Risks for chronic obstructive pulmonary disease (COPD) C. Obstructive sleep apnea D. Alcohol use E. Oral health ANS: A, C, E Feedback: Health promotion areas related to the nose, sinuses, mouth, and throat include tobacco use, obstructive sleep apnea, oral heath, and cancer. Alcohol use would not be cited as a health-promotion area for the nose, sinuses, mouth, and throat, nor would risks for COPD. PTS: 1 REF: p. 414 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 5. When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy?

A. Low-grade fever B. History of macular rash C. Frequent childhood infections D. Family history of diabetes ANS: C Feedback: Frequent upper respiratory infections in childhood should raise the nurse's suspicion of allergy. Chronic inflammation of the respiratory tract may lead to mucosal damage with resultant chronic infections (e.g., sinusitis). The findings of low-grade fever, history of macular rash, or family history of diabetes would not necessarily raise the suspicion of allergy.

PTS: 1 REF: p. 411 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A mother brings her 6-month-old child to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the client's mouth to best confirm a complication of the treatment?

A. Swollen uvula B. Red and white patches in the throat C. White patches firmly attached to the buccal mucosa D. White coated tongue ANS: D Feedback: A white coating of the tongue may be oral candidiasis. This condition is very common in clients taking antibiotics. Red and white patches in the throat might indicate strep throat, which would be an unexpected finding. The uvula may be swollen with allergic reactions. White patches attached to the buccal mucosa suggest leukoplakia.

PTS: 1 REF: p. 421 OBJ: 6 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

A. Deviated septum B. Obstructed turbinate C. Swollen nasal passages D. Hypertrophied adenoids ANS: A Feedback: The nurse assesses the client's nares for patency when inserting a tube into the nose for feeding. A deviated septum or obstructed nares may make insertion difficult.

The nares may be obstructed, but the turbinate would not be. If the client is breathing through the nose, the nurse would not suspect swollen nasal passages. The nurse would not suspect hypertrophied adenoids in an older adult client.

PTS: 1 REF: p. 433 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. A client presents at the urgent care clinic with severe pain and pressure around the eyes.

The nurse practitioner suspects a sinus infection. What is considered the typical standard diagnostic technique in evaluating sinus disease?

A. transillumination

B. computed tomography (CT) scanning C. percussion of the sinus cavities D. magnetic resonance imaging ANS: B Feedback: The typical diagnostic technique in evaluating sinus disease is a CT scan.

Historically, nurse practitioners assess the sinus cavities with transillumination, but this method has limited clinical significance and provides inconsistent results. The other options are not used to assess this condition.

PTS: 1 REF: p. 418 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 9. The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate?

A. Heat stroke B. Viral infection C. Inadequate hydration D. Allergy ANS: C Feedback: Dryness or cracking may indicate inadequate hydration. Lesions or aphthous ulcers may represent a viral infection. Swelling or edema of the lips suggests allergy.

Heat stroke does not present with dry, cracked lips.

PTS: 1 REF: p. 420 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. A nurse caring for a client admitted 2 days ago following a cerebral vascular accident.

The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

A. Impaired dentition B. Alteration in mobility C. Altered cerebral perfusion D. Impaired swallowing ANS: D Feedback: Impaired swallowing is associated with problems in oral, pharyngeal, or esophageal structure or function. Related findings include delayed swallowing; gurgly voice; frequent coughing, choking, or gagging; inability to clear oral cavity; and food falling from the mouth. The scenario described does not mention impaired dentition, alteration in mobility, or altered cerebral perfusion.

PTS: 1 REF: p. 426 OBJ: 9 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. What is the purpose of the tongue? (Select all that apply.)

A. Provides resonance to the voice B. Manipulates solids and liquids when eating and drinking C. Helps with the identification of sweet, sour, salty, and bitter tastes D. Assists in speech production E. Aids in the production of saliva ANS: B, C, D Feedback: The tongue manipulates solids and liquids in chewing and swallowing. It is also involved in speech production and taste. The anterior two thirds of the tongue surface contain taste buds known as vallate papillae, which identify sweet, sour, salty, and bitter tastes. The other options are distracters for the question.

PTS: 1 REF: p. 406 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 12. The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)

A. X B. VIII C. VII D. IX E. XII ANS: C, D, E Feedback: The autonomic nervous system and cranial nerves VII (facial) and IX (glossopharyngeal) innervate secretions of the major and minor salivary ducts. Cranial nerve XII (hypoglossal) innervates the submandibular glands. Cranial nerves VIII and X are not involved.

PTS: 1 REF: p. 407 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Select 13. A nurse is conducting an admission assessment on an older adult client with an intractable oral infection. The client tells the nurse that he cannot smell things as well as he once could. What should the nurse do initially?

A. Recognize that the sense of smell decreases with age

B. Conduct olfaction tests C. Notify the physician immediately D. Verify the client's ability to taste all flavors ANS: A Feedback: Olfactory sensory fibers decrease after the age of 60 years. In the oral cavity, a thinning of the soft tissue of the cheeks and tongue results in an increased risk of ulcerations, infections, and oral cancers. The nurse would not conduct tests on the client's sense of smell or taste, nor would he or she notify the physician immediately.

PTS: 1 REF: p. 408 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergies?

A. If a parent has allergies, the child has a 25% chance of developing them as well B. Children will outgrow their allergies C. Allergy can affect any target organ in the body D. There are few effective treatments for allergies ANS: C Feedback: Allergy can affect any target organ in the body. The nose and respiratory mucosa are the entry port for inhalant allergens. Thus, the nose and respiratory tract are common targets for inflammatory responses from allergen exposure. If one parent has allergies, the child has a 50% chance of developing allergies. Many allergies are lifelong problems; allergies can be managed and treated.

PTS: 1 REF: p. 413 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 15. Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?

A. Vegetable omelet B. Garlic chicken C. Chocolate pudding D. Salad with ginger dressing ANS: A Feedback: Dietary recommendations for this bleeding disorder include decreasing foods high in salicylates, such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E. A vegetable omelet would be the most appropriate food choice since it doesn't contain salicylates or antiplatelet supplements.

PTS: 1 REF: p. 414 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 16. Which information in the client's history is a priority safety concern?

A. Cleft lip and palate repair surgery B. Diminished sense of smell and taste C. Recent immigrant complains of cough D. Removal of oral cancerous lesion ANS: C Feedback: Incidence of tuberculosis is approximately nine times higher among U.S. immigrants (W.H.O., 2013). Diminished senses of smell and taste may produce safety risks but are not as high priority as the immediate threat of tuberculosis, which is contagious. Lack of smell and taste are not contagious conditions. Removal of a cancerous lesion in the past does not pose an immediate concern like tuberculosis. Cleft lip and palate surgery are not immediate safety concerns like tuberculosis.

PTS: 1 REF: p. 417 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 17. The nurse is at a school health fair and is teaching a group of teenagers about preventing periodontitis. Which statement made by a teen indicates understanding of the teaching?

A. "Vaping can lead to periodontitis."

B. "Periodontitis can be prevented by getting sufficient sleep."

C. "Periodontitis is primarily caused by lack of exercise."

D. "Frequent sinus infections are indicative of periodontitis."

ANS: A Feedback: The use of smokeless tobacco such as snuff and dip and electronic cigarettes (vaping) is becoming more popular and has been linked to oral cancers, periodontitis, and tooth loss. Sinus infections, exercise frequency, and sleep are not associated with periodontitis.

PTS: 1 REF: p. 414 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is assessing a client who appears to have a swollen thyroid gland (goiter).

Which of the following is a priority question the nurse should ask the client?

A. "Do you have any difficulty swallowing?"

B. "Do you have difficulty sleeping at night?"

C. "What type of table salt do you use?"

D. "Has your weight changed over the last few months?"

ANS: A Feedback: Dysphagia (difficulty swallowing) may accompany a growth or lesion on the thyroid gland. Swallowing difficulties are common in hospitalized patients and may prolong the length of stay because of an inability to obtain adequate nutrition for healing.

Difficulty swallowing can compromise the airway, making it the priority in the assessment. The other choices relate to the thyroid but are not a priority as they don't affect the client's airway.

PTS: 1 REF: p. 416 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19.

The nurse is caring for a client admitted to the medical surgical unit with neck tenderness, drooling, and dysphagia. In reviewing the orders from the health care provider (see above), which order should the nurse question?

A. regular diet as tolerated B. acetaminophen 10-15mg/kg IV q 4-6 hours PRN for pain or fever C. strict intake and output D. complete blood count with differential ANS: A Feedback: The client with dysphagia should be assessed and tested for risk of aspiration prior to being given a regular diet. Acetaminophen via IV is appropriate for a client who can't take medication orally. Strict intake and output should be monitored to assess for changes in hydration as the client is at risk of aspiration and not drinking as much as usual. A complete blood count is a general lab test that can help identify causes for the client's symptoms.

PTS: 1 REF: p. 423 OBJ: 6 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 20.

The nurse is caring for a client in a medical-surgical unit. In reviewing the assessment notes (see above), the nurse considers which findings to be indicative of the need for a focused oral assessment?

A. weight change B. reactive pupils C. hypoactive bowel sounds

D. level of consciousness ANS: A Feedback: Weight loss and xerostomia or dry mouth can be associated with a decline in oral health. Hypoactive bowel sounds, reactive pupils, and being alert are not abnormal findings related to oral health.

PTS: 1 REF: p. 427 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 16: Thorax and Lungs Assessment 1. When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

A. Softly repeat the words "one-two-three" B. Say "ninety-nine" C. Cough each time the stethoscope is moved D. Say the letter "e" ANS: A Feedback: Softly whispering "one-two-three" while the nurse auscultates the chest is a correct instruction for the whispered pectoriloquy test. Having the client say "ninety-nine" is used to test bronchophony. Saying the letter "e" is used to test egophony. Having the client cough is useful if an abnormal sound is heard during auscultation to determine if coughing clears the lungs.

PTS: 1 REF: p. 468 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 2. What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

A. Friction rub B. Decreased breath sounds C. Sibilant wheeze D. Stridor ANS: A Feedback: In pleuritis, inflamed pleural surfaces lose their normal lubrication and rub together during breathing. Reduced volume of pleural fluid increases the transmission of lung sounds and leads to a possible friction rub. Decreased breath sounds may indicate an obstruction due to little air moving in and out. Sibilant wheezes are often heard with bronchitis; stridor occurs with severe broncholaryngo spasms, such as croup. Stridor is associated with a loud, high-pitched crowing that is characteristic of epiglottis or other conditions that partially obstruct the upper airway.

PTS: 1 REF: p. 472 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 3. Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury?

A. There is loss of involuntary respiratory control.

B. The client will respond negatively to increased stimuli.

C. There is an increased level of carbon dioxide in the blood.

D. The client's oxygen levels in the blood will be increased.

ANS: A Feedback: The brainstem contains the medulla and the pons, which control involuntary respiratory effort. The negative response to stimuli is unrelated to the client's respiratory effort. The client's breathing patterns will change according to cellular demands. The levels of carbon dioxide and oxygen in the blood also will vary based on the client's respiratory efforts as well as interventions used to sustain these efforts.

PTS: 1 REF: p. 451 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 4. During a health history, a client tells the nurse that "I can't breathe well at night when I'm lying down". The client also reports an interrupted sleep pattern caused by waking up with trouble breathing and a nagging cough. Considering the client's reports, what medical condition should the nurse's assessment be focused on?

A. Pneumonia-related dyspnea B. Tuberculosis-related cough C. Bronchitis D. Heart failure induced orthopnea ANS: D Feedback: Difficulty breathing when lying supine (orthopnea) may be associated with heart failure. Paroxysmal nocturnal dyspnea (severe dyspnea that awakes a person from sleep) also is associated with heart failure. There is no indication that the client might have pneumonia, tuberculosis, or bronchitis. These conditions would most likely involve a client's report of cough with or without mucus production.

PTS: 1 REF: p. 457 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. What color of sputum would support the diagnosis of heart failure?

A. White B. Yellow C. Pink D. Rust ANS: C Feedback: Pink sputum is associated with heart failure. White sputum typically is seen with the common cold. Yellow sputum suggests a bacterial infection. Rust-colored sputum is associated with tuberculosis or pneumococcal pneumonia.

PTS: 1 REF: p. 457 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 6. Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?

A. Diabetes mellitus B. Heart failure C. Chronic obstructive pulmonary disease D. System lupus erythematosus ANS: C Feedback: The client is assuming the tripod position which is often seen in chronic obstructive pulmonary disease. A client with heart failure would most likely assume an orthopneic position to ease any breathing difficulties. The tripod position is usually not associated with diabetes or systemic lupus.

PTS: 1 REF: p. 460 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. The nurse assesses chest expansion in a young adult and finds it to be 8 cm. What phrasing should the nurse use to document this assessment finding?

A. Limited expansion B. Normal expansion C. Hypoexpansion D. Hyperexpansion ANS: B Feedback: Normal chest expansion ranges 5 to 10 cm symmetrically. A finding of 8 cm would be within the normal parameters and not limited. The other options are terms related to the over- or underexpansion of the chest or lungs and are not commonly used.

PTS: 1 REF: p. 463 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

A. Hyperresonance B. Dullness C. Resonance D. Tympany ANS: A

Feedback: Hyperresonance would be noted in a client with emphysema due to air trapping. Dullness is noted with fluid or solid tissue replacing air in the lung. Resonance is the normal finding on lung percussion. Tympany would be noted over areas of air, such as a gastric bubble in the stomach.

PTS: 1 REF: p. 464 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 9. What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?

A. Refer the client for further medical evaluation.

B. Auscultate for egophony.

C. Perform bronchophony.

D. Have the client cough and then listen again.

ANS: D Feedback: If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds (egophony and bronchophony) would be done as part of any assessment of the thorax.

PTS: 1 REF: p. 467 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. A client arrives in the emergency department after a severe motor vehicle accident. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. What pathophysiological process is likely the cause of this breathing pattern?

A. Diabetic ketoacidosis B. Renal failure C. Narcotic overdose D. Severe brain damage ANS: D Feedback: The respiratory pattern observed is Biot's respirations that may be seen with meningitis or severe brain damage. Diabetic ketoacidosis would reveal Kussmaul respirations that are characterized by an increased rate and depth. Renal failure would reveal Cheyne-Stokes respirations characterized by a regular pattern of alternating deep and rapid breathing with periods of apnea. A narcotic overdose would reveal hypoventilation or possibly Cheyne-Stokes respirations.

PTS: 1 REF: p. 479 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment

KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 11. Which nursing action would be most important for the nurse to implement when auscultating the thorax for adventitious breath sounds?

A. Listening at each site for at least one complete respiratory cycle B. Having the client breathe deeply through the mouth C. Being alert to the client's comfort and offer rest periods D. Auscultating the base at the level of the sixth rib ANS: A Feedback: Although having the client breathe deeply through the mouth and being alert to the client's comfort are important when auscultating the lungs, it would be most important to listen at each site for one complete respiratory cycle to obtain the most accurate information. The nurse would auscultate from the apices to the bases at T10 and laterally from the axilla down to the seventh or eighth rib.

PTS: 1 REF: p. 467 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?

A. Biot's B. Bradypnea C. Kussmaul D. Cheyne-Stokes ANS: D Feedback: Cheyne-Stokes respirations, regular respiratory pattern alternating with periods of deep, rapid breathing followed by periods of apnea, may result from severe heart failure. Biot's respirations (irregular pattern of varied depth and rate followed by periods of apnea) may be seen with severe brain damage or meningitis. Bradypnea is a rate less than 10/min and can be associated with medication-induced depression of the respiratory center, diabetic coma, or neurologic damage. Kussmaul respirations are associated with diabetic ketoacidosis.

PTS: 1 REF: p. 479 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. When percussing the scapula of a client, which sound characteristic would the nurse expect to hear?

A. Resonance B. Dullness C. Flatness

D. Hyperresonance ANS: C Feedback: Normally, percussion over the scapula elicits flat tones since that is the sound of normal bone. Resonance is heard over the normal lung tissue. Dullness is heard when fluid or solid tissue replaces air in the lung. Hyperresonance is elicited in cases of trapped air, such as in emphysema or pneumothorax.

PTS: 1 REF: p. 464 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 14. When assessing the apices of the lungs, the nurse would locate them at which position?

A. At the level of the diaphragm B. Near the level of the eighth rib C. Slightly above the clavicle D. At about the tenth rib ANS: C Feedback: The apex of each lung extends slightly above the clavicle. The base is at the level of the diaphragm. Laterally, lung tissue reaches the level of the eighth rib; posteriorly, the base lies at about the tenth rib.

PTS: 1 REF: p. 450 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 15. The nurse is assessing the various lobes of the lungs. The nurse must assess which lobe anteriorly?

A. Left upper lobe B. Left lower lobe C. Right upper lobe D. Right middle lobe ANS: D Feedback: The right middle lobe of the lung does not extend to the posterior side of the thoracic wall and, thus, must be assessed from the anterior surface alone. The other lung lobes can be assessed anteriorly and posteriorly.

PTS: 1 REF: p. 449 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

16. A nurse asks a client to say "ninety-nine" while palpating the posterior thorax. The nurse is demonstrating effective technique in assessing for what respiratory characteristic?

A. Fremitus B. Egophony C. Chest expansion D. Bronchophony ANS: A Feedback: Fremitus is assessed by asking a client to say 'ninety-nine' as the nurse palpates the thorax. Bronchophony is assessed by asking the client to say 'ninety-nine' as the nurse auscultates the chest wall. Chest expansion is assessed by measuring the distance the examiner's thumbs move when the client takes a deep breath. Egophony is assessed by having the client repeat the letter 'e' as the nurse auscultates.

PTS: 1 REF: p. 464 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. After teaching a group of students about age-related changes in the lungs, the instructor determines that the teaching was successful when the students identify which of the following as an age-related change?

A. Increased resiliency B. Loss of elasticity C. Increased functional capillaries D. Loss of subcutaneous fat ANS: B Feedback: Aging leads to a loss of lung elasticity, fewer functional capillaries, and a loss of lung resiliency. There is a loss of subcutaneous fat, but this may make the sternum and ribs appear more prominent on inspection. It does not affect the lungs.

PTS: 1 REF: p. 451 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. The nurse demonstrates appropriate technique when using what part of the hand to assess for fremitus in a client?

A. Dorsal hand surface B. Pads of fingers C. Palmar base D. Fist ANS: C

Feedback: The palmar base or ulnar surface of the hand is best for assessing tactile fremitus because the area is especially sensitive to vibratory sensation. The dorsal surface of the hand is used to assess temperature. The fist is used in blunt percussion.

Finger pads are used for fine discrimination such as pulses, texture, and size.

PTS: 1 REF: p. 464 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is caring for a client who has a 15-year, one-pack-a-day smoking history.

Which of the following questions would be the most beneficial for the nurse to ask the client?

A. "Are you interested in smoking cessation information?"

B. "Why do you smoke so much?"

C. "Do others in your household smoke?"

D. "Have you ever tried a nicotine replacement?"

ANS: A Feedback: All patients who smoke should be asked at every appointment about their readiness to stop smoking. Asking why a client smokes so often is judgmental and nontherapeutic. Asking about others in the household who smoke would be pertinent if the nurse were assessing for secondhand smoke exposure. Asking the client if they have ever tried a nicotine replacement may be helpful but is not the best option as the question is closed-ended and there are several choices available for those interested in quitting smoking.

PTS: 1 REF: p. 455 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

The nurse is caring for a client in a medical-surgical unit and reviews the above assessment notes. What is the priority question for the nurse to ask the client?

A. "Have you ever been screened for tuberculosis?"

B. "How often are you exercising?"

C. "How long have you been a smoker?"

D. "Does your blood sugar usually run low?"

ANS: A Feedback: Tuberculosis is characterized by night sweats, crackles, and rust-colored sputum. Exercising would not cause rust colored-sputum. The nurse should avoid assuming the client has a history of smoking. The client's blood sugar is within the normal range.

PTS: 1 REF: p. 481 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 16: Thorax and Lung Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

Chapter 17: Heart and Neck Vessels Assessment 1. Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle?

A. Internal jugular vein B. External jugular vein C. Sternomastoid D. Carotid artery ANS: D Feedback: The carotid arteries are located in the depression between the trachea and the sternomastoid muscle in the anterior neck. They follow bilaterally along the trachea from clavicle to jaw. The internal jugular vein is found in the sternal notch. The more superficial external jugular vein is visible in the depression above the middle of the clavicle.

PTS: 1 REF: p. 485 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. Across the lifespan, a nurse knows what characteristic of the female heart is consistently true?

A. Is normally smaller than the male heart B. Weighs more than a male heart C. Is normally larger than a male heart D. Normally beats more slowly than a male heart ANS: A Feedback: The total size of the heart is approximately that of a clenched adult fist. The female heart is normally smaller and weighs less than the male heart across all age groups. The female heart does not consistently beat more slowly than a male heart.

PTS: 1 REF: p. 484 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. Where is Erb's point located?

A. 4th left rib space B. 3rd right rib space C. 4th right rib space D. 3rd left rib space ANS: D

Feedback: Erb's point is located on the left side of the chest. Walk the fingers one rib space at the left sternal border (approximately 1 inch apart) to locate the 3rd intercostal space (ICS) on the left; this is the third site for auscultation, Erb's point. Walk the fingers to the 4th or 5th ICS for the fourth site, called the tricuspid area. Move the fingers along the 5th ICS to the midclavicular line for the 5th location, the mitral area.

PTS: 1 REF: p. 503 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 4. The right 2nd rib space is the first location for cardiac auscultation and is also known as: A. Erb's point.

B. the tricuspid area.

C. the aortic area.

D. the mitral area.

ANS: C Feedback: The most important landmark is the sternal angle at the right 2nd rib space.

Erb's point, the aortic area, and the mitral area are located on the left side of the chest.

PTS: 1 REF: p. 503 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client?

A. High-protein, low-fat meals B. Low-fat, low-cholesterol meals C. High-protein, low-carbohydrate meals D. Low-cholesterol, low-carbohydrate meals ANS: B Feedback: This client should follow a low-fat, low-cholesterol diet. It would be inappropriate to teach the client to eat high-protein or low-carbohydrate meals since they are not the focus of the management of elevated cholesterol levels.

PTS: 1 REF: p. 509 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 6. A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea?

A. Shortness of breath

B. Painful breathing C. Rapid breathing D. Inability to breathe ANS: A Feedback: Clients with heart failure may be short of breath from fluid accumulation in the pulmonary bed. Onset may be sudden with acute or chronic pulmonary edema. It is important to assess how much activity brings on dyspnea, such as rest, walking on a flat surface, or climbing. The other options listed are distracters to the question.

PTS: 1 REF: p. 495 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. An older adult client reports a need to get up during the night to urinate. What assessment will provide the most relevant information concerning the management of client's nocturia?

A. "What do you think is causing this need to urinate so often?"

B. "Are you tired in the morning because of this?"

C. "Is there a family history of this problem?"

D. "Have you made any lifestyle changes because of this?"

ANS: D Feedback: Nocturia is a common symptom associated with the redistribution of fluid from the legs to the core when lying. Clients may avoid drinking water after dinner because of this. The question most pertinent to this scenario is if the client has made any changes because of this. Information concerning family history, morning tiredness, and the client's perception of the cause of nocturia has less relevance for managing the urinary problem.

PTS: 1 REF: p. 496 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. What instructions should the nursing instructor stress when teaching the students how to optimally position the client to best assess venous pulses? (Select all that apply.)

A. Place a pillow behind the client head and neck.

B. Encourage the client to flex the neck to improve vein exposure.

C. Emphasize the shadows of the pulsations with a bright penlight.

D. Place the head of the bed 30° to 45°.

E. Have the client turn the head away from the side being examined.

ANS: D, E

Feedback: Positioning of the client would be with the head of the bed at 30° to 45° to promote visibility of the pulsation. The nurse would remove the pillow to avoid flexing the neck and to improve vein exposure. The right side is easiest to see; it may help for the client to turn the head away from the side being examined. The nurse would use lighting that emphasizes the shadows of the pulsations versus a bright light.

PTS: 1 REF: p. 500 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 9. Where would the nurse expect to find the point of maximum impulse (PMI) when assessing an older client with a history of cardiomegaly with a hypertrophied left ventricle?

A. Between the 4th and the 5th intercostal space (ICS) at the MCL B. Lateral and inferior to the 4th and 5th intercostal space (ICS) and the midclavicular line (MCL) C. Lateral and superior to the 4th and 5th intercostal space (ICS) and the midclavicular line (MCL) D. Lower left sternal border ANS: B Feedback: The enlarged heart of cardiomegaly displaces the point of maximum impulse (PMI) laterally and inferiorly. The nurse would observe for a heave or lift, which appears as a forceful thrusting on the chest and results from an enlarged left ventricle. A right ventricular heave is observed at the lower left sternal border. The remaining options would not be appropriate assessment points when considering the client's history.

PTS: 1 REF: p. 502 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A. A thrill B. A thrust C. A heave D. A normal finding ANS: A Feedback: Thrills are vibrations detected on palpation. A palpable, rushing vibration (thrill) is caused from turbulent blood flow with incompetent valves, pulmonary hypertension, or septal defects. This vibration is usually in the location of the valve in which it is associated. A thrust or a heave is a forceful thrusting on the chest, which is not a normal finding.

PTS:

1

REF: p. 503

OBJ: 4

NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 11. While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

A. Aortic ejection click B. Split sound C. Pericardial murmur D. Pericardial friction rub ANS: D Feedback: The pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. A murmur is a blowing or swooshing sound that occurs due to turbulent blood flow through the heart or great vessels. One normal variation in heart sounds is the split heart sound. When the valves close at the same time, one S2 is heard for both valves. If the valves close at slightly different times, however, two discernible components of the same sound are heard, a situation referred to as a split heart sound. Aortic ejection sounds are best heard at the apex.

PTS: 1 REF: p. 508 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 12. The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client's heart sounds?

A. Arrhythmia B. An opening snap C. Wide splitting D. S3 sound ANS: C Feedback: Wide splitting occurs when a bundle branch block delays activation of the right ventricle. It also can happen when stenosis of the pulmonic valve or pulmonary hypertension delays emptying of the right ventricle. The nurse would not expect to auscultate an arrhythmia since it is a reflection of heart rate. An opening snap indicates that the mitral valve is mobile and "snaps" during early diastole from high atrial pressure, such as with mitral stenosis. Blood rushes into ventricles abnormally resistant to filling, distending the ventricular walls and causing vibration that results in a S3 sound.

PTS: 1 REF: p. 505 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 13. A client has been admitted to the cardiac unit and test results are available. The nurse is writing a plan of care for this client. On what would the nurse base interventions?

A. Patterns of subjective and objective data B. Patterns of test results C. Areas for care planning D. Areas that the client requests ANS: A Feedback: Cardiac testing ranges from low-risk ECG to more invasive cardiac catheterization. Laboratory and diagnostic testing helps confirm and expand information obtained through subjective and objective data collection. Results from such tests help identify patterns of data that indicate areas for care planning and interventions. "Patterns of test" results is a partially correct option, but it does not recognize the subjective data gathered from the client. Care planning, like interventions, is based on both subjective and objective data clusters. If the client requests help in certain areas, that is subjective data.

PTS: 1 REF: p. 509 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 14. An emergency department nurse is assessing an adult client who is reporting chest pain.

The client states that the pain gets worse with movement. What further assessment should the nurse make?

A. Auscultation at the 5th intercostal space (ICS) B. Palpation at the point of maximum impulse (PMI) C. Assessment at the midclavicular line (MCL) D. Palpation of the costochondral junction ANS: D Feedback: With chest pain that increases with movement, palpation of the costochondral junction is performed to determine if the pain is of musculoskeletal origin. Auscultation at the 5th ICS assesses the tricuspid area, the location of the tricuspid valve. PMI is a term used to describe the area where the apical pulsation can be seen or palpated. The MCL is used to describe the location of heart sounds and impulses.

PTS: 1 REF: p. 503 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

15. The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

A. "Murmur heard over right carotid artery" B. "Split sound auscultated over right carotid artery" C. "Right carotid bruit auscultated" D. "S2 sound heard over right carotid artery."

ANS: C Feedback: Bruits are swooshing sounds similar to the sound of the blood pressure. They result from turbulent blood flow related to atherosclerosis. A bruit is audible when the artery is partially obstructed. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. Neither split sounds nor an S2 is heard over arteries.

PTS: 1 REF: p. 502 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 16. An older adult client presents at the office of the primary care physician with fatigue and heart palpitations. These reports support what cardiac related diagnosis?

A. Heart failure B. Atrial fibrillation C. Atrial hypertrophy D. Ventricular arrhythmia ANS: B Feedback: Symptoms of atrial fibrillation include fatigue, palpitations, and heart failure with loss of the "atrial kick" that supports ventricular filling. Symptoms of heart failure include weight gain, shortness of breath, and edema. Atrial hypertrophy and ventricular arrhythmia are not found more often in the elderly, and they do not have symptoms including a "wet cough."

PTS: 1 REF: p. 491 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound?

A. S1 B. S2 C. Preload D. Afterload ANS: B

Feedback: Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators.

PTS: 1 REF: p. 505 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is caring for an older adult client. Which of the following findings would be considered normal when comparing the client's current assessment findings to those of five years ago?

A. elevated blood pressure B. altered mental status C. decreased body mass index D. frequent heart palpitations ANS: A Feedback: In the older adult, changes in the heart and BP are primarily due to age-related stiffening of the vasculature and decreased responsiveness to stress hormones. Blood and pulse pressures increase as a result of the stiffened blood vessels. Additionally, body mass index increases, causing the heart to work harder. Heart palpitations are not normal and could be a sign of atrial fibrillation. Altered mental status is not a normal age-related finding.

PTS: 1 REF: p. 490 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is assisting a student nurse in assessing the hepatojugular reflux on a client.

Which action by the student nurse would need the nurse to intervene to stop?

A. Applies pressure over the left upper quadrant B. Applies pressure for greater than 10 seconds C. Uses the palmar side of the hand D. Uses a pressure of approximately 30 to 40 mm Hg ANS: A Feedback: The hepatojugular reflux is used to assess for multiple cardiac conditions. The nurse should press gently on the liver using the palmar side of the hand. The gentle pressure of 30 to 40 mm Hg should be applied to the right upper quadrant or the middle abdomen for at least 10 seconds but can be applied for up to one minute. A positive result is noted when the height of the neck veins increase by 3 centimeters or more. A positive result of the hepatojugular reflux test is highly sensitive and specific for right ventricular fluid overload.

PTS: 1 REF: p. 507 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 20.

The nurse is caring for a client in a medical-surgical unit and reviews the above assessment notes. Which is the priority question that the nurse should ask the client?

A. "How long have your feet been swollen?"

B. "Have you had the chills recently?"

C. "How long have you had chest pain?"

D. "Are you trying to gain weight?"

ANS: A Feedback: When blood flow out of the heart is reduced, blood returning to the heart through the veins backs up, causing fluid to accumulate in the dependent areas of the body. Usually standing exacerbates leg edema. It is important to understand how long the client has been experiencing edema as well as the level of severity. The notes do not mention any sort of chest pain, the client is afebrile, and the client's weight change is insignificant, making these findings normal.

PTS: 1 REF: p. 496 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 17: Heart and Neck Vessels Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

Chapter 18: Peripheral Vascular with Lymphatics Assessment 1. What are the functions of the lymphatic system? (Select all that apply.)

A. Maintaining protein balance B. Draining lymph from the bloodstream C. Fighting infection D. Hydrating the thymus E. Maintaining fluid balance ANS: A, C, E Feedback: The lymphatic system consists of the lymph nodes and lymphatic vessels as well as the spleen, tonsils, and thymus. It maintains fluid and protein balance and functions with the immune system to fight infection. The lymph system does not drain lymph from the bloodstream or hydrate the thymus.

PTS: 1 REF: p. 526 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 2. Which of the following veins drain into the superior vena cava? (Select all that apply.)

A. Lower extremities B. Upper torso C. Head D. Upper extremities E. Lower torso ANS: B, C, D Feedback: The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium. The lower extremities and lower torso drain into the inferior vena cava.

PTS: 1 REF: p. 524 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 3. A nurse is preparing a teaching plan for a client newly diagnosed with peripheral arterial disease. To address the most modifiable risk factors, what risk factors would the nurse include? (Select all that apply.)

A. High-fat diet B. Low-protein diet C. Anaerobic exercise D. Smoking E. Activity level ANS: A, D, E

Feedback: Identifying options for the modification of risk factors can significantly improve the outcome for clients with peripheral arterial disease. The most modifiable risk factors are smoking, high-fat diet, and limited activity level. Low-protein diets and anaerobic exercise are not considered modifiable risk factors for peripheral arterial disease.

PTS: 1 REF: p. 531 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 4. A nurse is caring for a client diagnosed with chronic lymphedema. In preparing a teaching plan for this client, what would be essential for the nurse to address when considering psychosocial wellness?

A. Exercise plan B. Body image C. Treatment D. Pathophysiology ANS: B Feedback: Clients with chronic lymphedema may experience disfigurement that affects their body image and self-esteem. It is essential for nurses to address these areas that affect quality of life. Addressing exercise, treatment, and pathophysiology is not considered as essential for the nurse to address in teaching as are body image and self-esteem.

PTS: 1 REF: p. 532 OBJ: 10 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 5. The nursing instructor is discussing the collection of subjective information when assessing a client with arterial, venous, and lymphatic disorders. What would the instructor tell the students to include in the subjective portion of the health assessment?

A. Plan for modifying risk factors B. Education on nonmodifiable risk factors C. Identification of cardiovascular risk factors D. History related to grandparents' health ANS: C Feedback: The subjective portion of the health assessment includes the identification of cardiovascular risk factors and history related to those symptoms that are frequently associated with arterial, venous, and lymphatic disorders. The subjective portion of the health assessment would not include a plan for modifying risk factors, education on nonmodifiable risk factors, or a history of the grandparents' health.

PTS: 1 REF: p. 529 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer?

A. "The area of pain tells us what treatment will work best for you."

B. "The area of cramping indicates whether you may have numbness and tingling also."

C. "The area of pain can help us identify what risk factor is predominant."

D. "The area of cramping is close to the area of arterial occlusion."

ANS: D Feedback: The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. The other options are distracters to the question.

PTS: 1 REF: p. 551 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause?

A. Peripheral arterial disease B. Chronic lymphedema C. Venous insufficiency D. Arterial aneurysm ANS: A Feedback: Peripheral arterial disease can present with cramping and may result in muscle atrophy. Hypertrophy may result from activity in which the client uses one arm more than the other, such as tennis. Muscle atrophy is not caused by chronic lymphedema, venous insufficiency, or arterial aneurysm.

PTS: 1 REF: p. 536 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

A. Atherosclerosis B. Normal finding C. Possible lymphoma D. No lymphedema

ANS: B Feedback: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

PTS: 1 REF: p. 539 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 9. When assessing for acute arterial occlusion, what would the nurse focus on? (Select all that apply.)

A. Pain B. Paralysis C. Pallor D. Paresthesia E. Purple coloration ANS: A, B, C, D Feedback: Assessment for acute arterial occlusion involves evaluation of the "Six Ps": pain, poikilothermia, paresthesia, paralysis, pallor, and pulselessness. "Purple coloration" is not included since the occlusion would not cause bleeding or bruising.

PTS: 1 REF: p. 529 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 10. An older adult has been admitted to the emergency department. The client reports pain in his back and abdomen and shortness of breath. What might the nurse suspect is causing the symptoms?

A. Iliac vein obstruction B. Aortic aneurysm C. Lymphadenopathy D. Renal lymph obstruction ANS: B Feedback: Assessment findings associated with aortic aneurysm include chest pain, abdominal pain, back pain, shortness of breath, laterally pulsatile mass on palpation, and a bruit. These symptoms are not indicative of an iliac vein obstruction, lymphadenopathy, or renal lymph obstruction.

PTS: 1 REF: p. 532 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

11. Which pulse is located at approximately the inner third of the antecubital fossa when the palm is held upward?

A. Epitrochlear B. Radial C. Ulnar D. Brachial ANS: D Feedback: The brachial pulses are located at approximately the inner third of the antecubital fossa when the palm is held up. It is not usually necessary to palpate the ulnar pulse, which is difficult to locate. The radial pulse site is used when assessing the pulse for vital signs. Epitrochlear is not a term used to identify a pulse.

PTS: 1 REF: p. 537 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 12. What pulse is located in the groove between the medial malleolus and the Achilles tendon?

A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Femoral ANS: A Feedback: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe.

PTS: 1 REF: p. 540 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 13. A newly admitted client has given their health history and undergone a physical assessment. Laboratory data and diagnostic study results are on the chart. What is the nurse's next step in caring for the client?

A. Notify the health care provider of laboratory results.

B. Develop a plan of care.

C. Inform the client and family of diagnostic study results.

D. Start giving medication.

ANS: B

Feedback: Because of the systemic nature of cardiovascular diseases, nurses must critically investigate far beyond the initial reason for which the client sought care. Once the nurse has analyzed the history, physical assessment, laboratory data, and diagnostic study results, the next step is to develop a plan of care. The nurse would notify the health care provider only of abnormal laboratory results. It is the physician's responsibility to inform the client/family of the results of diagnostic studies. Medication is given as ordered from the time the client is admitted.

PTS: 1 REF: p. 544 OBJ: 10 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A client is given a nursing diagnosis of activity intolerance related to pain and claudication with ambulation. What would be an appropriate intervention for this client?

A. Assess for pain, pulses, pallor, paresthesia, and paralysis B. Assess dorsalis pedis and posterior tibial pulse bilaterally C. Gradually increase activity D. Assess with a Doppler and notify the physician ANS: C Feedback: When a client has insufficient energy to endure or complete required or desired daily activities, an appropriate intervention is to gradually increase activity, refer client to physical therapy as indicated, and allow rest periods before and after activity.

The assessment of pain, pulses, pallor, paresthesia, and paralysis is an intervention for "risk for peripheral neurovascular dysfunction." Options B and D reflect interventions for "altered tissue perfusion, arterial related to reduced blood flow."

PTS: 1 REF: p. 546 OBJ: 9 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 15. How should the nurse document a normal pulse in the medical record?

A. +2/4 B. +2/3 C. +3/3 D. +3/4 ANS: A Feedback: The nurse documents a normal pulse as +2/4. The other options are distracters to the question.

PTS: 1 REF: p. 541 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice

16. Students are practicing documentation of peripheral vascular and lymphatic assessment before going into the clinical setting. A student documents the following: Lower left leg cool to touch with dorsalis pedis, back knee pulse and femoral pulse palpable. How could the following charting be changed to communicate information in appropriate medical terminology?

A. Left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable B. Left lower leg cool to touch with femoral, posterior popliteal, dorsalis, and pedis pulses palpable C. Left extremity cool to touch with femoral, posterior popliteal, dorsalis, and pedis pulses palpable D. No changes are necessary ANS: A Feedback: Appropriate medical terminology would be "left lower extremity cool to touch with femoral, posterior popliteal, and dorsalis pedis pulses palpable." The other options do not use the proper medical terminology for the entire description.

PTS: 1 REF: p. 537 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 17. What statement is considered true for varicose veins? (Select all that apply.)

A. They are seen less often in obese people.

B. They are seen more often in people older than 50 years.

C. They are more common in women.

D. They may be familial.

E. They are always accompanied by lymphedema.

ANS: B, C, D Feedback: Primary varicose veins are seen more often in people older than 50 years and in those with obesity. Varicose veins are more common in women, which may be related to the increased venous stasis that accompanies pregnancy. Varicose veins and lymphedema may be familial.

PTS: 1 REF: p. 528 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 18. When doing a shift assessment on a newly admitted client, the nurse notes lack of hair on the right lower extremity; thickened nails on the right lower digits; dry, flaky skin on the right lower extremity; and diminished tibial pulses bilaterally and absent pedal pulses. What nursing diagnosis should be added to the plan of care?

A. Risk for peripheral neurovascular dysfunction B. Activity intolerance related to pain and claudication with ambulation

C. Altered tissue perfusion, arterial related to reduced blood flow D. Pain related to decreased blood flow and altered tissue perfusion ANS: C Feedback: Signs of altered tissue perfusion, arterial related to reduced blood flow include decreased oxygen, resulting in a failure to nourish tissues at the capillary level; reduced hair on the extremity; thick nails; dry skin; weak or absent pulses; pale skin; cool, reduced sensation; and prolonged capillary refill. The other options are distracters to the question.

PTS: 1 REF: p. 528 OBJ: 10 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. A trauma client reports pain in the left lower extremity. The nurse notes that the extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What nursing diagnosis might the nurse use?

A. Pain related to decreased blood flow and altered tissue perfusion B. Activity intolerance related to pain and claudication with ambulation C. Altered tissue perfusion, arterial related to reduced blood flow D. Risk for peripheral neurovascular dysfunction ANS: D Feedback: Those with risk for peripheral neurovascular dysfunction are at risk for a disruption in circulation, sensation, or motion of an extremity. Risk factors include trauma, fractures, mechanical compression, surgery, burns, immobilization, and obstruction. The other options are distracters to the question.

PTS: 1 REF: p. 529 OBJ: 10 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 20. The client asks the nurse about how to prevent further complications associated with peripheral artery disease. Which modifications should the nurse teach the client? (Select all that apply.)

A. Decrease intake of food high in saturated fat.

B. Increase physical activity to five times per week.

C. Decrease blood pressure.

D. Cease smoking.

E. Assess the bottoms of their feet once per week.

ANS: A, B, C, D Feedback: Decreasing saturated fat in the diet, smoking cessation, taking steps to lower blood pressure, and exercise can decrease complications risks associated with peripheral artery disease. Because peripheral artery disease can quickly lead to arterial ulcers, clients should check their feet daily (not weekly).

PTS: 1 REF: p. 529 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 18: Peripheral Vascular and Lymphatic Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select

Chapter 19: Breast and Axillae Assessment 1. A nursing instructor is discussing the functions of the breasts. A student asks about the function of the Montgomery glands. What would be the instructor's best answer?

A. "They secrete a protective lubricant during lactation."

B. "They are the lactiferous ducts."

C. "They aid in supporting breast tissue."

D. "They are lymph nodes in the axillae."

ANS: A Feedback: Small sebaceous glands called Montgomery glands secrete a protective lubricant when a woman lactates. Montgomery glands are not lactiferous ducts and are not associated with milk production; they do not aid in the support of breast tissue; they are not lymph nodes in the axillae but are found in the breast tissue (areola) itself.

PTS: 1 REF: p. 557 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 2. Where are the acini cells located?

A. Nipple B. Lobules of the breast C. Lactiferous ducts D. Breast sinus ANS: B Feedback: The glandular tissue consists of 15 to 20 glandular lobes in each breast that extend from the nipple in a radial fashion. Within each lobe, 20 to 40 lobules contain milk-producing acini cells. When milk is produced, it drains into the lactiferous ducts; the milk from each lobe empties into one sinus that terminates at the nipple.

PTS: 1 REF: p. 557 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes?

A. Inside the upper arm B. Along the lateral edge of the scapulae C. High in the axillae at the top of the ribs D. Inside the lateral axillary fold ANS: C

Feedback: The central axillary (midaxillary) nodes are palpable high up in the axillae at the top of the ribs. These nodes receive lymph from the lateral, posterior, and anterior axillary nodes. The anterior axillary (pectoral) nodes are located inside the lateral axillary fold along the pectoralis major muscle. The lateral axillary (brachial) nodes are located inside the upper arm along the humerus. The posterior axillary (subscapular) nodes lie inside the posterior axillary fold along the lateral edge of the scapulae.

PTS: 1 REF: p. 558 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 4. When assessing the breast and axillae, the nurse remembers that most lymph drains where?

A. Bilateral axillary nodes B. Bilateral mammary nodes C. Ipsilateral mammary nodes D. Ipsilateral axillary nodes ANS: D Feedback: Most lymph drains into the axillary lymph nodes on the same side (ipsilateral lymph nodes). None of the other options are associated with axillary lymph node drainage.

PTS: 1 REF: p. 558 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A nurse is teaching a client about self breast examination. What would the nurse emphasize? (Select all that apply.)

A. Inspection B. Pain C. Timing D. Palpation E. Pallor ANS: A, C, D Feedback: It is important to guide clients through self breast examination that emphasizes timing, inspection, and palpation. Pain and pallor are not emphasized when teaching self breast examination.

PTS: 1 REF: p. 560 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select

6. What is considered a modifiable risk factor for breast cancer?

A. Obesity B. Age C. Genetics D. Asthma ANS: A Feedback: It is important for women to be aware of their specific risk factors for breast cancer. A modifiable risk factor for breast cancer is obesity. Asthma is not correlated with breast cancer. Genetics and age are not modifiable risk factors.

PTS: 1 REF: p. 564 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 7. While assessing an adult woman new to the clinic, the nurse should perform a subjective assessment of what risk factors?

A. Onset of menstruation 13 years or after B. Bottle fed all three children C. High-protein, low-carbohydrate diet D. History of breast cancer in second-degree relatives ANS: B Feedback: Some risk factors that the nurse assesses during subjective data collection are a family history of breast cancer in first-degree relatives (client's mother and grandmother), early onset of menstruation (age 11 years), bottle feeding of children, obesity, high-fat diet, and lack of exercise.

PTS: 1 REF: p. 562 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. Included in the subjective assessment of the breast are the client's statements about what topics? (Select all that apply.)

A. Breast size B. Palpation C. Surgeries D. Nipple discharge E. Personal history ANS: C, D, E

Feedback: Subjective data collection begins with the current health history related to the breast (such as breast discomfort, masses or lumps, or nipple discharge) and continues with questions related to past history (previous breast disease; surgeries; menstrual, pregnancy, and lactation history; and past hormone replacement therapy), family history (of breast cancer or other breast disease), and personal history (breast trauma, surgery, and self-care behaviors). Palpation and breast size are not part of subjective data collection.

PTS: 1 REF: p. 562 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Select 9. The nurse encourages a client to perform a monthly self-breast examination between what days of the menstrual cycle?

A. 1 to 3 B. 4 to 7 C. 8 to 11 D. 12 to 15 ANS: B Feedback: The best time to examine the breasts is when they are least congested and smallest (in adult women, days 4 to 7 of the menstrual cycle). The other options suggest times when the breasts are congested or enlarged.

PTS: 1 REF: p. 568 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 10. An adult woman reports to the nurse that she has an area on her breast that is dimpled and "looks like the skin on an orange." These characteristics are associated with what breast disorder?

A. Early cancer B. Fibroadenoma C. Fibrocystic disease D. Blocked lymph drainage ANS: D Feedback: Peau d'orange appearance is caused by breast edema from blocked lymph drainage and indicates advanced cancer. Orange peel dimpling does not indicate early cancer, fibroadenoma (cysts), or fibrocystic disease.

PTS: 1 REF: p. 569 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

11. When assessing the breasts, the client asks why is it important to lift her arms over her head. What is the basis for the nurse's response?

A. Adds tension to suspensory ligaments B. Minimize dimpling and retraction C. Deemphasizes suspensory ligament retraction D. Accentuates signs of unilateral nipple inversion ANS: A Feedback: Lifting the arms over the head adds tension to the suspensory ligaments and accentuates any dimpling or retraction. Lifting of the arms does not accentuate signs of unilateral nipple inversion, nor does it de-emphasize suspensory ligament retraction.

Lifting the arms would maximize dimpling and retraction if it were present.

PTS: 1 REF: p. 570 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 12. A woman is 2 days postoperative after a right breast mastectomy. Included in the discharge teaching is care of the surgical incision. What would be the most appropriate intervention for this client?

A. Provide for a home health nurse to assist in care of the incision B. Provide a mirror to visualize the incision C. Make a referral to the wound care nurse D. Teach signs and symptoms of wound infection ANS: B Feedback: The nurse would provide a mirror for the client to visualize tissue and incisions. A home health referral and wound care referral would not be the most appropriate interventions for this client nor would teaching signs and symptoms of wound infection.

PTS: 1 REF: p. 574 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 13. When would be the best time during the month for a post-menopausal woman to perform self-breast examination?

A. First day of each month B. Last two weeks of month C. First two weeks of month D. A convenient day of each month ANS: D

Feedback: With the cessation of menses, hormonal changes no longer affect the breasts.

For this reason, clients can choose a convenient day of each month to perform SBEs. With this information, none of the other options present the best time.

PTS: 1 REF: p. 568 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 14. When considering malignancy, what signs/symptom determined through assessment of the breast requires additional assessment? (Select all that apply.)

A. Hyperpigmentation B. Erythema C. Pain D. Peau d'orange E. Unilateral vascular appearance ANS: A, D, E Feedback: Redness (erythema) and heat can indicate infection or inflammation.

Hyperpigmentation can signify cancer. A unilateral vascular appearance could indicate increased blood flow to a malignancy (produced by dilated superficial veins). Peau d'orange appearance is caused by breast edema from blocked lymph drainage and indicates advanced cancer. Pain is associated with trauma or possibly infection.

PTS: 1 REF: p. 568 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 15. A teenage boy is embarrassed by his tender and enlarged breasts. What would be the most appropriate nursing intervention to help the teen manage this problem?

A. Teaching the client that hormone therapy may be required B. Reassuring the teen that this is both normal and temporary C. Preparing the client for further genetic testing D. Encouraging the teen to seek counseling to deal with permanent body image issues ANS: B Feedback: During mid-puberty, one or both male breasts commonly and temporarily enlarge because of changing hormone levels, a condition referred to as gynecomastia.

Pubescent males also may develop breast buds or tenderness, which also is usually temporary. Almost one third of adolescent males have these conditions, which usually resolve in 1 to 2 years. Gynecomastia is physically benign but can cause emotional distress. Reassurance that this is temporary and normal may help alleviate the distress.

Because of its temporary nature, neither hormone therapy or counseling is required.

Gynecomastia is not a genetic problem.

PTS: 1 REF: p. 560 OBJ: 8 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. The nurse practitioner is examining a client and notes an axillary lymph node approximately 1.5 cm in size, tender, and movable. The nurse practitioner also notes an erythematous 3-cm abrasion on the client's upper arm. The client tells the nurse practitioner that she fell in the garden while fertilizing her plants. What nursing diagnosis would the nurse practitioner include in the plan of care?

A. Infectious process related to abrasions B. Fear related to possible diagnosis of breast cancer C. Inflammation related to abrasions D. Grieving related to probable diagnosis of breast cancer ANS: B Feedback: The greatest fear a woman has related to these symptoms is that she has breast cancer, although often the cause is benign. The scenario describes inflammation at the sight of the abrasion; it does not state that the client has an infectious process. Grieving would not be addressed prior to a diagnosis being confirmed.

PTS: 1 REF: p. 562 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. A mother of three young children is newly diagnosed with breast cancer. The client tells the nurse that she is so sad and cannot stop crying. She adds that she feels like she is less of a woman and is having trouble sleeping. When initiating the plan of care, what would be the most appropriate nursing diagnosis to address the client's immediate needs?

A. Altered body image B. Altered self-concept C. Grieving D. Altered sleeping pattern ANS: C Feedback: Manifestations of grieving related to loss of breast, functional ability, and cancer diagnosis include sadness, crying, anger, depression, altered eating and sleep patterns, and reliving of past experiences. All options may be appropriate, but for this client, the most correct option is grieving since her emotional state will impact treatment..

PTS: 1 REF: p. 576 OBJ: 6 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Caring BLM: Cognitive Level: Analyze NOT: Multiple Choice

18. An older female client states she is upset about her sagging breasts. She states, "I know it's because I haven't been sexually active since my husband died and my hormones are all dried up." What is the nurse's best response?

A. "What you're experiencing is an expected effect of the aging process."

B. "If you are involved in community activities, you may meet some men your age."

C. "I can talk to your healthcare provider about hormone replacement therapy."

D. "Appearance is insignificant when normal physical changes occur."

ANS: A Feedback: The suspensory ligaments relax, causing breasts to sag and droop. Breasts also decrease in size and lose elasticity. Nipples become smaller, flatter, and less erectile. Axillary hair may stop growing at this time. These changes are more apparent in the eighth and ninth decades of life. The client's concern is the physical change of sagging breasts, not meeting men. Sagging breasts are expected changes; hormone therapy is not recommended. Appearance may be very significant to some clients regardless of age.

PTS: 1 REF: p. 560 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The parents of a newborn express concern upon seeing the pediatrician palpate and gently express a small amount of whitish, milk-like liquid from the baby's nipples. They anxiously ask, "What can be done to fix this problem?" What is the nurse's best response?

A. "Your baby will be placed on hormone therapy to dry up the fluid."

B. "The pediatrician will refer your baby to a specialist for evaluation."

C. "Nothing is wrong with your baby. This liquid will clear up spontaneously."

D. "You should feed your baby formula only until this condition resolves."

ANS: C Feedback: Enlarged breast tissue and white discharge (commonly called witch's milk) in newborns of either gender may occur for the first few weeks of life, secondary to the effects of maternal estrogens. If breast enlargement, witch's milk, or both are present, it is important to reassure the newborn's parents/caregivers that nothing is wrong and the conditions will resolve spontaneously. The baby does not need further evaluation, hormone therapy, or a change in diet since this condition is considered normal for the first few weeks after birth.

PTS: 1 REF: p. 559 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. A nurse working at a community health fair is providing education related to breast cancer screening and prevention. The nurse should teach others to follow up with a health care provider if they experience which of the following?

A. Nipple turning inward B. Loss of breast elasticity with aging C. Bilateral breast tenderness during menses D. Decreased nipple size with aging ANS: A Feedback: A nipple turning inward or nipple retraction should always be further investigated to rule out cancer. In adults, unilateral or bilateral breast tenderness may accompany menses, and this is also considered a normal finding. In older adults, breast tissue may decrease, elasticity may decrease, and nipples may become smaller, flatter, and less erectile.

PTS: 1 REF: p. 562 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 19: Breasts and Axillae Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 20: Abdominal Assessment 1. Where is the linea alba located?

A. Middle of the ventral abdominal wall B. Lower edge of the costal margin C. Anterior-superior iliac spine of the iliac bones D. Xiphoid process of the sternum ANS: A Feedback: Four layers of large, flat muscles form the ventral abdominal wall and are joined at the midline by a tendinous seam, the linea alba. The lower edge of the costal margin and the anterosuperior iliac spine of the iliac bones are landmarks used to divide the abdomen into regions. The abdomen is a large cavity extending from the xiphoid process of the sternum down to the superior margin of the pubic bone.

PTS: 1 REF: p. 586 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. What structure borders the abdominal cavity posteriorly?

A. The lower rib cage B. The vertebral column C. The kidneys D. The midaxillary lines ANS: B Feedback: The abdominal cavity is bordered in the back by the vertebral column and paravertebral muscles and at the sides and front by the lower rib cage and abdominal muscles. The other options are not associated with the abdominal cavity's posterior border.

PTS: 1 REF: p. 586 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. What is one of the functions of the spleen?

A. Storing albumin B. Producing white blood cells C. Storing vitamin E D. Producing macrophages ANS: D Feedback: The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The spleen does not store albumin or vitamin E, nor does it produce white blood cells.

PTS: 1 REF: p. 588 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 4. The nurse is admitting a new client to the floor and asks if the client has any dizziness.

Why does the nurse do this?

A. To assess for liver problems B. To assess for pancreatic problems C. To check for possible dehydration D. To check for an absorption problem ANS: C Feedback: Dizziness may result from possible dehydration linked to inadequate fluid or caloric intake. Pancreatic problems and liver problems do not cause dizziness. An absorption problem would not cause dizziness in and of itself.

PTS: 1 REF: p. 591 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 5. When palpating a client's abdomen, the nurse notes that the liver has a firm edge. What is the likely cause of his abnormal characteristic?

A. Cirrhosis B. Liver failure C. Calcification of the liver D. Splenomegaly ANS: A Feedback: A firm hepatic edge is indicative of cirrhosis. A firm edge does not indicate liver failure or calcification. Such an edge is associated with hepatomegaly, not splenomegaly.

PTS: 1 REF: p. 604 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 6. A shift report indicates that an African American client has symptoms of both jaundice and splenomegaly. Considering the client's ethnicity and diagnoses, what is the likely medical diagnosis?

A. Pancreatitis B. Leukemia C. Sickle cell anemia D. Colon cancer

ANS: C Feedback: African Americans more commonly present with sickle cell anemia, G6PD deficiency, and lactose intolerance. Those with sickle cell disease may have splenomegaly and jaundice on examination. While jaundice is associated with pancreatitis, African Americans are not a high-risk population for this disease.

Ashkenazi Jews have the greatest risk of colon cancer. Leukemia does not present with either jaundice or splenomegaly.

PTS: 1 REF: p. 597 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 7. While auscultating a client's abdomen, the student notes sounds that are both high-pitched and rushing. The student demonstrates an understanding of abnormal bowel sounds when proposing what to be the cause of these sounds?

A. Diarrhea B. Adynamic ileus C. Intestinal fluid D. Partial intestinal obstruction ANS: D Feedback: High-pitched, rushing sounds indicate partial intestinal obstruction. Increased bowel sounds occur with diarrhea and early intestinal obstruction. Decreased bowel sounds occur with adynamic ileus and peritonitis. High-pitched, tinkling bowel sounds indicate intestinal fluid, air under tension in a dilated bowel, and inadequate bowel sounds.

PTS: 1 REF: p. 601 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. What causes the characteristic features of coffee-ground emesis?

A. Digested blood B. Decreased peristalsis C. Active bleeding D. Irritated intestinal lining ANS: A Feedback: Coffee-ground emesis is digested blood; bloody emesis is an active bleed with undigested blood. Green emesis usually results from reduced peristalsis with irritation.

PTS: 1 REF: p. 601 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning

BLM: Cognitive Level: Understand

NOT: Multiple Choice

9. The nurse is assessing a client and notes dullness to percussion in the lowest point of the abdomen. When rolling the client to the left, the nurse notes that there is now dullness on the left side. This indicates ascites, which can be caused by A. Congestive heart failure and pyelonephritis B. Cirrhosis and nephrosis C. Metastatic neoplasms and coronary artery disease D. Congestive heart failure and coronary artery disease ANS: B Feedback: Ascites is the accumulation of fluid in the abdomen. The fluid descends with gravity, resulting in dullness to percussion in the lowest point of the abdomen based on client position. Changing the client's position should move the fluid shift to the most dependent point. Ascites occurs in cirrhosis of the liver, congestive heart failure, nephrosis, peritonitis, and metastatic neoplasms. The other options are distracters to the question.

PTS: 1 REF: p. 619 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 10. An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What medical diagnosis is associated with the assessment finding?

A. Gastroenteritis B. Liver disease C. Appendicitis D. Enlarged spleen ANS: C Feedback: Rovsing's sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen.

PTS: 1 REF: p. 621 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. What structure in the abdomen provides the blood vessels to the intestinal tract?

A. Mesentery B. Aorta C. Peritoneum D. Spleen ANS: A

Feedback: The fan-like mesentery supplies blood vessels and nerves to the intestinal tract. The aorta and inferior vena cava supply oxygenated blood to the cells and organs in the lower half of the body. The spleen produces and stores red blood cells. It also produces macrophages. The spleen stores platelets and activates B and T lymphocytes.

The peritoneum is the membrane that lines the abdominal cavity.

PTS: 1 REF: p. 588 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 12. What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?

A. Epigastric B. Hypogastric C. Hypochondriac D. Inogastric ANS: B Feedback: The regions of the abdomen are named from right to left and top to bottom: right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right inguinal, hypogastric, and left inguinal.

PTS: 1 REF: p. 588 OBJ: 9 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 13. The nurse is caring for a client being treated for a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?

A. Esophagus B. Small intestine C. Descending colon D. Oropharynx ANS: B Feedback: Absorption of nutrients takes place almost exclusively in the small intestine.

The esophagus propels the food bolus by means of slow peristaltic movements into the stomach. The descending colon is part of the large intestine. Mastication occurs in the mouth, then food moves into the oropharynx and esophagus for food propulsion through the digestive tract.

PTS: 1 REF: p. 589 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

14. A client presents complaining of nausea, vomiting, and acute abdominal pain. What is the nurse's first action?

A. Obtain a 24 hour diet recall.

B. Document a detailed health history.

C. Ask the client when the pain began.

D. Ask about pertinent risk factors.

ANS: C Feedback: If a client has an acute abdominal problem, the history and physical examination will be focused on that problem, so that much of the history taking will be eliminated. Severe dehydration from nausea and vomiting, fever, and acute abdominal pain are potentially life-threatening symptoms that require prompt attention. Pain is the chief complaint and should be assessed before a diet recall, obtaining a health history, and identifying risk factors.

PTS: 1 REF: p. 590 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. The nurse performing an abdominal assessment should proceed in what order? (Place all items in correct order.)

A. Palpation B. Inspection C. Ensure a warm, comfortable environment.

D. Auscultation E. Ask the client to lie supine.

F. Percussion ANS: C, E, B, D, F, A Feedback: After ensuring a comfortable environment and asking the client to lie supine, the order of assessment of the abdomen is different from previous systems. Inspection is followed by auscultation for bowel sounds before percussion and palpation. Failure to adhere to this order may result in the alteration of bowel sounds from either percussion or palpation, leading to inaccurate findings.

PTS: 1 REF: p. 600 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Drag and Drop 16. The nurse auscultates hyperactive bowel sounds in the ascending colon and absent bowel sounds in the descending colon. What is the nurse's best action?

A. Request a soft diet for the client.

B. Tell the client not to eat or drink anything.

C. Decrease the intravenous fluid rate.

D. Administer scheduled oral antacid medication.

ANS: B Feedback: Bowel sounds increase and decrease and indicate GI motility. They may be hyperactive at a point above a partial bowel obstruction and decreased or nonexistent below the point of obstruction. The client may have a bowel obstruction and should not eat or drink anything, including medications by mouth. The nurse should then notify the healthcare provider of these findings. While the client is NPO, the client is usually on intravenous fluid. The nurse should not decrease the rate.

PTS: 1 REF: p. 601 OBJ: 8 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 17. The nurse is assessing the abdomen of a client. While percussing the abdomen, what normal sound does the nurse expect to hear?

A. Tympany B. Dullness C. Hollow sound D. Friction rub ANS: A Feedback: Generalized tympany predominates over the abdomen because of air in the stomach and intestines. An enlarged area of dullness would be heard over an enlarged liver or spleen. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastases. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor. A hollow sound would not be expected at the normal spleen.

PTS: 1 REF: p. 603 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 18. The nurse is teaching a group of new nurses about gastrointestinal changes associated with age. The nurse should provide additional education when a new nurse lists which of the following changes? (Select all that apply.)

A. Peristalsis increases with age B. Older adults are more sensitive to abdominal pain C. Changes in dentition can affect chewing capabilities D. Abdominal muscle mass decreases with age E. Fat accumulates with age around the lower abdomen ANS: A, B

Feedback: Older adults are less likely to feel pain with abdominal conditions and do not always present with classic symptoms. Motility and peristalsis decrease with age, which may result in bloating and constipation. Fat around the waistline, changes in dentition, and decreased abdominal muscle mass are associated with age-related abdominal changes.

PTS: 1 REF: p. 589 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Select 19. The nurse is assessing a client in the emergency department. The client was involved in a motor vehicle accident and is experiencing left upper abdominal pain. The nurse should intervene when another health care provider does which of the following?

A. Attempts to palpate the spleen B. Uses the left arm for phlebotomy C. Orders a spiral computerized tomography (CT) scan D. Places a cervical collar on the client ANS: A Feedback: If trauma to the spleen is suspected, the spleen should not be palpated.

Palpation could cause the spleen to rupture and the nurse should intervene to prevent this from happening. The nurse would expect for the client to be placed in a cervical collar as the client was in a motor vehicle accident. The cervical collar should remain in place until the neck and spine are deemed stable. A spiral computerized tomography (CT) scan is expected to be ordered to rapidly help identify injuries sustained during the accident.

The nurse should also expected blood to be drawn quickly from any site available to monitor the hemoglobin and hematocrit, as there is a need to check for internal bleeding.

PTS: 1 REF: p. 607 OBJ: 8 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

The nurse is caring for a client being admitted to the hospital for acute right lower quadrant pain and a positive Rovsing sign. Which of the orders (above) should the nurse question?

A. Barium enema B. Nothing by mouth C. Intravenous IV fluid replacement: 125ml per hour NS D. Acetaminophen 500mg IV q 6 hours PRN for pain ANS: A Feedback: A positive Rovsing sign is indicative of an acute appendicitis. A barium enema should not be performed on a patient demonstrating symptoms of an appendicitis.

The barium can cause the inflamed area of the bowel to rupture. A diet of nothing by mouth is expected until the cause for the client's pain is identified. While not eating and drinking, IV fluid replacements are necessary. IV pain medication is an expected order for a client in acute abdominal pain.

PTS: 1 REF: p. 612 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 20: Abdominal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

Chapter 21: Musculoskeletal Assessment 1. A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

A. Adducting and abducting B. Dorsiflexion and plantar flexion C. Supination and pronation D. Rotation and supination ANS: B Feedback: The terms used to describe the movements of the tibiotalar joint are dorsiflexion and plantar flexion. Adducting means to move a part of the body toward the midline. Abducting is moving a part of the body away from the midline. Supination is a motion where the foot or palm of the hand is moved to a surface up position. Pronation is a motion where the foot or palm of the hand is moved to a surface down position.

Rotation is simply the movement of the joint. Rotation could be either internal or external in nature.

PTS: 1 REF: p. 629 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 2. For a nursing exam, students must label a diagram using the correct medical terminology. Where would the students label the metacarpophalangeal joint?

A. In the finger B. In the hand C. Between the hand and the finger D. In the foot ANS: C Feedback: The metacarpophalangeal and interphalangeal joints permit finger movement.

The other options do not accurately describe the appropriate location.

PTS: 1 REF: p. 628 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 3. A school-age client has been diagnosed with genu valgum. What is the other name for this condition?

A. clubfoot B. flat feet C. bowlegs D. knock-kneed ANS: D

Feedback: Many children have a temporary period of genu valgum, but persistent knock-knee may be genetic or the result of metabolic bone disease. The client may need to swing each leg outward while walking to prevent striking the planted limb with the moving limb. The strain on the knee frequently causes anterior and medial knee pain.

Physical therapy and surgical intervention may be required. Bowlegs, also known as genu varum, are when the knees do not touch when the child stands with the feet together. Bowlegs are considered normal up to the age of 2 to 3 years, but may persist until age 6. Clubfoot, also known as congenital talipes equinovarus (CTEV), is a congenital deformity that rotates the foot internally at the ankle. Flat feet is a deformity of the foot where the arch collapses or never properly forms.

PTS: 1 REF: p. 668 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 4. On the Morse Fall Scale, a secondary diagnosis indicates an increase in the final score by how many points?

A. 10 points B. 15 points C. 20 points D. 25 points ANS: B Feedback: A secondary diagnosis increases the score by 15 points. Based on this knowledge, the other options are incorrect.

PTS: 1 REF: p. 658 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. A 3-month-old infant has been diagnosed with congenital hip dislocation. What is a confirmatory test for this disease?

A. Trendelenburg's test B. Heberden's test C. Bouchard's test D. Phalen's test ANS: A Feedback: In congenital hip dislocation, the head of the femur is displaced from the acetabulum. This condition is seven times more common in females. Signs include asymmetric gluteal creases, uneven limb length, and limited abduction of flexed thigh.

Diagnosis for newborns is a positive Barlow-Ortolani sign. Older children will have a positive Trendelenburg's sign. Heberden's nodes are hard, nontender bony growths on the distal intraphalangeal joints, while Bouchard's nodes are the same finding on the proximal intraphalangeal joints. Phalen's test is positive in carpal tunnel syndrome.

PTS: 1 REF: p. 669 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 6. A client is thought to have a balance problem. What would be an advanced method of assessing balance in this client? (Select all that apply.)

A. Walking heel to toe B. Standing on one foot C. Romberg's test D. Standing E. Hopping on one foot ANS: C, D, E Feedback: To assess balance, the nurse asks the client to walk on tiptoes, on heels, in heel-to-toe fashion (tandem walking), and backward. The client should also step to each side and sit down and stand. Advanced assessment of balance includes the Romberg's test, standing, and hopping on one foot.

PTS: 1 REF: p. 638 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 7. A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

A. Crepitus B. Grating noise C. Tactile emphysema D. Popping and cracking noises ANS: A Feedback: Crepitus may be heard as a popping sound and may be felt as grating in the joint as it moves. The other options are incorrect since they are not considered medical terms that describe the assessment findings.

PTS: 1 REF: p. 640 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 8. When determining a client's strength, it is necessary to implement what assessment?

A. Comparing one side to the other B. Assessing the extremities at the same time C. Comparing upper and lower extremities

D. Assessing upper and lower extremities at the same time ANS: A Feedback: When assessing muscle tone and strength, it is necessary to compare one side to the other. It is not necessary to compare the upper extremities to the lower extremities or to assess them at the same time since doing so has no relevance to the strength of similar muscles.

PTS: 1 REF: p. 640 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A client is admitted to the unit. The nurse notes that the medical record for this client lists a fall risk of 75 per the Morse Fall Risk Assessment. What would be an appropriate nursing intervention?

A. Assess for orthotics B. Use environmental cues C. Use an accessory high seat on the toilet D. Encourage the client to use canes bilaterally ANS: B Feedback: A high score indicates a risk for falling and indicates a need for preventive interventions. Examples include frequent reminders, a bed alarm, or environmental cues.

The other options are not appropriate intervention for the situation noted in the question.

PTS: 1 REF: p. 657 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. Which of the following tools would a nurse practitioner be more likely than a registered nurse to use during the performance of a musculoskeletal assessment on a client to measure maximum flexion of a joint?

A. Flashlight B. Gradiometer C. Scale D. Goniometer ANS: D Feedback: A goniometer measures the angle at which a joint can flex or extend. Nurses do not use flashlights or gradiometers during musculoskeletal assessments. The registered nurse would be more likely than the advanced practice nurse to use a scale to weigh a client.

PTS: 1 REF: p. 640 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment

KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 11. A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

A. C8 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender B. All findings within normal limits C. Neck assessment WNL D. C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender ANS: D Feedback: Normal findings are that the C7 and T1 spinous processes are prominent. The paravertebral, sternocleidomastoid, and trapezius muscles are fully developed, symmetrical, and nontender. Therefore, other options are incorrect.

PTS: 1 REF: p. 646 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 12. The nurse is assessing the musculoskeletal system of a teenage boy for participation in athletics. The nurse would expect to find that this client's bones are what as compared to a female of the same age?

A. No difference B. Larger and stronger C. Longer and stronger D. More curved ANS: B Feedback: Gender affects the skeletal system. Males have larger and stronger bones than women; therefore, males are less prone to problems related to osteoporosis. Male bones are not the same as female bones; they are not necessarily longer and they do not have a greater curvature.

PTS: 1 REF: p. 630 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 13. Many variations related to ethnicity are visible in the musculoskeletal system. (Select all that apply.)

A. Asian Americans have denser bones than other races.

B. Native Americans have an anterior curvature to their femurs.

C. Polynesian Americans have a posterior curvature to their femurs.

D. African Americans have straight femurs.

ANS: B, D Feedback: The curvature of long bones results from both ethnicity and body weight.

African Americans have straight femurs, while Native Americans have anteriorly curved femurs. Polynesian ethnicity doesn't present with a posterior femoral curve. Asian ethnicity doesn't result in especially dense bones.

PTS: 1 REF: p. 630 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 14. The nurse is receiving report on a client with a nursing diagnosis of activity intolerance.

What would be an appropriate nursing intervention for this client?

A. Use footwear that facilitates walking and prevents injury B. Promote reconditioning C. Use assistive devices D. Ask for input on habits and preferences ANS: B Feedback: For the client with activity intolerance, the nurse would determine the cause of intolerance and promote reconditioning. Footwear is not going to solve the problem of activity tolerance. The client does not have a problem with mobility, for which assistive devices would be most helpful. Assessing habits and presences is irrelevant.

PTS: 1 REF: p. 659 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 15. The nurse is developing a plan of care for a client found to have a strength problem.

What would be an appropriate nursing diagnosis for this client?

A. Activity intolerance B. Self-care deficit C. Impaired physical mobility D. Impaired walking ANS: C Feedback: The most appropriate diagnosis would be impaired physical mobility related to reduced strength and ROM. Activity intolerance and self-care deficit would not correctly identify the situation at hand. Impaired walking is incorrect since it is limited in scope.

PTS: 1 REF: p. 660 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

16. An older adult client has been admitted to the unit. The client has problems with fine motor movement. What would be important to do for this client?

A. Open all packages and arrange the meal tray while communicating actions to the client B. Teach the client to call for assistance when getting up to bathroom C. Evaluate for assistance devices D. Assess gross motor function ANS: A Feedback: Opening packages and arranging trays prior to encouraging the client to eat independently are important interventions for the client with limited fine motor skills.

The other options are incorrect since none are directly involved in the care of a client with fine motor problems.

PTS: 1 REF: p. 660 OBJ: 6 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 17. A teenage client is brought to the emergency department with an injury to the left ankle after a skateboard accident. Diagnostic films show a fracture across the epiphyses. The doctor explains that the client may not have full range of motion and that the left leg may be shorter than the right leg. The parents ask why one leg may be shorter than the other.

What would be the nurse's best answer?

A. The epiphysis is the growth plate B. The fracture crosses the part of the bone where the bone lengthens C. Any fracture of a bone has the potential of decreasing length in the leg bone D. Bone growth in boys generally stops about this time ANS: B Feedback: Bones elongate by increasing the cartilage at epiphyses, or growth plates, at the ends of long bones. The cartilage later calcifies. This lengthening continues until approximately 21 years, when the epiphyses close. Any injury to the epiphyses before closure may result in bone deformity. The other options do not provide accurate information regarding this type of injury.

PTS: 1 REF: p. 625 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 18. A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?

A. Encourage early weight bearing and ambulation.

B. Apply an ice pack to the affected extremity.

C. Check for a pulse, color, temperature, and capillary refill.

D. Splint and immobilize the affected extremity.

ANS: C Feedback: The first nursing actions include taking vital signs, monitoring pulses, and assessing color, temperature, and capillary refill distal to the injury to evaluate tissue perfusion. The ankle should then be immobilized after assessment. An ice pack may be applied after assessing for temperature and pulses, etc. The first action is no weight bearing until the ankle is fully assessed.

PTS: 1 REF: p. 631 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is assessing a client who presents with shoulder pain. No signs of inflammation are present. What is the nurse's priority action?

A. Notify the healthcare provider immediately.

B. Administer prescribed pain medication.

C. Assess for shortness of breath.

D. Check for passive range of motion.

ANS: C Feedback: Suspect a cardiac origin for reports of shoulder pain without tenderness or inflammation. Assess for shortness of breath, nausea, and diaphoresis. If these symptoms are present, the client needs to be sent to an emergency department for assessment of cardiac ischemia. Cardiac ischemia is an emergency; therefore assessing for shortness of breath is priority. If present, then the nurse should notify the healthcare provider. Passive range of motion is not as relevant as shortness of breath. Pain medication cannot be administered without a prescription.

PTS: 1 REF: p. 647 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. The nurse is planning care for a client diagnosed with Alzheimer disease who has an apraxic gait. Which intervention should be included in the plan of care?

A. Allow for extra time when ambulating.

B. Ensure the client is wearing adaptive shoes.

C. Gradually increase activity when symptoms subside.

D. Assist the client to place the heel of the foot first when walking.

ANS: A

Feedback: Clients with Alzheimer disease and an apraxic gait have difficulty initiating walking and their gait is slow and shuffling. Extra time should be provided when ambulating to prevent falls. The clients with an apraxic gait do not need to wear adaptive shoes. Adaptive shoes are worn by those with a limb length discrepancy. Alzheimer disease symptoms will last for the rest of the person's life. Waiting for the symptoms to subside will not alter the client's gait. Clients with an apraxic gait don't need assistance placing the heel first when walking. Clients with footdrop or a steppage gait may have difficulty placing the heel first when walking.

PTS: 1 REF: p. 666 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 21: Musculoskeletal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 22: Neurological and Mental Status Assessment 1. As people age, several neurological changes occur. Neurons, brain size, and neurotransmitters decrease. What are some of the results of aging on the neurological system? (Select all that apply.)

A. Slower thought processing B. Reduced response to stimuli C. Delayed reflexes D. Inability to process nutrients E. More frequent seizures ANS: A, B, C Feedback: Neurons of the central nervous system, brain size, and neurotransmitters decrease with aging. Results include slower thought processing, reduced response to stimuli, and delayed reflexes. Inability to process nutrients is not a neurological change related to aging. Seizures in any age group represent a medical disorder requiring attention from a health care provider.

PTS: 1 REF: p. 681 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 2. A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

A. Vital signs B. Neurologic system C. Cardiac function D. Coordination ANS: D Feedback: The cerebellum's primary functions include coordination and smoothing of voluntary movements, maintenance of equilibrium, and maintenance of muscle tone.

Therefore, a priority assessment area would be coordination. The other options listed are distracters.

PTS: 1 REF: p. 677 OBJ: 1 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 3. A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?

A. Remote memory B. Sensation C. Mental status exam D. Balance

ANS: D Feedback: Balance and coordination are functions of the pyramidal and extrapyramidal tracts of the motor and cerebellar systems. Remote memory and mental status exam provide information about the client's cognitive ability. Testing for sensation would address issues with specific cranial nerves or problems involving the parietal lobe.

PTS: 1 REF: p. 677 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 4. The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

A. 1+ B. 2+ C. 3+ D. 4+ ANS: C Feedback: Brisk reflexes or reflexes that are more active than normal are documented as 3+. Reflexes that are decreased and less active than normal are documented as 1+; reflexes that are normal are documented as 2+; reflexes that are hyperactive and very brisk with rhythmic oscillations are documented as 4+.

PTS: 1 REF: p. 701 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 5. A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

A. Lock the fingers together and pull against each other.

B. Clench the jaw tightly.

C. Squeeze a thigh with the opposite hand.

D. Stretch the arms overhead.

ANS: A Feedback: Having the client interlock his or her hands is a reinforcement technique that aids in enhancing the reflex response in the legs. Clenching the jaw or having the client squeeze one thigh with the opposite hand would be a reinforcement technique for testing arm reflexes. Stretching the arms overhead would be both inappropriate and ineffective in facilitating this assessment.

PTS: 1 REF: p. 704 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

A. Ask the client to differentiate sharp and dull sensations on the face B. Have the client smile, frown, and wrinkle the forehead C. Palpate the temporal and masseter muscles while the client clenches teeth D. Assess dilatation of pupils with direct light ANS: C Feedback: To test the motor function of the trigeminal nerve (CN V), the nurse would ask the client to clench the teeth and palpate the temporal and masseter muscles for contraction. Touching the client's face for dullness or sharp sensations tests the sensory function of the trigeminal nerve. Having the client frown, smile, and wrinkle the forehead tests the motor function of the facial nerve (CN VI). Assessing pupillary dilation tests the oculomotor (CN III) nerve.

PTS: 1 REF: p. 694 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 7. Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?

A. Inability to detect sharp and dull stimuli B. Inability to wrinkle the forehead C. Closure of the affected eye from swelling D. Muscle spasm of the lower face on the affected side ANS: B Feedback: Inability to close eyes, wrinkle forehead, or raise the forehead, along with paralysis of the lower part of the face on the affected side, is seen with Bell's palsy.

Inability to detect sharp and dull stimuli is associated with lesions of the trigeminal nerve (CN V). Closure of the affected eye from swelling would suggest trauma. Paralysis, not muscle spasm, occurs with Bell's palsy.

PTS: 1 REF: p. 694 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

A. Stationary soft palate on phonation B. Deviation of uvula when client says "ah" C. Asymmetrical soft palate D. Uvula and soft palate rising bilaterally ANS: D

Feedback: Normal findings associated with testing cranial never IX and cranial nerve X include a uvula and soft palate rising bilaterally and symmetrically on phonation. A stationary or asymmetrical soft palate or deviation of the uvula would be considered an abnormal finding.

PTS: 1 REF: p. 694 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. The nurse is preparing to assess balance in an older adult client. Which test would the nurse plan on possibly omitting from the exam?

A. Romberg B. Tandem walking C. Gait D. Hop on one foot ANS: D Feedback: Hopping on one foot is often impossible for the older adult because of decreased flexibility and strength and may place the client at risk. The nurse needs to ensure the client's safety by standing close by, especially with tandem walking and Romberg's testing because some older clients may have difficulty with maintaining balance. However, these tests would not be omitted. Older clients may have a slow uncertain gait. Testing the client's gate would not be omitted.

PTS: 1 REF: p. 696 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. When explaining how the nurse would test graphesthesia, which of the following would the nurse include?

A. Client will close the eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object B. Client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time C. The nurse will simultaneously touch the client in the same area on both sides of the body and the client will identify where the touch occurred D. The nurse will briefly touch the client and the client will need to identify where the touch occurred ANS: A

Feedback: Graphesthesia is the ability to identify what is being drawn on the client's body when the client's eyes are closed. Two-point discrimination is tested by having the client identify the number of points felt when touched with the ends of two applicators at the same time. Extinction is tested by simultaneously touching the client in the same area on both sides of the body at the same points and having the client identify the area touched. Point localization is tested by briefly touching the client and then asking the client to identify the points touched.

PTS: 1 REF: p. 700 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 11. When documenting the findings of a neurologic assessment, which of the following would be most important?

A. Verify the data before documenting.

B. Describe the client's response.

C. Label the client's behavior.

D. Record objective data primarily.

ANS: B Feedback: Although data verification is important, when documenting the neurologic assessment findings, it is important to describe the client's response rather than label the behavior. Subjective and objective data must be documented.

PTS: 1 REF: p. 704 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 12. During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

A. Spastic hemiparesis B. Parkinsonian gait C. Scissors gait D. Cerebellar ataxia ANS: D Feedback: A wide-based, staggering, unsteady gait and positive Romberg test (client unable to stand with feet together) suggest cerebellar ataxia. Spastic hemiparesis is characterized by a flexed arm held close to the body while the client drags the toes of the leg or circles it stiffly outward and forward. A Parkinsonian gait is a shuffling gait. A scissors gait is a short stiff gait with the thighs overlapping each other with each step.

PTS: 1 REF: p. 719 OBJ: 7 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 22: Neurological and Mental Status Assessment

KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

A. 42-year-old Caucasian woman who smokes B. 68-year-old African American male with hypertension C. 55-year-old Caucasian male who has two beers a week D. 35-year-old African American who has sleep apnea ANS: B Feedback: Risk factors include older adulthood (risk doubling each decade after age 55), male sex, African American race, hypertension, smoking, chronic alcohol intake (more than three drinks per day), and sleep apnea among others. In the clients listed, the 68-year-old African American male with hypertension has the greatest risk due to his age, race, and hypertension. The other clients would be at risk, but the risk would be less.

PTS: 1 REF: p. 684 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 14. A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test cranial nerve I. Which of the following would the nurse do?

A. Use a Snellen chart to test visual acuity B. Ask the client to identify scents C. Test extraocular eye movements D. Perform the Weber's test ANS: B Feedback: Cranial nerve I is the olfactory nerve, which would be tested by having the client occlude one nostril and identify a scent. Using the Snellen chart tests cranial nerve II, the optic nerve. Testing extraocular eye movements evaluates cranial nerve III (oculomotor), cranial nerve IV (trochlear), and cranial nerve VI (abducens). The Weber's test evaluates cranial nerve VIII (acoustic/vestibulocochlear).

PTS: 1 REF: p. 693 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 15. A nursing instructor is describing the peripheral nervous system to a group of students.

The instructor would explain that there are how many pairs of spinal nerves?

A. 8 B. 11 C. 24 D. 31

ANS: D Feedback: The peripheral nervous system consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves. The other options are distracters to the question.

PTS: 1 REF: p. 679 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 16. Which of the following would lead the nurse to suspect meningeal irritation?

A. Hips and knees remain relaxed and motionless when neck is flexed B. Reports of decreased pain with flexion of the hips and knees C. Discomfort behind the knee with full extension of the leg D. Pain and flexion of the hips and knees with neck flexion ANS: D Feedback: Pain and flexion of the hips and knees are positive Brudzinski's signs and suggest meningeal irritation. Pain and increased resistance to extending the knee when the client's leg is flexed at both the hip and the knee and then straightened are positive Kernig's signs suggesting meningeal irritation. Discomfort behind the knee during full extension when testing for Kernig's sign occurs in many normal people.

PTS: 1 REF: p. 705 OBJ: 4 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 17. The nurse enters a client's room to administer a prescribed anticoagulant for atrial fibrillation. The client exhibits new onset facial drooping and slurred speech. What is the nurse's priority action?

A. Administer the PO anticoagulant immediately.

B. Assess the client's bleeding time before medication administration.

C. Ask the client to raise both arms in front of the client's body.

D. Assess the client's vital signs and cranial nerves.

ANS: C Feedback: Atrial fibrillation increases risk for stroke because quivering atria can lead blood to stagnate and then form small clots. A clot that breaks off can circulate to the brain and block the artery, causing an embolic stroke. In sickle cell disease, blood cells tend to be stickier, causing clots to form more easily in narrowed arteries. This client's symptoms are consistent with a possible stroke. The nurse's priority is to perform a brief focused assessment and notify the healthcare provider right away. Administering the medication and checking the labs are not priorities of care during the acute phase of a stroke. Vital signs should be assessed right away, but it is not necessary to test cranial nerves initially.

PTS:

1

REF: p. 686

OBJ: 9

NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

A. Notify the healthcare provider.

B. Re-assess in 15 minutes.

C. Document the findings.

D. Ask the client to open eyes on command.

ANS: C Feedback: A GCS score of 15 is the maximum score indicating the client's neurological status is normal. Therefore, the nurse should document the findings. This information makes all the remaining options incorrect.

PTS: 1 REF: p. 682 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is reviewing the plan of care for a client with peripheral neuropathy. Which intervention by the client should the nurse be concerned about?

A. Limit use of a heating pad to 15 minutes at a time.

B. Inspect feet daily using a mirror.

C. Test bath water temperature with the hands.

D. Wear clean white cotton socks.

ANS: A Feedback: Clients with peripheral neuropathy can be easily burned by a heating pad that is too hot. The client should test bath water with hands first to ensure the temperature isn't too hot. Clients should inspect feet using a mirror if needed and wear white socks.

This will enable the client to identify blisters, sores, cuts, or splinters that they might not be able to feel. Cotton socks will also help reduce friction on the feet and toes that could lead to blistering.

PTS: 1 REF: p. 699 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. The nurse is caring for a client brought to the emergency department with confusion, unilateral facial drooping, and right-sided weakness. The nurse knows there is a need to perform an abbreviated acute assessment. Which is not part of the abbreviated acute assessment?

A. Cranial nerve testing B. Pupillary reaction

C. Gross assessment of sensation D. Vital signs ANS: A Feedback: When situations indicating the likelihood of a stroke are identified, rapidly assessing key areas included in the neurological examination is the first step in determining the nature of the problem and possible urgent interventions. This abbreviated acute assessment includes items such as assessing pupilary reaction, obtaining vital signs, and completing a gross assessment of sensation. It does not include testing each of the cranial nerves.

PTS: 1 REF: p. 682 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 22: Neurological and Mental Status Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

Chapter 23: Male Genitalia and Rectum Assessment 1. Where is the corona of the penis found?

A. At the base of the glans B. At the root of the penis C. At the tip of the glans D. At the root of the corpus spongiosum ANS: A Feedback: The penis contains three distensible structures: two corpora cavernosa, which form the dorsum and sides of the penis, and a single corpus spongiosum, which forms the bulb. The other options all refer to subdivisions of the penis.

PTS: 1 REF: p. 723 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 2. During health class, a student asks the school nurse about the function of the testicles.

What would be the nurse's best reply?

A. To produce smegma B. To produce testosterone C. To produce estrogen D. To produce semen ANS: B Feedback: The function of the testicles is to produce spermatozoa (sperm) and testosterone. The function of the testicles is not to produce smegma, estrogen, or semen.

PTS: 1 REF: p. 724 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 3. Where is the rectum located in a male?

A. Inferior to the anus B. At the junction of the sigmoid and transverse colon C. Superior to the anus D. Superior to the rectal ampulla ANS: C Feedback: The rectum is approximately 12 cm long and is superior to the anus. The other options do not accurately identify the location of the rectum.

PTS: 1 REF: p. 725 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning

BLM: Cognitive Level: Understand

NOT: Multiple Choice

4. In men, what are located on either side of the urethra just below the prostate gland?

A. Skene's glands B. Bartholin's glands C. Seminiferous tubule D. Bulbourethral glands ANS: D Feedback: The bulbourethral glands are located on either side of the urethra immediately below the prostate gland. Skene's and Bartholin's glands are not found in males. Inside each testicle is a series of coiled ducts known as seminiferous tubules, which is where spermatogenesis occurs.

PTS: 1 REF: p. 725 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. An adult male client comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, "Do you have any current or chronic illnesses such as diabetes, hypertension, respiratory problems, or cardiovascular disease?" Why does the nurse ask this question?

A. To assess risk for erectile dysfunction B. To refer the client to a pulmonologist C. To assess risk for limited range of motion D. To determine the need for involvement from an internist ANS: A Feedback: Men with diabetes, hypertension, neurologic respiratory problems, or cardiovascular disease are at increased risk for erectile dysfunction. The other options are not related to health related issues.

PTS: 1 REF: p. 734 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 6. During the examination of a 72-year-old man, the nurse practitioner notes the client has a history of benign prostatic hypertrophy (BPH). How would the nurse practitioner expect the prostate gland to feel?

A. Tender B. Hard, nodular C. Rubbery D. Firm, nontender ANS: C

Feedback: A rubbery or boggy glandular consistency suggests BPH, a common finding in men older than 60 years. A tender testicle, one that is hard and nodular, or a firm and nontender testicle is not indicative of BPH. PTS: 1 REF: p. 742 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 7. While preparing to conduct a rectal examination on an older male adult client, the nurse notes the client has a history of cancer. The nurse should know that peritoneal metastases create what in the peritoneum?

A. Nodularity B. Edema C. Inflammation D. Extreme rectal pain ANS: A Feedback: Because the anterior rectal wall is in contact with peritoneum, the nurse may be able to detect the tenderness of peritoneal inflammation and nodularity of peritoneal metastases. Peritoneal metastases do not cause edema, inflammation, or extreme rectal pain.

PTS: 1 REF: p. 741 OBJ: 4 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 8. The nurse is caring for an older adult male client who has had surgery on his rectum and perineum. What would be an appropriate intervention for this client?

A. Explain the procedure to the client B. Teach the client exercises to strengthen the pelvic floor C. Begin discharge planning for this client D. Teach the client how to keep the rectum clean ANS: B Feedback: Teaching the client exercises to strengthen the pelvic floor will help restore function to the area. It would not be appropriate to explain the procedure to the client, because the procedure has already been done. Discharge planning begins when the client is first admitted. The nurse cannot teach the client how to keep the rectum clean, because the rectum is an internal organ of the body.

PTS: 1 REF: p. 748 OBJ: 2 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

9. A clinic nurse is admitting a teenage client with complaints of itching and burning in his genital area. He tells you "I am sure I have an sexually transmitted infection. This will be the third one in 3 months." What intervention would be most appropriate with this client?

A. Provide samples of spermicides to client B. Provide client with educational material on testicular cancer C. Assess the client's knowledge and understanding of safe sexual practices D. Teach the client correct use of condom to prevent pregnancy ANS: C Feedback: The nurse needs to assess this client's knowledge and understanding of safe sexual practices to ensure correct teaching and prevention. Spermicides will not protect the client from future sexually transmitted infections. The client's situation does not involve testicular cancer. Although correct condom use could be important, the client's most immediate problem is recurring STIs, not pregnancy prevention.

PTS: 1 REF: p. 745 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 10. The nurse is documenting current health concerns during the health history of an older adult male client. Identification of what may help most at this time?

A. Number of sexual partners B. Number of sexually transmitted infections C. Sexual preference D. Previous problems ANS: D Feedback: Identification of previous problems may help when documenting current health concerns. The other options would not be helpful in documenting current health concerns.

PTS: 1 REF: p. 730 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 11. An older adult male client has come to the clinic for his annual physical examination.

The nurse knows that the fibromuscular structures of the prostate gland in this client have atrophied with aging. What might obscure the natural physiology?

A. Prostate nodules B. Benign prostatic hyperplasia (BPH) C. Perineal cancer D. Penile cancer ANS: B

Feedback: As the male ages, the fibromuscular structures of the prostate gland atrophy.

Ironically, benign hyperplasia of the glandular tissue often obscures the atrophy of aging.

Prostate nodules, perineal cancer, and penile cancer would not obscure this natural physiologic process.

PTS: 1 REF: p. 727 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 12. A young male adult has come to the emergency department with purulent drainage from an area on his penis that was pierced 48 hours ago. What would be important for the nurse to discuss with the client? (Select all that apply.)

A. Ways to avoid infection B. Significance of the piercing to the client C. Care of the piercing D. Sensation in the area of the piercing E. Where the piercing was done ANS: A, C Feedback: In a professional nonjudgmental manner, it is important to talk to the client about the care of the piercing. Because this site is very prone to infection, discussion should involve how the client cleans the piercing and ways to avoid infection. It would not be important for the nurse to elicit from the client the significance of the piercing, the sensation in the area of the piercing, or where the piercing was done.

PTS: 1 REF: p. 727 OBJ: 2 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 13. A male teenage client is admitted to the emergency department with an acute scrotum.

One nursing diagnosis for this client is severe pain related to acute scrotum. What conditions cause a medical diagnosis of acute scrotum? (Select all that apply.)

A. Herniation B. Ischemia C. Infectious conditions D. Hydrocele E. Orchiectomy ANS: A, B, C Feedback: Acute scrotum pain may be caused by ischemia, trauma, infections, inflammation, herniation, and chronic conditions with an acute exacerbation. Although differential diagnosis is broad, an accurate physical assessment and history can often accurately define the condition. Hydroceles and orchiectomies do not cause severe pain.

PTS: 1 REF: p. 728 OBJ: 8 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 14. An adult male client comes to the clinic complaining of awakening at night to void and voiding more than once in a 2-hour time period. The client has a history of bladder irritation. What would be an appropriate nursing diagnosis for this client?

A. Ineffective sexuality pattern B. Risk for infection C. Risk for urge incontinence D. Urinary retention ANS: C Feedback: The most appropriate nursing diagnosis is risk for urge incontinence related to irritation of bladder. Risk factors for this diagnosis are voiding more than once every 2 hours and awakening at night. urinary retention would be a concern if the client was unable to urinate, or urinated frequently with only small amounts of urine voided.

Frequent urination at night is not a risk for infection. The symptoms noted are not related to ineffective sexuality pattern.

PTS: 1 REF: p. 746 OBJ: 8 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 15. An uncircumcised male with poorly controlled diabetes is being seen in the clinic. The client is found to have scars and narrowing of the urethral opening. What condition would the nurse suspect?

A. Balanoposthitis B. Epispadias C. Paraphimosis D. Phimosis ANS: A Feedback: Balanitis or balanoposthitis is inflammation of the glans and prepuce and occurs in uncircumcised men, many of whom have poorly controlled diabetes. Scars and narrowing of the urethral opening may cause inflammation, infections, and foul discharge. The scarring may make it difficult to clean under the foreskin. Epispadias is a condition that results when the urethra opening is not at the tip of the penis.

Paraphimosis is a condition where the foreskin becomes trapped behind the glans penis.

Phimosis is a condition where the foreskin cannot be fully retracted over the glans penis.

PTS: 1 REF: p. 753 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

16. A male infant is born with the urethral meatus opening on the underside of the penis.

When providing information to the parents, what is the correct terminology to use for this condition?

A. Phimosis B. Hypospadias C. Epispadias D. Paraphimosis ANS: B Feedback: With hypospadias, the urethral meatus opens on the ventral side of the penis.

The deviation of the meatus makes it difficult to urinate when standing. The physical appearance of the penis is altered, sometimes causing body image disturbances.

Phimosis is when the prepuce cannot be retracted over the glans. Paraphimosis occurs when the retracted prepuce cannot be placed back over the glans. Epispadias occurs when the urethral meatus opens on the dorsal surface of the penis.

PTS: 1 REF: p. 754 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 17. The nurse is providing a sex education informational session for a group of male clients.

Which information should the nurse include?

A. Males under age 30 should be immunized against Hepatitis C. B. The hepatitis A vaccine is recommended for men who have sex with men.

C. Hepatitis B vaccine is recommended only for males in the healthcare profession.

D. Hepatitis A can be prevented by condom use.

ANS: B Feedback: SAFETY ALERT <SA> The Centers for Disease Control and Prevention (CDC, 2006) recommend the hepatitis A vaccine for unimmunized men who have sex with men. The CDC recommends the hepatitis B vaccine for all unimmunized people at risk for STIs. Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). HCV infection sometimes results in an acute illness, but most often becomes a chronic condition that can lead to cirrhosis and liver cancer. There is no vaccine for hepatitis C. Hepatitis B is spread through sexual contact or contact with blood and body fluids.

Hepatitis A is spread through the fecal-oral route, not sexual.

PTS: 1 REF: p. 731 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse is teaching a client about medications used for erectile dysfunction. Teaching was effective when the client makes which of the following statements?

A. "This medication will cause more blood to flow to the penis."

B. "The medication is most effective when taken with a full bladder."

C. "The medication will not be effective because I'm circumcised."

D. "This medication will dilate my prepuce."

ANS: A Feedback: Medications used for erectile dysfunction facilitate smooth muscle relaxation and increase blood flow to the penis. The efficacy of erectile dysfunction medication is not altered by circumcision or lack of circumcision. Similarly, the efficacy of the medication is not improved by being taken with a full bladder. The prepuce, also called the foreskin of the penis, does not dilate when taking erectile dysfunction medication.

PTS: 1 REF: p. 723 OBJ: 2 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 19. The nurse is teaching a group of student nurses in the lab about male anatomical differences and assessment. Which of the following should be included in the teaching?

A. The assessment should be completed in a warm room.

B. The scrotum should be covered with non-elastic taut skin.

C. The client should raise their arms when assessing the scrotal sac.

D. The prepuce should not be retracted.

ANS: A Feedback: Scrotal examination should occur in a warm room as the sac rises towards the body in colder temperatures. The arms do not need to be raised for the assessment. The client should be standing or lying comfortably. The skin on the scrotal sac should be loose and wrinkled. If the client is circumcised, the prepuce should be gently retracted for inspection. The prepuce should not be forcibly retracted.

PTS: 1 REF: p. 724 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 20. The nurse is talking with parents of a newborn male about circumcision. The nurse should intervene when one of the parents makes which of the following statements?

A. "Circumcision is recommended by the American Academy of Pediatrics."

B. "Circumcision decreases the risk of urinary tract infections."

C. "Circumcision lowers the risk of ulcerative sexually transmitted infections."

D. "Circumcision is a family decision, not a medical one."

ANS: A Feedback: The American Academy of Pediatrics does not recommend routine circumcision for newborn males. The decision to circumcise a newborn male should be made by the family and not decided by the medical team. Research indicates that circumcision lowers the risk of urinary tract infections and ulcerative sexually transmitted infections such as gonorrhoea.

PTS:

1

REF: p. 726

OBJ: 2

NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 23: Male Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 24: Female Genitalia and Rectum Assessment 1. A nurse is teaching a sex education class at the local university. In a pre-lecture quiz, the nurse asks what the two small folds that extend from the clitoral hood to the posterior fourchette of the vagina are called. What would be the correct answer?

A. Labia minora B. Labia majora C. Posterior fourchette D. Vestibule ANS: A Feedback: The ventral surface of the glans is known as the frenulum and is where the labia minora, two small folds that extend from clitoral hood to the posterior fourchette of the vagina, fuse. The labia majora is the set of folds that extend from the mons pubis to the perineum. The posterior fourchette is the fold of skin on the posterior side of the vagina, toward the anus. The vestibule is the area containing both the urethral and vaginal openings, protected by the labia minora.

PTS: 1 REF: p. 762 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 2. A student nurse is caring for a client who has just had a hysterectomy. The clinical instructor asks the students what ligaments support the uterus. The best answer would be what? (Select all that apply.)

A. Ovarian B. Cardinal C. Round D. Broad E. Infundibulopelvic ANS: B, C, D Feedback: The freely mobile uterus is supported bilaterally by the round, cardinal, uterosacral, and broad ligaments. The ovarian and infundibulopelvic ligaments support the ovaries.

PTS: 1 REF: p. 762 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 3. During a high school health class, a student asks the school nurse where fertilization most often takes place. What would be the nurse's most correct answer?

A. Ovary B. Fimbriae C. Uterus

D. Fallopian tube ANS: D Feedback: Fertilization occurs in the fallopian tubes. Fertilization does not generally take place in the ovary, fimbriae, or the uterus.

PTS: 1 REF: p. 763 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 4. What ligament holds the ovaries in place?

A. Broad B. Uterosacral C. Round D. Infundibulopelvic ANS: D Feedback: The ovaries are held in place by ligaments called the infundibulopelvic and ovarian ligaments. The uterus is supported by the uterosacral, round, and broad ligaments.

PTS: 1 REF: p. 764 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 5. In what Tanner stage is pubic hair darker, coarser, and curled, spreading sparsely over the junction of the mons pubis.

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 ANS: C Feedback: In Tanner Stage 3, hair is considerably darker, coarser, and more curled. It spreads sparsely over the junction of the mons pubis. Stage 1 has no pubic hair; Stage 2 has long, slightly pigmented, downy hair that is straight or only slightly curled chiefly along the labia. Stage 4 has pubic hair that is adult in type, but the area covered by it is still considerably smaller than in most adults. There is no spread to the medial surface of the thighs.

PTS: 1 REF: p. 766 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

6. In an African American girl, puberty may begin before what age?

A. 8 years B. 9 years C. 10 years D. 11 years ANS: A Feedback: According to the American Congress of Obstetricians and Gynecologist Committee on Adolescent Health Care, the U.S. median age at menarche is 12.4 years.

African American girls begin puberty on average 5.5 months earlier than the U.S. median age, and may even begin puberty before 8 years of age.

PTS: 1 REF: p. 767 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 7. An older adult woman comes to the clinic for her yearly examination. What would be an appropriate question to ask the client during the nursing assessment?

A. Have you had a sexually transmitted infection in the past 12 months?

B. Does your genital area itch excessively?

C. Are you sexually active?

D. What type of contraception are you using?

ANS: C Feedback: Regular sexual activity is normal in older adults and encouraged unless it causes pain. Generally speaking, an older adult woman would be at low risk for a recent sexually transmitted infection. The nurse would not ask the older adult about genital itching unless the client reported this symptom. An older adult woman would not need contraception.

PTS: 1 REF: p. 776 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 8. A teenage girl was brought to the clinic by her mother, who reports that her daughter has a boyfriend with whom the teenager is considering becoming sexually active. What should the nurse do to make the client as comfortable as possible during the nursing assessment? (Select all that apply.)

A. Reassure the client that all information is kept confidential B. Ask the client's permission to share information with her parents C. Obtain the history with the client still dressed D. Be seated at eye level or lower E. Make sure the room is private and comfortable ANS: A, C, D, E

Feedback: When obtaining the history, the room should be private and comfortable, and the nurse should be seated at eye level or lower to the client. The nurse should reassure the client that all information is kept confidential. It is best to obtain the history while the client is still dressed. This reduces embarrassment and vulnerability of the client. The nurse would not ask the client for permission to share the information with her parents.

PTS: 1 REF: p. 769 OBJ: 8 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 9. A young adult woman presents at the clinic stating, "I think I have a yeast infection."

The nurse notes this is the third time in the past 90 days that this client has been to the clinic for yeast infections. What should the nurse consider as a comorbidity to be discussed with this client?

A. Maternal DES use B. Diabetes C. Infectious hepatitis A D. Cervical cancer ANS: B Feedback: A client with recurring yeast infections should be evaluated for diabetes and HIV. None of the other options are associated with recurrent yeast infections.

PTS: 1 REF: p. 770 OBJ: 3 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 10. What health promotion measure would be most important to teach a client regarding sexually transmitted infections (STIs)?

A. Teach that "the pill" helps guard against sexually transmitted infections.

B. Provide information on HIV prevention through use of oral contraceptives.

C. Provide information about oral sex and its risks.

D. Teach about use of condoms, especially for those in monogamous relationships.

ANS: C Feedback: Oral contraceptives do not protect against STIs. Clients need information about oral sex and its risks, including transmission of STIs. Condom use is especially important for those not in monogamous relationships.

PTS: 1 REF: p. 773 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

11. The nurse practitioner is performing a pelvic examination on a female adult client during the annual examination. With an index finger inserted into the client's vagina, the nurse asks the client to bear down slightly. For what is the nurse assessing?

A. Vaginal tone B. Rectocele C. Cystocele D. Pelvic organ prolapse ANS: D Feedback: This measure tests for prolapse of the pelvis. To check vaginal tone, the nurse would ask the client to squeeze the vaginal muscles around the examiner's index finger.

Rectocele and cystocele are not assessed for in this manner.

PTS: 1 REF: p. 782 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. The Papanicolaou test is a screening tool for what?

A. Cervical cancer B. Vaginal cancer C. Ovarian cancer D. Labial cancer ANS: A Feedback: The Papanicolaou or Pap smear is a screening tool for cervical neoplasia. It is not a screening tool for vaginal, ovarian, or labial cancer.

PTS: 1 REF: p. 770 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 13. Inspection of the female external genitalia begins with what?

A. Inguinal area B. Mons pubis C. Pubic hair D. Skin ANS: B Feedback: Inspection begins with the mons pubis. Inspection of the inguinal area, pubic hair, and skin follows inspection of the mons pubis.

PTS: 1 REF: p. 780 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice

14. When assessing a new young adult client, the nurse notes a history of ineffective family coping, an inability to make appropriate judgments, and unachieved developmental tasks. What nursing diagnosis would be appropriate?

A. Ineffective sexuality patterns B. Risk for unwanted pregnancy C. Ineffective health maintenance D. Risk for infection ANS: C Feedback: Abnormal findings associated with ineffective health maintenance include an inability to make appropriate judgments, ineffective family coping, and unachieved developmental tasks. None of the above assessment information points to the other nursing diagnoses listed.

PTS: 1 REF: p. 790 OBJ: 9 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 15. What is the purpose of the rectovaginal examination?

A. Palpate the vaginal wall for evidence of a cystocele B. Palpate the vaginal wall for evidence of a rectocele C. Palpate the vaginal wall for evidence of uterine prolapse D. Palpate the vaginal wall for evidence of a urethral caruncle ANS: B Feedback: This examination is used to evaluate any rectocele (bulging of rectum into the vagina) or rectovaginal fistula (opening between the vagina and the rectum allowing feces to enter the vagina). A cystocele is a protrusion of the bladder into the anterior vaginal canal and beyond. Uterine prolapse involves the descent of the uterus into the vagina and beyond. A urethral caruncle develops from ectropion of the posterior urethral wall.

PTS: 1 REF: p. 778 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 16. When doing a bimanual examination of the ovaries, the nurse practitioner palpates quickly and gently. Why should this part of the examination be brief?

A. If palpated, ovaries feel like a large walnut B. Ovaries have no feeling C. Ovaries are similar to gonads in their sensitivity D. The ovary can never be felt ANS: C

Feedback: The ovaries are similar to gonads in their sensitivity, and so palpation is done quickly and gently to avoid discomfort. The ovary is often not felt, especially in older menopausal women, but it can sometimes be palpated. In such cases, it should feel like a small almond.

PTS: 1 REF: p. 787 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 17. A nurse practitioner documents as follows: "Client reports pain and tenderness over area of right ovary and a history of irregular menses."

With which of the following diagnoses are these findings consistent?

A. Ovarian cyst B. Salpingitis C. Pelvic inflammatory disease D. Ovarian cancer ANS: A Feedback: With an ovarian cyst, there may be pain, tenderness over the ovary, irregular menses, and intraperitoneal bleeding if it ruptures. A solid ovarian mass raises the possibility of ovarian cancer, which is the second most frequent reproductive cancer.

Salpingitis and pelvic inflammatory disease are different names for the same condition, which does not manifest with the documented findings.

PTS: 1 REF: p. 787 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. An adult woman presents at the clinic with a grayish vaginal discharge with a 'fishy' odor. What should the nurse suspect?

A. Candidiasis B. Bacterial vaginosis C. Chlamydia D. Gonorrhea ANS: B Feedback: Bacterial vaginosis presents with a creamy white to gray secretion that coats the vaginal walls and exhibits a strong "fishy" odor. This finding is not consistent with candidiasis, chlamydia, or gonorrhea. Chlamydia does not have to present with drainage, but when noted, it is yellowish in color. Gonorrhea does not have to present with drainage, but when noted, is often yellowish-green in color. Candidiasis, a yeast infection, presents as a thick white cottage-cheese like discharge.

PTS: 1 REF: p. 786 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 19. A 27-year-old female client with a history of endometriosis and amenorrhea reports severe right-sided pelvic pain. What is the nurse's priority action?

A. Collect a stool specimen.

B. Assess the client's vital signs.

C. Inquire if client has multiple sexual partners.

D. Palpate for liver enlargement.

ANS: B Feedback: An ectopic pregnancy is an urgent situation; suspect this condition if a normally menstruating female has had amenorrhea for a period of 5 to 6 weeks and a history of endometriosis. A ruptured ectopic pregnancy can result in internal bleeding, so the vital signs should be assessed immediately. The nurse will need to collect a urine, not stool, specimen to perform a pregnancy test. The client may be suffering from a sexually transmitted infection; however vital signs are the most important data to collect first to assess for internal hemorrhaging. The client's symptoms are most consistent with ectopic pregnancy, not liver enlargement.

PTS: 1 REF: p. 775 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. The nurse has provided education about the HPV vaccine to a 20-year-old female client.

The client needs further teaching if she makes which statement?

A. "I need to have my female health exam every other year."

B. "I need to return for two more injections after the first one."

C. "This vaccine targets the types of HPV that cause cervical cancer."

D. "I am going to see if I can quit smoking by using the patch."

ANS: A Feedback: The CDC and the United States Preventive Services Task Force (USPST) still recommend annual screening even if the client has received the vaccine. The HPV vaccination is a 3-part series. HPV vaccines target HPV types 16 and 18, which cause 70% of cervical cancer cases. The only cervical cancer symptoms are precancerous changes in the cervix, which can be detected during regular pelvic examinations.

Smoking is a risk factor that increases the chance of developing cervical cancer.

PTS: 1 REF: p. 770 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 24: Female Genitalia and Rectal Assessment KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 25: Pregnancy 1. While assessing a new client, the nurse asks about a family history of genetic illnesses.

The client states that her mother has diabetes. For which of the following is this client at increased risk?

A. Diabetes B. Hypertension C. Twins D. Seizures ANS: A Feedback: Positive family history of diabetes may increase the client's risk for it as well.

Clients with a family history of diabetes are not at increased risk for hypertension, twins, or seizures.

PTS: 1 REF: p. 817 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 2. An obstetric client has a history of psychiatric illness. Which psychiatric problems would the nurse assess for exacerbations of in a pregnant client? (Select all that apply.)

A. Gambling addiction B. Dementia C. Depression D. Anxiety E. Eating disorders ANS: C, D, E Feedback: Clients with a history of depression, anxiety, or eating disorders are at risk for exacerbations during pregnancy and postpartum. Gambling addiction and dementia are not risks in pregnancy.

PTS: 1 REF: p. 816 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 3. The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?

A. Separation of the muscles of the abdominal wall B. Raising of the uterus into the abdomen C. Relaxation of the kidneys D. Movement of the bladder to the rear of the pelvis behind the uterus ANS: A Feedback: By 20 weeks' gestation, muscles of the abdominal wall may begin to separate (diastasis recti) and not return to normal approximation until several weeks after childbirth. The term diastasis recti does not refer to the raising of the uterus into the abdomen, relaxation of the kidneys, or movement of the bladder.

PTS: 1 REF: p. 825 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 4. A client of normal weight and new to the obstetric clinic asks the nurse how much weight to gain during pregnancy. What is the best response the nurse can give?

A. 5 lbs over the first 3 months; 5 lbs over the second three months; 10 lbs over the last three months B. 7 lbs over the first 3 months; 7 lbs over the second three months; 7 lbs over the last three months C. 10 lbs over the first 20 weeks; 1 lb per week after that D. 5 lbs over the first 20 weeks; 2 lbs per week after that ANS: C Feedback: A simple rule of thumb for a woman of normal prepregnant weight is to gain about 10 lbs by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25 to 30 lbs. The other options are distracters to the question.

PTS: 1 REF: p. 822 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A woman entering her third trimester of pregnancy asks the nurse how much weight she should gain during this trimester. What is the nurse's best answer?

A. 0.5 lb/week B. 1 lb/week C. 1.5 lb/week D. 2 lbs/week ANS: B Feedback: A woman of normal prepregnant weight should gain about 10 lbs by 20 weeks and about 1 lb/week for the remaining 20 weeks, for a total of 25 to 30 lbs. The other options are distracters to the question.

PTS: 1 REF: p. 822 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 6. A client in her third trimester comes in for a routine prenatal visit. The nurse places her in a comfortable position and attaches the tocodynamometer and ultrasound monitor to the client's abdomen. What is the purpose of this test?

A. Assesses readiness for dilation B. Assesses fetal position

C. Assesses fetal well-being D. Assesses readiness for delivery ANS: C Feedback: During the third trimester, the client may be scheduled for a nonstress test (NST) in conjunction with her prenatal visit. The purpose of the NST is to assess fetal well-being. If the client is scheduled for an NST, the nurse will put the client on the electronic fetal monitor after her usual data are gathered. The nurse puts the client in a comfortable position, places the tocodynamometer on the fundus to measure uterine contractions, and places the ultrasound monitor where the fetal heart can be heard and measure its rate (FHR). The nurse checks periodically to make sure that the sensors are tracing accurately and that the mother is still comfortable. If the monitoring strip is not becoming reactive, the nurse may offer the mother a position change or a drink of juice in hopes of stimulating the fetus to react to these changes. The nurse reports any sign of fetal distress to the provider immediately.

PTS: 1 REF: p. 828 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice 7. At each prenatal visit, a client provides a urine sample to the health care provider. What is this urine sample tested for at each visit?

A. Protein and glucose B. Glucose and white blood cells C. Protein and albumin D. White blood cells and albumin ANS: A Feedback: Typically, the nurse weighs the client, records her blood pressure, assesses her urine for protein and glucose, and identifies any problems or concerns. A client's urine is not tested for white blood cells or albumin.

PTS: 1 REF: p. 822 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 8. The nurse is teaching a class about pregnancy to a group of expectant mothers. What would be the primary method of prevention that the nurse would focus on related to hemorrhoids and constipation?

A. Take a mild laxative daily B. Decrease the intake of fiber C. Increase the intake of protein D. Increase exercise ANS: D

Feedback: Pregnant women are at risk for constipation. Straining during bowel movements can also cause painful or itchy hemorrhoids. The primary way to prevent hemorrhoids is to prevent constipation by increasing exercise and intake of fiber and water. The nurse would not encourage a pregnant woman to use a daily laxative.

Increasing protein is not a method to prevent constipation and hemorrhoids.

PTS: 1 REF: p. 826 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 9. A teenage girl comes to the clinic and reports that she thinks she is pregnant. A pregnancy test is positive. While developing a care plan for this client, the nurse should consider the client's age and associated risk factors, which include what? (Select all that apply.)

A. Preeclampsia B. Underdeveloped pelvis C. Inadequate nutrition D. Gestational diabetes E. Pyelonephritis ANS: A, B, C Feedback: Pregnant teens have increased nutritional requirements because they, too, are still growing. In addition, their pelvises may not be fully developed. Pregnant teens are at increased risk for complications, especially preeclampsia, probably from inadequate nutrient intake. Pregnant teens are not documented as being at increased risk for pyelonephritis or gestational diabetes.

PTS: 1 REF: p. 814 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 10. A client at 39 weeks' gestation presents at the labor and delivery suite saying that she is in labor. She reports that her water has not broken yet. Physical assessment reveals that the client is not in true labor. The nurse explains that what the client is feeling are Braxton Hicks contractions. What assessment findings would tell the nurse that these contractions are, in fact, Braxton Hicks? (Select all that apply.)

A. 30 to 45 seconds in duration B. Fewer than five in 1 hour C. Not painful D. Resolve with position change E. Less than 30 seconds ANS: B, D, E

Feedback: Braxton Hicks contractions prepare the body for labor. They are usually irregular in frequency and duration, with fewer than five in 1 hour. They are also short (less than 30 seconds) but may be painful. These contractions may begin as early as the second trimester, especially for clients who have had babies before, but are more common in the third trimester. They often resolve with position changes, a hot shower, hydration, or relaxation.

PTS: 1 REF: p. 820 OBJ: 7 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 11. A client presents at the emergency department. During the assessment, the nurse notes the following: Client is a 22-week primipara, age 25, pulse 82, BP 110/76, temp 38.3°C (100.9°F). The client is diagnosed with pyelonephritis. What would be the treatment of choice?

A. Hospitalization and intravenous antibiotics B. Oral antibiotics and bed rest at home C. Hospitalization and intravenous hydration D. Home care and oral hydration and antibiotics ANS: A Feedback: Pyelonephritis can develop when a urinary tract infection (UTI) is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, characterized by severe flank pain and a fever above 38°C (100.4°F). While pyelonephritis is often treated on an outpatient basis for nonpregnant clients, during pregnancy, pyelonephritis requires intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. The other options are distracters to the question.

PTS: 1 REF: p. 813 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 12. What is the primary purpose of asking a pregnant woman about her religious preference?

A. To know whom to call if the client asks for a cleric B. To identify religious beliefs that may affect the mother or the fetus C. To aid in research on how many births occur yearly in a religious denomination D. To have a cleric of the right denomination in the hospital during the birth ANS: B Feedback: Examples of beliefs that can affect the care of pregnant women include the following: Jehovah's Witnesses accept no blood products, even to save the life of the mother or the fetus. While the other options are not incorrect, they are not the primary reason to assess for religious preference.

PTS:

1

REF: p. 815

OBJ: 9

NAT: Client Needs: Psychosocial Integrity TOP: Chapter 25: Pregnancy KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 13. A woman in her second trimester of pregnancy calls the obstetrician's office and tells the nurse that she is having pains all around her umbilicus. What would be the nurse's best response?

A. "You are having growing pains. There is nothing to worry about."

B. "These pains are caused by the stretching of ligaments as your uterus grows. They occur when you change position ."

C. "These are called Braxton Hicks contractions. They are a kind of 'practice' for when the baby is born."

D. "You are having preterm labor. Go to the emergency room right away."

ANS: B Feedback: About halfway through pregnancy, women commonly feel a stretching pain all around the umbilicus. The pain is similar to "growing pains," which usually subside by the end of the first trimester. These second-trimester pains are similar in origin, resulting from additional ligaments stretching as the uterus accommodates the growing fetus. However, they are not growing pains, per se, nor are they Braxton Hicks contractions or preterm labor.

PTS: 1 REF: p. 820 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 14. The nurse is assessing an adult pregnant client for the first time during her initial visit to the obstetric clinic. The client is currently at 8 weeks' gestation. During the assessment, the client reports that she is experiencing sharp stabbing pains in her lower abdomen, especially when she changes position. How would the nurse document this finding?

A. The client is having growing pains B. The client is having a miscarriage C. The client is having preterm labor D. The client is having Braxton Hicks contractions ANS: A Feedback: In the first trimester, sharp pains in the lower abdomen are common.

Stretching of the round and broad ligaments that support the growing uterus causes them, which are usually very short (less than 5 seconds) and have a stabbing quality. They are not repetitive but are often associated with position changes or, later, fetal movements.

The nurse would not document this finding as miscarriage, preterm labor, or Braxton Hicks contractions.

PTS: 1 REF: p. 819 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Communication and Documentation

BLM: Cognitive Level: Analyze

NOT: Multiple Choice

15. Which of the following clients would most likely be found to have undergone female circumcision during a genital examination?

A. East Asian B. African C. Pacific Islander D. Eastern European ANS: B Feedback: Some African cultures practice female circumcision as a ritual. This practice reduces the size of the female introitus, which requires assessment before childbirth. The other options do not present cultures that engage in female circumcision. .

PTS: 1 REF: p. 815 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 16. Pregnant women of advanced maternal age are at increased risk for what? (Select all that apply.)

A. Genetic anomalies in the fetus B. Increased preexisting health problems C. Gestational diabetes D. Cephalopelvic disproportion E. Miscarriage ANS: A, B, E Feedback: Pregnant women of advanced maternal age are those who will be 35 years or older at the estimated date of birth. They are at increased risk for miscarriage and genetic anomalies and may have increased preexisting health problems (e.g., fibroids, advanced endometriosis, hypertension). They are not at increased risk for cephalopelvic disproportion or gestational diabetes.

PTS: 1 REF: p. 814 OBJ: 9 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Select 17. What is the most appropriate nursing intervention when writing a care plan for a pregnant woman and using the nursing diagnosis "Readiness for enhanced family coping due to new role?"

A. Help the client move toward an enriching lifestyle B. Educate the client about nutrition and overeating, exercise, and stress management techniques C. Provide breast-feeding support D. Assess the structure, resources, and coping abilities of the family

ANS: D Feedback: The most appropriate intervention is to assess the structure, resources, and coping abilities of the family. This intervention is the only one that addresses the family's overall coping needs. Helping the pregnant woman move toward an enriching lifestyle or improve health practices is a useful intervention but is not most appropriate in this scenario. Nothing about the scenario directly involves a need for breast-feeding support.

PTS: 1 REF: p. 832 OBJ: 10 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. An ultrasound is being performed to assess the cardiac activity of a 10-week-old fetus.

The client asks the nurse if she can find out the sex of the baby during the ultrasound.

What is the nurse's best response?

A. "If the sonographer can obtain adequate pictures, he or she can tell you."

B. "Your healthcare provider will tell you after the sonogram has been read by the radiologist."

C. "It's too early to visualize the sex organs of the fetus at ten weeks."

D. "You'll be able to tell the sex of the baby when you see the male or female genitalia."

ANS: C Feedback: By 20 weeks of gestation, the fetus is large and developed enough so that all major organs are visible on ultrasound, including the sex organs that indicate gender.

None of the remaining options provide accurate information to answer the client's question.

PTS: 1 REF: p. 810 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 25: Pregnancy KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is assessing a pregnant female in the outpatient clinic. The client exhibits a fever and complains of having flank pain for the past two days. What is the nurse's priority action?

A. Administer prescribed antipyretic.

B. Call the lab to obtain blood cultures.

C. Explain that an antibiotic will be called in to her preferred pharmacy.

D. Notify the healthcare provider.

ANS: D

Feedback: A condition in pregnancy requiring immediate attention is pyelonephritis, which occurs when a urinary tract infection is not treated promptly. Because the immune system does not fight infections as well during pregnancy, a bladder infection can quickly become a kidney infection, which is characterized by severe flank pain and a fever. Although the nonpregnant client with pyelonephritis is often treated on an outpatient basis, during pregnancy pyelonephritis require intravenous antibiotics immediately to prevent generalized sepsis, which is potentially fatal. Based on the client's symptoms, the nurse should notify the healthcare provider right away before an antipyretic is administered or before obtaining blood cultures, if cultures are necessary.

PTS: 1 REF: p. 813 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 20. The nurse is planning care for a client who was admitted following the diagnosis of an ectopic pregnancy. What should the nurse include in the plan of care?

A. Describe the grieving process.

B. Assist the client to develop a birth plan.

C. Teach the client about sexual changes during pregnancy.

D. Explain the importance of adding more fiber to the diet.

ANS: A Feedback: Ectopic pregnancy occurs when the embryo implants outside of the uterus.

The pregnancy is not viable, is considered a medical emergency, and will result in termination of the pregnancy. The rest of the options are associated with a healthy pregnancy. If the pregnancy were viable, the nurse would teach about proper nutrition including a diet high in fiber, protein, fruits, and vegetables. Nurses often assist clients with developing a birthing plan. In an ectopic pregnancy, the termination is completed as an emergency procedure and a birthing plan would not be used. Sexual changes associated with pregnancy should be discussed in a healthy pregnancy.

PTS: 1 REF: p. 809 OBJ: 10 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 25: Pregnancy KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 26: Newborns and Infants 1. During a class on growth and development, students learn that the motor development of infants follows a predictable pattern. What are the characteristics of this pattern? (Select all that apply.)

A. Caudallocephalic B. Central to distal C. Gross to fine D. Right to left E. Cephalocaudal ANS: B, C, E Feedback: Motor development progresses in predictable patterns: cephalocaudally, central to distal, and gross to fine. Motor development does not progress right to left.

"Caudallocephalic" is a simple distracter for this question.

PTS: 1 REF: p. 841 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Select 2. A young mother asks the clinic nurse how her baby is going to learn to talk. What would the nurse answer? (Select all that apply.)

A. Pretending B. Watching C. Interacting with the environment D. Listening E. Overcoming frustration ANS: B, C, D Feedback: The infant learns language through listening, watching, and interacting with the environment. The infant does not learn to speak through pretending or overcoming frustration.

PTS: 1 REF: p. 841 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Select 3. A long and difficult labor results in the birth of a 7 lb, 6 oz infant. The nurse knows that critical components of the assessment of this infant include what? (Select all that apply.)

A. Is the newborn term gestation?

B. Is the newborn responsive?

C. Does the baby demonstrate a good cry?

D. Does the newborn want to nurse immediately after birth?

E. Does the newborn have good muscle tone?

ANS: A, B, C, E

Feedback: The nurse must ask four key assessment questions about each newborn's health: Is the newborn term gestation (37 weeks or greater)? Is the newborn breathing or crying? Does the newborn have good muscle tone? The newborn not wanting to nurse immediately after birth is not a critical component of the infant assessment.

PTS: 1 REF: p. 842 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 4. Parents bring an 8-month-old boy to the emergency department, reporting that their child "just is not acting right." Nursing assessment shows that the infant's pulse is 165 beats/min. Respiratory rate, blood pressure, and temperature are within normal limits.

Mild nasal flaring is noted. What should the nurse suspect?

A. Cardiac decompensation B. Foreign body in trachea C. Sepsis D. Respiratory distress ANS: D Feedback: Most emergent situations for the newborn involve respiratory decompensation. Signs of newborn respiratory distress include increased respiratory and heart rates, nasal flaring, and intercostal and substernal retractions. The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest).

The child is not exhibiting cardiac decompensation, foreign body in trachea, or sepsis.

PTS: 1 REF: p. 842 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A group of students is preparing a class presentation on infant sleeping and Sudden Infant Death Syndrome. The presentation would include which of the following?

A. Explain the importance of maintaining functioning smoke alarms on every floor and in every sleeping area of the home B. Teach parents to use pillows for their infants C. Teach parents that it is okay for them to sleep with their infants occasionally D. Teach parents about placing the baby on his back to sleep.

ANS: D Feedback: Appropriate education topics involve teaching parents the importance of not sleeping with infants and safe sleep practices for infants, who are to always be placed on their backs to sleep, with no pillows or excessively soft bedding or toys in cribs. Smoke alarms have nothing to do with sleeping and Sudden Infant Death Syndrome.

PTS: 1 REF: p. 844 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

6. A 6-month-old infant comes to the clinic with his mother. The mother tells the nurse that her child seems to have one cold after another. What would be appropriate assessment questions for the nurse to ask? (Select all that apply.)

A. Has the infant been exposed to anyone with a communicable illness?

B. Has the infant traveled with the family recently?

C. Has the infant had trouble breathing?

D. Is there an associated cough or sneezing?

E. What has been the infant's temperature pattern?

ANS: C, D, E Feedback: To evaluate respiratory complaints/distress, the nurse would ask the following questions: Has the infant had trouble breathing? Have there been any episodes in which the infant turned blue? Does the infant have frequent colds? Is there an associated cough or sneezing? Is there any sputum production or secretions? Has the infant had a stuffy or runny nose? Has the parent noticed any wheezing? What has been the infant's temperature pattern? Are the infant's immunizations up-to-date? The other options are appropriate to ask when assessing fever and no fever is mentioned in the question.

PTS: 1 REF: p. 847 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select 7. The mother of a 9-month-old girl calls the clinic. She tells the nurse that her daughter has developed a rash. The nurse asks a series of questions to assess the rash. Why would it be important for the nurse to ask these questions?

A. Helps the nurse conceptualize the rash B. Helps the nurse determine if the child is contagious C. Helps the nurse know if this is a childhood communicable disease D. Helps pinpoint possible causes ANS: D Feedback: These questions help pinpoint possible causes. Many skin conditions have predictable patterns of spread, parts of the body affected, and associated symptoms, such as pruritis (itching). It is important to differentiate if the symptoms are localized versus systemic or if there might be an infectious versus an allergic origin. All the other opinions fail to address the need to find the cause and treatment for the rash.

PTS: 1 REF: p. 847 OBJ: 3 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 8. A nursery nurse is assessing the neurologic status of a newborn. What area would the nurse be assessing?

A. Pain B. Weight and length C. Reflexes

D. Ability to eat ANS: C Feedback: Evaluation of newborn reflexes gives information about neurologic status.

Pain, weight and length, and ability to eat do not give information about neurologic status.

PTS: 1 REF: p. 862 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 9. The nurse practitioner is using an otoscope to assess the ears of a 1-year-old. What would it be important for the nurse practitioner to do?

A. Pull the ear lobe up and back B. Brace the hand holding the otoscope against the infant's face C. Have the infant supine with the head held by the nurse D. Have the infant sit with the head held by the nurse ANS: B Feedback: The nurse always braces the hand holding the otoscope against the infant's face, so that if the infant moves, the otoscope moves with him or her to avoid injuring the tympanic membrane. "Pull the ear lobe up and back" is for assessing the ears of an adult. "Have the infant supine with the head held by the nurse" and "Have the infant sit with the head held by the nurse" are incorrect, the parent would hold the infant's head while the infant sits on the parent's lap.

PTS: 1 REF: p. 858 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. While assessing a 6-week-old infant new to the clinic, the nurse notices that the infant's ears fall below the imaginary line that runs from the inner canthus of the eye to the outer canthus and ear. What might indicate to the nurse that this finding is a normal variant in this case?

A. The mother has low-set ears.

B. There is no normal variant for low-set ears.

C. All infants tend to have low-set ears before 2 months.

D. The child also has many a prominent birthmark.

ANS: A Feedback: It may be helpful to note if either parent has low-set ears. If so, then the low-set ears may be an inherited normal variant. None of the remaining options present accurate information regarding an infant's ears.

PTS: 1 REF: p. 858 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

11. The nurse is assessing a 4-month-old infant who appears very pale but is not cyanotic.

The nurse suspects that the infant has anemia. What would be the priority nursing action?

A. Assess oxygen saturation B. Order a thyroid test C. Order a laboratory test to assess for iron D. Assess the nail beds and conjunctiva ANS: A Feedback: If an infant is pale and anemia is suspected, it is prudent to check the oxygen saturation. This is because it takes at least 5 grams of reduced hemoglobin to produce the typical blueness of cyanosis. Infants with anemia often do not have enough hemoglobin to exhibit cyanosis, even though they have very low oxygen saturation levels. Nurses do not order laboratory tests. The nurse would already have assessed the nail beds and conjunctivae before suspecting anemia.

PTS: 1 REF: p. 859 OBJ: 5 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. A newborn is noted to have a yellowish cast to his skin and sclera. Laboratory testing shows him to have an elevated bilirubin level. What nursing intervention is appropriate for this client?

A. Initiate early feeding B. Withhold feeding until a physician gives an order for it to begin C. Withhold feeding until bilirubin levels drop D. Immediately start phototherapy ANS: A Feedback: Early feeding stimulates stooling and subsequent removal of bilirubin. The nurse would not withhold feeding for the child with an elevated bilirubin level or start phototherapy without an order.

PTS: 1 REF: p. 866 OBJ: 8 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 13. An infant has a nursing diagnosis of ineffective thermoregulation related to immaturity of neurologic and endocrine systems. The infant's temperature remains low. What nursing intervention would be important?

A. Promote skin-to-skin contact with the mother B. Keep the newborn's head covered C. Do not allow the family to hold the infant D. Change the infant's diaper at least every hour ANS: B

Feedback: For this infant, keeping the head covered to help regulate body temperature is the most important intervention. Promoting skin-to-skin contact with the mother would mean the child would need to be undressed; therefore, it is not the most appropriate response for this scenario. Not allowing the family to hold the infant and changing the diaper every hour are not necessary interventions for this scenario.

PTS: 1 REF: p. 866 OBJ: 8 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. What newborn assessment finding varies according to heritage?

A. Waist circumference B. Length C. Leg length D. Shoulder width ANS: B Feedback: The length and weight of the newborn and infant varies according to heritage, so ranges outside of usual may be normal for some clients. Leg length, waist circumference, and shoulder width are not assessed on a newborn.

PTS: 1 REF: p. 841 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 15. When assessing a newborn, the nurse finds areas at the base of the spine that look like bruises. The nurse knows that these areas are most common in infants of which of the following ethnic backgrounds?

A. Pacific Islanders B. Italian American C. African American D. Irish American ANS: C Feedback: The nurse is assessing slate gray nevi (previously known as Mongolian spots), which are more common in infants of African American, Asian, and Native American origin. This spotting is not common among the other ethnic populations provided as options.

PTS: 1 REF: p. 847 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 16. A nurse is presenting a class to new mothers preparing for postpartum discharge from the hospital. What topics would the nurse be sure to include in teaching? (Select all that apply.)

A. Choking prevention

B. Bundling the baby C. Suffocation prevention D. Reading to the baby E. Sleep positioning ANS: A, C, E Feedback: The leading cause of injury-related death for infants is choking and suffocation. Parents require anticipatory guidance to avert preventable injury and illness.

Prevention of suffocation includes teaching about proper sleep positioning. Reading to the baby and bundling the baby are distracters.

PTS: 1 REF: p. 844 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 17. The nurse is admitting an 8-month-old infant to the pediatric unit. Vital signs are T 36.4oC (97.5oF), heart rate 160 bpm, and respiratory rate 38/min. The client exhibits circumoral cyanosis and nasal flaring. Auscultation reveals diminished lung sounds in the bases of both lungs and grunting. What nursing diagnosis would be appropriate when writing the care plan for this child?

A. Inadequate gas exchange related to pneumonia B. Respiratory decompensation related to inability to breathe C. Cardiac decompensation related to tachycardia D. Inadequate tissue perfusion related to heart rate ANS: A Feedback: The first sign of respiratory distress in a newborn is often tachypnea (heart rate greater than 160 at rest). Moderate respiratory distress includes nasal flaring, retractions of the chest wall, grunting auscultated with a stethoscope, cyanosis on room air, and abnormal blood gas values. Severe distress is indicated by increasing work of breathing, deep retractions, audible grunting, and central cyanosis. Nothing in the scenario indicates cardiac decompensation or inadequate tissue perfusion related to heart rate. While the client is having difficulty breathing, the child is not totally unable to breathe.

PTS: 1 REF: p. 842 OBJ: 8 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 18. The nurse assessing a 3-month-old child in the clinic asks the mother if she has childproofed the home. For what would the nurse be assessing when asking this question?

A. Parenting B. Lifestyle-related risk factors C. Family resources D. Health status

ANS: B Feedback: This question involves an assessment of lifestyle and personal habits associated with risk factors. It is not asking to assess parenting, the environment, or the infant's health status.

PTS: 1 REF: p. 843 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Caring BLM: Cognitive Level: Apply NOT: Multiple Choice 19. During acute assessment of a newborn, what questions should a nurse ask before providing care at the mother's bedside? (Select all that apply.)

A. Does the newborn have good muscle tone?

B. Is the newborn term gestation (37 weeks or greater)?

C. Is the newborn pink in color?

D. Is the amniotic fluid clear?

E. Is the newborn breathing or crying?

ANS: A, B, D, E Feedback: The nurse must ask four key assessment questions about the newborn's health: 1. Is the newborn term gestation (37 weeks or greater)? 2. Is the amniotic fluid clear? 3.

Is the newborn breathing or crying? 4. Does the newborn have good muscle tone? If the answer to all four questions is "Yes," then the newborn is adapting well and may receive care at the bedside with his or her mother. Therefore, option C is incorrect.

PTS: 1 REF: p. 842 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 20. Which assessment finding is priority for the nurse to address during an assessment of a one-week-old neonate?

A. Small tonsils and adenoids B. Mucus in the nasal passages C. Lack of deciduous teeth D. Poor pupillary reflex ANS: B Feedback: Newborns are obligatory nose breathers and, therefore, have significant distress when their nasal passages are obstructed. Pupillary reflex is poor at birth and improves at 5 months of age. Deciduous tooth eruption takes place between the ages of 6 and 24 months. The tonsils and adenoids are small in relation to body size and hard to see at birth.

PTS: 1 REF: p. 842 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 26: Newborns and Infants KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 27: Children and Adolescents 1. The nurse is assessing a teenage client who has reached puberty. What glands would the nurse know have become active?

A. Eccrine B. Apocrine C. Pineal D. Parathyroid ANS: B Feedback: Apocrine (sex) glands become active at puberty. Eccrine, pineal, and parathyroid have been active since birth.

PTS: 1 REF: p. 892 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 2. A teenage client comes to the clinic. He tells the nurse that he attends parties every weekend where alcohol is served. What is the most appropriate topic for client teaching?

A. Safe sex practices B. Nutrition for adolescence C. Physiologic changes in adolescence D. Drinking and driving ANS: D Feedback: Whether the client is driving or a passenger in a vehicle, the client is at risk for being involved in a motor vehicle accident related to driver impairment due to the influence of substances. While the other topics represent important teaching areas, the biggest concern involves the client's drinking.

PTS: 1 REF: p. 886 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 3. A teenage client shows symptoms of human papillomavirus during a health surveillance visit. What is the first action the nurse should take to educate the client about the condition?

A. Reassure the client that findings will remain confidential B. Recruit the help of the client's parents C. Explain how girls are more susceptible to sexually transmitted infections (STIs) D. Describe all the risks of unprotected sex ANS: A

Feedback: To help the client understand the situation, the first thing to do is reassure the client this will be kept confidential, even from the client's parents. Explaining the susceptibility to infection and describing all the risks of unprotected sex will be ineffective if the client is worried about confidentiality. Also, being open and respectful of the client's decision to have sex will greatly help deliver preventative messages.

PTS: 1 REF: p. 881 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Analyze NOT: Multiple Choice 4. A school age client comes to the emergency department with abdominal pain. The nurse notes that when the client walks to the treatment room, he is walking on his toes. What might the nurse suspect is wrong with this child?

A. Incarcerated hernia B. Appendicitis C. Testicular torsion D. Wilms' tumor ANS: B Feedback: If the child points to the right lower quadrant (RLQ) or only tiptoes, appendicitis should be ruled out with abdominal scans. A child would not show the above symptoms with an incarcerated hernia, testicular torsion, or Wilms' tumor.

PTS: 1 REF: p. 888 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 5. A teenage client is visiting the pediatric clinic for leg pain. The client's mother states that the client has been limping for "2 to 3 weeks." What does the nurse know needs to be ruled out? (Select all that apply.)

A. Dislocation B. Wilms' tumor C. Simple fracture D. Graves' disease E. Bone tumor ANS: A, C, E Feedback: If the client consistently limps, then fractures, dislocations, and bone tumors should be ruled out. A compound fracture comes through the skin and is easily visible.

Graves' disease is associated with hyperthyroidism and would have nothing to do with leg pain. Wilms' tumor is associated with cancer of the kidney and is also not associated with leg pain.

PTS: 1 REF: p. 888 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents

KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 6. The nurse is assessing a school age client for a school physical examination. The client is a recent immigrant to the United States; this is the client's first visit to the clinic. When doing the initial assessment, the nurse would assess their nutrition by asking what questions? (Select all that apply.)

A. Do you eat pork?

B. Do your grandparents live with you?

C. Is family food prepared at home?

D. With whom do you eat?

E. What food do you eat for the last meal of the day?

ANS: C, D, E Feedback: Questions about nutrition include who eats together, what is eaten, where food is obtained, who prepares food, and how food is prepared. These norms contribute to the health of the child and are important components of a nutritional assessment.

These norms are not known unless the provider asks about them. They are different for each family based not on race but on familial cultural norms. Information about consumption of pork and whether grandparents live with the child would not shed direct light on the child's nutrition.

PTS: 1 REF: p. 880 OBJ: 8 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 7. According to Bright Futures, within what context should the nurse address the child's health needs?

A. School and extended family B. Community and health care facilities C. Family and community D. Family and school ANS: C Feedback: Bright Futures is a national health-promotion and disease-prevention initiative that addresses children's health needs within the context of family and community. It acknowledges that a multitude of support people and agencies are necessary to raise healthy children and to build the necessary foundation for them to develop into productive adult citizens. Therefore, health assessment of the child or adolescent also includes assessing community support, environmental exposures, and potential opportunities for health promotion.

PTS: 1 REF: p. 885 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

8. When working with children, what diagnostic tests are indicated specifically for child examinations?

A. Lead levels B. Tuberculosis test C. Urinalysis D. None ANS: D Feedback: No laboratory or diagnostic tests are recommended specifically for children and adolescents. All remaining options are recommended only for symptomatic at-risk children.

PTS: 1 REF: p. 902 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 9. A pre-teen client has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this client, what would be the most appropriate intervention?

A. Provide information for age-appropriate community activities B. Identify normal findings in the client C. Assess parenting D. Provide information that contributes to an improved state of health ANS: D Feedback: The most pertinent intervention is to provide information that contributes to an improved state of health. Parenting would be assessed throughout childhood but is not the most appropriate intervention for a pre-teen client with pneumonia. Age-appropriate community activities are not a concern for a client with a respiratory infection.

PTS: 1 REF: p. 903 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 10. The nurse is doing an initial assessment on a school age client admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal.

How would the nurse chart these findings?

A. Eyes are PERRLA with corneal light reflexes equal bilaterally B. Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal C. Eyes are WNL D. Eyes are PERRLA with EOMs at 180 degrees bilaterally ANS: B

Feedback: Normal findings would be documented as follows: eyes are PERRLA; EOMs are at 180 degrees; corneal light reflexes are equal; there is no deviation during the cover and alternate cover tests; fundoscopic examination reveals a distinct disc with no vessel nicking. This makes all remaining options incorrect.

PTS: 1 REF: p. 893 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 11. The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult?

A. 1 to 2 B. 3 to 4 C. 5 to 6 D. 7 to 8 ANS: C Feedback: By 5 to 6 years, normal visual acuity should approximate that of adults (20/20 in both eyes). By the age of 7 to 8 years visual acuity should be the same as an adult.

Options A and B are incorrect because in children younger than 5 years of age visual acuity should be 20/40, changing to 20/30 at approximately the age of 4 years.

PTS: 1 REF: p. 893 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Remember NOT: Multiple Choice 12. An instructor asks a student nurse, "What is the most common infectious disease of childhood?" What would be the student nurse's best answer?

A. Dental caries B. Otitis media C. Thrush D. Otitis externa ANS: A Feedback: Dental caries are the most common infectious disease in childhood. Otitis media and thrush are common infectious diseases but not the most common in childhood. Otitis externa is a common finding, but again, not the most common.

PTS: 1 REF: p. 896 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

13. A mother brings her 4-year-old child to the clinic and explains to the nurse that her child turns blue sometimes while playing. The nurse assesses the child's pulses and notes a significant difference in the pulses in the upper and lower extremities. The nurse would suspect that the child has what?

A. Tetralogy of Fallot B. Coarctation of the aorta C. Femoral artery aneurysm D. Transposition of the great vessels ANS: B Feedback: Coarctation of the aorta can present with unequal pulses between the upper and lower extremities. None of the other options present in the manner described in the scenario. Tetralogy of Fallot may exhibit with or without cyanosis. Usually clients will exhibit a heart murmur, difficulty feeding, failure to gain weight, dyspnea on exertion, and clubbing of the fingers and toes. Transposition of the great vessels is an congenital condition where the great vessels (superior and inferior vena cava, pulmonary artery, pulmonary vein, and aorta) are in abnormal positions. All vessels do not have to be involved in this condition. Symptoms would differ depending on the exact involvement of the vessels. Femoral artery aneurysm is a distracter.

PTS: 1 REF: p. 899 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A preschool client arrives at the emergency department with severe acute abdominal pain and tenderness. The nurse would expect this client to be evaluated for what? (Select all that apply.)

A. Stomach virus B. Gastroenteritis C. Ulcerative colitis D. Appendicitis E. Incarcerated umbilical hernia ANS: B C, D Feedback: Significant abdominal tenderness requires further evaluation for appendicitis, Crohn's disease, ulcerative colitis, and gastroenteritis. The child would not be evaluated for a stomach virus until the more emergent conditions were ruled out. These symptoms are not consistent with an incarcerated umbilical hernia.

PTS: 1 REF: p. 899 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select

15. A woman brings her preschool age child to the clinic. The mother states that she was giving her child a bath and noted irritation around the child's rectum. The nurse would expect the child to be evaluated for what? (Select all that apply.)

A. Sexual abuse B. Constipation C. Hemorrhoids D. Worms E. Yeast infection ANS: A, B, D Feedback: Rectal irritation or fissures require further evaluation for constipation, worms, or sexual abuse. Irritation is not an indication of hemorrhoids or a yeast infection.

PTS: 1 REF: p. 901 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 16. The nurse is collecting a history on a 4-year-old and discovers that the child is being cared for by his grandmother during the days while the parents are at work. The grandmother's house was built in the early 1940s. Which lab should the nurse prepare to collect from the child?

A. Potassium level B. Lead level C. Iron level D. Bleeding time ANS: B Feedback: If a child lives in or regularly visits a house or child care facility built before 1950, the child should have a lead level drawn. None of the other options would be supported by the information provided in the scenario.

PTS: 1 REF: p. 883 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 17. The nurse is assessing a 3-year-old child. The history reveals that the bilirubin level for this child postnatally was 30 mcg/dL. What is the nurse's priority assessment based on this value?

A. Blood pressure B. Rectal temperature C. Reflexes D. Kidney function ANS: C

Feedback: Extremely elevated postnatal bilirubin levels (greater than or equal to 25 mcg/dL) may be associated with neurological problems. Therefore, assessing reflexes, as part of a neurological assessment for this child, is priority. Blood pressure, rectal temperature, and kidney function are not part of a neuro exam.

PTS: 1 REF: p. 882 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action?

A. Apply oxygen via nasal cannula B. Transport the child for chest x-ray C. Provide reassurance to calm the child D. Encourage prolonged exhalation by having child blow up a balloon ANS: A Feedback: Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually results from a respiratory disorder or significant blood loss. (Even children with a known congenital heart problem rarely present in acute distress from ischemic heart disease.) The additional work of breathing is evidenced in a distressed child by nasal flaring accompanied by supracostal, intercostal, and subcostal chest retractions (Fig. 27.2) or abdominal breathing.

Administration of oxygen and support of the child's ability to breathe are the first interventions. Physiological distress is priority to address, then reassurance and efforts to calm the child can be attempted. Oxygen should be applied before a chest x-ray is obtained. Oxygen can be worn during the x-ray. Prolonged expiration is not the priority treatment during acute distress until oxygen is applied and a complete assessment is performed.

PTS: 1 REF: p. 880 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 19. The nurse is educating a new mother about safety precautions for a child who is beginning to walk. What information should the nurse include in this teaching session?

A. Wearing helmets when bike riding B. Increasing formula intake to meet caloric needs C. Setting up gates around stairs D. Team sport precautions ANS: C

Feedback: Safety precautions in children change according to age group because of the variation in their developing motor abilities. For instance, covering electrical outlets is important after a child begins to be able to sit properly, whereas protecting the child from falls down stairs begins to matter more once the child can roll, crawl, or walk. A child just beginning to walk is too young developmentally for bike riding and playing team sports. Most children begin to walk around one year of age, at which time formula is recommended to be replaced with milk and other foods.

PTS: 1 REF: p. 886 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 20. A 3-year-old child has arrived at the clinic for a physical exam. The nurse should perform which action when completing the growth chart?

A. Mark body mass index (BMI) as not applicable on the growth chart.

B. Measure height with child in the recumbent position.

C. Obtain head circumference and plot results on the growth chart.

D. Weigh child using the stadiometer.

ANS: C Feedback: Growth charts for boys and girls vary. Charts for children from birth to 2 years old are for heights measured while recumbent; charts for children 2 to 18 years are for children measured upright with a stadiometer. Children are weighed on a calibrated scale. For children older than 2 years of age, health care providers calculate and plot body mass index (BMI) on the appropriate BMI chart. Head circumference is measured on children from birth to 3 years old and plotted on similar growth charts. The stadiometer measures height, not weight.

PTS: 1 REF: p. 879 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 27: Children and Adolescents KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

Chapter 28: Older Adults 1. When caring for an older adult, the nurse would know that wound healing rate reduces normally with aging by what percent?

A. 20% B. 30% C. 40% D. 50% ANS: D Feedback: Decreased mitotic activity of cells that accompanies aging normally leads to a 50% reduction in rate of wound healing. Based on this information, the remaining options are incorrect.

PTS: 1 REF: p. 910 OBJ: 1 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 2. An older adult client comes to the clinic and reports difficulty with driving at night.

What would be the most appropriate response from the nurse to provide when attempting to address the client's concern?

A. "It is nothing to worry about."

B. "It's just something that happens with aging."

C. "With aging, the pupils do not respond to light as quickly, so many people have difficulty driving at night."

D. "This can be serious and needs to be evaluated by the physician immediately."

ANS: C Feedback: Aging results in slowed pupillary responses that lead to a difficulty in accommodating to changes in light, difficulty with night driving, and problems with glare. Providing the client with false assurances is not therapeutic. While it is true the condition is likely a result of aging, merely mentioning that doesn't address the client's concerns. The final option is misleading and inaccurate and therefore incorrect.

PTS: 1 REF: p. 910 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 3. What screening tool is most commonly used to identify older adults at high nutritional risk who may need interventions to improve nutritional status?

A. LAWTON B. MUST C. FIM D. KATZ ANS: B

Feedback: The Malnutrition Universal Screening Tool (MUST) is one of the most commonly used tests, consisting of evaluation of the body mass index (BMI), history of unexplained weight loss, and illness. Once complete, a malnutrition risk of low, medium, or high is assigned. The LAWTON measures ADL capabilities, as do the FIM and the KATZ. PTS: 1 REF: p. 916 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 4. A student is giving an oral presentation in the geriatric nursing class about insomnia.

What are the risk factors the student should cite? (Select all that apply.)

A. Male gender B. Female gender C. Increased age D. Medical illness E. Depression ANS: B, C, D, E Feedback: Insomnia may be either acute or chronic. It may affect falling asleep, staying asleep, or early morning wakening. Risk factors include female gender, increased age, medical or psychiatric illness, and shift work.

PTS: 1 REF: p. 920 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 5. A nurse is treating an older adult client who may be a victim of elder abuse. The nurse knows that many times elder abuse is not reported because of what?

A. Some clients are ashamed to admit being hurt by someone.

B. Some clients do not remember being hurt.

C. Some clients do not think that health care providers can help them.

D. Some clients do not think that they are being abused.

ANS: A Feedback: Many victims of elder abuse are isolated; some are ashamed and embarrassed or feel guilt and self-blame. In addition, some elders experience fear of reprisal, retribution from caregivers, or losing their home or independence. Others are pressured by relatives not to report. Failure to report elder abuse is usually not the result of forgetfulness, skepticism of the ability of health providers to give assistance, or comprehension about what is happening. While the other options are possible, none are considered significant reasons for the failure to report abuse.

PTS: 1 REF: p. 921 OBJ: 2 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 28: Older Adults KEY: Integrated Process: Caring

BLM: Cognitive Level: Apply

NOT: Multiple Choice

6. A client has come to the clinic for a routine checkup. The client is 77 years old, weighs 198 pounds (89.8 kg) with a body mass index (BMI) of 34.1, stands 5'4" (162.5 cm), and lives alone. The client's B/P is 147/89, pulse is 80, and respirations 18. The nurse is planning client teaching. What is an appropriate topic to include in the teaching plan to best address health risks?

A. Keeping floors clear B. Maintaining social contacts C. Encouraging a diet that supports a normal BMI D. Providing information on classes on diabetes ANS: C Feedback: The client's current body mass index (BMI) is 34.1, which is above the range of 25 to 29 recommended for older adults. Thus, the most pressing concern is for the older adult to follow a diet that would support a normal BMI. Nothing in the scenario describes safety risks at home, social isolation, or current diabetes.

PTS: 1 REF: p. 919 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The nurse is preparing to conduct an admission assessment on an older adult client.

What would be important to do before interviewing this client?

A. Make sure the door is not blocked B. Speak in a louder than normal voice C. Turn up the client's hearing aid D. Reduce or eliminate background noise ANS: D Feedback: It is essential to reduce or eliminate background noise as much as possible when carrying on conversations. This includes turning off the television or radio in the client's room and closing the door to reduce sounds of telephones, beepers, alarms, or pagers. Before beginning the interview, it would not be necessary to make sure the door is not blocked or to speak in a louder than normal voice. The scenario does not say that the client is using a hearing aid.

PTS: 1 REF: p. 913 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Older Adults KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Understand NOT: Multiple Choice 8. The nurse is admitting an older adult client to the short stay unit for same-day surgery.

What information should the nurse have before beginning the interview process?

A. The client's view of her own health B. Whether the client uses a cane C. Whether the client is religious

D. The client's educational level ANS: D Feedback: Consideration of the client's educational level is critical, and interview questions should match the older adult's knowledge level. It would not be necessary to know the client's view of her health status, whether the client uses assistive devices, or whether the client is religious.

PTS: 1 REF: p. 913 OBJ: 4 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 9. The nurse is caring for an older adult who lives alone. The nurse notes that the client has poor hygiene and that his dress is inappropriate for the time of year. The nurse knows that these findings might be caused by what? (Select all that apply.)

A. Adult onset ADHD B. Medications C. Decreased functional ability D. Acute infection E. Dehydration ANS: B, C, D, E Feedback: Poor hygiene and inappropriate dress may indicate decreased functional ability or may result from medications, acute infection, dehydration, or nutritional status.

The scenario does not mention that the client has adult onset ADHD, so that option is incorrect.

PTS: 1 REF: p. 923 OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Select 10. The nurse is caring for an older adult client whose steps are uneven and shorter than most adults. How would the nurse explain this phenomenon?

A. The client has a narrower base of support.

B. The client walks bent forward.

C. The client's age makes this a normal characteristic.

D. The client has loss of balance.

ANS: C Feedback: As the adult ages, physical appearance changes, with sharper body contours and more angular facial features. Posture tends to have a general flexion, and the client's gait tends to have a wider base of support to compensate for diminished balance. Steps tend to be shorter and uneven. The client may need to use the arms to help aid in balance. While the remaining options may be true of the client, none provide an explanation for the characteristics of the client's steps.

PTS:

1

REF: p. 923

OBJ: 5

NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Choice 11. The nurse is doing a shift assessment on an older adult client with diabetes who has had a 2 pack/day smoking habit for 22 years. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler. When reviewing previous assessment findings, they show that pulses were weakly palpable. What would be the first nursing action?

A. Notify the primary provider B. Reevaluate the pulse again in 30 minutes C. Reevaluate the pulse again in 15 minutes D. Ask the client how the extremity feels ANS: A Feedback: Absent peripheral pulses are of great concern and should be noted in the record. The primary provider should be contacted if this finding is new. It is more common in a person with a long history of smoking or who has diabetes; it can seriously interfere with wound healing. The nurse would not delay to reevaluate the pulse in either 15 or 30 minutes. Asking the client how the extremity feels is appropriate but does not take precedence over notifying the primary provider.

PTS: 1 REF: p. 927 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 12. An aide tells the nurse that an older adult client has a pulse of 105 beats/min. Why is this finding of concern?

A. Older adults have poor cardiac reserves.

B. The client is likely taking many medications.

C. The client needs to be reassured that providers care.

D. Older adults usually have lower than normal pulse rates.

ANS: A Feedback: Pulses greater than 100 are abnormal and should be taken seriously. Because of their poor cardiac reserves, older adults do not tolerate these pulse rates well for long periods. The scenario does not mention the client's medications. Pulse rates on older adults often run in the 50-60 bpm range, but not always. While clients can benefit from reassurance, this is not the primary concern in this scenario. Polymedication therapies can produce an altered pulse rate, but that doesn't explain why the rate is a concern.

PTS: 1 REF: p. 926 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has just started taking morphine for advanced cancer, is constipated, and wonders what is causing this. What would be the nurse's best response?

A. "People can become constipated for no reason at all."

B. "People can become constipated when they eat a lot of fiber."

C. "People can become constipated when taking certain medications."

D. "People can become constipated when they are more active than usual."

ANS: C Feedback: Constipation is usually related to multiple medications, inactivity, and/or low fluid/bulk intake. Eating a lot of fiber does not cause constipation. There is generally a reason for constipation. Active people generally do not suffer from constipation.

PTS: 1 REF: p. 927 OBJ: 7 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 14. The nurse is caring for an older adult who is not eating because "it does not taste like what I eat at home." What would be an appropriate nursing intervention for this client?

A. Serve 5 to 6 small meals per day B. Assess food preferences and obtain favorite foods C. Serve in-between-meal snacks D. Serve more sweets because the client likes them ANS: B Feedback: Assessing food preferences and obtaining favorite foods should help promote intake. Serving more meals or in-between-meal snacks will not help if the client does not like the food. The scenario does not say the client likes sweets, and serving many of them would not promote optimal nutrition.

PTS: 1 REF: p. 921 OBJ: 9 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 28: Older Adults KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply NOT: Multiple Choice 15. What does the nurse use to formulate a nursing care plan?

A. Objective data B. Subjective data C. Assessment data D. A preprinted care plan ANS: C Feedback: The nurse uses assessment data to formulate a nursing care plan with client outcomes and interventions. The nurse uses both objective and subjective data, but neither is sufficient by itself. The nurse may use a preprinted care plan, but again, this is not the best answer for this question since the plan is based on specialized assessment data.

PTS: 1 REF: p. 932 OBJ: 10 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process

BLM: Cognitive Level: Remember

NOT: Multiple Choice

16. The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action?

A. Teach the client how to apply topical chemotherapeutic agents.

B. Prepare the client for a skin biopsy.

C. Warn the client of the likelihood of metastasis.

D. Encourage the client to wear sunscreen daily.

ANS: D Feedback: Sun exposure causes solar lentigines, a benign skin lesion also known as age or liver spots. Usually these lesions are diagnosed by appearance and biopsy is not necessary. Malignant melanomas, not solar lentigines, are known to metastasize. A chemotherapeutic agent is not prescribed for this type of benign lesion.

PTS: 1 REF: p. 910 OBJ: 7 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 17. The nurse is teaching an older adult client about safety precautions to take at home after being discharged. Which of the following should be included in the teaching? (Select all that apply.)

A. Keep cooking surfaces clean.

B. Decrease clutter.

C. Place an anti-slip mat in the shower.

D. Cover electrical outlets with clear plastic caps.

E. Ensure window blinds are cordless.

ANS: A, B, C Feedback: Teaching to promote home safety for older adults includes things like ensuring that clutter is decreased to prevent tripping hazards, non-slip mats are placed in the shower to prevent falls, and cooking surfaces are kept clean. Ensuring window blinds are cordless and covering electrical outlets with plastic covers are appropriate measures to promote safety in the home of a small child but are not necessary for older adults.

PTS: 1 REF: p. 919 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Older Adults KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Select 18. The nurse is observing a student nurse who is caring for a frail older adult who appears to be slightly shaky. The nurse should intervene when the student nurse does which of the following?

A. Asks the client to step up and stand on a scale to obtain weight.

B. Obtains the apical pulse by counting for one full minute.

C. Uses a pulse oximeter designed to be placed on the bridge of the nose.

D. Palpates the sternocleidomastoid and trapezius muscles.

ANS: A Feedback: A frail older adult who is shaky should not be asked to step up onto a standing scale, as this creates a risk of falling. The client who is shaky can be weighed using a wheelchair or bedscale. The apical pulse should be counted for one full minute.

Placement of the finger pulse oximetry probe can present a challenge in older adults, so using a sensor designed for the forehead or bridge of the nose would be acceptable.

Palpating the sternocleidomastoid and trapezius muscles is acceptable when assessing the head and neck.

PTS: 1 REF: p. 923 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is caring for an older adult client with a long history of smoking and diabetes.

Upon assessment the right peripheral pulse is absent. What is the immediate action that should be taken by the nurse?

A. Notify the health care provider.

B. Document the pulse as "weak".

C. Assess for a history of vascular disease.

D. Elevate the leg to heart level.

ANS: A Feedback: Absent peripheral pulses are of great concern and the primary health care provider should be contacted. The absence of a pulse indicates decreased oxygenation within the limb and can gravely impact tissue integrity. Because the pulse was absent, documenting that the pulse is "weak" would be misleading and inappropriate. It would be beneficial to elevate the limb but the priority is to ensure the health care provider is notified so swift action to preserve tissue integrity can be taken, if necessary.

PTS: 1 REF: p. 923 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

20.

A nurse in a long-term care facility reviews the documented assessment on an older adult (above). Which of the findings should the nurse recognize as age-related changes?

(Select all that apply.)

A. Scalp hair thin, rigid nail beds bilaterally B. Pupils equal, round, reactive to light; presbyopia noted C. Pulse 68, no murmurs or gallops D. Slight dry cerumen noted in left ear; right ear is clear E. Abdomen soft; non-tender, hyperactive bowel sounds in all four quadrants ANS: A, B Feedback: Aging causes nail beds to become more rigid, thicker, and more brittle, with slowed growth. Older adults also often experience thinning hair and hair loss. In addition, older adults may have difficulty focusing properly (presbyopia), and may have difficulty with glare and accommodating to changes in light. A pulse of 68 and the absence of murmurs and gallops is a normal finding for all adults. Dry cerumen in the ears is also a normal finding for all adults and is not associated with aging. Hyperactive bowel sounds in all four quadrants is an abnormal finding, but this finding is not associated with age. It is likely caused by the client having just eaten or being extremely hungry.

PTS:

1

REF: p. 924-925

OBJ: 3

NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 28: Older Adults KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select

Chapter 29: Assessment of the Hospitalized Adult 1. At the beginning of the shift, an older adult hospitalized for pneumonia reports shortness of breath with an oxygen saturation of 90% on room air. Which type of assessment should the nurse perform at this time?

A. Comprehensive B. Immediate C. Shift D. Focused ANS: B Feedback: An immediate assessment should be performed for urgent problems. A focused assessment concentrates on assessing for possible problems related to the client's diagnosis and condition. A comprehensive assessment is a more detailed assessment which evaluates progress toward a goal. A shift assessment is performed at the beginning of shift and includes an abbreviated exam.

PTS: 1 REF: p. 940 OBJ: 9 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 2. The RN may delegate which care component to a nursing assistant?

A. Evaluating vital signs B. Wound care and assessment C. Check client's pain level D. Ambulation assistance ANS: D Feedback: The RN may delegate individual components of care but does not delegate the nursing process itself. The main functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. For example, if the nurse delegates taking vital signs to a nursing assistant, he or she is responsible for making sure that the data is accurately collected and for following up if findings are abnormal. The nursing assistant may collect vital signs, but the RN is responsible for evaluation. Assessment is always the RN's responsibility, which includes wound assessment and assessing pain level.

PTS: 1 REF: p. 954 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 3. When delegating tasks, the RN adheres to the Five Rights of Delegation principle which includes which rights? (Select all that apply.)

A. Right task B. Right time C. Right circumstances

D. Right person E. Right directions ANS: A, C, D, E Feedback: The Five Rights of Delegation include: right task, right circumstance, right person, right directions and communication, right supervision and evaluation. Right time is associated with medication administration.

PTS: 1 REF: p. 941 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Select 4. The nurse is admitting an older male client diagnosed with congestive heart failure.

Several risk factors for falls have been identified on the admission database. What is the nurse's best action to prevent falls?

A. Use two client identifiers, such as name and date of birth.

B. Scan the client's armband before medication administration.

C. Use SBAR and medical terminology for verbal communication.

D. Utilize safety alarms that are available on the unit.

ANS: D Feedback: Using safety alarms, such as bed alarms, can help prevent falls. Using SBAR and medical terminology improve staff communication. Scanning the client's armband and using two client identifiers ensure the nurse identifies the client correctly but do not prevent falls.

PTS: 1 REF: p. 943 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 5. The RN caring for a newly admitted client after central-line placement should complete which priority assessment?

A. Auscultate lung sounds bilaterally B. Reconcile all home medications C. Capillary refill of extremities D. Signs of infection at insertion site ANS: A Feedback: The nurse must evaluate the interventions provided for effectiveness and complications. For example, when a central line is placed, it can lead to pneumothorax, mortality, or a central line-associated bloodstream infection. Airway and breathing are always priority concerns; therefore the nurse should auscultate the lungs to assess for a pneumothorax and any breathing problems. Medication reconciliation is done on admission but is not priority over airway and breathing. Capillary refill is part of a complete assessment but not priority after central line placement. Infection at the insertion site is a potential problem and is not priority over airway and breathing.

PTS: 1 REF: p. 940 OBJ: 5 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 6. The RN working on a surgical unit should be prepared to question which of these orders?

A. Check intracranial pressure.

B. Change a central line dressing.

C. Administer a narcotic infusion.

D. Reapply a staple in an incision.

ANS: D Feedback: As a nurse, you are responsible for certain physiological NCLEX competencies as part of the RN scope of practice (N.C.S.B.N., 2017). Checking intracranial pressure, changing a central line dressing, and administering a prescribed narcotic infusion all fall within the RN's scope of practice. Applying sutures or staples is within a surgeon's or an APRN's scope of practice.

PTS: 1 REF: p. 941 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 7. The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action?

A. Confirm the client's identity with visitors who are present.

B. Ask the client for name and birth date, then administer the medications.

C. Scan the barcode on the client's chart, then administer the medications.

D. Leave the room to obtain another armband for the client.

ANS: D Feedback: The nurse should obtain another armband for the client; that's the safest action. Confirming identity with visitors does not meet national client safety standards.

Just asking the client for name and birth date means that the barcode system is bypassed; this is not necessary. The medications are scheduled, not emergent, so the nurse has time to get another armband and avoid a barcode override. Scanning the barcode on a chart does not ensure the client in the room is the right client. Another client could have wandered into this client's room.

PTS: 1 REF: p. 942-943 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice

8. The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

A. Hang the IV solution the client's assigned nurse left on the pole.

B. Obtain an IV bag of the current solution and hang it.

C. Review the client's prescribed medication orders.

D. Discontinue the current solution and disconnect it from the client.

ANS: C Feedback: The nurse should review the client's current orders to confirm which IV solution should be infused. Hanging the IV bag that was left on the pole is assuming that the assigned nurse hung the correct IV solution. Nurses should always verify orders themselves. Obtaining a bag of the current IV solution to hang is assuming, rather than verifying, as well. Discontinuing the solution is not necessary while verifying the orders.

PTS: 1 REF: p. 942-943 OBJ: 2 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 9. Which assessment finding on a hospitalized adult client requires urgent intervention?

A. Left-sided weakness after stroke that occurred 3 days ago B. 2+ dorsalis pedis pulse in left foot C. Urine output of 100 mL in 8 hours D. Oxygen saturation of 95% on room air ANS: C Feedback: An acute change in urine output less than 50 mL (about 1-3/4 oz) over 4 hours requires urgent intervention. Some weakness is expected after a stroke. +2 pulses are normal. An oxygen saturation of 95% is not a great cause for concern in an adult.

PTS: 1 REF: p. 945 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 10. A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action?

A. Administer another dose of morphine early.

B. Notify the healthcare provider.

C. Tell the client he/she can not have anymore pain medication.

D. Document the pain assessment findings and reassess in 30 minutes.

ANS: B

Feedback: Uncontrolled pain, especially after narcotic administration, requires urgent reassessment and intervention. Without an order to administer other pain medication, the nurse must notify the healthcare provider. Administering another dose of morphine outside current orders is outside the RN's scope of practice. The client may have another problem occurring that needs to be investigated and should not just be told that additional pain medication is not an option. For example, the client could be suffering from compartment syndrome, a complication compromising circulation and characterized by pain not relieved by pain medication.

PTS: 1 REF: p. 944-945 OBJ: 7 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 11. The RN notes the following assessment findings on a hospitalized older adult client admitted with a diagnosis of acute confusion and urinary tract infection: BP 131/75, P 70, RR 18, temp 97.2, oriented to person, place, time, and purpose; denial of urinary complaints. What is the nurse's next action?

A. Document the vital sign findings as abnormal.

B. Ensure the call bell is within reach before leaving the room.

C. Assess the client's level of consciousness.

D. Plan to reassess in 30 minutes.

ANS: B Feedback: All of the assessment are within expected ranges for an older adult; therefore no further immediate action is required but to ensure the call bell is within reach. The findings do need to be documented; however the vital signs are normal, not abnormal. If the client can answer questions appropriately to determine orientation to person, place, time, and purpose, the client is obviously awake and alert; the level of consciousness has already been assessed. Since the assessment findings are normal, there is no indication or need to reassess sooner than routine hourly rounds.

PTS: 1 REF: p. 946 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 12. The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?

A. Decrease to 44 beats/minute B. Decrease to 54 beats/minute C. Increase to 112 beats/minute D. Increase to 90 beats/minute ANS: A Feedback: Acute and urgent situations such as the following warrant immediate attention and interventions: Acute change in heart rate to fewer than 50 or greater than 120 beats per minute.

PTS: 1 REF: p. 945 OBJ: 6 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 13. The RN enters a hospitalized client's room and observes that bedside bronchoscopy equipment has been left at the bedside, the client's morphine analgesia unit is unlocked, and the client's respirations are 6 breaths/minute. The nurse administers the narcotic antidote. What is the nurse's next priority action?

A. Notify the hospital ethics board.

B. Call the rapid response team.

C. Complete an incident report.

D. Document the findings in the medical record.

ANS: B Feedback: The priority action is to assist the client's breathing by administering the narcotic antidote and notifying the rapid response team. The rapid response team will intervene during this critical period. By calling the rapid response team a group of providers will be summoned to the bedside to immediately assess and treat the client.

The incident does need to be reported and document; the hospital legal and ethics committee may be asked to review the incident. However, the priority action is to improve the client's physiological status.

PTS: 1 REF: p. 946 OBJ: 9 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 14. In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?

A. Document the highlights of the physical exam.

B. Place the completed assessment in the medical record.

C. File the admission database for nurse only access.

D. Omit the fall risk assessment since the client is a young adult.

ANS: B Feedback: The database should be placed in the medical record for access by all healthcare professionals who may need to review the client's information. The nurse should allow some time for documentation of findings and analysis of data. In addition to positive findings, it is essential to document absence of findings because, in the legal world, "if it's not documented, it's not done." The database should be completed in its entirety on admission. The client may be young, but an initial fall assessment score should be assessed.

PTS: 1 REF: p. 948 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care

TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 15. After collecting subjective and objective data for the admission database, what is the nurse's next action?

A. Set nurse-driven goals for the client.

B. Evaluate effectiveness of nursing actions.

C. Validate the client's identified problems.

D. Discuss the action plan with the client.

ANS: C Feedback: The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care can not be completed until the client's problems are validated and mutual goals are set.

PTS: 1 REF: p. 948 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. As a beginning nurse, how can abnormal assessment findings best be evaluated for the need for further investigation? (Select all that apply.)

A. Look for trends in declining status.

B. Consult with other healthcare providers.

C. Review diagnostic test results.

D. Ask for a more experienced nurse's opinion.

E. Adapt nursing interventions based on intuition.

ANS: A, B, C, D Feedback: The nurse should use clinical judgment to determine which data are most important. Initially, as a beginning nurse, you may need to consult with a more experienced nurse about which items to assess, but with experience typical patterns emerge. Adapt these assessments to the specific clients and practice area. By identifying trends of improving or declining status, treatment can be modified as necessary. You consult with other health care providers about the need for changes in the client's orders or further diagnostic testing. The beginning nurse usually has not yet developed a keen sense of nursing intuition.

PTS: 1 REF: p. 948 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 17. The nurse should use which assessment tool to assess the client's risk for skin breakdown?

A. Braden Scale B. Hendrich II C. Morse Scale D. VTE prophylaxis algorithm ANS: A Feedback: The Braden Scale or Norton Scale, or another skin assessment tool should be used to assess for skin breakdown risk factors according to hospital standard protocol.

The Hendrich II and Morse scale assess fall risk. Upon admission, clients are evaluated for venous thromboembolism (VTE) risk; but a separate skin assessment tool is used as well.

PTS: 1 REF: p. 949 OBJ: 8 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 18. The RN should intervene and further educate the nursing assistant when observing which action?

A. Independently pulling an immobile client up in bed B. Assisting feeding a client ground chicken with dentures in place C. Ambulating a client using a walker in the hallway D. Propping a client on the side using pillows under the hip, knees, and shoulder ANS: A Feedback: Friction/shear forces are risks to breaks in skin integrity that can occur when pulling a client up in bed alone. The nursing assistant needs to ask for assistance when repositioning an immobile client. Assisting with feeding or ambulating, and using pillows under bony prominences to prevent pressure ulcers are all appropriate nursing assistant tasks.

PTS: 1 REF: p. 951 OBJ: 2 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 19. A client in the emergency department is short of breath and at risk for becoming fatigued. While collecting the history, what is the nurse's best action?

A. Obtain a detailed and comprehensive history of symptoms.

B. Complete the general survey only on this client.

C. A physical assessment is all that is necessary at this time.

D. Ask the client's relatives about the client's history.

ANS: D

Feedback: The nurse may need to gather history from secondary sources such as the chart or relatives to avoid fatiguing the acutely ill client. Because a hospitalized client is more often sicker than nonhospitalized clients, the nurse would prioritize which data to collect related to the presenting problems and perform a basic screening of other body systems. The nurse uses clinical judgment about which items to include and which to omit. Adapt assessment techniques to the individual client situation. Priority history of the current symptoms is necessary besides just the physical assessment and general survey.

PTS: 1 REF: p. 947 OBJ: 4 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 20.

The nurse is caring for a client in a medical-surgical unit with acute abdominal pain and reviews the above orders. Which of the orders can the nurse delegate to the nursing assistant? (Select all that apply.)

A. Activity as tolerated, gait belt for ambulation B. Measure intake and output C. Complete blood cell count, stat D. Morphine IV, 0.5mg/kg/dose every 4 hours for pain E. Oxygen 2-4 liters nasal cannula, titrate to keep oxygen saturation above 90% ANS: A, B Feedback: The nurse can delegate basic needs, especially those associated with activities of daily living. Ambulating the client with a gait belt and measuring intake and output do not require the scope of the RN and can be delegated. Obtaining laboratory tests, giving intravenous medication, and titrating oxygen require nursing judgment.

PTS: 1 REF: p. 947 OBJ: 8 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 29: Assessment of the Hospitalized Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select

Chapter 30: Head-to-Toe Assessment of Adult 1. A student nurse asks the instructor why it is necessary to do a comprehensive health assessment on a new client. What would be the instructor's best response?

A. "A new client needs a more complete assessment."

B. "It is a better assessment than any other assessment."

C. "The comprehensive health assessment integrates all body systems and helps give the nurse an overall impression of the client's condition."

D. "You need to know what is going on with the client at that point in time."

ANS: C Feedback: The comprehensive health assessment integrates all body systems; findings help the nurse form an overall impression of the client and the client's condition. While many new clients do need more complete assessments, there are times when new clients first require emergency or focused assessments. Comprehensive assessments are not qualitatively better than focused or emergency assessments if used at inappropriate times or settings. A focused assessment is just as likely to help the nurse determine what is going on with the client at that point in time as a comprehensive assessment is.

PTS: 1 REF: p. 962 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Analyze NOT: Multiple Choice 2. When conducting a focused health assessment, the nurse asks questions specifically targeting the client's: A. culture.

B. gender.

C. sexual orientation.

D. specific issues and symptoms.

ANS: D Feedback: The nurse focuses questions on issues and symptoms specific to the client. In this way, the client is viewed as a person who has multiple things that are affected by the health status. These questions are related to the client's primary problems and concerns.

A focused assessment does not ask questions specifically about culture, gender, or sexual orientation.

PTS: 1 REF: p. 960 OBJ: 1 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Remember NOT: Multiple Choice 3. Students are learning about subjective data collection. What data are collected subjectively? (Select all that apply.)

A. Risk factors B. Common symptoms

C. Family history D. Auscultated sounds E. Visualized signs ANS: A, B, C Feedback: Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated sounds and visualized signs are part of objective data collection.

PTS: 1 REF: p. 960 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Select 4. When collecting subjective data, the nurse gives the client time and encouragement to do what?

A. Tell stories about his or her family B. Express complaints C. List common findings D. Tell about the client's concerns ANS: D Feedback: The nurse gives the client time and encouragement to tell their story and experience of health or illness. Doing so provides an opportunity for the client to express concerns; it often forms the foundation for a therapeutic relationship. Subjective data collection involves learning about the client's family history and health concerns, but the nurse would steer the conversation away from social discussions of the client's family or too many unrelated complaints. Common findings are part of objective data collection and are driven by the health provider, not the nurse.

PTS: 1 REF: p. 960 OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 5. A nursing instructor is explaining to students about primary prevention services that nurses offer as part of their professional responsibilities. What would the instructor list as these services?

A. Palpation B. Auscultation C. Screening D. Rehabilitation ANS: C Feedback: Screening and resulting teaching are primary prevention services that nurses offer as part of their professional responsibilities. Palpation and auscultation are techniques of physical examination. Rehabilitation is a tertiary prevention service.

PTS: 1 REF: p. 962 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Remember NOT: Multiple Choice 6. The nurse is assessing risk factors on a new clinic client. These risk factors are assessed according to what?

A. The individual's age B. The individual's risks C. The individual's gender D. The individual's lifestyle ANS: B Feedback: The nurse assesses risk factors according to the individual's risks (e.g., injury in a teenager, genetic diseases in a pregnant woman). All the remaining options have some component of the correct answer, but risk includes all those factors.

PTS: 1 REF: p. 968 OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 7. The nurse is conducting a head-to-toe assessment on a client. Which observation(s) by the nurse would be cause for concern? (Select all that apply.)

A. Freckles B. Rashes C. Goose bumps D. Lesions E. Infestations ANS: B, D, E Feedback: The nurse inspects the skin with each corresponding body area for rashes, lesions, or infestations (such as fleas or lice). Freckles and goose bumps would not be noted as a concern.

PTS: 1 REF: p. 971 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Select 8. While assessing a client's eyes, the nurse notes a depressed corneal response. In what type of client would this finding be considered normal?

A. A client with cataracts B. A client wearing of contact lenses C. A client with a history of macular degeneration D. A client who is blind

ANS: B Feedback: Depressed or absent corneal response is common in contact lens wearers. The conditions referenced in the other options are not associated with a depressed corneal response.

PTS: 1 REF: p. 972 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 9. The nurse is assessing an older adult client who complains about being "very tired" all the time. What is the best way to assess this client?

A. In a warm, well-lighted room B. Divided over several time periods C. Like all other clients D. Slowly in a draft-free room ANS: B Feedback: The older adult may fatigue easily and need to have the assessment divided over several time periods. A draft-free, warm, well-lighted room may be beneficial but is not the most correct answer for this scenario. The nurse would not assess this client like all other clients.

PTS: 1 REF: p. 985 OBJ: 1 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 10. When considering the culture of a client, the nurse would be aware that what is true in some cultures?

A. A health care provider of the same gender is preferred.

B. Only a male health care provider is acceptable.

C. A chaperone always has to be with the client.

D. A translator is always necessary.

ANS: A Feedback: In some cultures, clients prefer to have a health care provider of the same gender. None of the remaining options provide accurate information. The question does not indicate the gender of the client or that the client does not speak English. A chaperone might sometimes be necessary.

PTS: 1 REF: p. 970 OBJ: 5 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Caring BLM: Cognitive Level: Understand NOT: Multiple Choice

11. The nurse is palpating the abdomen of a client newly admitted to the unit. What would be an abnormal finding?

A. Softness B. Guarding C. Nonpalpable organs D. Nontender areas ANS: B Feedback: Abnormal findings on abdominal palpation are large masses, hardness, tenderness with guarding or rigidity, and rebound tenderness. The nurse would expect the abdomen to be soft and nontender, with generally nonpalpable organs.

PTS: 1 REF: p. 976 OBJ: 6 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice 12. When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this?

A. Popliteal pulses 1-2+ B. Popliteal pulses 2-3+ C. Popliteal pulses 3-4+ D. Popliteal pulses 4+ ANS: B Feedback: Correct documentation would be, "Popliteal pulses 2-3+." Therefore, the remaining options are incorrect.

PTS: 1 REF: p. 977 OBJ: 7 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 13. The nurse is caring for a client who fell from a two-story building and was brought to the emergency department by ambulance. Initial findings include asymmetry of the thorax and paradoxical respirations. The nurse would document these findings as what?

A. Flail chest B. Barrel chest C. Scoliosis D. Kyphosis ANS: A Feedback: Asymmetry and paradoxical respirations occur in flail chest. They do not occur in barrel chest, scoliosis, or kyphosis. Flail is an urgent acute condition, unlike the other options which are chronic in nature. Kyphosis and scoliosis are spinal conditions that result in spinal deformities. Barrel chest is a chronic condition found in chronic diseases such as COPD.

PTS: 1 REF: p. 978 OBJ: 7 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 14. A nurse is caring for a client with inflammatory bowel changes and has identified a nursing diagnosis of "Diarrhea related to inflammatory changes in the bowel." What would be an appropriate intervention for this diagnosis?

A. Use a heat or cold pack for pain relief.

B. Ensure adequate hydration and electrolyte replacements.

C. Provide periods of rest by clustering care.

D. Gather resources for home care and daily activities.

ANS: B Feedback: An appropriate intervention for diarrhea is to ensure adequate hydration and electrolyte replacements. Pain relief measures, rest, and home care resources would not be primary concerns in this case.

PTS: 1 REF: p. 981-982 OBJ: 8 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 15. A new client presents at the clinic and reports difficulty hearing. During the interview, the client asks the nurse to repeat questions several times. Examination of the ears reveals large amounts of cerumen filling the canals bilaterally. What would be an appropriate outcome for this client?

A. The client will return to the clinic every two months to have ears cleaned B. The client will learn to safely clean ears with cotton swabs C. Ears will be cleaned at the clinic with hearing improved D. The client will clean ears at home ANS: C Feedback: The appropriate outcome is for ears to be cleaned with correct technique at the clinic and the client subsequently reporting improved hearing. "The client will return to the clinic every two months to have ears cleaned" represents an outcome that is too vague. Cotton swabs should not be used to clean the ears. If the client was capable of correctly cleaning the ears at home, the client would not have wound up with the problem necessitating the clinic visit.

PTS: 1 REF: p. 973 OBJ: 3 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 16. What type of assessment would a nurse perform on a client being admitted to the hospital?

A. Screening B. Focused C. Acute D. Comprehensive ANS: D Feedback: The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay. "Acute" is not a term commonly used to describe a type of assessment.

PTS: 1 REF: p. 960-962 OBJ: 1 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice 17. The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

A. Assess blood pressure.

B. Check for pupil reaction.

C. Ensure a patent airway.

D. Count respirations.

ANS: C Feedback: If skin color is cyanotic or pale, breathing is difficult, posture is strained, facial expression is anxious, and overall appearance indicates distress, focus on the immediate problem. Airway, breathing, circulation should be assessed first for a client in distress.

PTS: 1 REF: p. 960 OBJ: 6 NAT: Client Needs: Safe, Effective Care Environment: Management of Care TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Choice 18. The nurse is assessing a client who has a radial pulse of 138 beats per minute. What action should the nurse take?

A. Obtain the apical pulse for one full minute.

B. Notify the health care provider.

C. Assess the pedal pulses bilaterally.

D. Document bradycardia.

ANS: A Feedback: When obtaining vital signs, if the pulse is irregular the apical pulse should be taken for one full minute before notifying the physician. The pulse would be described as tachycardia, not bradycardia. Assessing the pedal pulses bilaterally is important but is not the priority.

PTS:

1

REF: p. 970

OBJ: 6

NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice 19. The nurse is caring for an older adult client with a blood pressure of 186/98 mm Hg. The client asks, "What is happening to me?" Which of the following is the best response by the nurse?

A. "Your blood pressure is elevated, so we should talk more after I complete your assessment."

B. "You are an older adult so it's normal to have high blood pressure."

C. "You need to eliminate salt from your diet right away."

D. "How often do you have blurred vision and numbness and tingling?"

ANS: A Feedback: It's important to be honest when data are abnormal, and this is best represented by the statement, "Your blood pressure is elevated, so we should talk more after I complete your assessment." The nurse should avoid false reassurances such as, "You are an older adult so it's normal to have high blood pressure." The nurse should provide objective data and avoid making statements like, "You need to eliminate salt from your diet" without all of the data being collected first. Although blood pressure may increase with age, the blood pressure described in the question is alarmingly high and will need to be addressed without upsetting the client. The client may become upset if the nurse continues to ask questions without responding to the client's concern first.

PTS: 1 REF: p. 971 OBJ: 5 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level: Apply NOT: Multiple Choice 20. After performing a physical assessment, the nurse recognizes that which of the following findings should be shared with the health care provider as soon as possible?

A. Positive Babinski sign B. Capillary refill in index finger less than 3 seconds C. Aorta palpable, smooth D. Deep tendon reflexes 3+ bilaterally ANS: A Feedback: A positive Babinski sign is indicative of a possible poor neurological outcome and the health care provider should be notified immediately. The other findings are within defined limits and are expected findings.

PTS: 1 REF: p. 978 OBJ: 6 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 30: Head-to-Toe Assessment of the Adult KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice