Chapter 7 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 7

Question 1

Type: MCSA

The nurse is entering the room to assess a newly admitted client. Which of the following best describes the purpose for a general survey? The general survey:

1. allows for vital signs prior to starting exam.

2. provides an opportunity for the client to relax before the exam.

3. yields information to guide the physical assessment.

4. provides the information necessary for the diagnosis.

Correct Answer: 3

Rationale 1: Vital signs are not part of the general survey. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior.

Rationale 2: The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax.

Rationale 3: The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment.

Rationale 4: The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment.

Global Rationale: The general survey allows the nurse to observe the client and gain clues to guide the remainder of the assessment. Vital signs are not part of the general survey. The purpose of the general survey is to allow the nurse the opportunity to gather clues to guide the rest of the assessment; the purpose is not to give the client an opportunity to relax. The general survey consists of four major observations: physical appearance, mental status, mobility, and behavior. The general survey does not provide the necessary information to identify client problems or nursing diagnosis, but rather serves as a guide for a more detailed assessment.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Describe the general survey as part of a comprehensive health assessment.

Question 2

Type: MCSA

The nurse observes the client walking into the room and climbing up on the exam table. The nurse notes this activity as a way to obtain data related to which of the following?

1. The clients mobility status

2. Subjective assessments related to ambulation

3. Activity tolerance

4. Strength of upper and lower extremities

Correct Answer: 1

Rationale 1: During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the clients mobility. These data will then be incorporated into the remainder of exam and history.

Rationale 2: Observation is an objective assessment.

Rationale 3: Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior.

Rationale 4: Watching the client walk and sit gives the nurse information about the strength of a clients lower extremities, but tells the nurse nothing about the clients upper extremity strength.

Global Rationale: During a general survey, the nurse observes the client performing routine activities, such as walking and sitting. This allows the nurse to begin to gather data about the clients mobility. These data will then be incorporated into the remainder of exam and history. Observation is an objective assessment. Activity tolerance is not a component of the general survey. The general survey consists of physical appearance, mental status, mobility, and behavior. Watching the client walk and sit gives the nurse information about the strength of a clients lower extremities, but tells the nurse nothing about the clients upper extremity strength.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.1: Describe the general survey as part of the comprehensive health assessment.

Question 3

Type: MCMA

The nurse is assessing an adult client. Which of the following observations should the nurse include when documenting the general survey of this client?

Standard Text: Select all that apply.

1. Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16.

2. Thin, well-nourished male client, appears younger than stated age.

3. Client moves about exam room without difficulty.

4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation.

5. Responds appropriately to questions.

Correct Answer: 2,3,5

Rationale 1: Blood pressure 112/68, pulse 68, 98.6 (F), respiratory rate 16. The vital signs are objective information, but not part of the actual general survey.

Rationale 2: Thin, well-nourished male client, appears younger than stated age. The general survey is composed of 4 major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the clients physical appearance, one of the components of the general survey.

Rationale 3: Client moves about exam room without difficulty. The documentation client moves about exam room without difficulty describes the clients overall mobility, another component of the general survey.

Rationale 4: Abdomen flat, nondistended, bowel sounds present, nontender on palpation. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey.

Rationale 5: Responds appropriately to questions. The documentation responds appropriately to questions comments on the nurses observations regarding the clients behavior and mental status, 2 other components of the general survey.

Global Rationale: The general survey is composed of 4 major categories of observation: physical appearance, mental status, mobility, and behavior of the client. The documentation thin, well-nourished male client, appears younger than stated age reflects the clients physical appearance, one of the components of the general survey. The documentation client moves about exam room without difficulty describes the clients overall mobility, another component of the general survey. The documentation responds appropriately to questions comments on the nurses observations regarding the clients behavior and mental status, 2 other components of the general survey. The vital signs are objective information, but not part of the actual general survey. The documentation abdomen flat, nondistended, bowel sounds present, nontender on palpation is specific to the abdominal assessment and not part of the general survey.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.2: Identify components of the general survey.

Question 4

Type: MCSA

The nurse is preparing to assess a clients mental status within the general survey. Which of the following should the nurse use to assess this status?

1. Note the number of times the client looks to significant other while answering interview questions.

2. Ask the client to describe elements of his health history.

3. Study the clients clothing selections.

4. Notice the clients ability to make eye contact during the examination.

Correct Answer: 2

Rationale 1: Observing the client walking into the examination room would help assess mobility.

Rationale 2: The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status.

Rationale 3: Studying the clients clothing selections would help assess physical appearance.

Rationale 4: Noticing the clients ability to make eye contact would help assess client behavior.

Global Rationale: The general survey is composed of four major categories of observation: physical appearance, mental status, mobility, and client behavior. Asking the client to describe elements of his health history would help assess mental status. Observing the client walking into the examination room would help assess mobility. Studying the clients clothing selections would help assess physical appearance. Noticing the clients ability to make eye contact would help assess client behavior.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.2: Identify parts of the general survey.

Question 5

Type: MCSA

During an interview with an older adult client, the nurse notes the client is confused as to day and time. The nurse would document this finding as an indicator of which of the following?

1. Affect and mood

2. Orientation

3. Willingness to cooperate

4. Level of anxiety

Correct Answer: 2

Rationale 1: The clients affect and mood are revealed through speech, body language and facial expression.

Rationale 2: Clients ability to state name, location, and the date and time of day assesses orientation to person, place, and time.

Rationale 3: The client was not uncooperative, but rather confused to day and time.

Rationale 4: Like affect and mood, the clients level of anxiety is revealed through speech, body language and facial expression.

Global Rationale: Clients ability to state name, location, and the date and time of day assesses orientation to person, place, and time. The clients affect and mood are revealed through speech, body language and facial expression. The client was not uncooperative, but rather confused to day and time. Like affect and mood, the clients level of anxiety is revealed through speech, body language and facial expression.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.2: Identify components of the general survey.

Question 6

Type: MCSA

The nurse is obtaining the initial vital signs on a client in the emergency room with seizure activity of unknown etiology. The nurse should choose which of the following methods to obtain the most accurate reading of the clients temperature?

1. Axillary

2. Oral

3. Rectal

4. Tympanic

Correct Answer: 3

Rationale 1: Although axillary is the safest, it is also the least accurate.

Rationale 2: Measuring the temperature orally requires the clients cooperation, which is not possible during seizure activity.

Rationale 3: A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth.

Rationale 4: Measuring the temperature tympanically requires the clients cooperation, which is not possible during seizure activity.

Global Rationale: A rectal temperature should be taken if the client is comatose, confused, having seizures, or unable to close the mouth. Although axillary is the safest, it is also the least accurate. Both oral and tympanic require the clients cooperation in order to maintain safety, which is not possible during seizure activity.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 7

Type: HOTSPOT

The nurse is assessing a clients left femoral pulse. Identify the area on the diagram below where the nurse would locate this pulse.

Screen Shot 2015-09-24 at 11.44.59 AM

Standard Text: Select the correct area on the image.

Screen Shot 2015-09-24 at 11.45.59 AM

Correct Answer:

Rationale : The nurse would palpate the left femoral pulse over the left femoral artery of the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 8

Type: MCSA

The nurse is caring for a pediatric client and needs to obtain vital signs. Which of the following route and sequence will the nurse use to obtain vital signs on a healthy newborn?

1. Rectal temperature, respirations, pulse rate

2. Respirations, pulse rate, blood pressure, rectal temperature

3. Respirations, apical pulse rate, axillary temperature

4. Oral temperature, respirations, pulse rate, blood pressure

Correct Answer: 3

Rationale 1: The temperature should be taken last, as it may cause the infant to cry, altering the rate of respirations and pulse.

Rationale 2: A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of 2.

Rationale 3: Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the temperature. The rectal temperature is the most accurate; however an axillary temperature is appropriate since it can lead to rectal perforation.

Rationale 4: Oral temperatures are not used for temperature measurement in children under the age of 5.

Global Rationale: Respirations should be assessed first in the assessment of a newborn, followed by the apical pulse, and finally the infants temperature. While the rectal temperature is the most accurate, there is risk of rectal perforation. This question addresses a healthy newborn; therefore an axillary temperature is appropriate. The temperature (any route) should be assessed last, as it may cause the infant to cry, altering the rate of respirations and pulse. A blood pressure is not a routine vital sign obtained on a healthy infant. If a blood pressure is done, a Doppler stethoscope is used in infants and children under the age of 2. Oral temperatures are not used for temperature measurement in children under the age of 5.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 9

Type: MCSA

A young adult client presents to the clinic complaining of a sore throat, swollen glands, and fever following oral surgery for extraction of impacted wisdom teeth. In order to complete the initial assessment of this client, the nurse needs to obtain the clients temperature. Which method should the nurse choose for this assessment?

1. Oral

2. Tympanic

3. Rectal

4. Axillary

Correct Answer: 2

Rationale 1: The nurse would not want to use the oral route for this client since the client has recently had oral surgery.

Rationale 2: The nurse should take the clients temperature using a tympanic thermometer. Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using the ear for temperature assessment is quick, noninvasive, and reliable.

Rationale 3: A rectal temperature is invasive and unnecessary in the assessment of this clients temperature.

Rationale 4: The axillary route is sometimes used in the temperature assessment of infants and children. It is considered the least accurate method of measurement.

Global Rationale: The nurse should take the clients temperature using a tympanic thermometer. Infection may be a concern in this client; therefore, an accurate temperature is necessary. Using the ear for temperature assessment is quick, noninvasive, and reliable. The nurse would not want to use the oral route for this client since the client has recently had oral surgery. A rectal temperature is invasive and unnecessary in the assessment of this clients temperature. The axillary route is sometimes used in the temperature assessment of infants and children. It is considered the least accurate method of measurement.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 10

Type: MCSA

While assessing an adult clients pulse, the nurse notes an irregular rate. The nurse should assess the pulse by counting the beats for:

1. 2 minutes.

2. 1 minute.

3. 30 seconds and multiply by 2.

4. 15 seconds and multiply by 4.

Correct Answer: 2

Rationale 1: It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute.

Rationale 2: With any irregular pulse, the rate needs to be counted for 1 full minute.

Rationale 3: If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2.

Rationale 4: Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore should not be used in assessing the rate.

Global Rationale: With any irregular pulse, the rate needs to be counted for 1 full minute. It is not necessary for the nurse to count the pulse for 2 minutes, as heart rate is expressed in beats per minute. If the pulse is regular, the nurse may count the beats for 30 seconds and multiply by 2. Counting for 15 seconds and multiplying by 4 may not yield an accurate result, and therefore should not be used in assessing the rate.

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 11

Type: MCSA

The nurse educator is preparing an inservice on pain management for the staff. One of the staff nurses asks, What is the most important part of a pain assessment? How should the nurse educator respond to this question?

1. Pain is only partially subjective and primarily a physiologic experience, so vital signs are the most important assessment.

2. A clients response to pain is always based on the underlying cause, so the clients admitting diagnosis is important.

3. Vital signs are not reliable indicators of acute pain, because only some clients are able to elicit a change in blood pressure or pulse rate.

4. The response to pain is unique and based on numerous factors, which need to be assessed.

Correct Answer: 4

Rationale 1: Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience and no two people experience pain in the same way. A patients level of pain cannot be determined by his physiologic response only.

Rationale 2: Pain is unique to each person and may be experienced differently by clients with the same diagnosis.

Rationale 3: Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates.

Rationale 4: Pain is a subjective experience, and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status.

Global Rationale: Pain is a subjective experience, and the response is unique to each individual. The factors that impact the response are numerous and include age, sex, culture, and developmental level, as well as previous experience with pain and health status. Vital signs are only a portion of the pain assessment. The nurse must consider many factors since pain is an individual experience and no two people experience pain in the same way. A patients level of pain cannot be determined by his physiologic response only. Pain is unique to each person and may be experienced differently by clients with the same diagnosis. Vital signs can be indicators of pain. In the early stages of acute pain, the sympathetic nervous system is stimulated, causing increases in blood pressure, pulse, and respiratory rates.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.3: Measure vital signs.

Question 12

Type: FIB

During the assessment of an adult clients blood pressure, the nurse notes the following on the sphygmomanometer: first faint tapping sounds at 136, swishing sounds at 120, clear tapping sounds at 108, muffled sounds at 98, and silence at 76. This nurse would document this clients blood pressure as_____________.

Standard Text:

Correct Answer: 136/76

Rationale : The sounds above are the 5 phases of Korotkoffs sounds. The first sound heard (Phase 1) is recorded as the systolic blood pressure. This is when the blood pressure cuff has been released just enough to allow the first spurts of blood to pass through the artery. Phase 2 is marked by the period in which the sounds change from tapping to swishing; blood flows turbulently through the artery. Phase 3 is when blood flows through the artery during systole but collapses during diastole; the sounds are crisp and tapping. During Phase 4, the sounds become muffled and have a soft blowing quality. The pressure in the cuff does not completely collapse the artery in any part of the cardiac cycle. The diastolic blood pressure is marked by the beginning of silence (Phase 5). This is when the cuff no longer collapses the artery, and blood is free flowing through the artery.

Global Rationale:

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 13

Type: MCSA

The nurse is assessing a 15-month-old baby. The nurse should assess this babys pulse rate by using the:

1. Radial artery.

2. Brachial artery.

3. Apical site.

4. Carotid artery.

Correct Answer: 3

Rationale 1: In older children and adults, the radial artery is used to assess the pulse.

Rationale 2: In preschool children, the brachial artery is used to assess the pulse.

Rationale 3: The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age.

Rationale 4: The carotid pulse is assessed in adult clients as part of the cardiovascular assessment.

Global Rationale: The apical site is the site of choice to assess the pulse rate of a child who is under 2 years of age. In preschool children, the brachial artery is used to assess the pulse. In older children and adults, the radial artery is used to assess the pulse. The carotid pulse is assessed in adult clients as part of the cardiovascular assessment.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 14

Type: MCMA

The nursing instructor is observing the student nurse take a blood pressure on an older adult client. The nursing instructor intervenes when the student nurse is observed doing which of the following?

Standard Text: Select all that apply.

1. The student nurse ushers the client into the exam room and immediately assesses the clients blood pressure.

2. The student nurse places the blood pressure cuff on the clients arm over a lightweight, long-sleeved sweater.

3. The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure.

4. The student nurse has the client sit in a chair and supports the clients arm on a table at the level of the heart.

5. The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery.

Correct Answer: 1,2,3

Rationale 1: The student nurse ushers the client into the exam room and immediately assesses the clients blood pressure. The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading.

Rationale 2: The student nurse places the blood pressure cuff on the clients arm over a lightweight, long-sleeved sweater. The clients blood pressure should be assessed on a bare arm. If the client is wearing a long sleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve.

Rationale 3: The student nurse immediately reinflates the cuff after identifying the palpatory systolic blood pressure. Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 1530 seconds before inflating the cuff again.

Rationale 4: The student nurse has the client sit in a chair and supports the clients arm on a table at the level of the heart. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up.

Rationale 5: The student nurse places the blood pressure cuff on the thigh of a client with a bilateral mastectomy and takes the blood pressure using the popliteal artery. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery.

Global Rationale: The client should sit quietly for at least 5 minutes before the blood pressure is taken. Immediately assessing the blood pressure after a client walks from the waiting room to exam room may not yield an accurate reading. The clients blood pressure should be assessed on a bare arm. If the client is wearing a long-sleeved garment and it can be pushed up without constricting the arm, this is acceptable; otherwise the arm should be removed from the sleeve.
Once the cuff is inflated and the nurse identifies the palpatory systolic blood pressure, the nurse should wait at least 1530 seconds before inflating the cuff again. In order to obtain an accurate blood pressure, the client should be seated with the arm slightly flexed, supported at the level of the heart with palm facing up. Clients who have suffered trauma to the upper extremities, have shunts in the upper extremities, or have had mastectomies should not have their blood pressures assessed on the affected sides. The nurse can place the blood pressure cuff on the thigh and assess the blood pressure using the popliteal artery.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.3: Measure vital signs.

Question 15

Type: MCSA

The nurse is assessing a toddler when the childs mother tells the nurse that the child has had a fever for the past two days. When the nurse asks the mother what the temperature has been, the mother replies that she hasnt actually taken it but the childs skin has felt very warm. Which of the following would be the most appropriate response for the nurse?

1. When our skin feels warm, it means our blood vessels are constricted.

2. The only reliable indicator of body temperature is by feeling the forehead.

3. Our skin temperature changes when our surroundings change temperature.

4. The temperature of the skin is not related to what is happening inside our bodies.

Correct Answer: 3

Rationale 1: Fever causes vasodilation, not vasoconstriction.

Rationale 2: When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer.

Rationale 3: The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed.

Rationale 4: The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch.

Global Rationale: The surface temperature of the body is constantly changing in response to environmental influences and as a result is not a reliable indicator of actual health status. To obtain accurate temperature, the core temperature, or the temperature of the deep tissues of the body, needs to be assessed. Fever causes vasodilation, not vasoconstriction. When fever is present, the skin all over the body may feel warm, not just the forehead, thus the only reliable indicator of body temperature is measuring the core temperature with a thermometer. The temperature of the skin is related to what is happening inside the body. Fever is a sign of the disruption of homeostasis in the body. This may be due to a bacterial or viral infection. Fever causes vasodilation, which can make the skin feel warm to the touch.

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 16

Type: MCMA

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98. The nurse understands that the following factors may be applicable in this situation.

Standard Text: Select all that apply.

1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood.

2. Arteriosclerosis increases blood vessel elasticity.

3. Arteriosclerosis decreases blood vessel compliance.

4. Age decreases blood vessel elasticity.

5. Arteriosclerosis plays no role in the blood pressure of this client.

Correct Answer: 3,4

Rationale 1: Arteriosclerosis decreases the ventricular force necessary for ejection of blood. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure.

Rationale 2: Arteriosclerosis increases blood vessel elasticity. Arteriosclerosis decreases the elasticity of the arteries.

Rationale 3: Arteriosclerosis decreases blood vessel compliance. Arteriosclerosis results in hardened and rigid arteries, which are less compliant.

Rationale 4: Age decreases blood vessel elasticity. Elasticity of blood vessels decreases with age and also leads to increased blood pressure.

Rationale 5: Arteriosclerosis plays no role in the blood pressure of this client. Arteriosclerosis plays no role in the blood pressure of this client.

Global Rationale: Arteriosclerosis results in hardened and rigid arteries, which are less compliant. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure. Arteriosclerosis decreases the elasticity of the arteries. Arteriosclerosis has a direct effect on blood pressure; decreased elasticity and compliance is directly related to the increase in blood pressure.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 17

Type: MCSA

The nurse needs to take a blood pressure on a very thin client, and the only cuff available is a standard size. The nurse would anticipate which of the following readings?

1. An accurate reading

2. A falsely elevated reading

3. The reading will depend on the overall health of the client

4. A false low reading

Correct Answer: 4

Rationale 1: In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result.

Rationale 2: When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated.

Rationale 3: While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment.

Rationale 4: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the clients arm. The length of the bladder should equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the circumference of the limb.

Global Rationale: In this situation, the bladder of the cuff is too wide, resulting in the blood pressure reading being falsely low. To obtain accurate blood pressure readings, it is imperative that the nurse select the proper cuff. The bladder of the blood pressure cuff must be an appropriate fit in both length and width for the clients arm. The length of the bladder should equal 80% of the circumference of the limb. The width of the bladder should equal 40% of the circumference of the limb. In a very thin client, a small (or even pediatric) blood pressure cuff should be used to obtain an accurate reading. Using a standard cuff on this client will yield a falsely low result. When the bladder of the cuff is too narrow, the blood pressure reading will be falsely elevated. While the reading will depend on the overall health of the client, it is important to obtain an accurate reading by using the proper equipment.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.4: Discuss the factors that affect vital signs.

Question 18

Type: MCSA

The nurse is caring for a client diagnosed with breast cancer, who underwent a left-sided mastectomy two days prior. The nurse has delegated vital signs on this client to the patient care assistant (PCA). What specific instructions should the nurse provide to the (PCA) in delegating this task?

1. Take the blood pressure on the right arm.

2. No special instructions are needed.

3. Take the blood pressure on the left arm.

4. Take the blood pressure on both arms for a baseline.

Correct Answer: 1

Rationale 1: The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained.

Rationale 2: The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings.

Rationale 3: The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures.

Rationale 4: It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made.

Global Rationale: The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained. The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings. The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made.

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 19

Type: MCSA

A young adult client notes height as 5 feet 11 inches and weight as 200 lbs. Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. The nurse identifies the most likely reason for this discrepancy between the clients self-reported height and weight and the objective information indicates:

1. The client does not have a scale at home.

2. The client may have a image of self inconsistent with actual findings.

3. The client did not want to tell the truth.

4. The client is trying to hide a chronic illness.

Correct Answer: 2

Rationale 1: The best reason for the inconsistency is the client has a different image of himself than what is objectively measurable.

Rationale 2: The nurse has no way of knowing if the client has a scale at home and does not account for the discrepancy in height.

Rationale 3: The inconsistency between reported height and weight and actual height and weight does not mean the client is being untruthful; it is what the client believes to be true.

Rationale 4: The inconsistency between reported height and actual height and weight does not indicate that the client is trying to hide a chronic illness.

Global Rationale: The best reason for the inconsistency is the client has a different image of himself than what is objectively measurable. The nurse has no way of knowing if the client has a scale at home and does not account for the discrepancy in height. The inconsistency between reported height and weight and actual height and weight does not mean the client is being untruthful; it is what the client believes to be true. The inconsistency between reported height and actual height and weight does not indicate that the client is trying to hide a chronic illness.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 20

Type: MCSA

During the evening assessment of a febrile client admitted to the nursing unit with abdominal pain, the nurse assesses a lower than normal blood pressure and a rapid pulse. These findings suggest to the nurse that the client may be experiencing:

1. anxiety.

2. an abdominal infection.

3. a medication reaction.

4. a diurnal variation

Correct Answer: 2

Rationale 1: The physiologic response to anxiety is increased heart rate and increased blood pressure.

Rationale 2: The lowered blood pressure and increased heart rate in a febrile client with abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an increase in heart rate.

Rationale 3: There is no information to suggest that the client is experiencing a reaction to medication.

Rationale 4: Diurnal variation of blood pressure is exhibited by lower morning blood pressure that increases throughout the day.

Global Rationale: The lowered blood pressure and increased heart rate in a febrile client with abdominal pain is suggestive of infection. Fever causes vasodilation, which in turn causes an increase in heart rate. The physiologic response to anxiety is increased heart rate and increased blood pressure. There is no information to suggest that the client is experiencing a reaction to medication. Diurnal variation of blood pressure is exhibited by lower morning blood pressure that increases throughout the day.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7.4: Discuss the factors that affect vital signs.

Question 21

Type: MCSA

An older adult client says to the nurse, Im gaining weight around my middle and my legs look like chicken legs. An appropriate response by the nurse to this client is:

1. Older people often put on weight around the middle, but lose muscle in the legs, making the legs appear thinner. This is normal.

2. Have you been doing any exercises to slim down your middle?

3. This is very unusual. I will let the healthcare provider know.

4. Lets talk about your diet to see why youre gaining weight around your middle.

Correct Answer: 1

Rationale 1: Older adults experience a decrease in overall muscle mass and they lose subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the abdomen and hips. This is a normal occurrence in the older adult client.

Rationale 2: While exercise is important for overall health and the client should be encouraged to participate in 30 minutes of exercise on most days, this is a normal occurrence in the older adult and this should be explained to the client.

Rationale 3: This is not an unusual finding in an older adult client. It is not necessary to alert the healthcare provider.

Rationale 4: Excessive calorie intake would lead to weight gain all over the body, not just the middle.

Global Rationale: Older adults experience a decrease in overall muscle mass and they lose subcutaneous fat in the face forearms and legs; however, there is an increase in fat deposits in the abdomen and hips. This is a normal occurrence in the older adult client. While exercise is important for overall health and the client should be encouraged to participate in 30 minutes of exercise on most days, this is a normal occurrence in the older adult and this should be explained to the client. This is not an unusual finding in an older adult client. It is not necessary to alert the healthcare provider. Excessive calorie intake would lead to weight gain all over the body, not just the middle.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 22

Type: MCSA

The night nurse is reviewing the vital signs of a client in an extended care facility. The nurse notes the clients oral temperature at 6 a.m. was 98.0F, but that evening, the clients oral temperature was 99.2F. The nurse suspects that this variation in temperature is indicative of:

1. The clients temperature has been improperly assessed either in the morning or evening; the nurse cant be sure which.

2. The client is developing an infection.

3. The client is experiencing stress.

4. The clients temperature is demonstrating diurnal variations.

Correct Answer: 4

Rationale 1: The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day.

Rationale 2: There is no evidence to suggest the temperatures were incorrectly assessed and the same routes were used for both assessments.

Rationale 3: There is no evidence to suggest that the client is developing an infection other than the higher evening body temperature.

Rationale 4: There is nothing to suggest that this client is under a great deal of stress which may elevate body temperature.

Global Rationale: The difference in body temperature is evidence of diurnal variation. Core body temperature is lowest during the early morning and becomes higher during the course of the day. There is no evidence to suggest the temperatures were incorrectly assessed and the same routes were used for both assessments. There is no evidence to suggest that the client is developing an infection other than the higher evening body temperature. There is nothing to suggest that this client is under a great deal of stress, which might elevate body temperature.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 23

Type: MCMA

A nurse has been asked to present a program on blood pressure for a group of adults at a community center. Which of the following true statements should the nurse incorporate into the presentation?

Standard Text: Select all that apply.

1. Females tend to have higher blood pressure readings than males of the same age.

2. Middle-aged African American males tend to have higher blood pressures than American males of European descent.

3. Stress can result in an increase in blood pressure.

4. Blood pressure readings tend to be lowest in the evening.

5. During physical activity, blood pressure decreases.

Correct Answer: 2,3

Rationale 1: Females tend to have higher blood pressure readings than males of the same age. After puberty, females tend to have lower blood pressure readings than males of the same age.

Rationale 2: Middle-aged African American males tend to have higher blood pressures than American males of European descent. African American males over the age of 35 tend to have higher blood pressure readings than American males of European descent.

Rationale 3: Stress can result in an increase in blood pressure. Stress increases cardiac output and arterial vasoconstriction, resulting in increased blood pressure.

Rationale 4: Blood pressure readings tend to be lowest in the evening. Blood pressure is sensitive to diurnal variations; blood pressure is lower in the morning and peaks in the late afternoon.

Rationale 5: During physical activity, blood pressure decreases. During physical activity, blood pressure increases due to the increase in cardiac output.

Global Rationale: African American males over the age of 35 tend to have higher blood pressure readings than American males of European descent. Stress increases cardiac output and arterial vasoconstriction, resulting in increased blood pressure. After puberty, females tend to have lower blood pressure readings than males of the same age. Blood pressure is sensitive to diurnal variations; blood pressure is lowest in the morning and peaks in the late afternoon. During physical activity, blood pressure increases due to the increase in cardiac output.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.4: Discuss factors that affect vital signs.

Question 24

Type: MCMA

A client presents to the primary care clinic and is disheveled in appearance, with stained, dirty clothing, body odor, and uncombed hair. Based on this observation, which of the following should the nurse assess during the history and physical exam?

Standard Text: Select all that apply.

1. Occupation

2. Depression

3. Smoking history

4. Self-concept

5. Immunization status

Correct Answer: 1,2,4

Rationale 1: Occupation. The way a client dresses and maintains physical hygiene may provide clues to the clients occupation (perhaps the client has a physical job and has just come from work).

Rationale 2: Depression. The way a client dresses and maintains physical hygiene may provide clues to the state of the clients mental health.

Rationale 3: Smoking history. The clients disheveled appearance does not directly clue the nurse to explore the clients smoking history. Clues that would lead the nurse to fully explore the clients smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough.

Rationale 4: Self-concept. The way a client dresses and maintains physical hygiene may provide clues to the clients sense of self-esteem and body image.

Rationale 5: Immunization status. The observations made by the nurse do not clue the nurse to assess the clients immunization status.

Global Rationale: The way a client dresses and maintains physical hygiene may provide clues to a variety of things, such as what the client does for a living (perhaps the client has a physical job and has just come from work), the clients sense of self-esteem and body image, as well as be an indicator of mental illness, anxiety, or depression. The clients disheveled appearance does not directly clue the nurse to explore the clients smoking history. Clues that would lead the nurse to fully explore the clients smoking history would include the smell of smoke on the client, the discoloration of the fingers from tobacco, hoarseness of the voice, and/or a cough. The observations made by the nurse do not clue the nurse to assess the clients immunization status.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 25

Type: MCSA

The nurse is doing a general survey on an infant for a well-child check. During the survey, the baby has a liquid stool. The mother becomes very angry and asks the nurse to change the diaper because she just cant deal with the odor. This response is important to the nurse because:

1. the child may have an illness causing diarrhea.

2. it may be a reflection of the mother-child relationship.

3. the mother may be feeding the child a poor diet.

4. the child may have an illness that is increasing the odor of stool.

Correct Answer: 2

Rationale 1: The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mothers response is inappropriate.

Rationale 2: Observation of the interaction between the child and mother can provide information suggestive of child abuse. The mothers demonstration of disgust with any aspect of childs behavior or such things as odor or stool can be clues that there may be a problem with the relationship and should be evaluated further.

Rationale 3: The loose stool may be the result of the childs diet; however, the mothers response is inappropriate.

Rationale 4: The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mothers response is inappropriate.

Global Rationale: Observation of the interaction between the child and mother can provide information suggestive of child abuse. The mothers demonstration of disgust with any aspect of childs behavior or such things as odor or stool can be clues that there may be a problem with the relationship and should be evaluated further. The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mothers response is inappropriate. The loose stool may be the result of the childs diet; however, the mothers response is inappropriate. The loose stool may be a sign of illness; however, there is not enough information to determine if the child is ill, and the mothers response is inappropriate.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 26

Type: MCSA

The nursing assistant brings the nurse the following vital signs for an older adult client: Temperature 97.4F (oral), BP 165/70, Pulse Rate 84/min, and Respirations 28. After reviewing the vital signs, the nurse should do which of the following?

1. Continue to monitor the client.

2. Tell the nursing assistant to recheck the temperature.

3. Obtain an order for an antihypertensive.

4. Obtain an order for oxygen therapy.

Correct Answer: 1

Rationale 1: Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time.

Rationale 2: The temperature is within a normal range for this client; there is no need to recheck the temperature.

Rationale 3: While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this clients blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated.

Rationale 4: The clients vital signs are within a normal range; there is no indication for oxygen therapy.

Global Rationale: Normal variations in vital signs occur with aging. Body temperature may be decreased due to a decrease in the thermoregulatory control and loss of subcutaneous fat. The pulse rate remains within the normal range of 60 to 100 BPM. A decrease in vital capacity and inspiratory reserve volume may result in an increased respiratory rate. Because systemic arteries lose elasticity with aging, the heart has greater resistance to pump against, which can result in an increased systolic blood pressure. No interventions are needed at this time. The temperature is within a normal range for this client; there is no need to recheck the temperature. While the systolic blood pressure reading is higher than the upper limit of normal, one elevated reading of 165 systolic is not an indication for antihypertensive therapy. The nurse should continue to monitor this clients blood pressure and alert the healthcare provider if the systolic blood pressure remains elevated. The clients vital signs are within a normal range; there is no indication for oxygen therapy.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 27

Type: MCSA

The nurse is obtaining the height and weight of an older adult client. The client asks why the height is 1 inch less than last year. What is the best response by the nurse?

1. Your bones are weaker and are shrinking.

2. I am sure you are mistaken and just dont remember from last year.

3. Your height decreases with age due to musculoskeletal changes.

4. Stand up straighter this time and we will measure again.

Correct Answer: 3

Rationale 1: During the older adult years the bones may lose density, but they do not shrink.

Rationale 2: To confront the client and say I am sure you are mistaken and just dont remember from last year is an inappropriate response and does not answer the clients question.

Rationale 3: Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect.

Rationale 4: There can also be a flexion of the hips and knees, which affects the ability to stand erect.

Global Rationale: Height of older adults may decrease as a result of thinning of the intervertebral discs. There can also be a flexion of the hips and knees, which affects the ability to stand erect. During the older adult years the bones may lose density, but they do not shrink. To confront the client and say I am sure you are mistaken and just dont remember from last year is an inappropriate response and does not answer the clients question.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 28

Type: MCSA

The nurse is caring for a client with pneumonia and has obtained the following vital signs: Temperature 101.2F (oral), BP 100/70, Pulse Rate 110/min, and Respirations 22. The clients oxygen saturation level is 96%. The nurse should clarify which of the following orders?

1. Administer acetaminophen (Tylenol) 650 mg every 4 hours prn fever.

2. Administer intravenous (IV) fluids: 0.9% Normal Saline Solution at 125 ml/hour.

3. Start oxygen therapy at 3L/minute via nasal cannula.

4. Send for chest x-ray.

Correct Answer: 3

Rationale 1: The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever.

Rationale 2: The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate.

Rationale 3: The nurse should clarify the oxygen therapy order. Although the clients respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The clients oxygen saturation level of 96% is within normal limits; therefore the client does not need oxygen therapy.

Rationale 4: A chest film would be indicated to determine the extent of pulmonary involvement.

Global Rationale: The nurse should clarify the oxygen therapy order. Although the clients respiratory rate is slightly increased, this is an expected finding in a client with fever and a diagnosis of pneumonia. The clients oxygen saturation level of 96% is within normal limits; therefore the client does not need oxygen therapy. The order for acetaminophen (Tylenol) is appropriate and is to be given as needed for fever. The order for IV fluids is appropriate as fluids help to thin secretions and make up for increased insensible loss due to fever and increased respiratory rate. A chest film would be indicated to determine the extent of pulmonary involvement.

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 29

Type: MCSA

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA). The LPN asks the RN if the pulse oximeter needs to be placed on the client. What is the nurses best response to the LPN?

1. Please place the pulse oximeter on the client.

2. I will let you know after I complete my assessment.

3. Thanks, but that is something I have to do for the client.

4. We dont have an order to do that.

Correct Answer: 2

Rationale 1: Clients in DKA may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It reflects only the percentage of oxygen saturation of hemoglobin.

Rationale 2: The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter.

Rationale 3: If the RN determines the pulse oximeter is needed, the RN could delegate the task to the LPN.

Rationale 4: This would not require a healthcare providers order.

Global Rationale: The nurse should complete the assessment to determine any respiratory abnormalities before using the pulse oximeter. Clients in DKA may not require a pulse oximeter as it does not provide information about acid-base balance or blood glucose levels. It reflects only the percentage of oxygen saturation of hemoglobin. If the RN determines the pulse oximeter is needed, the RN could delegate the task to the LPN. This would not require a healthcare providers order.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 30

Type: MCSA

The nurse in interviewing a client observes changing of position frequently, wringing hands, and laughing at inappropriate times. Which of the following would be appropriate for the nurse to include in the assessment based on this information?

1. Anxiety assessment

2. Mental status testing

3. Attention deficit testing

4. Nutrition assessment

Correct Answer: 1

Rationale 1: Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview, it may be a reflection of anxiety related to the situation or a need for further assessment.

Rationale 2: Mental status testing would be indicated if the client demonstrates confusion.

Rationale 3: The nurse does not conduct attention deficit testing. This is beyond the nurses scope of practice.

Rationale 4: The observations by the nurse do not provide clues to the clients nutritional state.

Global Rationale: Body language and verbal responses can be key indicators of anxiety. If the patient exhibits anxiety during the interview it may be a reflection of anxiety related to the situation or a need for further assessment. One means used to further evaluate the anxiety is the use of an anxiety scale. Mental status testing would be indicated if the client demonstrates confusion. The nurse does not conduct attention deficit testing. This is beyond the nurses scope of practice. The observations by the nurse do not provide clues to the clients nutritional state.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 31

Type: MCSA

The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. The nurse would include which of the following when continuing the pain assessment on this client?

1. Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies

2. Intensity, quality, location, and impact on ADLs

3. Intensity, quality, pattern, and precipitating factors

4. Intensity, quality, precipitating and relieving factors, and impact on ADLs

Correct Answer: 1

Rationale 1: Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies and emotional responses. The description of client in the question already includes the quality, location, and pattern.

Rationale 2: The client has already identified the quality and location of the pain.

Rationale 3: The client has already identified the quality and pattern of the pain.

Rationale 4: The client has already identified the quality of the pain.

Global Rationale: Pain assessment should include data about the location, intensity, quality, pattern, precipitating factors, actions undertaken for relief of pain and effects, impact on ADLs, coping strategies, and emotional responses. The description of the client in the question already includes the quality, location, and pattern. The client has already identified the quality and location of the pain. The client has already identified the quality, location, and pattern of the pain.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 32

Type: MCMA

The nurse is conducting a class on hypertension, when a client asks what the numbers in the blood pressure mean. Which of the following statements would the nurse correctly use to answer the clients question?

Standard Text: Select all that apply.

1. Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest.

2. Diastolic pressure is the arterial pressure between ventricular contractions.

3. Systolic pressure, indicated by the top number, is the result of the heart rate.

4. Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation.

5. Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts.

Correct Answer: 1,4

Rationale 1: Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest. The nurse should use terms the client can understand to respond to this question about blood pressure. Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest, and Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation, both explain blood pressure in terms the client should understand.

Rationale 2: Diastolic pressure is the arterial pressure between ventricular contractions. While the statement Diastolic pressure is the arterial pressure between ventricular contractions is correct, these are not terms a client is likely to understand.

Rationale 3: Systolic pressure, indicated by the top number, is the result of the heart rate. The systolic pressure is not a direct result of the heart rate.

Rationale 4: Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation. The nurse should use terms the client can understand to respond to this question about blood pressure. Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation is a statement that a client can understand.

Rationale 5: Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts. The statement Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts, while a true statement, is not one that a lay person will understand.

Global Rationale: The nurse should use terms the client can understand to respond to this question about blood pressure. Diastolic pressure, indicated by the bottom number, is the pressure in the arteries when the heart is at rest, and Systolic pressure, indicated by the top number, reflects the pressure in the arteries when the heart contracts and pumps blood into general circulation. Both explain blood pressure in terms the client should understand. While the statement Diastolic pressure is the arterial pressure between ventricular contractions is correct, these are not terms a client is likely to understand. The systolic pressure is not a direct result of the heart rate. The statement Systolic pressure is the pressure at the height of the wave, when the left ventricle contracts, while a true statement, is not one that a lay person will understand.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 33

Type: MCSA

During a physical assessment the client asks the nurse repeatedly, Is everything ok? The nurse believes this client is demonstrating:

1. A poor self-concept.

2. Inappropriate affect.

3. Confusion.

4. Anxiety.

Correct Answer: 4

Rationale 1: A clients level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if everything is ok could be evidence of worry about the outcome of the examination.

Rationale 2: Evidence of a poor self-concept would include poor personal hygiene practices.

Rationale 3: An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet.

Rationale 4: Confusion would be demonstrated by a client who is not oriented to person, place, or time.

Global Rationale: A clients level of anxiety is reflected in speech, body language, and facial expressions. Repeatedly asking if everything is ok could be evidence of worry about the outcome of the examination. Evidence of a poor self-concept would include poor personal hygiene practices. An inappropriate affect would be demonstrated if the client responding inappropriately to a situation, such as laughter when discussing the death of a pet. Confusion would be demonstrated by a client who is not oriented to person, place, or time.

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 34

Type: MCSA

An older adult client has edema of the lower extremities despite being prescribed medication for this symptom. Which of the following should the nurse do first to assist this client?

1. Discuss the finding with the clients healthcare provider.

2. Provide the client with support hose.

3. Review the clients current medications.

4. Document the finding in the medical record.

Correct Answer: 3

Rationale 1: The nurse should discuss the clients current medications because older adult clients might be prescribed multiple medications, which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of the clients medication schedule and history.

Rationale 2: The nurse should complete the clients assessment before contacting the healthcare provider.

Rationale 3: Providing the client with support hose might not be beneficial or indicated at this time.

Rationale 4: Documenting the finding is important; however, it is not something that should be completed first.

Global Rationale: The nurse should discuss the clients current medications because older adult clients might be prescribed multiple medications, which can combine to produce dangerous side effects. The schedules for multiple medications may be confusing and result in overmedication, forgotten doses, negative side effects, or ineffectiveness of medication. Therefore, the nurse must conduct a thorough assessment of the clients medication schedule and history. The nurse should complete the clients assessment before contacting the healthcare provider. Providing the client with support hose might not be beneficial or indicated at this time. Documenting the finding is important; however, it is not something that should be completed first.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Question 35

Type: MCSA

The nurse is assessing a client who has had a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this clients level of pain?

1. The nurse asks the clients family member to place a number on the clients pain using a scale of 0 (no pain) to 10 (most pain), since the family member knows the client best.

2. The nurse considers the clients behavior and vital signs and determines a number from the pain scale (010) based on these objective findings.

3. The nurse uses the Wong-Baker FACES pain rating scale.

4. The nurse reviews the previous pain assessments and makes a determination based on these findings.

Correct Answer: 3

Rationale 1: The family member is not able to accurately identify the clients pain level because pain is entirely subjective and personal.

Rationale 2: The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is.

Rationale 3: Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the FACES pain scale and ask the client to point to the picture that most closely correlates with current level of pain.

Rationale 4: Previous assessments can help the nurse to determine a pattern of the client pain and pain control, but does not give the nurse any clues about the clients current pain.

Global Rationale: Pain is an entirely subjective and personal experience. Because this client has difficulty with verbal expression, but no other deficits, the nurse could use the FACES pain scale and ask the client to point to the picture that most closely correlates with current level of pain. The family member is not able to accurately identify the clients pain level because pain is entirely subjective and personal. The nurse incorporates objective findings into a thorough pain assessment, but pain is ultimately what the client says it is. Previous assessments can help the nurse to determine a pattern of the client pain and pain control, but does not give the nurse any clues about the clients current pain.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7.5: Apply critical thinking during the initial nurse-client encounter.

Leave a Reply