HESI A2 - Critical Thinking

1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active.
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1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active.
Rationale

Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries that must be assessed and treated promptly.
1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?

A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors.

Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?
1. Administer 6 L of oxygen via nasal cannula.
2. Assess the client's neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate.
Rationale
Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication.
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?

A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question
D) Open-ended question

Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.
3. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel won't spin. Which action should the nurse implement first?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it.
Rationale

Correct -1. The nurse should always praise the child for attempts at cooperation even if the child did not accomplish what the nurse asked.
3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:

A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics.
C) using biased or leading questions.

Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer.
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
1. The child diagnosed with type 1 diabetes who has a blood glucose level
of 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
of 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%.
Rationale

Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:

A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment.
D) uncomfortable talking about his son's treatment.

Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?
1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
deficit-hyperactivity disorder (ADHD).
Rationale

Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this medication must be administered first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time; therefore, this medication does not have to be adminis- tered first.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?

A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the communication.
D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.
A) Determine the communication method he prefers.

Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime.
6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing. Which interventions should the nurse implement? Prioritize the nurse's actions from first (1) to last (5). 1. Perform cardiac compression 30:2. 2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness. 5. Open the infant's airway.Rationale Correct Answer: 4, 5, 3, 2, 1 4. The nurse must first determine the infant's responsiveness by thumping the baby's feet. 5. The nurse should then open the child's airway using the head-tilt chin-lift tech- nique, with care taken not to hyperextend the neck. Then the nurse should look, listen, and feel for respirations. 3. The nurse then administers quick puffs of air while covering the child's mouth and nose, preferably with a rescue mask. 2. The nurse should determine whether the infant has a pulse by checking the brachial artery. 1. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2.6. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A) "Do you take medicine?" B) "Do you sterilize the bottles?" C) "Do you have nausea and vomiting?" D) "You have been taking your medicine, haven't you?"A) "Do you take medicine?" Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.7. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies departmentA) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.7. The 3-year-old client has been admitted to the pediatric unit. Which task should the nurse instruct the unlicensed assistive personnel (UAP) to perform first? 1. Orient the parents and child to the room. 2. Obtain an admission kit for the child. 3. Post the child's height and weight at the HOB. 4. Provide the child with a meal tray.Rationale Correct - 1.The first intervention after the child is ad- mitted to the unit is to orient the parents and child to the room, the call system, and the hospital rules, such as not leaving the child alone in the room.8. The clinic nurse is preparing to administer an intramuscular (IM) injection to the 2-year-old toddler. Which intervention should the nurse implement first? 1. Immobilize the child's leg. 2. Explain the procedure to the child. 3. Cleanse the area with an alcohol swab. 4. Administer the medication in the thigh.Rationale Correct - 2-The nurse must explain any procedure in words the child can understand. It does not matter how old the child is.8. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed.B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.9. The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is priority? 1. Imbalanced nutrition. 2. Fluid volume deficit. 3. Knowledge deficit. 4. Risk for infection.Rationale Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec- trolyte homeostasis is priority.9. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.10. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child diagnosed with nephrotic syndrome. 2. Petechiae for the child diagnosed with leukemia. 3. Drooling for a child diagnosed with acute epiglottitis. 4. Elevated temperature in a child diagnosed with otitis media.Rationale Correct - 3-Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely occluding the air- way. This warrants immediate interven- tion. The nurse should notify the HCP and obtain an emergency tracheostomy tray for the bedside.10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary.A) Ask the patient about the item and its significance. Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.11. Which client should the pediatric nurse assess first after receiving the a.m. shift report? 1. The 6-month old child diagnosed with bacterial meningitis who is irritable and crying. 2. The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has edema of the face. 3. The 11-month old child diagnosed with Reye syndrome who is lethargic and vomiting. 4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs and decreased urine output.Rationale Correct - 4. Sunken eyeballs and decreased urine out- put are signs of dehydration, which is a life-threatening complication of diarrhea; therefore, this child should be assessed first.11. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans: A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick.B) consider these symptoms a part of normal living, not symptoms of ill health. Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.12. The pediatric clinic nurse is triaging telephone calls. Which client's parent should the nurse call first? 1. The 4-month-old child who had immunizations yesterday and the parent is report- ing a high-pitched cry and a 103°F fever. 2. The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever. 3. The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin. 4. The 3-year-old child whose mother called and reported her daughter may have chickenpox.Rationale Correct 1-A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore, this parent needs to be called first to bring the child to the clinic.12. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief? A) A person is able to work and produce. B) A person is happy, stable, and feels good. C) All aspects of the person are in perfect balance. D) A person is able to care for others and function socially.C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.13. The parent of a 12-year-old male child with a left below-the-knee cast calls the pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it feels like his foot is asleep." Which action should the nurse implement first? 1. Prepare to bifurcate the left below-the-knee cast. 2. Tell the parent to bring the child to the office. 3. Instruct the parent to elevate the left leg on two pillows. 4. Notify the child's orthopedist of the situation.Rationale Correct - 3. The nurse should first take care of the client's body by having the parent elevate the left leg.13. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: A) germs and viruses. B) supernatural forces. C) eating imbalanced foods. D) an imbalance within his or her spiritual nature.B) supernatural forces. Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.14. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: A) will comply with the treatment prescribed. B) has obviously given up her beliefs in naturalistic causes of disease. C) may also be seeking the assistance of a shaman or medicine man. D) will need extra help in dealing with her illness and may be experiencing a crisis of faith.C) may also be seeking the assistance of a shaman or medicine man. Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.14. Which child requires the nurse to notify the healthcare provider? 1. The 1-year-old child with iron deficiency anemia who has dark-colored stool. 2. The 3-year-old child with phenylketonuria (PKU) whose parent does not feed the child any meat or milk products. 3. The 5-year-old child with rheumatic heart fever who is having difficulty breathing. 4. The 7-year-old child diagnosed with acute glomerulonephritis who has dark "tea"-colored urine.Rationale Correct - 3-A complication of rheumatic heart disease is valvular disorders that may be mani- fested by respiratory problems; therefore, the nurse should notify the child's health- care provider.15. The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first? 1. The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo- cele who has bulging fontanels. 2. The 3-month-old child 2 days postoperative temporary colostomy secondary to Hirschsprung's disease who has a moist, pink stoma. 3. The 9-month-old child with a cleft palate repair who is spitting up formula and refusing to eat. 4. The 4-year-old child 1 day postoperative for repair of hypospadias who has clear amber urine draining from indwelling catheter.Rationale Correct - 1-Bulging fontanels is a sign of increased intracranial pressure, which is a compli- cation of neurological surgery; therefore, this child should be assessed first.15. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).16. The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse? 1. The staff nurse performs gentle range-of-motion (ROM) exercises to extremities. 2. The staff nurse puts the client's bed in the lowest position possible. 3. The staff nurse takes the client in a wheelchair to the activity room. 4. The staff nurse places the child in semi-Fowler's position to eat lunch.Rationale Correct - 4-The child should be positioned upright to prevent aspiration during meals; there- fore, this action would require the charge nurse to intervene.16. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.17. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation? 1. The nurse requests the UAP to check the circulation on the child with a cast. 2. The nurse asks the UAP to feed an infant who has just had a cleft palate repair. 3. The nurse has the UAP demonstrate a catheterization for a child with a neurogenic bladder. 4. The nurse checks to make sure the UAP's delegated tasks have been completed.Rationale Correct - 4. The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately.17. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.A) children have spiritual needs that are influenced by their stages of development. Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.18. The nurse on a pediatric unit has received the a.m. shift report and tells the unli- censed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first? 1. Determine what the UAP did not understand about the instruction. 2. Tell the HCP the UAP did not follow the nurse's direction. 3. Ask the mother why she was feeding her child if the child was NPO. 4. Notify the dietary department to hold the child's meal trays.Rationale Correct - 1.Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first.18. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?"D) "What cultural or spiritual beliefs are important to you?" Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.19. The charge nurse on the six-bed pediatric burn unit is making shift assignments and has one registered nurse (RN), one scrub technician, one unlicensed assistive personnel (UAP), and a unit secretary. Which client care assignment indicates the best use of the hospital personnel? 1. The RN performs daily whirlpool dressing changes. 2. The unit secretary transcribes the HCP's orders. 3. The scrub technician medicates the client prior to dressing changes. 4. The UAP places the current laboratory results on the chart.1-The scrub technician is assigned to perform daily whirlpool dressing changes, which is a lengthy procedure. Therefore, assigning the one RN to this task would be inappropriate because he or she cannot be unavailable for an extended period of time. **2-One of the responsibilities of the unit secretary is to transcribe the HCP's orders, but the licensed nurse retains total responsibility for the correctness and accuracy of the transcribed orders. 3-The scrub technician cannot administer medications. 4-The unit secretary and laboratory personnel are responsible for posting laboratory data into the client's charts. The UAP should be on the unit taking care of the clients.19. When planning a cultural assessment, the nurse should include which component? A) Family history B) Chief complaint C) Medical history D) Health-related beliefsD) Health-related beliefs Pages: 19-20. Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.20. The RN and the UAP are caring for clients on a pediatric surgical unit. Which tasks would be most appropriate to delegate to the UAP? Select all that apply. 1. Pass dietary trays to the clients. 2. Obtain routine vital signs on the clients. 3. Complete the preoperative checklist. 4. Change linens on the clients' beds. 5. Document the clients' intake and output.1, 2, 4, and 5 are correct. 1. The UAP can pass the dietary trays to the clients because it does not require judgment. 2. One of the responsibilities of the UAP is taking routine vital signs on clients. 3. The nurse must complete the preoperative checklist because it requires nursing judg- ment to determine whether the client is ready for surgery. 4. One of the responsibilities of the UAP is changing bed linens. 5. The UAP can document the client's in- take and output, but the UAP cannot evaluate the numbers.20. When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable.B. provided consistent information and therefore is reliable. Page: 50. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.21. Which client should the charge nurse on the pediatric unit assign to the most experienced nurse? 1. The 4-year-old child diagnosed with hemophilia receiving factor VIII. 2. The 8-year-old child with headaches who is scheduled for a CT scan. 3. The 6-year-old child recovering from a sickle cell crisis. 4. The 11-year-old child newly diagnosed with rheumatoid arthritis.1-The administration of blood products does not require the most experienced nurse. 2-Preparing a child for a routine procedure does not require the most experienced nurse. 3-The child recovering from a sickle cell crisis would not require the most experienced nurse. **4-The child newly diagnosed with a chronic disease, which will have acute exacerba- tions, requires extensive teaching; there- fore, the most experienced nurse should be assigned to this child and family.21. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? A. Patient denies usual childhood illnesses. B. Patient states he was a "very healthy" child. C. Patient states sister had measles, but he didn't. D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles).22. The charge nurse is making shift assignments on a pediatric oncology unit. Which delegation/assignment would be most appropriate? 1. Delegate the unlicensed assistive personnel (UAP) to obtain routine blood work from the central line. 2. Instruct the licensed practical nurse (LPN) to contact the leukemia support group. 3. Assign the chemotherapy-certified RN to administer chemotherapeutic medication. 4. Have the dietitian check the meal trays for the amount eaten.1-Only an RN can withdraw blood from a central line. 2. The social worker or case manager is respon- sible for referring clients to support groups. This is not an expected responsibility of a floor nurse/LPN. **3. Only chemotherapy-certified RNs can administer antineoplastic, chemothera- peutic medications. This is a national minimal standard of care according to the Oncology Nursing Society. 4. The dietician is responsible for ensuring that the proper food is provided along with evalu- ating the child's nutritional intake, not checking the amount of food eaten—this is the responsibility of the nursing staff.22. The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? A. "Maybe she is just teething." B. "I will check her ear for an ear infection." C. "Are you sure she is really having pain?" D. "Please describe what she is doing to indicate she is having pain."D. "Please describe what she is doing to indicate she is having pain." Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.23. The nurse observes the unlicensed assistive personnel (UAP) bringing a cartoon video to a 6-year-old female child on bed rest so that she can watch it on the television. Which action should the nurse take? 1. Tell the UAP that the child should not be watching videos. 2. Explain that this is the responsibility of the child life therapist. 3. Praise the UAP for providing the child with an appropriate activity. 4. Notify the charge nurse that the UAP gave the child videos to watch.1. A 6 year old child on best rest needs an appropriate activity to help with distraction; a cartoon video would be an age appropriate activity. 2. The child life therapist is responsible for recreational and developmental activity for the hospitalized child, but any staff member should address the child's psychosocial needs. **3. Part of the delegation process is to evaluate the UAP's performance of duties, and the nurse should praise any initiative on the part of the UAP in being a client advocate. 4. Videos are one of the few age-appropriate activities to occupy a 6-year-old on bed rest; therefore, there is no reason to notify the charge nurse.23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizationsD. Reactions to previous hospitalizations Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.24. Which newborn should the nurse in the neonatal intensive care unit (NICU) assign to a new graduate who has just completed an NICU internship? 1. The 1-day-old infant diagnosed with a myelomeningocele. 2. The 2-week-old infant who was born 6 weeks premature. 3. The 3-hour-old infant who is being evaluated for esophageal atresia. 4. The 1-week-old infant diagnosed with tetralogy of Fallot.1-The newborn with the myelomeningocele has a portion of the spinal cord and mem- branes protruding through the back and is at risk for hydrocephalus and meningitis; this client should be assigned to a more experi- enced nurse. **2-The new graduate who has completed the NICU internship should be able to care for a premature infant because care is primarily supportive. 3-Esophageal atresia, a congenital anomaly in which the esophagus does not completely develop, is a clinical and surgical emergency. It puts the newborn at risk for aspiration be- cause the upper esophagus ends in a blind pouch with the lower part of the esophagus connected to the trachea. This newborn should be assigned to a more experienced nurse. 4-Tetralogy of Fallot is a cyanotic, congenital anomaly. It includes a combination of four defects of the heart, all of which result in unoxygenated blood being pumped into the systemic circulation. This newborn must be assigned to an experienced nurse.24. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities.D. It helps to determine how a person is managing day-to-day activities. Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.25. The newly hired nurse is working on a pediatric unit and needs the unlicensed assistive personnel (UAP) to obtain a urine specimen on an 11-month-old infant. Which statement made to the UAP indicates the nurse understands the delegation process? 1. "Be sure to weigh the diaper when obtaining the urine specimen." 2. "Do you know how to apply the urine collection bag?" 3. "Use a small indwelling catheter when obtaining the urine specimen." 4. "I need for you to get a urine specimen on the infant."1-Weighing the diaper is the procedure for de- termining the infant's urinary output and is not part of the procedure for obtaining a urine specimen. **2-The NCSBN position paper in 1995 defined delegation as transferring to a competent individual the authority to perform a selected nursing task in a se- lected situation. The nurse retains the accountability for the delegation. The nurse must determine whether the UAP has the ability and knowledge to perform a task. This question clarifies whether the UAP has the ability to obtain a urine specimen. 3-Obtaining a urine specimen with an in- dwelling catheter on an 11-month-old infant would require more expertise than a UAP would have on the pediatric unit. Furthermore, it does not determine whether the UAP understands how to do the procedure. 4. This statement does not determine whether the UAP understands how to perform the procedure of obtaining a urine specimen from an 11-month-old infant.25. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?"B. "Are you able to dress yourself?" Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.26. Which task is most appropriate for the pediatric nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Ask the UAP to orient the parents and child to the room. 2. Tell the UAP to prepare the child for an endoscopy. 3. Request the UAP to log roll the client who had a spinal surgery. 4. Instruct the UAP to assess the child's developmental level.**1-The UAP can orient the parents and child to the room, and demonstrate how to use the call light, how the bed works, or how the television works. 2-The UAP cannot prepare a child for en- doscopy; this requires assessment and evaluation to determine if the child is ready for the procedure. 3-There must be at least two people to log roll a child, and the UAP cannot do this procedure alone. 4-The nurse cannot delegate assessment to the UAP.26. The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. A. "How much junk food does your child eat?" B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" D. "Does he take a children's vitamin?" E. "Can he tell time?" F. "Does he have any food allergies?"B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" E. "Can he tell time?" Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.27. Which behavior by the unlicensed assistive personnel (UAP) warrants intervention by the nurse? 1. The UAP weighs the child's diaper on a scale and records the urine output on the intake & output (I&O) sheet. 2. The UAP sits with the child while the parent goes down to the cafeteria to get something to eat. 3. The UAP bathes the child with congenital dislocated hip with the Pavlik harness on the child. 4. The UAP applies wrist restraints on the 7-month-old who is 1 day postoperative cleft palate repair.1-The UAP can weigh the diapers and obtain urine output. The nurse must evaluate the output. 2-A child under 12 years of age cannot be left alone in the room, and the UAP could stay with the child while the parent gets some- thing to eat. 3-The Pavlik harness should not be removed, so bathing the child in the harness is appro- priate and does not warrant intervention. **4- The 7-month-old should have elbow restraints, not wrist restraints. Elbow restraints prevent the child from putting fingers into the mouth, but allow the child to move the arms.27. During an examination, the nurse can assess mental status by which activity? A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questionsC) Observing the patient and inferring health or dysfunction Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.28. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.C) may take a little longer to respond, but his general knowledge and abilities should not have declined. Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected.28. The nurse is caring for pediatric clients. Which tasks are most appropriate to assign to an unlicensed assistive personnel (UAP) and/or a licensed vocational nurse (LPN)? Select all that apply. 1. Instruct the LPN to teach the parent of a child new diagnosed with type 1 diabetes. 2. Tell the UAP to apply an ice collar to the child who is 1 day postoperative tonsillectomy. 3. Ask the UAP to place ointment on a child's diaper rash around the anal area. 4. Request the LPN to double-check the medication dose for the child receiving an antibiotic. 5. Tell the LPN to transcribe the healthcare provider's orders for the child with cystic fibrosis.2, 3, 4, and 5 are correct. 1. The nurse cannot assign teaching to the LPN. 2. The UAP can apply an ice collar since the client is stable. 3. The UAP can apply ointment to a diaper rash—it is a medication but it can be applied by the UAP. 4. The LPN can double-check a dose of medication. The nurse can assign med- ication administration to an LPN. 5. The LPN can transcribe a healthcare provider's orders.29. The nurse is discharging a 4-month-old child with a temporary colostomy. Which intervention should the nurse implement? 1. Request the UAP to complete the discharge written documentation. 2. Tell the LPN to show the parent how to irrigate the colostomy. 3. Ask the UAP to remove the child's intravenous catheter. 4. Request the UAP to escort the parent and child to the car.1-The nurse cannot delegate teaching to the UAP. 2-The LPN could teach a client how to irrigate a colostomy, but a 4-month-old is inconti- nent of stool; therefore, irrigating the colostomy is not done. 3-The LPN or nurse should remove the IV catheter of a 4-month-old child, not the UAP. **4-The UAP can escort the child and parents to the car.29. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.B) It is usually sufficient to gather mental status information during the health history interview. Page: 73. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.30. The unlicensed assistive personnel (UAP) tells the nurse the child with Down syndrome who is 2 days postoperative appendectomy is having pain. Which intervention should the nurse implement first? 1. Tell the UAP to check the child's vital signs. 2. Assess the child's abdominal dressing and pain immediately. 3. Notify the healthcare provider. 4. Check the MAR for last time pain medication was administered.1-The UAP can take vital signs but the nurse should assess the child to determine whether this is routine postoperative pain (expected), or whether a complication is occurring. **2. A rule of thumb—if anyone else gives the nurse information about a client, the nurse should first assess the client before taking any further action. 3. The nurse may need to notify the HCP, but not before assessing the child. 4. The nurse may need to administer pain med- ication but not prior to assessing the child.30. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"A) "How do you feel today?" Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.31. The 8-year-old male child in the pediatric unit is refusing to ambulate postopera- tively. Which intervention would be most appropriate? 1. Give the child the option to ambulate now or after lunch. 2. Ask the parents to insist the child ambulate in the hall. 3. Refer the child to the child developmental therapist. 4. Tell the child he can watch a video game if he cooperates.**1.The nurse should offer the child choices that ensure cooperation with the thera- peutic regimen. The choices are when the child will ambulate, not whether the child will ambulate. 2. The nurse could ask the parents for help in making sure the client ambulates, but this may cause a rift in the nurse/parent/child re- lationship. This is not the most appropriate intervention. 3. The child development therapist could assist with activities that would encourage the client to ambulate, but the nurse should take control of the situation and ensure the client ambulates. This is not the most appropriate intervention. 4. This is bribery, and the nurse should not use this technique to ensure cooperation with the therapeutic regimen.31. During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"B) "Tell me about what you plan to do once you are discharged from the hospital." Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.32. The clinic nurse overhears a mother in the waiting room tell her 6-year-old son, "If you don't sit down and be quiet, I am going to get the nurse to give you a shot." Which action should the nurse implement? 1. Do not take any action because the mother is attempting to discipline her son. 2. Tell the child the nurse would not give him a shot because the mother said to. 3. Report this verbally abusive behavior to Child Protective Services. 4. Tell the mother this behavior will cause her son to be afraid of the nurses.1. The nurse must take action or the child will be afraid of the nurse. 2. The nurse should discuss the inappropriate comment with the mother, not with the child. 3. If every nurse who overheard this type of comment reported it to Child Protective Services, it would only unnecessarily increase the workload in an already overloaded system. Furthermore, reporting perceived potential abuse to Child Protective Services is a very serious accusation. **4. The nurse should explain to the mother that threatening the child with a shot will cause the child to be frightened of healthcare professionals. This type of comment is inappropriate and should not be used to discipline a child.32. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).C) Mental status functioning is inferred through assessment of an individual's behaviors. Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.33. The parents of an infant born with Down syndrome are holding their infant and crying. The father asks, "I have heard children like this are hard to take care of at home." Which referral would be most appropriate for the parents? 1. The Web site for the National Association for Down Syndrome. 2. The hospital chaplain. 3. A Down syndrome support group. 4. A geneticist.1. There is a Web site to obtain information about Down syndrome, but this type of re- ferral would not be the most appropriate for parents who need to deal with emotional as- pects of having a child with special needs. 2. The hospital chaplain is an important part of the multidisciplinary healthcare team but would not have specialized knowledge re- garding caring for a special needs child. **3. According to the NCLEX-RN® test plan, referrals are included in management of care. The most appropriate referral would be to a support group where other parents who have special needs children can share their feelings and provide ad- vice on how to care for their child in the home. 4. Although Down syndrome results from a trisomy chromosome 21, it is primarily associated with maternal age over 35 years. Furthermore, a geneticist would not have specialized knowledge regarding caring for a special needs child.33. When performing a physical assessment, the technique the nurse will always use first is: A) palpation. B) inspection. C) percussion. D) auscultation.B) inspection. Pages: 115-116. The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.34. The charge nurse on the pediatric unit hears the overhead announcement of Code Pink (infant abduction), newborn nursery. Which action should the charge nurse implement? 1. Send a staff member to the newborn nursery. 2. Explain the situation to the clients and visitors. 3. Continue with the charge nurse's responsibilities. 4. Station a staff member at all the unit exits.1. The newborn nursery does not need any more people in the area. Personnel are needed to monitor any and all exits. 2. The purpose of using code names to alert hospital personnel of emergency situations is to avoid panic among the clients and visitors; therefore, the nurse should not explain the situation to the clients and visitors. 3. Any time there is an overhead emergency an- nouncement, the charge nurse is responsible for following the hospital emergency plan. **4. Code Pink means an infant has been abducted from the newborn nursery. The priority intervention is to prevent the ab- ductor from taking the child from the hospital, which can be prevented by plac- ing a staff member at all of the unit exits.34. The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the: A) fingertips because they're more sensitive to small changes in temperature. B) dorsal surface of the hand because the skin is thinner than on the palms. C) ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. D) palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.B) dorsal surface of the hand because the skin is thinner than on the palms. The dorsa (backs) of hands and fingers are best for determining temperature because the skin there is thinner than on the palms. Fingertips are best for fine, tactile discrimination; the other responses are not useful for palpation.35. The mother of a 4-year-old child diagnosed with Duchenne's muscular dystrophy is overwhelmed and asks the nurse, "I have been told a case manager will come and talk to me. What will they do for me?" Which statement indicates the nurse understands the role of the case manager? 1. "You will have a case manager so that the hospital can save money." 2. "She will make sure your child gets the right medication for muscular dystrophy." 3. "She will help you find the resources you need to care for your child." 4. "The case manager helps your child to have a normal life expectancy."1.Even though case management is a strategy to ensure coordination of care while reduc- ing costs, the nurse should not share this with the mother. 2. The case manager is not responsible for ensuring that the client receives the correct medication; it is the responsibility of the HCP. **3. According to the NCLEX-RN® test blueprint, questions on case management are included. The case manager will coordinate the care for a client with a chronic illness with other members of the multidisciplinary healthcare team. This attempts to prevent duplication of ser- vices and allows the mother to have a specific individual to coordinate services to meet the child's needs. 4. The life expectancy of a child with Duchenne's muscular dystrophy is approximately 25 years. The case manager is not responsible for help- ing the child have a normal life expectancy.35. The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Pages: 115-116. Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.36. The nurse is assigned to the pediatric unit performance improvement committee. The unit is concerned with IV infection rates. Which action should the nurse implement first when investigating the problem? 1. Contact central supply for samples of IV start kits. 2. Obtain research to determine the best length for IV dwell time. 3. Identify how many IV infections have occurred in the last year. 4. Audit the charts to determine if hospital policy is being followed.1 .Although this would not be the first step in investigating a problem, this action may be initiated if it is determined to be the cause for the increase in infection rates. 2. The nurse should utilize evidenced-based practice research when proposing changes because it is part of the performance im- provement process, but it is not the first in- tervention when investigating the problem. **3. The first intervention is to determine the extent of the problem and who owns the problem. The NCLEX-RN® test blue- print includes performance improvement (quality improvement) in the manage- ment of care content. 4. This action may need to be implemented once it is determined whether there is a problem with IV infection rates. However, this would be the second step in the process.36. The nurse would use bimanual palpation technique in which situation? A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and painB) Palpating the kidneys and uterus Pages: 115-116. Bimanual palpation requires the use of both hands to envelop or capture certain body parts or organs such as the kidneys, uterus, or adnexa. The other situations are not appropriate for bimanual palpation.37. The clinic nurse is discussing a tubal ligation with a 17-year-old adolescent with Down syndrome. The adolescent does not want the surgery, but her parents (who are also in the room) are telling her she must have it. Which statement by the nurse would be an example of the ethical principle of justice? 1. "I think this requires further discussion before scheduling this procedure." 2. "You will not be able to have children after you have this procedure." 3. "You should have this procedure because you could not care for a child." 4. "You can refuse this procedure and your parents can't make you have it."**1. The ethical principle of justice is to treat all clients fairly, without regard to age, socioeconomic status, or any other vari- able, including clients with special needs. This statement supports the adolescent's right to her opinion even though she has Down syndrome. 2.If the adolescent needs clarification of the procedure, this would be an appropriate re- sponse, which is an example of the ethical principle of veracity or truth telling. 3.This statement is an example of the ethical principle of paternalism, in which the nurse knows what is best for the client. 4.This is an example of autonomy, in which the client has the right to self-determination. The Nuremburg Code of ethics specifically supports the rights of individuals with special needs against being forced to participate in procedures they do not want.37. When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A) consider this a normal finding. B) palpate this area for an underlying mass. C) reposition the hands and attempt to percuss in this area again. D) consider this an abnormal finding and refer the patient for additional treatment.A) consider this a normal finding. Pages: 116-117. Percussion over relatively dense organs, such as the liver or spleen, will produce a dull sound. The other responses are not correct.38. The school nurse has referred an 8-year-old student for further evaluation of vision. The single mother has told the school nurse she does not have the money for the eval- uation or glasses. Which action by the nurse would be an example of client advocacy? 1. Tell the mother the child cannot read the board. 2. Refer the mother to a local service organization. 3. Ask the mother if the family is on Medicaid. 4. Loan the mother money for the examination.1.Although this may be the case, this is not client advocacy, and doing so may make the mother feel guilty about not being able to afford glasses for her child. **2.This is an example of client advocacy because many local service organizations, such as the Lions Club or the Rotary Club, will subsidize the cost of the vision test and glasses. 3.Medicaid does not pay for glasses, and it is not the school nurse's business whether the family is on Medicaid. 4.The nurse should not loan the mother money because this crosses professional boundaries.38. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: A) auscultate over the area with a fetoscope. B) use a goniometer to measure the pulsations. C) use a Doppler device to check for pulsations over the area. D) check for the presence of pulsations with a stethoscope.C) use a Doppler device to check for pulsations over the area. Page: 120. Doppler devices are used to augment pulse or blood pressure measurements. Goniometers measure joint range of motion. A fetoscope is used to auscultate fetal heart tones. Stethoscopes are used to auscultate breath, bowel, and heart sounds.39. The emergency department (ED) nurse is scheduling the 16-year-old client for an emergency appendectomy. Which intervention should the nurse implement when obtaining permission for the surgery? 1. Withhold the narcotic pain medication until the client signs the permit. 2. Have the client's parent or legal guardian sign the operative permit. 3. Explain the procedure to the client and the parents in simple terms. 4. Get a visitor from the ED waiting area to witness the parent's signature.1. The 16-year-old client is not old enough to sign the permit; therefore, pain medication would not be withheld. **2. Legally, a child under the age of 18 must have a parent or legal guardian sign for informed consent. The nurse should de- termine whether the child is aware of the situation and assents to the procedure. 3. The surgeon is responsible for explaining the procedure; the nurse is responsible for witnessing the signature on the operative permit. 4. The nurse is responsible for witnessing the signature. Having a visitor sign the operative permit is a violation of HIPAA.39. When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. B) Wash hands before and after every physical patient encounter. C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.B) Wash hands before and after every physical patient encounter. Page: 120. The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.40. The unit manager has been notified by central supply that many client items are missing from stock and have not been charged to the client. Which action should the nurse manager implement regarding the lost charges? 1. Send out a memo telling the staff to follow the charge procedures. 2. Form a performance improvement committee to study the problem. 3. Determine whether the items in question are being restocked daily. 4. Schedule a staff meeting to discuss how to prevent further lost charges.1. A written memo does not allow the staff to have input into how to correct the problem. This memo might lead to blaming and arguments among the staff. 2. The performance improvement committee is designed to improve client care, not to address management issues. 3. This is implying that the unit manager does not believe the central supply lost charges. If the unit manager has this concern, it should be addressed directly with the central supply supervisor. **4. Because the staff is responsible for following the hospital procedure for charging for items used in client care, the unit manager should discuss this with staff to determine what should be done to correct the problem.40. The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examinationB) At the end of the examination Page: 123. Elicit the Moro or "startle" reflex at the end of the examination because it may cause the infant to cry.41. Which child's behavior warrants notifying the child developmental specialist? 1. The 1-year-old child who cries when the parent leaves the room. 2. The 2-year-old child who can talk in two- or three-word sentences. 3. The 3-year-old child who is toilet trained for bowel and bladder. 4. The 4-year-old child who throws frequent temper tantrums.1. A 1 yr old child who cries when the parent leaves the room is developmentally on target 2. The 2-year-old who can speak in two- or three-word sentences is developmentally on target. 3. The 3-year-old should be toilet trained by this age. **4. The toddler (age 1-3) is expected to throw temper tantrums, but a 4-year-old child should not be doing this; therefore, the child is not developmentally on target and the child developmental specialist should be notified.41. A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? A) Auscultate the lungs and heart while the infant is still sleeping. B) Examine the infant's hips because this procedure is uncomfortable. C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.A) Auscultate the lungs and heart while the infant is still sleeping. Pages: 122-124. When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.42. Which child should the nurse assign to the new graduate who has just completed orientation to the pediatric unit? 1. The 5-year-old child admitted in a sickle cell crisis whose patient-controlled analgesia (PCA) pump is not controlling the child's pain. 2. The 6-year-old child in Russell's traction for a fractured femur who has insertion pin sites that are inflamed and infected. 3. The 12-year-old child who is newly diagnosed with type 1 diabetes who needs medication teaching. 4. The 16-year-old female diagnosed with scoliosis who is being admitted for inser- tion of a spinal rod in the morning.42. 1. The child with uncontrolled pain would require a more experienced nurse. 2. Infected skeletal pin sites can lead to osteomyelitis, which would require a more experienced nurse. 3. This child and parents require extensive teaching and should be assigned to a more experienced nurse. **4. The new graduate should be able to com- plete preoperative teaching and prepare the young client for surgery. This client is stable.42. The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips D) A change in overall body proportion, a longer trunk, and shorter extremitiesC) The presence of kyphosis and flexion in the knees and hips Page: 149. Changes that occur in the aging person include more prominent bony landmarks, decreased body weight (especially in males), a decrease in subcutaneous fat from the face and periphery, and additional fat deposited on the abdomen and hips. Postural changes of kyphosis and slight flexion in the knees and hips also occur.43. Which action by the emergency department (ED) nurse warrants intervention by the charge nurse? 1. The nurse is elevating the right arm of a child who appears to have fractured the wrist. 2. The nurse is notifying Child Protective Services for a child who is suspected of being sexually abused. 3. The nurse is assessing the tonsils on a 4-year-old child who has a sore throat and is drooling. 4. The nurse is obtaining a midstream urine specimen for the child who is complain- ing of burning upon urination.1. Elevating the arm to help decrease edema is an appropriate intervention and does not warrant intervention. 2. The nurse is legally obligated to notify CPS for any suspected child abuse. **3. A child who is drooling may have epiglot- titis and opening the mouth may lead to respiratory distress. This action warrants intervention by the charge nurse. 4. The nurse needs to confirm a urinary tract infection by obtaining a urine specimen.43. When assessing the force, or strength, of a pulse, the nurse recalls that it: A) is usually recorded on a 0- to 2-point scale. B) demonstrates elasticity of the vessel wall. C) is a reflection of the heart's stroke volume. D) reflects the blood volume in the arteries during diastole.C) is a reflection of the heart's stroke volume. Page: 134. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.45. Which interventions should the nurse implement to help establish a nurse/parent relationship? Select all that apply. 1. Include the parents when developing the plan of care for their child. 2. Encourage the parents to hold their child as much as possible. 3. Allow the parents to verbalize their feelings of fear and anxiety. 4. Tell the parents to never leave while the child is hospitalized. 5. Request the parents to bring toys from home the child will enjoy.1 and 3 are correct. 1. Including the parents in developing the plan of care will help establish a positive relationship. 2. Holding their child will help with the child/parent relationship, but not with the nurse/parent relationship. 3. Allowing the parents to vent their feel- ings will help form a positive nurse/ parent relationship. 4. The nurse must not make the parents feel guilty if they have to work while the child is hospitalized. A relative can stay with the child if parents have to work. 5. This will help the child/parent relationship not the nurse/parent relationship.44. When assessing the quality of a patient's pain, the nurse should ask which question? A) "When did the pain start?" B) "Is the pain a stabbing pain?" C) "Is it a sharp pain or dull pain?" D) "What does your pain feel like?"D) "What does your pain feel like?" Page: 164. To assess the quality of a person's pain, have the patient describe the pain in his or her own words.46. The nurse is caring for clients on the pediatric unit. Which child would warrant a referral to the early childhood development specialist? 1. The 9-month-old child who says only "mama" or "dada." 2. The 11-month-old child who walks hanging onto furniture. 3. The 8-month-old child who sits by leaning forward on both hands. 4. The 4-month-old infant who turns from the abdomen to the back.1.The 9-month-old infant's language and cog- nitive skills include imitating sounds, saying single syllables, and beginning to put sylla- bles together. Using "mama" and "dada" indicates this child is developmentally on target. 2. The 10- to 12-month-old infant can walk with one hand held or cruise the furniture, but will usually crawl to get places more rapidly. This behavior indicates the child is developmentally on target. **3.The 8-month-old infant should be able to sit steadily unsupported; therefore, this child is developmentally delayed and warrants a referral to the early childhood development specialist. Leaning forward on both hands to sit is normal for a 6-month-old. 4.The 4-month-old infant should be able to turn from the abdomen to back; there- fore, this child is developmentally on target.45. The nurse is providing care for a 68-year-old woman who is complaining of constipation. What concern exists regarding her nutritional status? A) The absorption of nutrients may be impaired. B) The constipation may represent a food allergy. C) She may need emergency surgery for the problem. D) The gastrointestinal problem will increase her caloric demand.A) The absorption of nutrients may be impaired. Page: 182. Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with nutrient intake or absorption. The other responses are not correct.47. The 10-year-old child diagnosed with leukemia is scheduled for a bone marrow aspiration. Which intervention is most important when obtaining informed consent for the procedure? 1. Obtain assent from the child. 2. Have the parent sign the permit. 3. Refer any questions to the HCP. 4. Witness the signature on the permit.**1.The most important intervention for this child is to make sure the child has some control and input into the decision mak- ing. It is customary to obtain assent from children 7 years of age and older. Assent means the child has been fully informed about the procedure and concurs with those giving the informed consent. 2.The parents must sign the permit because the child is under age 18, but the most im- portant intervention is to make sure the child is included and aware of decisions being made about his or her body. 3.The nurse may be able to clarify some of the child's or parent's questions and does not need to refer all questions to the HCP. 4.Witnessing the signature on the permit is required prior to the child's having surgery, but it is not the most important intervention.46. During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? A) Certain drugs can affect the metabolism of nutrients. B) The nurse needs to assess the patient for allergic reactions. C) Medications need to be documented on the record for the physician's review. D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.A) Certain drugs can affect the metabolism of nutrients. Page: 183 Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.48. The 13-year-old client has just delivered a 4-pound baby boy. The stepfather of the client becomes verbally abusive to the nurse when he is asked to leave the room. The client is withdrawn and silent. Which legal action should the nurse implement? 1. Call hospital security to come to the room. 2. Contact Child Protective Services. 3. Refer the child to the social worker. 4. Ask the client whether she feels safe at home.1.The nurse should call hospital security when a client or visitor is being abusive, but this is not a legal action. **2.Legally, the nurse is required to report any suspected child abuse. A 13-year-old child who is having a baby and is with- drawn and silent along with a potential abuser who is trying to control access to the child should make the nurse suspect child abuse. 3.Referring the client to a social worker is not a legal action. 4.Asking the client whether she feels safe at home is an appropriate assessment question, but it is not a legal action.47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors is most likely to affect the nutritional status of an elderly person? A) Increase in taste and smell B) Living alone on a fixed income C) Change in cardiovascular status D) Increase in gastrointestinal motility and absorptionB) Living alone on a fixed income Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an elderly person's nutritional status.49. The fire alarm on the pediatric unit has just started sounding. Which action should the charge nurse implement first? 1. Call the hospital operator to find out the location of the fire. 2. Ensure that all visitors and clients are in the room with the door closed. 3. Prepare to evacuate the clients and visitors down the stairs. 4. Make a list of which clients are not currently on the unit.1.The charge nurse must first make sure that clients and visitors are safe. Someone will notify the charge nurse about the location of the fire. **2.Safety of the clients and visitors is prior- ity; therefore, ensuring that they are in a room with the door closed is the first intervention. 3.The charge nurse may need to prepare for evacuation, but it is not the first intervention. 4. Although making a list of clients not cur- rently on the unit is an appropriate interven- tion, the charge nurse must first ensure the safety of the clients and visitors who are on the pediatric unit.48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are evaluated, which is important for the nurse to remember? A) These measurements are no longer necessary for the elderly. B) Derived weight measures may be difficult to interpret because of wide ranges of normal. C) These measurements may not be accurate because of changes in skin and fat distribution. D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least 90 degrees.C) These measurements may not be accurate because of changes in skin and fat distribution. Page: 191 Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to obtain and interpret in older adults because of sagging skin, changes in fat distribution, and declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity in the elderly.50. A nurse overhears two other nurses talking about a client in the hospital dining room. Which action should the nurse implement first? 1. Notify the HIPAA officer about the breach of confidentiality. 2. Immediately report the two nurses to their clinical manager. 3. Document the situation in writing and submit to the Chief Nursing Officer (CNO). 4. Tell the two nurses they are violating the client's confidentiality.1. .The HIPAA officer can be notified of the breach of confidentiality, but the nurse must first confront the two nurses and correct the behavior. 2. The nurses can be reported to their clinical manager, but the nurse must first confront the two nurses and correct the behavior. 3. The situation can be documented in writing and turned into the HIPAA officer (not the CNO), but the nurse must first confront the two nurses and correct the behavior. **4. This is a violation of HIPAA; therefore, the nurse must first confront the two nurses and correct the behavior.49. The nurse needs to perform anthropometric measures of an 80-year-old man who is confined to a wheelchair. Which of the following is true in this situation? A) Changes in fat distribution will affect the waist-to-hip ratio. B) Height measurements may not be accurate because of changes in bone. C) Declining muscle mass will affect the triceps skinfold measure. D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity.B) Height measurements may not be accurate because of changes in bone. Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair or those over 60 years of age because of osteoporotic changes.51. The nurse is caring for newborns in the nursery. Which newborn warrants immediate intervention by the nurse? 1. The 8-hour-old newborn who has not passed meconium. 2. The 15-hour-old newborn who is slightly jaundiced. 3. The 4-hour-old newborn who is jittery and irritable. 4. The 10-hour-old newborn who will not stop crying.1.The nurse would not be concerned about not passing meconium until at least 24 hours after delivery. 2. The nurse would not be concerned about a newborn who is slightly jaundiced until after 24 hours after delivery, at which point the HCP would investigate to determine whether the jaundice is pathological. **3. A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia. The nurse could feed the newborn glucose water or provide more frequent, regular feedings. 4. Although the nurse should determine why the newborn will not stop crying, the new- born who is showing signs of hypoglycemia warrants immediate intervention.50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes that directly affect the nutritional status of the elderly include: A) slowed gastrointestinal motility. B) hyperstimulation of the salivary glands. C) an increased sensitivity to spicy and aromatic foods. D) decreased gastrointestinal absorption causing esophageal reflux.A) slowed gastrointestinal motility. Page: 176. Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.53. The nurse who has never worked on the maternity ward has been pulled from the surgical unit to work in the newborn nursery. Which assignment would be most appropriate for the nurse to accept? 1. Perform an assessment on the newborn. 2. Assist the pediatrician with a circumcision. 3. Gavage feed a newborn who is 8 hours old. 4. Transport newborns to the mothers' room.1.The nurse should not accept any assign- ment for which he or she is unqualified. A newborn assessment requires specialized knowledge and skills to detect potential complications. 2. The nurse who is not familiar with the pro- cedure or the unit should not be assigned to assist a pediatrician to perform a procedure. 3. This is a dangerous procedure because the nurse must insert a tube into the newborn's stomach. A nurse who is not familiar with this procedure should refuse the assignment. **4. Any nurse can take an infant to the mother's room and check the bands to ensure the right infant is with the right mother. This is an appropriate task for a nurse who has never worked in the nursery.51. The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.B) circulatory status. Page: 211. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.54. The nurse is instructing the unlicensed assistive personnel (UAP) on gross motor skill activity that is appropriate for a developmentally delayed 9-month-old infant. Which activity should the nurse delegate to the UAP? 1. Help the child to sit without support. 2. Teach the child to catch the beach ball. 3. Reward the child with food for sitting up. 4. Teach the child to blow a kiss.**1. The 9-month-old infant should be able to sit without support. Therefore, the nurse should instruct the UAP to perform the developmental task of helping the child sit without support. 2. Teaching a child to catch a beach ball would be appropriate for a 15- to 18-month-old child, so the nurse should not instruct the UAP to perform this task. 3. The UAP should not use food as a reward or comfort measure because it may lead to childhood obesity. 4. Teaching a child how to blow a kiss is a language/cognitive activity and will not help the child's gross motor development.52. A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding? A) Color variation B) Border regularity C) Symmetry of lesions D) Diameter less than 6 mmA) Color variation Pages: 212-213. Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.55. Which incident should the primary nurse report to the clinical manager concerning a violation of information technology guidelines? 1. The nurse keeps the computer screen turned away from public view. 2. The nurse researches medications using the online formulary. 3. The nurse shares the computer access code with another nurse. 4. The nurse logs off the computer when leaving the terminal.1. Making sure no one can view the screen is an appropriate information technology guideline. 2. Researching medication online is ensuring safe and effective nursing care and shows that the nurse is keeping abreast of new medications. **3. According to the NCLEX-RN® test blueprint, the nurse must be knowledge- able of information technology. Giving another nurse his or her access code is a very serious violation of information technology guidelines and should be reported. 4. Logging off the computer is an appropriate information technology guideline.53. An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination? A) Smooth mucous membranes and lips B) Dry mucous membranes and cracked lips C) Pale mucous membranes D) White patches on the mucous membranesB) Dry mucous membranes and cracked lips Page: 215. With dehydration, mucous membranes look dry and lips look parched and cracked. The other responses are not found in dehydration.56. The nurse is caring for clients in a pediatric emergency department (ED). Which client should the nurse assess first? 1. The child with a dog bite on the left hand who is bleeding. 2. The child who has a laceration on the right side of the forehead. 3. The child with a fractured tibia who will not move the foot. 4. The child who has ingested a bottle of prenatal vitamins.1. A dog bite is an emergency, but it is not life threatening; therefore, this child would not be assessed first. 2. The child with a head laceration must be assessed, but not before a child who might die of medication poisoning. 3. The child with a fractured tibia would not be expected to move the foot. **4. A child who ingested a bottle of prenatal vitamins presents a medication poisoning that is a potentially life-threatening situa- tion. This child must be assessed first to determine how many vitamins were taken, how long ago they were taken, and whether or not the vitamins contained iron. The child's neurological status must also be assessed.54. A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nailsD) Clubbing of the nails Pages: 217-218. Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.57. The nurse is caring for a client in a children's medical center. Which behavior indicates the nurse understands the pediatric client's rights? 1. The nurse administers an injection without talking to the child. 2. The nurse covers the 5-year-old child's genitalia during a code. 3. The nurse discusses the child's condition with the grandparents. 4. The nurse leaves an uncapped needle at the client's bedside.1. The pediatric client has the right to an explanation of procedures being done to his or her body. **2. The pediatric client has a right to be treated with dignity and respect. Just because the child is being coded does not mean the nurse should allow the child's body to be exposed to everyone in the room. 3. The pediatric client has a right to confiden- tiality, and the parents/legal guardians are the only individuals who have a right to the child's health information. Talking to the grandparents is a violation of HIPAA unless the parents have approved. 4. The nurse is responsible and accountable to protect the health, safety, and rights of the pediatric client. Leaving an uncapped needle at the bedside could cause serious harm to the child.55. The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as sclerodermaC) Severe dehydration Page: 215. Decreased skin turgor is associated with severe dehydration or extreme weight loss.58. The home health nurse is planning the care of a 14-year-old client diagnosed with leukemia who is receiving chemotherapy. Which psychosocial problem is priority for this client? 1. Diversional activity deficit. 2. High risk for infection. 3. Social isolation. 4. Hopelessness.1. Diversional activity deficit would be appro- priate if the client did not have sufficient activities to keep him or her occupied. Most children of this age will watch television, play video games, or read books. 2. The client has leukemia and is receiving chemotherapy, which leads to an increased risk of infection; however, this is a physiolog- ical problem, not a psychosocial problem. **3. The client will be isolated from peers and schools because of the high risk of infec- tion resulting from the immunosuppres- sion secondary to chemotherapy and the disease process. At this stage, the child needs to be developing peer relationships and independence from parents. There- fore, social isolation is the priority psy- chosocial problem for this client. 4. The nurse should not identify hopelessness because childhood leukemia has a good prognosis.56. A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral.59. The nurse is administering IV fluids to a 3-year-old client. Which action by the nurse would warrant intervention by the charge nurse? 1. The nurse places the IV on an infusion pump. 2. The nurse does not use a volume-controlled chamber. 3. The nurse checks the child's IV site every hour. 4. The nurse labels the IV tubing with date and time.1.Placing the IV line on an infusion pump helps to make sure the client does not receive an overload of IV fluid. Most facilities require an IV pump and volume-controlled chamber when administering fluids in a pediatric clinic. **2.A volume-controlled chamber (Buretrol) is a device that is used with children when administering IV fluids. The cham- ber is filled with 1 hour's amount of fluid so that the child will not inadvertently re- ceive an overload of fluid. Fluid volume overload is a potentially life-threatening situation in children. 3. The site should be checked frequently to en- sure that the IV does not infiltrate; therefore, this does not warrant intervention. 4. The IV tubing should not be used longer than 72 hours; therefore, labeling the tubing with the date and time would not warrant intervention.57. The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender. B) curved nails with a convex profile and ridges across the nail. C) a nail base that feels spongy with an angle of the nail base of 150 degrees. D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. Pages: 217-218. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.60. The nurse is caring for clients on a psychiatric pediatric unit. Which action by the nurse is reportable to the state board of nursing? 1. The nurse leaves for lunch and does not return to complete the shift. 2. The nurse fails to check the ID band when administering medications. 3. The nurse has had three documented medication errors in the last 3 months. 4. The nurse has admitted to having an affair with another staff member.**1. Abandonment is a reportable offense to the state board of nursing in every state. Reportable offenses could result in stipulations made to the nurse's license. 2. This is failure to follow the five rights of medication administration, but it is not a reportable offense. 3. Multiple medication errors are a manage- ment issue, not a reportable offense. 4.Having an affair with a fellow employee is not a reportable offense.58. A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient's fingernails? A) Splinter hemorrhages B) Paronychia C) Pitting D) Beau linesC) Pitting Pages: 248-250. Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.61. The nurse is working in a free healthcare clinic. Which client situation warrants further investigation? 1. The child diagnosed with rheumatoid arthritis who is wearing a copper bracelet. 2. The mother of a child with a sunburn who is using juice from an aloe vera plant on the burn. 3. The grandmother who reports rubbing Vick's Vapo-Rub on the child's chest for a cold. 4. The father who tells the nurse that the child receives a variety of herbs every day.1. A copper bracelet may or may not help the child with rheumatoid arthritis, but because it will not hurt the child, it does not warrant further investigation. 2. Aloe vera is used in many topical burn prepa- rations; therefore, this practice would not warrant further investigation. 3. Vick's VapoRub may or may not help the child's cold, but, because it will not hurt the child, it does not warrant further investigation. **4. Herbal products are not regulated by the Food and Drug Administration, and there is very little (if any) research on herbal use with children. The nurse should at least investigate which herbs the child is receiving before taking further action.59. The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination? A) Tachycardia B) Constipation C) Rapid dyspnea D) Atrophied nodular thyroidA) Tachycardia Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.62. The unlicensed assistive personnel (UAP) tells the primary nurse that the 4-year-old child is alone in the room because the mother went to the cafeteria to get something to eat. Which action should the nurse implement first? 1. Arrange for the mother to have a tray sent to the room. 2. Go to the cafeteria and ask the mother to return to the room. 3. Tell the UAP to stay with the child until the mother returns. 4. Notify social services that the mother left the child alone.1.This is an appropriate nursing intervention so that the mother will not have to leave her child, but it is not the first intervention. The child's safety is priority. 2. The nurse could go to the cafeteria and tell the mother to return to the room, but during this time the UAP should stay with the child. **3. The child's safety is priority; therefore, the nurse should have the UAP stay with the child until the mother returns. 4. Social services would not need to be notified at this time. If the mother continually leaves the child alone, then this would be an appropriate action.60. During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings? A) Positive Macewen sign B) Premature closure of the sagittal suture C) Headache, vertigo, tinnitus, and deafness D) Elongated head with heavy eyebrow ridgeC) Headache, vertigo, tinnitus, and deafness Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.63. The nurse is evaluating an 18-month-old child in the pediatric clinic. Which data would indicate to the nurse that the child is not meeting tasks according to Erikson's Stages of Psychosocial Development? 1. The child stamps his or her foot and says "no" frequently. 2. The child does not interact with the mother. 3. The child cries when the mother leaves the room. 4. The child responds when called by name.1.An 18-month-old child should be throwing temper tantrums. This indicates the child is developing a sense of autonomy. **2.An 18-month-old child should cling to the mother and interact continuously with the primary caregiver. A child not interacting with the mother is not meeting the task of developing a sense of autonomy. 3.The child has met the task of trust when he or she cries if the mother leaves the room. 4.When a child responds to his or her name, it indicates a sense of identity; therefore, the task is met.61. A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: A) cachexia. B) Parkinson's syndrome. C) myxedema. D) scleroderma.C) myxedema. Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.62. The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: A) pulled to the affected side. B) pushed to the unaffected side. C) pulled downward. D) pulled downward in a rhythmic pattern.B) pushed to the unaffected side. Pages: 262-263. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.64. Which statement by the female charge nurse indicates she has an autocratic leadership style? 1. "You must complete all the a.m. care before you take your morning break." 2. "I don't care how the work is done as long as it is completed on time." 3. "I would like to talk to you about your ideas on a new staffing mix." 4. "I think we should have a pot luck lunch tomorrow because it is Saturday."**1. An autocratic manager uses an authori- tarian approach to direct the activities of others. This individual makes most of the decisions alone without input from other staff members. 2. A laissez-faire manager maintains a permis- sive climate with little direction or control. 3. A democratic manager is people oriented and emphasizes efficient group functioning. The environment is open, and communication flows both ways. 4. A democratic manager is people oriented and emphasizes efficient group functioning.65. The nurse is evaluating the care of a 5-year-old client with a cyanotic congenital heart defect. Which client outcome would support that discharge teaching has been effective? 1. The mother makes the child get up when squatting. 2. The child is playing in the dayroom without oxygen. 3. The father buys the child a baseball and a bat. 4. The nurse finds unopened packs of salt on the meal tray.1. Squatting relieves the hypoxic episodes, and the child should be able to remain in the squatting position. 2. The child with a cyanotic, congenital heart defect should have oxygen when being active. 3. This indicates the father does not understand that the child will not be able to participate in active sports because of the stress that is placed on the heart. **4. This behavior indicates the child under- stands the importance of salt restriction because of potential congestive heart failure.63. During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? A) Rickets B) Dehydration C) Mental retardation D) Increased intracranial pressureB) Dehydration Pages: 265-266. Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.69. The unconscious 4-year-old child is brought to the emergency department by para- medics; the child has bruises covering the torso in varying stages of healing. The nurse notes small burn marks on the child's genitalia. Which actions should the nurse implement? Select all that apply. 1. Notify Child Protective Services. 2. Ask the parent how the child was injured. 3. Perform a thorough examination for more injuries. 4. Tell the parents that the police have been called. 5. Prepare the child for skull x-rays and a CT scan.1, 3, and 5 are correct. 1. This child has injuries consistent with child abuse. Child Protective Services and the police should be notified. 2. This could result in not being able to prose- cute the perpetrator if the nurse is not trained in forensic medicine. 3. The nurse should determine the full extent of the child's injuries. 4. The nurse should not notify the parent of the potential involvement. The police are fully capable of doing this for themselves. The nurse could instigate an inflammatory situation with this action. 5. The child needs x-ray studies to deter- mine the extent of internal injuries.64. The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: A) allergies. B) a sinus infection. C) nasal congestion. D) an upper respiratory infection.A) allergies. Page: 275. Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.70. The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. 1. Teach the parent about weighing diapers to determine output status. 2. Show the parent the call light and explain safety regimens. 3. Assess the toddler's tissue turgor. 4. Place the appropriate size diapers in the room. 5. Take the toddler's vital signs.Rationale Correct Answer: 5, 3, 2, 4, 1 5. Taking the vital signs is part of the assess- ment and a beginning point for the nurse. 3. Since the child has been losing fluids, the nurse should assess tissue turgor to try and determine whether fluid replacement by the parents has been effective. 2. The nurse should make sure that the parents do not leave the child alone in the room and make sure the parents are aware of any safety measures used to protect the toddler from abduction and how to call the nurse in case of need. 4. The parents will need to change diapers so the child will not develop skin irrita- tion problems. 1. When the nurse provides diapers it is a good opportunity to teach the parents about weighing the diapers before and after the child soils them.65. A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A) "Vision is not totally developed until 2 years of age." B) "Infants develop the ability to focus on an object at around 8 months." C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." D) "Most infants have uncoordinated eye movements for the first year of life."C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." Page: 284. Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate on a single image with both eyes simultaneously.Why is it important for the nurse to ask a patient what medications he or she is taking? A) Certain drugs can affect the metabolism of nutrients. B) The nurse needs to assess the patient for allergic reactions. C) Medications need to be documented on the record for the physician's review. D) Medications can affect one's memory and ability to identify food eaten in the last 24 hours.A) Certain drugs can affect the metabolism of nutrients. Rationale Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.66. The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair folliclesB) Unequal pupillary constriction in response to light Pages: 305-308. Pupils are small in old age, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.When assessing the quality of a patient's pain, the nurse should ask which question? A) "When did the pain start?" B) "Is the pain a stabbing pain?" C) "Is it a sharp pain or dull pain?" D) "What does your pain feel like?"D) "What does your pain feel like?" Rationale To assess the quality of a person's pain, have the patient describe the pain in his or her own words.67. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: A) check for the presence of exophthalmos. B) suspect that the patient has hyperthyroidism. C) ask the patient if he or she has a history of heart failure. D) assess for blepharitis because this is often associated with periorbital edema.C) ask the patient if he or she has a history of heart failure. Page: 312. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.A 6-month-old infant has been brought to the well-child clinic for a check-up. She is currently sleeping. What should the nurse do first when beginning the examination? A) Auscultate the lungs and heart while the infant is still sleeping. B) Examine the infant's hips because this procedure is uncomfortable. C) Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach. D) Wake the infant before beginning any portion of the examination to obtain the most accurate assessment of body systems.A) Auscultate the lungs and heart while the infant is still sleeping. Rationale When the infant is quiet or sleeping is an ideal time to assess the cardiac, respiratory, and abdominal systems. Assessment of the eye, ear, nose, and throat are invasive procedures and should be performed at the end of the examination.68. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision. B) shadow or diminished vision in one quadrant or one half of the visual field. C) loss of peripheral vision. D) sudden loss of pupillary constriction and accommodation.B) shadow or diminished vision in one quadrant or one half of the visual field. Page: 316. With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.69. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration. B) her vision is normal for someone her age. C) she has the beginning stages of cataract formation. D) she has increased intraocular pressure or glaucoma.A) she may have macular degeneration. Page: 285. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination? A) There is no need to wash one's hands after removing gloves, as long as the gloves are still intact. B) Wash hands before and after every physical patient encounter. C) Wash hands between the examination of each body system to prevent the spread of bacteria from one part of the body to another. D) Wear gloves throughout the entire examination to demonstrate to the patient concern regarding the spread of infectious diseases.B) Wash hands before and after every physical patient encounter. Rationale The nurse should wash his or her hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Hands should be washed after gloves have been removed, even if the gloves appear to be intact. Gloves should be worn when there is potential contact with any body fluids.When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable.B. provided consistent information and therefore is reliable. Rationale A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.70. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: A) retinal detachment. B) diabetic retinopathy. C) acute-angle glaucoma. D) increased intracranial pressure.D) increased intracranial pressure. Pages: 319-320. Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched. Rationale Light palpation is performed initially to detect any surface characteristics and to accustom the person to being touched. Tender areas should be palpated last, not first.71. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. A) The patient may experience sensitivity to light, nausea, and halos around lights. B) The patient experiences tunnel vision in late stages. C) Immediate treatment is needed. D) Vision loss begins with peripheral vision. E) It causes sudden attacks of increased pressure that cause blurred vision. F) There are virtually no symptoms.B) The patient experiences tunnel vision in late stages. D) Vision loss begins with peripheral vision. F) There are virtually no symptoms. Pages: 308-309. Open-angle glaucoma is the most common type of glaucoma; there are virtually no symptoms. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? A. "Maybe she is just teething." B. "I will check her ear for an ear infection." C. "Are you sure she is really having pain?" D. "Please describe what she is doing to indicate she is having pain."D. "Please describe what she is doing to indicate she is having pain." Rationale With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination.72. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? A) "Do you ever notice ringing or crackling in your ears?" B) "When was the last time you had your hearing checked?" C) "Have you ever been told you have any type of hearing loss?" D) "Was there any relationship between the ear pain and the discharge you mentioned?"D) "Was there any relationship between the ear pain and the discharge you mentioned?" Pages: 327-328. Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.When performing a physical assessment, the technique the nurse will always use first is: A) palpation. B) inspection. C) percussion. D) auscultation.B) inspection. Rationale The skills requisite for the physical examination are inspection, palpation, percussion, and auscultation. The skills are performed one at a time and in this order (with the exception of the abdominal assessment, where auscultation takes place before palpation and percussion). The assessment of each body system begins with inspection. A focused inspection takes time and yields a surprising amount of information.73. The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding? A) A high-tone frequency loss B) Increased elasticity of the pinna C) A thin, translucent membrane D) A shiny, pink tympanic membraneA) A high-tone frequency loss Pages: 337-338. A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizationsD. Reactions to previous hospitalizations Rationale Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure.74. During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" The nurse recognizes that this symptom indicates: A) vertigo. B) pruritus. C) tinnitus. D) cholesteatoma.C) tinnitus. Pages: 328-329. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities.D. It helps to determine how a person is managing day-to-day activities. Rationale The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment.75. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which of the following? Select all that apply. A) Hearing loss related to aging begins in the mid 40s. B) The progression is slow. C) The aging person has low-frequency tone loss. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. F) Hearing loss reflects nerve degeneration of the middle ear.B) The progression is slow. D) The aging person may find it harder to hear consonants than vowels. E) Sounds may be garbled and difficult to localize. Page: 326. Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound is impaired also.During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"B) "Tell me about what you plan to do once you are discharged from the hospital." Rationale A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.76. When assessing a patient's lungs, the nurse recalls that the left lung: A) consists of two lobes. B) is divided by the horizontal fissure. C) consists primarily of an upper lobe on the posterior chest. D) is shorter than the right lung because of the underlying stomach.A) consists of two lobes. Pages: 413-414. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"A) "How do you feel today?" Rationale Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.77. During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: A) adventitious sounds and limited chest expansion. B) increased tactile fremitus and dull percussion tones. C) muffled voice sounds and symmetrical tactile fremitus. D) absent voice sounds and hyperresonant percussion tones.C) muffled voice sounds and symmetrical tactile fremitus. Pages: 429-430. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?"B. "Are you able to dress yourself?" Rationale Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment.78. A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? A) Obtain a detailed history of the patient's allergies and history of asthma. B) Tell the patient to sleep on his or her right side to facilitate ease of respirations. C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. D) Assure the patient that this is normal and will probably resolve within the next week.C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.B) It is usually sufficient to gather mental status information during the health history interview. Rationale The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview.79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? A) Between the scapulae B) Third intercostal space, MCL C) Fifth intercostal space, MAL D) Over the lower lobes, posterior sideA) Between the scapulae Page: 424. Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. A. "How much junk food does your child eat?" B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" D. "Does he take a children's vitamin?" E. "Can he tell time?" F. "Does he have any food allergies?"B. "How many teeth has he lost, and when did he lose them?" C. "Is he able to tie his shoelaces?" E. "Can he tell time?" Rationale Questions about tooth loss, ability to tell time, and ability to tie shoelaces are appropriate questions for a developmental assessment. Questions about junk food intake and vitamins are part of a nutritional history. Questions about food allergies are not part of a developmental history.80. The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile fremitus: A) is caused by moisture in the alveoli." B) indicates that there is air in the subcutaneous tissues." C) is caused by sounds generated from the larynx." D) reflects the blood flow through the pulmonary arteries."C) is caused by sounds generated from the larynx." Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies departmentA) A trained interpreter Rationale whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible.81. When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: A) sounds normally auscultated over the trachea. B) bronchial breath sounds and are normal in that location. C) vesicular breath sounds and are normal in that location. D) bronchovesicular breath sounds and are normal in that location.C) vesicular breath sounds and are normal in that location. Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable.B. provided consistent information and therefore is reliable. Rationale A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct.82. The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: A) dullness. B) tympany. C) resonance. D) hyperresonance.A) dullness. Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.83. The nurse knows that auscultation of fine crackles would most likely be noticed in: A) a healthy 5-year-old child. B) a pregnant woman. C) the immediate newborn period. D) association with a pneumothorax.C) the immediate newborn period. Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed.B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Rationale Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions.When planning a cultural assessment, the nurse should include which component? A) Family history B) Chief complaint C) Medical history D) Health-related beliefsD) Health-related beliefs Rationale Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history.84. During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? A) Airway obstruction B) Emphysema C) Pulmonary consolidation D) AsthmaC) Pulmonary consolidation Page: 446. Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing.A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Rationale The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it.85. The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? A) Wheezes B) Bronchial sounds C) Bronchophony D) Whispered pectoriloquyA) Wheezes Page: 445. Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?"D) "What cultural or spiritual beliefs are important to you?" Rationale The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.86. An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: A) asthma. B) atelectasis. C) lobar pneumonia. D) heart failure.A) asthma. Page: 451. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary.A) Ask the patient about the item and its significance. Page: 21 Rationale amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures.87. During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? A) Listen to at least one full respiration in each location. B) Listen as the patient inhales and then go to the next site during exhalation. C) Have the patient breathe in and out rapidly while the nurse listens to the breath sounds. D) If the patient is modest, listen to sounds over his or her clothing or hospital gown.A) Listen to at least one full respiration in each location. Pages: 426-427. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs.A) children have spiritual needs that are influenced by their stages of development. Rationale Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.88. During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus. B) crepitus. C) friction rub. D) adventitious sounds.B) crepitus. Page: 424. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families.C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Rationale In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).89. The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: A) atelectatic crackles, and that they are not pathologic. B) fine crackles, and that they may be a sign of pneumonia. C) vesicular breath sounds. D) fine wheezes.A) atelectatic crackles, and that they are not pathologic. Pages: 429-430. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain.B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. Rationale In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.90. The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. B) As the patient says "ninety-nine" repeatedly, the examiner hears the words "ninety-nine" clearly. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. E) As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.A) Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C) When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D) As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. Page: 446. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A) "Do you take medicine?" B) "Do you sterilize the bottles?" C) "Do you have nausea and vomiting?" D) "You have been taking your medicine, haven't you?"A) "Do you take medicine?" Rationale In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time.91. During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence. C) fluid volume overload. D) ventricular hypertrophy.B) blood flow turbulence. Page: 471. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C) Request a sign language interpreter before meeting with him to help facilitate the communication. D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading.A) Determine the communication method he prefers. Rationale The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime.92. During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular lineD) Fifth left intercostal space at the midclavicular line Pages: 473-474. The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is: A) just changing positions. B) more comfortable in this position. C) tired and needs a break from the interview. D) uncomfortable talking about his son's treatment.D) uncomfortable talking about his son's treatment. Rationale Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic.93. The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Pages: 475-476. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: A) talking too much. B) using confrontation. C) using biased or leading questions. D) using blunt language to deal with distasteful topics.C) using biased or leading questions. Rationale This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer.94. The nurse is assessing a patient's apical impulse. Which of these statements is true regarding the apical impulse? A) It is palpable in all adults. B) It occurs with the onset of diastole. C) Its location may be indicative of heart size. D) It should normally be palpable in the anterior axillary line.C) Its location may be indicative of heart size. Page: 473 | Page: 492. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? A) Reflection B) Facilitation C) Direct question D) Open-ended questionD) Open-ended question Rationale The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic.95. During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicositiesC) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Pages: 504-505. Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. Rationale Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior.96. During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.B) early clubbing. Page: 506. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.97. When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.C) consider this a normal finding and proceed with the peripheral vascular evaluation. Pages: 506-507. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.98. The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.B) Regular "lub, dub" pattern Pages: 510-511. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.99. When using a Doppler ultrasonic stethoscope, the nurse recognizes arterial flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing soundC) Swishing, whooshing sound Pages: 515-516. When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.100. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) AbsentB) Normal Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.101. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) HyperresonanceA) Dullness Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note.102. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colonD) Sigmoid colon Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.103. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.D) Percuss and palpate the midline area above the suprapubic bone. Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.104. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.C) normal abdominal aortic pulsations. Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.105. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.B) peritonitis. Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.D) hyperactive bowel sounds. Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.107. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular lineB) A tympanic percussion note in the umbilical region Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).108. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.B) 5 minutes. Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.109. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle testB) Test for Murphy's sign Page: 551. Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.110. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumorC) Umbilical hernia Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.111. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.B) Test for Blumberg's sign. D) Perform iliopsoas muscle test. Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.112. When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5D) 5 Pages: 578-579. Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.113. The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swellingB) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances Page: 608. In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.114. During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: A) cranial nerve dysfunction. B) lesion in the cerebral cortex. C) normal changes due to aging. D) demyelinization of nerves due to a lesion.C) normal changes due to aging. Page: 629. Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.115. In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? A) "Does your family know you are drinking every day?" B) "Does the tremor change when you drink the alcohol?" C) "We'll do some tests to see what is causing the tremor." D) "You really shouldn't drink so much alcohol; it may be causing your tremor."B) "Does the tremor change when you drink the alcohol?" Page: 632. Intention tremor/ senile tremor is relieved by alcohol, although this is not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.116. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A) Firm, rigid resistance to movement B) Mild, even resistance to movement C) Hypotonic muscles as a result of total relaxation D) Slight pain with some directions of movementB) Mild, even resistance to movement Page: 637. Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretch. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.117. When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): A) ataxia. B) lack of coordination. C) negative Homans' sign. D) positive Romberg sign.D) positive Romberg sign. Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.118. During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate? A) The nurse would not do this part of the examination because results would not be valid. B) The nurse would perform the tests, knowing that mental status does not affect sensory ability. C) The nurse would proceed with the explanations of each test, making sure the wife understands. D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time. The nurse should ensure validity of the sensory system testing by making sure the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.119. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? A) Lack of reflexes B) Normal reflexes C) Diminished reflexes D) Hyperactive reflexesD) Hyperactive reflexes Hyperreflexia is the exaggerated reflex seen when the monosynaptic reflex arc is released from the influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect120. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.A) These are normal findings resulting from aging. Page: 659. Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and weakness of voluntary movement. The other responses are incorrect.121. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.D) decreased level of consciousness. Pages: 660-661. A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.122. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary responseC) Level of consciousness, motor function, pupillary response, and vital signs Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.123. During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injuryB) Increased intracranial pressure Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.124. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongataA) Cerebrum Pages: 621-622 | Page: 660. The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other options structures are not responsible for a person's level of consciousness.