NCLEX Questions

A nurse is providing care for a patient who had a transurethral resection of his prostate this morning. The patient is receiving continuous bladder irrigation, and the urinary catheter is now occluded. The nurse is planning to contact the patient's health care provider and communicate using the SBAR (Situation-Background-Assessment-Recommendation) format. Which statement is a component of communication using SBAR?

A) What do you think could be causing this occlusion

B) I think that we should manually irrigate his catheter.

C) What do you know about this patient and his history?

D) Could you please provide some direction for his care?

B) "I think that we should manually irrigate his catheter."

Proposing a recommendation is a component of the "R" component of SBAR communication. Asking the health care provider for possible contributing factors to the problem or for general direction may be appropriate in some circumstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient and his circumstances, not ask an open-ended question regarding the health care provider's familiarity.

Telehealth devices are commonly used to provide which types of patient care (select all that apply.)?

A) Evaluation of weight loss

B) Medication administration

C) Video assessment of wounds

D) Monitoring peak flow meter results

E) Real-time blood pressure

A, C, D, E

In which patient care delivery model does the nurse plan and coordinate the aspects of patient care with other disciplines focusing on continuity of care and interprofessional collaboration even if the nurse is absent?

A) Team nursing model

B) Primary nursing model

C) Total patient care

D) Case management nursing model

C) Primary nursing model

The primary nursing model includes planning the patient's care and coordinating and communicating all aspects of care with other disciplines and those providing care in the nurse's absence. The focus is on continuity of care and interprofessional collaboration. Team nursing uses the RN as the team leader to organize and manage the care for a group of patients with other ancillary workers. The RN has authority and accountability for the quality of care delivered by the team only during the work period. In a total patient care model, the nurse is accountable for the complete care of the patient during the assigned shift. Case management is not a model of care delivery but a collaborative process that involves assessing, planning, facilitating, and advocating for health services with a variety of resources to promote cost-effective outcomes.

A nurse is monitoring all of the patients in an outpatient procedure area for complications of administering IV fluids. What type of nursing function is being demonstrated by the nurse?

A) Dependent

B) Independent

C) Autonomous

D) Collaborative

D) Collaborative

A collaborative nursing function is demonstrated when the nurse monitors patients for complications of acute illness, administers IV fluids and medications per health care provider's orders, and implements nursing interventions such as providing emotional support or teaching about specific procedures. Nursing functions may be dependent, collaborative, or independent. The nurse functions dependently when carrying out medical orders. Physician-initiated nursing functions may include administering medications, performing or assisting with certain medical treatments, and assisting with diagnostic tests and procedures. Independent nursing functions include interventions such as promotion and optimization of health, prevention of illness, and patient advocacy.

A group of nurses has a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers. What will this change in practice encompass (select all that apply.)?

A) Consulting with the wound care and ostomy nurse

B) Nurses' expertise and bodies of experience and knowledge

C) The preferences of patients and their particular circumstances

D) The traditions that surround pressure ulcer practices on the unit

E) Journal articles that address the care of patients with pressure ulcers

A, B, C, E

Which interventions are independent nursing actions (select all that apply.)?

A) Reinserting an IV

B) Assessing lung sounds

C) Obtaining informed consent

D) Administering IV medications

E) Turning a patient every two hours

A, B, E

A nurse with an associate or baccalaureate degree who meets licensing requirements is qualified to practice as

A) a nurse practitioner

B) a certified specialist

C) an entry-level generalist

D) an advanced practice nurse

C) an entry-level generalist.

Entry-level nurses with an associate or baccalaureate degree are prepared to function as generalists. With experience and continued study, nurses may specialize in an area of practice and may obtain certification in nursing specialties. Certification usually requires clinical experience and successful completion of an examination. A nurse practitioner is an example of an advanced practice nurse. An advanced practice nurse has a minimum of a master's degree with advanced education in pharmacology and physical assessment as well as expertise in a specialized area of practice.

The nurse establishes priorities and determines outcomes for an individual patient during which phase of the nursing process?

A) Analysis

B) Planning

C) Evaluation

D) Assessment

B) Planning

During the planning phase of the nursing process, patient outcomes or goals are developed and nursing interventions are identified to accomplish the outcomes. The assessment phase of the nursing process includes the collection of subjective and objective patient information on which to base the plan of care. The evaluation phase of the nursing process determines if the patient outcomes have been met as a result of nursing interventions. Nursing diagnosis is the act of analyzing the assessment data and making a judgment about the nature of the data.

When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. This format is called a

A) concept map

B) critical pathway

C) clinical pathway

D) nursing care plan

A) concept map.

A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire interprofessional care team in the daily care goals for select health care problems.

When nurses disagree about the effectiveness of a commonly practiced nursing intervention, the best evidence for determining which intervention to use is

A) a systematic review of randomized controlled trails

B) a qualitative research study with a large sample size

C) a methodical Internet search using key medical terms

D) anecdotal evidence retrieved from two or more case studies

A) a systematic review of randomized controlled trials.

Systematic reviews of randomized controlled trials (RCTs) are considered the strongest level of evidence to answer questions about interventions (i.e., cause and effect).

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, which phase of the nursing process is being used?

A) planning

B) diagnosis

C) evaluation

D) implementation

D) Implementation

Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse's action of encouragement and instruction to the patient is part of carrying out a plan of action.

A patient is being prepared for discharge home after a laparoscopic cholecystectomy. Which team member can be assigned to complete a discharge assessment and provide patient teaching for post-discharge care?

A) Registered Nurse (RN)

B) Nursing technician (NT)

C) Unlicensed assistive personnel (UAP)

D) Licensed practical/vocational nurse (LPN/LVN)

A) Registered nurse (RN)

Nursing interventions that require independent nursing knowledge, skill, or judgment such as assessment, patient teaching, and evaluation of care cannot be delegated. These interventions are the responsibility of the RN. The scope of practice for LPN/LVNs is determined by each state board of nursing. The RN must know the legal scope of practical/vocational nursing practice and delegates and assigns nursing functions appropriately. In most states LPN/LVNs may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN. UAP are unlicensed individuals who serve in an assistive role to the RN and may include nursing assistants or technicians. The RN may delegate specific activities such as obtaining routine vital signs on stable patients, feeding/assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene.

What factor has been most clearly identified as an influence on the future of nursing practice?

A) Aging of the American population and increases in chronic illnesses

B) Increasing birth rates coupled with decreased average life expectancy

C) Increased awareness of determinants of health and improved self-care

D) Apathy around health behaviors and the relationship of lifestyle to health

A) Aging of the American population and increases in chronic illnesses

The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing.

A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse (LPN/LVN). Which statement accurately describes delegation?

A) The RN must teach the LPN how to administer the IV medications.

B) Ultimate responsibility for administering the medication lies with the LPN..

C) The RN is responsible for observing the LPN administer the IV medication

D) The RN is the one accountable for the quality of care that the patient receives.

D) The RN is the one accountable for the quality of care that the patient receives.

Delegation entails a redistribution of nursing work, but the RN remains ultimately responsible and accountable for the execution of the task. It would be inappropriate to delegate if the LPN was unfamiliar with the task. The RN is not obliged to observe the LPN's execution of the task.

A Muslim patient is hospitalized during the period of Ramadan and refuses his morning oral medications. What is the priority action by the nurse?

A) Place the medication in food.

B) Attempt to give the medication to the patient after sundown.

C) Inform the patient that if he does not take the medication now, he will not get better.

D) Inform the patient that if he does not take his medication, he will have to leave the hospital.

B) Attempt to give the medication to the patient after sundown.

Muslims fast during the daytime during the Islamic month of Ramadan. Such practices may affect when and how medications are taken. The medication may be administered after the period of fasting. The nurse must be culturally competent and respect the patient's religious and cultural beliefs. Placing the medication in food is unnecessary because the patient will not eat food during this time. Threatening the patient about leaving or becoming more ill is not therapeutic and will decrease the level of trust in the nurse-patient relationship.

What are the four components of cultural competence that nurses can demonstrate in providing nursing care regardless of the care delivery setting?

A) Awareness, knowledge, skill, and encounter

B) Patience, sensitivity, openness, and listening

C) Immersion, transcendence, imposition, and attitude

D) Ability, understanding, communication, and empathy

A) Awareness, knowledge, skill, and encounter

The four components of cultural competence are cultural awareness, cultural knowledge, cultural skill, and cultural encounter.

The nurse is caring for a Hispanic man who wishes to have a "traditional healer" come to the hospital in order to render care. What is an appropriate action by the nurse?

A) Obtain the services of a hougan after informing the primary care provider.

B) Obtain the services of a shaman after informing the primary care provider.

C) Obtain the services of a parteras after informing the primary care provider.

D) Obtain the services of a curandero after informing the primary care provider.

D) Obtain the services of a curandero after informing the primary care provider.

The nurse should respect the wishes of the patient and obtain the services of the curandero after informing the primary care provider. Informing the primary care provider may assist in cooperative care giving. This patient would not request a shaman, who is an American Indian traditional healer. A hougan is a traditional folk healer in the African American culture. A parteras is a lay midwife for a Hispanic female patient.

A nurse, while preparing to interview for employment in a rural hospital, identifies which chronic illnesses as more prevalent in rural areas than in urban areas of the United States?

A) Cancer and heart disease

B) Sexually transmitted infections

C) Alzheimer's disease and dementia

D) Chronic obstructive pulmonary disease

A) Cancer and heart disease

Chronic illnesses that are more prevalent in rural areas of the United States include cancer, heart disease, diabetes, depression, injury-related deaths, obesity, and substance abuse. Obesity and chronic illness rates for diabetes, hypertension, chronic obstructive pulmonary diseases, cancer, and stroke are higher among minority people. Alzheimer's disease and dementia are more common in the older adult. Urbanization is related to increased incidence of sexually transmitted infections.

What action observed by the charge nurse from a staff nurse would be most indicative of stereotyping and require further education?

A) The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients.

B) The nurse helps a recent immigrant to explore ways to pay for her newly prescribed antihypertensive medications.

C) The nurse prioritizes the assessment of obesity when providing care for African American and Mexican American women.

D) The nurse arranges for translation services to be provided for a patient who has recently emigrated from Sri Lanka and does not speak English.

A) The nurse advocates for bronchodilators to be prescribed for all newly admitted African American patients.

Stereotyping is considered to be the act of treating all members of a particular race, culture, or ethnic group alike. Although the prevalence and incidence of asthma is high among African Americans, it would be simplistic and inappropriate to provide asthma medications to all members of this group. Assessing a patient's ability to pay for medications and assessing for health problems that are common among particular genders and groups are both appropriate nursing actions that are reflective of recognized health disparities. Arranging for translation services for a patient who does not speak English is appropriate and justified.

The nurse identifies a patient at high risk for health care disparities. What should be included as important nursing actions to reduce health care disparities (select all that apply.)?

Select all that apply.

A) Passive listening

B) Relationship building

C) Taking foreign language classes

D) Participating in cross-cultural education

E) Using standardized evidence-based guidelines

B, C, D, E

The nurse is interested in developing her cultural competence. What behaviors can be adopted to do so?

A) Develop an understanding of all ethnic groups.

B) Identify the one culture about which she is interested in being competent.

C) Have extended contact with a cultural group to enhance understanding of its values and beliefs.

D) Understand the specific information about the patient's culture so the understanding can be applied to caring for the patient.

C) Have extended contact with a cultural group to enhance understanding of its values and beliefs.

Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than your own. The four components to develop cultural competence are (1) cultural awareness or the ability to understand the patient's unique cultural needs by understanding own cultural background and biases, (2) cultural knowledge or learning key aspects of a group's culture and how the patient relates to them by learning general information in predominant cultural groups in own geographic area and assessing the patient, (3) cultural skill or the ability to collect relevant cultural data from the patient by use of assessment skills, and (4) cultural encounter or having extended contact with a cultural group to enhance understanding of its values and beliefs by attending cultural events.

The nurse is developing a community outreach program for patients with limited health care access. Which patient would be most likely to benefit from this program?

A) A 65-yr-old upper class Hispanic man living in the city

B) A 78-yr-old Native American man living on a reservation

C) A 50-yr-old middle-class white woman living in a rural area

D) A 72-yr-old African American retired attorney living in a condominium

B) A 78-yr-old Native American man living on a reservation

Being older, being a minority, living in a rural area, and being of male gender are risk factors for experiencing health care disparities. Rural populations and Native Americans living on reservations may need to travel long distances to receive health care. Although urban living may also be a risk factor, an upper class man has the resources to access health care. The 50-year old middle-class white woman is not at risk for lacking access to health care. Although the 72-year old African American attorney is in the older adult category, he is not at risk since he still has available resources to access health care in the community.

An older adult from Nigeria is visiting an adult child. The child tries to encourage the patient to have the testing and treatment for a chronic productive cough. What behavior has occurred since the child now believes in American medical treatment?

A) Acculturation

B) Ethnocentrism

C) Race awareness

D) Cultural imposition

A) Acculturation

Acculturation is a process by which an individual learns how to take on many but not all values and practices of another culture. Ethnocentrism is the belief that one's own ways are superior to those of different cultural, ethnic, or racial backgrounds. Race is the divisions of humankind who share common ancestry and physical characteristics. Being aware of race would not have a positive impact on the child's beliefs about medical treatments in the United States. Cultural imposition is the process of imposing one's own cultural beliefs and practices on another person, which is not described in this question.

A patient being prepared for a major cardiac surgical procedure tells the nurse she is not religious but has spiritual beliefs. How would the nurse best base her response to the patient?

A) Beliefs about life, death, good, and evil

B) The use of prayer for intercession and thanksgiving

C) A person's effort to find purpose and meaning in life

D) A formal system of beliefs, including worship of God or gods

C) A person's effort to find purpose and meaning in life

Spirituality refers to a person's effort to find purpose and meaning in life. Religion is based on beliefs about life, death, good, and evil. Religion is a formal and organized system of beliefs, including belief in or worship of God or gods. Religious beliefs include the cause, nature, and purpose of the universe and involve prayer and rituals.

A nurse is explaining differences in the incidence, prevalence, mortality rate, and burden of diseases among specific population groups to community volunteers. The nurse is describing what concept?

A) Stereotyping

B) Ethnocentrism

C) Health disparities

D) Cultural competence

C) Health disparities

Health disparities are differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific population groups. Ethnocentrism refers to the belief that one's own ways are superior to those of others from different cultural, ethnic, or racial backgrounds. Stereotyping refers to viewing members of a specific culture, race, or ethnic group as being alike and sharing the same values and beliefs. Cultural competence is the ability to understand, appreciate, and work with individuals from cultures other than your own.

The adult children of a patient who is Hindu have requested a vegetarian diet for the patient. What is the nurse's most appropriate response?

A) Order a vegetarian diet for the patient.

B) Assess the family's rationale for choosing this particular diet.

C) Teach the family about the relationship between protein intake and wound healing.

D) Explore the benefits of a low-meat, high-protein diet with the family and the dietitian.

A) Order a vegetarian diet for the patient.

Culturally competent care is most clearly exemplified by carrying out the family's request. Exploring the family's rationale for this diet is not necessarily an inappropriate action, but the priority is to follow the family's request. Attempting to have meat included in the patient's diet would be inappropriate and violate the patient's cultural and religious beliefs.

The nurse is caring for a Spanish-speaking patient that speaks no English. What action should the nurse take when using an interpreter for communication with this patient?

A) Ask a family member to interpret.

B) Maintain eye contact with the patient.

C) Ask fewer questions to prevent fatigue.

D) Use medical terms wherever as possible.

B) Maintain eye contact with the patient.

The nurse should maintain eye contact with the patient and not the interpreter. The nurse should use a medical interpreter who is trained and understands medical terms. The nurse should use simple language, using as few medical terms as possible. The nurse should plan on taking at least double the amount of time if using an interpreter but should not skip health history questions because they may be important to patient perioperative safety.

The nurse is performing an assessment of a Chinese American patient wearing a jade bracelet on her left wrist. The nurse asks the patient about the significance of the bracelet and whether it can be removed before the scheduled diagnostic procedure. What behavior has the nurse demonstrated?

A) diversity

B) stereotyping

C) ethnocentrism

D) ultural competence

D) ultural competence

Acknowledging and exploring a patient's particular dress, adornments, or behaviors is a component of culturally competent care and is not indicative of ethnocentrism or stereotyping. Diversity denotes the relative numbers of individuals who belong to particular ethnic, racial, or cultural groups.

During the nurse's initial health assessment of an older adult patient, the nurse notes that the patient often makes self-deprecating statements, saying, "I'm just a nuisance to my children now" and "It would be easier for everyone if I didn't have to be such a burden to them." The nurse would document a problem in which functional health pattern?

A)Value-belief

B) Cognitive-perceptual

C) Coping-stress tolerance

D) Self-perception-self-concept

D) Self-perception-self-concept

These statements provide insight into the patient's self-concept and interactions with others. They do not provide direct insight into the patient's values or coping skills, nor do they necessarily indicate a cognitive or perceptual problem.

What order of physical examination techniques should be used when completing a thorough abdominal assessment?

A) Inspection, palpation, percussion, and auscultation

B) Inspection, auscultation, palpation, and percussion

C) Auscultation, inspection, percussion, and palpation

D) Inspection, auscultation, percussion, and palpation

D) Inspection, auscultation, percussion, and palpation

Four major techniques are used in performing the physical examination: inspection, palpation, percussion, and auscultation, which are usually performed in that sequence. The only exception to this sequence is for the abdominal examination, in which the sequence is inspection, auscultation, percussion, and palpation. Performing palpation and percussion of the abdomen before auscultation can alter bowel sounds and produce inaccurate findings.

The nurse is performing a general survey as part of the health assessment for a new patient in the pain clinic. What objective data should the nurse obtain as part of the general survey?

A) Body features and body movements

B) Auscultation of heart and lung sounds

C) 24-hour dietary recall from the patient

D) History of present illness and pain assessment

A) Body features and body movements

The major areas usually included in the general survey statement are (1) body features, (2) state of consciousness and arousal, (3) speech, (4) body movements, (5) obvious physical signs, (6) nutritional status, and (7) behavior. Vital signs and body mass index (BMI) (calculated from height and weight) are often included in the general survey statement. Assessment of heart and lung sounds is part of the physical examination. A 24-hour dietary recall from the patient is part of the health history (nutritional-metabolic functional health pattern) with evaluation of the quantity and quality of foods and fluids consumed and is subjective data. The history of present illness is part of the health history (health perception-health management functional health pattern) and the medical health history. This information is subjective data. A pain assessment is part of the health history (coping-perceptual functional health pattern) and is also subjective data.

Which action most clearly demonstrates a nursing focus rather than a medical focus?

A) The nurse recommends a change to the patient's insulin sliding scale.

B) The nurse interprets the results of the patient's most recent glucose tolerance test.

C) The nurse assesses the benefits of changing the patient to a new oral antihyperglycemic.

D) The nurse assesses the effect that a new diagnosis of diabetes has on the patient's lifestyle

D) The nurse assesses the effect that a new diagnosis of diabetes has on the patient's lifestyle

The focus of nursing care is the diagnosis and treatment of human responses to actual or potential health problems or life processes. Management of a patient's medication regimen and interpretation of diagnostic tests are indicative of a medical focus.

Indicate which data would be classified as objective data (select all that apply.)

Select all that apply.

A) Earache

B) Dizziness

C) Pitting edema

D) Cyanosis of lips

E) Shortness of breath

F) Hyperactive peristalsis

C, D, F

The patient was admitted via the emergency department (ED) with respiratory distress. What statement best describes the initial assessment of the patient after he is transferred to the medical-surgical unit?

A) An emergency assessment should be performed to ensure the patient's safety.

B) A focused assessment should be performed to be sure the ED did not overlook anything.

C) A focused assessment should be performed to determine if new problems have arisen since transfer.

D) A comprehensive assessment should be performed to determine the patient's respiratory status and response to treatment.

D) A comprehensive assessment should be performed to determine the patient's respiratory status and response to treatment.

On transfer from the ED to the medical-surgical unit, a complete comprehensive assessment should be performed to determine the patient's respiratory status and response to treatment. An emergency assessment should have been performed on arrival in the ED. A focused assessment would then be completed to assess the respiratory system and related body systems.

A 58-yr-old man is being admitted to the hospital for a thoracotomy and lung resection. Which assessment type is best for this patient?

A) Focused

B) Emergency

C) Abbreviated

D) Comprehensive

D)Comprehensive

A comprehensive assessment includes a detailed health history and physical examination of one body system or many body systems. It is typically done on admission to the hospital or onset of care in a primary care setting. In an emergency or critical care situation, an emergency assessment may be done by rapid, specific questioning of a patient while assessing and maintaining vital functions. A focused assessment is an abbreviated assessment used to evaluate the status of previously identified problems and monitor for signs of new problems. It can be done when a specific problem is identified. The patient's clinical manifestations should alert the nurse to the appropriate focused assessment. An abbreviated assessment is another term used to describe a focused assessment.

A 78-yr-old man is being admitted to the hospital for dyspnea related to bacterial pneumonia. The primary reason the nurse interviews the patient is to obtain

A) objective data to be used to diagnose a medical condition.

B) objective data while performing the physical examination.

C) a history about the patient's past and present state of health.

D) a general impression of the patient, including his or her behavior.

C) a history about the patient's past and present state of health.

The purpose of the patient interview is to obtain a health history (i.e., subjective data) about the patient's past and present health status. Objective data are data that can be observed or measured and are obtained using inspection, palpation, percussion, and auscultation during the physical examination. Usually subjective data are obtained by interview, and objective data are obtained by physical examination. A medical history is designed to collect data to be used primarily by the health care provider to determine the risk for disease and diagnose a medical condition. The general survey is a statement of the nurse's general impression of a patient, including behavioral observations. This usually occurs after completion of the health history (or interview).

A 72-yr-old woman has sought care for restless legs syndrome, a problem that has been causing her loss of sleep in recent weeks. The woman states that she attributes the problem to inadequate calcium intake, and she has responded by integrating more dairy products into her diet. Which aspects of symptom investigation does the nurse recognize as present in this situation (select all that apply.)?

Select all that apply.

A) Quality

B) Timing

C) Severity

D) Radiation

E) Precipitating and palliative

B, D, E

A 25-yr-old man is admitted with a fractured femur after a motor vehicle accident. While obtaining the health history, the nurse asks the patient about alcohol or substance abuse. What functional health pattern is being assessed?

A) Activity-exercise

B) Coping-stress tolerance

C) Self-perception-self-concept

D) Health perception-health management

D) Health perception-health management

Assessment of the health perception-health management functional health pattern focuses on the patient's perceived level of health and well-being and on personal practices for maintaining health. The questions for this pattern also seek to identify risk factors by obtaining a history of personal health habits (e.g., smoking, alcohol, drug use). Assessment of the activity-exercise pattern focuses on the patient's usual pattern of exercise, activity, leisure, and recreation. Assessment of coping-stress tolerance pattern describes the patient's general coping pattern and the effectiveness of coping mechanisms. Assessment of self-perception-self-concept pattern describes the patient's self-concept, which is critical in determining the way the person interacts with others.

In which situation would the nurse most likely conduct a comprehensive assessment?

A) When performing resuscitation on a trauma patient

B) When assessing the progression of a patient's ascites and edema

C) When admitting a patient to a medical unit from the emergency department

D) When assessing a patient who has been receiving rehabilitation after a stroke

C) When admitting a patient to a medical unit from the emergency department

A comprehensive assessment is most often performed at the beginning of a patient's course of care, such as when a patient is newly admitted to a unit or facility. Whereas emergency assessment is most appropriate during the immediate management of trauma or resuscitation, assessment of particular problems, such as ascites or decreased cognition, requires a focused assessment.

During an admission history and physical assessment, the patient describes symptoms to the nurse. What type of data should these descriptions be documented as?

A) Objective

B) Subjective

C) Generalized

D) Comprehensive

B) Subjective

Subjective data are collected by interviewing the patient and include information that can only be described or verified by the patient. Objective data, or signs, are data that can be observed or measured. Comprehensive data could be accumulated in a comprehensive assessment that includes a detailed health history and physical examination of one body system or many body systems. Although generalized data are not terminology used in nursing, a general survey will be an observation of the general state of health of the patient.

Seniors at a community center ask the nurse to suggest computer websites where they can learn more about health. Which websites would most likely provide accurate and current health information?

A) Government websites

B) Commercial websites

C) Websites designed for the health professional

D) Websites developed by an anonymous individual

A) Government websites

Websites sponsored by government agencies (.gov), educational institutions (.edu), and professional organizations or associations (.org) usually provide accurate and current health information. Commercial websites may represent a company or be sponsored by a company for commercial reasons and to sell products. However, commercial websites may have valuable and credible information. Health information on the website should be developed or reviewed by respected health professionals with expertise. Authors should be clearly identified. The website should clearly state whether the health information is intended for the consumer or the health professional.

Which actions best demonstrate the nurse's awareness of learning styles and the role that they play in patient and caregiver teaching (select all that apply.)?

Select all that apply.

A) Assess patients' preferred learning styles before teaching.

B) Prioritize the learning style with which the patient is most familiar and comfortable.

C) Use materials that appeal to a variety of learning styles, including the styles identified by the patient.

D) Provide written instructions to younger patients while using visual and audio aids when teaching older patients.

E) Provide visual and audio aids to younger patients while using written instructions when teaching older patients.

A, B

Which question elicits additional information to evaluate the patient's understanding of caring for a dressed wound?

A) "What will you do if the dressing is soiled?"

B) "Can you show me how to change your dressing?"

C) "Do you understand how to change your dressing?"

D) "Do you think you can change your dressing at home?"

A) "What will you do if the dressing is soiled?"

Open-ended questions provide more information about the patient's understanding than closed-ended questions that only require a "yes" or "no" response.

Which techniques would be most appropriate to enhance patient learning (select all that apply.)?

Select all that apply.

A) Obtain frequent feedback.

B) Have a quiet environment.

C) Explain information in great detail.

D) Involve the patient and caregiver in the process.

E) Emphasize relevancy of the information to the patient's lifestyle.

A, B, D, E

The nurse plans teaching for adult patients who are scheduled to be seen in the primary care office this week. A general goal of patient teaching includes

A) decreased pain.

B) health promotion.

C) disease identification.

D) increased quantity of life.

B) health promotion.

General goals of patient teaching include health promotion, prevention of disease, management of illness, and appropriate selection and use of treatment options. Improvement of quality (not quantity) of life is the major focus of patient teaching. A general goal of patient teaching is disease prevention (not identification of disease). Decreased pain and suffering is a specific goal.

The nurse notes that a male patient regularly asks about the purpose and potential side effects of each oral medication that he has received during his time in the hospital. How should the nurse best interpret the patient's questions?

A) The patient has an auditory learning style.

B) The patient is identifying his learning needs.

C) The patient is exhibiting a high level of health literacy.

D) The patient is experiencing anxiety related to his diagnosis and treatment.

B) The patient is identifying his learning needs.

The patient most likely is revealing his learning needs related to his medication regimen. It would be inaccurate to conclude that he has an auditory learning style, and concluding that he is experiencing anxiety would be premature. It would be incorrect to conclude that because he has numerous questions about an aspect of his care that he necessarily has a high level of health literacy.

A 28-yr-old female patient is in the contemplation stage of the behavior change model regarding her tobacco use. The nurse should

reinforce the stated need for change.

reinforce the positive outcomes of change.

increase the awareness of the need for change.

help the patient plan to deal with potential relapses.

reinforce the stated need for change.

The nurse should reinforce the stated need for change in the contemplation stage. The nurse should reinforce the positive outcomes of change in the preparation stage. The nurse should increase the awareness of the need for change in the precontemplation stage. The nurse should help patients plan to deal with potential relapses in the action stage.

The patient says she prefers to learn how to care for herself by watching how things are done rather than reading information or instructions. Which teaching strategy would be best for this patient?

Watching a DVD

Reading a pamphlet

Talking about her care with the nurse

Using the Internet to read about it

Watching a DVD

This patient has a visual or audio learning style and prefers not to learn by reading. The DVD would be the best teaching strategy. The nurse could also demonstrate how to do a skill with this patient.

Which teaching strategy is most likely to be the nurse's best choice for a person born before 1945?

Schedule group teaching sessions.

Show video recordings on a television.

Provide printed materials with diagrams.

Download health information to an electronic device.

Provide printed materials with diagrams.

Suggested teaching strategies for persons born before 1945 (Veterans): lecture or lecture-discussion or pictures and printed materials such as books. Suggested teaching strategies for persons born between 1981 and 2000 (Millennials): access to the Internet in the patient's room, discussion of reliable websites, download of health information to electronic devices, use of video games and game systems to teach health behaviors. Suggested teaching strategies for persons born between 1961 and 1980 (Generation X): group teaching sessions, support groups, role playing, web-based education materials. Suggested teaching strategies for persons born between 1945 and 1961 (Baby Boomers): lecture or lecture-discussion (e.g., PowerPoint presentation), use of patient education TV channels, printed materials.

A 51-yr-old male patient will need to change a dressing on an open leg wound after discharge. Which strategy should the nurse use to evaluate if the patient is able to perform the dressing change?

Have the patient complete the dressing change on a model.

Ask the patient to write down each step of the dressing change.

Observe the patient completing the dressing change on himself.

Provide printed instructions with pictures of how to do his dressing change.

Observe the patient completing the dressing change on himself.

Return demonstration is the best method for psychomotor skill evaluation. Having the patient complete the dressing change on a model may be adequate, but observing the patient completing the dressing change on himself is better. Providing printed instructions will be a helpful teaching strategy but will not allow evaluation of patient learning.

The nursing student is assigned to use motivational interviewing to motivate the patient to change dietary eating behaviors. Which statement shows the use of this technique?

"Tell me about the concerns you have about changing your diet."

"You have a big weakness for ice cream; we will need to change that."

"I would not want to change my diet, but I would do it so I don't get sicker."

"I feel sorry for you, but you must change your diet if you plan to feel better."

"Tell me about the concerns you have about changing your diet."

Motivational interviewing uses nonconfrontational interpersonal communication techniques to motivate patients to change behavior. Key aspects include listening instead of telling, adjusting to rather than opposing patient resistance, expressing empathy through reflective listening, focusing on the positive without criticizing the patient, gently persuading with the understanding that change is up to the patient, focusing on patient strengths, avoiding argument and direct confrontation, and helping the patient recognize the "gap" between where the patient is and where the patient hopes to be.

Based on adult learning principles, which situation indicates that the patient is ready to learn about taking enoxaparin (Lovenox) injections at home?

The patient is requesting pain medication.

The patient is falling asleep while watching the teaching DVD.

The patient wants to practice before injecting himself with the needle.

The patient is nervous and says he cannot do it as he picks up the syringe.

The patient wants to practice before injecting himself with the needle.

The patient wanting to practice before injecting himself is demonstrating the learner's orientation to learning by seeking out a resource for this stage of learning. The patient requesting pain medication and the tired patient demonstrate that they are not ready to learn. The nervous, unconfident patient demonstrates that the learner's self-concept is in need of encouragement and more teaching is needed. Other adult learning principles include the learner's need to know, prior experiences, and motivation to learn.

A 44-yr-old female patient with a long-standing history of type 1 diabetes has brought a number of printouts from websites to her most recent visit with her primary care provider. What statement could the nurse make to the patient regarding health information on the Internet?

It is best to make sure that you avoid websites that are not associated with a government agency.

You may have some good information there, but it is best to focus only on the information the doctor provides to you.

There is a great deal of misinformation on the Internet, so it is best to focus on printed material rather than electronic sources.

I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like.

I encourage you to find websites that are credible and reliable, and I can give you some information on making those decisions if you like.

The Internet can be a valid and useful source of health information. Patients may require instruction in determining which sites are of highest value. It would be inappropriate to dissuade the patient from using any electronic-based resources or to instruct her not to bring any such information to a visit with her health care provider. Nurses and patients both should ensure that sources are credible, but these sources are not necessarily limited to government websites.

Which teaching strategy would be best suited for a 20-yr-old patient?

Lectures or books

Websites or podcasts

Television or pamphlets

Role play or support groups

Websites or podcasts

The 20-yr-old patient is likely to be a multitasker who prefers interactive and virtual environments and has a short attention span. The Internet, websites, podcasts, and video game systems are recommended to teach health behaviors to Millennials. Veterans (born before 1946) prefer lecture and book strategies. Baby Boomers (born 1946-1964) prefer lecture and discussion, educational TV, or printed materials. Generation X (born 1965-1980) prefer group teaching, support groups, role playing, and Internet-based education materials.

What would be one method of individualizing learning for a patient's unique needs?

Use prepackaged learning materials.

Only teach the patient "need-to-know" information.

Have the patient arrange topic cards in order of priority.

Have the patient watch a video and then read a pamphlet.

Have the patient arrange topic cards in order of priority.

By allowing a patient to prioritize his or her own learning needs, the nurse can begin with the patient's most important needs and end with the least important. The other choices may be appropriate teaching strategies, but they do not individualize the learning needs.

The nurse is interviewing an older adult patient. What is the priority nursing action during the interview process?

Ensure all assistive devices are in place.

Interview the patient and caregiver together.

Perform the interview before administering analgesics.

Move on to the next question if the patient does not respond quickly.

Ensure all assistive devices are in place.

All assistive devices, such as glasses and hearing aids, should be in place when interviewing an older patient. It is best to interview the patient and caregiver separately to ensure a reliable assessment related to any possible mistreatment. The patient should be free from pain during the assessment in order to gather accurate information and may need extra time to respond to questions.

Which criterion must a 65-yr-old person meet in order to qualify for Medicare funding?

Being entitled to Social Security benefits

A documented absence of family caregivers

A validated need for long-term residential care

A history of failed responses to standard medical treatments

Being entitled to Social Security benefits

To qualify for Medicare, an individual must be entitled to receive Social Security benefits. Absence of caregivers and inadequate responses to treatment are not qualification criteria for Medicare, and the program does not cover residential care services.

A nurse is caring for an adult who sustained a severe traumatic brain injury following a motor vehicle accident. What type of practice setting will the nurse prepare the patient for on discharge?

Assisted living

Acute rehabilitation

Long-term acute care

Skilled nursing facility

Acute rehabilitation

Acute rehabilitation practice settings provide a post-acute level of care specializing in therapies for patients with neurologic or physical injuries, such as those with head trauma, spinal cord injury, or stroke.

A patient is diagnosed with chronic obstructive pulmonary disease (COPD). At what point should the nurse begin to include the patient's spouse in the teaching around the management of the disease?

As soon as possible

When the patient requests assistance from the spouse and family

When the patient becomes unable to manage symptoms independently

After the patient has had the opportunity to adjust to the treatment regimen

As soon as possible

In the management of chronic illness, it is desirable to include family caregivers in patient education and symptom management efforts as early in the diagnosis as possible.

A female patient with incontinence arrives early for appointments and social events so there is ready access to the restroom. Which tasks of the chronically ill is the patient demonstrating (select all that apply.)?

Select all that apply.

Controlling symptoms

Preventing social isolation

Preventing and managing a crisis

Denying the reality of the problem

Adjusting to changes in the course of the disease

Controlling symptoms

Preventing and managing a crisis

The nurse is performing an assessment for an older adult patient suspected of mistreatment. What assessment findings would lead the nurse to notify social services (select all that apply.)?

Select all that apply.

Agitation

Depression

Weight gain

Weight loss

Hypernatremia

Agitation

Depression

Weight loss

Hypernatremia

A nurse is interested in providing care for persons with chronic illnesses. Where should the nurse identify that most chronic illnesses are managed?

Hospice care.

Homeless shelters.

A community setting.

An acute care hospital.

A community setting.

Chronic illnesses (other than the acute phase or acute exacerbations) are usually managed in a community setting such as in ambulatory care, at home, in an assisted living facility, or in a skilled nursing facility. Diagnosis and the acute phase or acute exacerbations of a chronic illness are often managed in a hospital.

The nurse is planning discharge for a frail older adult patient covered under Medicare Part A health insurance. Which medical supply would be covered if needed?

Walker

Dentures

Eyeglasses

Hearing aids

Walker

Durable medical equipment, such as a walker used daily, is covered by Medicare Part A, but home safety equipment is not. Medicare Part A does not cover hearing aids, dentures, or eyeglasses.

An older adult patient admitted with an irregular cardiac rhythm has a much lower blood level of his home medication than expected. Which common cause of medication errors made by older adults should be suspected?

Shorter drug half-life leading to medication overdose

Decreased use of nonprescription over-the-counter drugs

Improved tolerance of adverse effects of prescribed drugs

Lack of financial resources to obtain prescribed medications

Lack of financial resources to obtain prescribed medications

Common causes of medication errors by older adults include poor eyesight, forgetting to take drugs, use of nonprescription over-the-counter drugs, use of medications prescribed for someone else, lack of financial resources to obtain prescribed medication, failure to understand instructions or importance of drug treatment, and refusal to take medication because of undesirable side effects. Drug half-life is increased in older adults.

A nurse who is providing care for an older adult patient recognizes the need to maximize the patient's mobility during recovery from surgery. What accurately describes the best rationale for the nurse's actions?

Continued activity prevents deconditioning.

Pharmacokinetics are improved by patient mobility.

Lack of stimulation contributes to the development of cognitive deficits in older adults.

Regularly scheduled physical rehabilitation provides an important sense of purpose for older patients.

Continued activity prevents deconditioning.

Older adults are highly susceptible to deconditioning, a process that can be slowed or prevented by regular physical activity. This consideration supersedes any possible effect on pharmacokinetics, prevention of cognitive deficits, or the patient's sense of purpose.

The nurse is developing a plan of care for an older adult patient. What should the nurse be sure to include in the plan of care?

Patient priorities should be the only focus of care.

Additional time related to declining energy reserves

Reduction of disease and problems should be the focus.

Tobacco cessation will help the patient cope with other illnesses.

Additional time related to declining energy reserves

Additional time is required with older patients with declining energy reserves. Patient priorities are considered to best meet the patient needs but will not be the only focus of care. Focusing on strengths and abilities as well as physical and mental status will facilitate goal setting to reduce disease or problems. As with all patients, safety is a primary concern, and decreasing tobacco use will improve all of the patient's body functioning.

A frail older adult with chronic heart failure is cared for in the home by her only child. What problem is indicated by the caregiver's failure to provide companionship or social stimulation?

Neglect

Sexual abuse

Abandonment

Violation of personal rights

Neglect

Characteristics of neglect include failing to provide social stimulation, leaving the person alone for long periods of time, and failing to provide companionship. Characteristics of sexual abuse include nonconsensual sexual contact, including touching inappropriately, and forcing sexual contact. Characteristics of abandonment include desertion of an older person by an individual who has assumed responsibility for providing care or by a person with physical custody. Characteristics of violation of personal rights include denying right to privacy or right to make decisions regarding health care or living environment and forcible eviction.

The nurse is supervising unlicensed assistive personnel (UAP) providing hygiene care to older adult residents in a care facility. What behavior observed by the nurse indicates education of the UAP is required?

Compassion for weakness and low activity

Identification of progressive loss of function

A negative attitude based on the age of the patient

Providing culturally competent care to older adults

A negative attitude based on the age of the patient

Ageism is a negative attitude based on age and leads to discrimination and disparities in the care given to older adults. Biologic aging is defined as the progressive loss of function. Frailty has been defined as the presence of three or more of the following: unplanned weight loss (?5=10 lb in the past year), weakness, poor endurance and energy, slowness, and low activity. The term ethnogeriatric describes the specialty area of providing culturally competent care to ethnic older adults.

A patient with Alzheimer's disease has had increased evidence of dementia and physical deterioration. What would be the best assistance to recommend to the caregiver spouse who is exhausted?

Adult day care

Long-term care

Home health care

Homemaker services

Adult day care

Adult day care provides social, recreational, and health-related services in a safe, community-based environment that would keep this patient safe and decrease the stress on the husband. Long-term care is used when the patient has rapid deterioration, the caregiver is unable to continue to provide care, and there is an alteration in or loss of the family support system. Home health care is used when there is supportive caregiver involvement for patients with health needs. Homemaker services provide services, but do not care for the patient.

A patient has a history of hypertension and type 1 diabetes mellitus. The patient exercises and eats a healthy diet. Which factors will most likely have a positive impact on biologic aging (select all that apply.)?

Select all that apply.

Exercise

Diabetes

Social support

Good nutrition

Coping resources

Exercise

Social support

Good nutrition

Coping resources

The nurse is administering medication to an older adult patient. What consideration related to aging should the nurse monitor when administering medications?

The excretion of the medication

The absorption of the medication

How the medication is distributed

The ability of the medication to metabolize

The ability of the medication to metabolize

Because the liver mass shrinks and hepatic blood flow and enzyme activity decrease in older adults, metabolism of drugs drops 1/2 to 2/3 of the rate of young adults. This increases the chance of drug toxicity and adverse drug events.

A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient?

"Is your sleep interrupted by severe episodes of itching at night?"

"Have you noticed any changes in the way sores or wounds heal?"

"Do you have any skin lesions that have changed in size or shape?"

"What changes if any have you noticed in your skin, hair, and nails?"

"Have you noticed any changes in the way sores or wounds heal?"

A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient?

Tiny purple spots on the skin

Large ecchymotic areas on the skin

Hyperkeratotic papules and plaques

Small, raised red areas on the soles of the feet

Tiny purple spots on the skin

Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient's mouth. The nurse would document this finding as a(n)

scar.

fissure.

atrophy.

excoriation.

fissure.

A fissure is a linear crack or break from the epidermis to the dermis. It can be dry as in athlete's foot or moist as in cracks at the corner of the mouth. A scar is abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area where epidermis is missing which exposes dermis (e.g., abrasion, scratch).

A patient with diabetes mellitus has been diagnosed with peripheral vascular disease. Which dermatologic manifestations should the nurse assess?

Redness of exposed areas of the skin on the hand, foot, face, or neck

Leathery, brownish skin on lower leg, pruritus, concave lesions with edema, scar tissue with healing

Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing

Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing

A patient with diabetes mellitus and peripheral vascular disease is likely to have loss of peripheral hair, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing. A patient with a nicotinic acid (niacin) deficiency manifests redness of exposed areas of the skin on the hand or foot, face, or neck and infected dermatitis. A patient with venous ulcers will have leathery, brownish skin on the lower leg, pruritus, concave lesions with edema, and scar tissue with healing. A patient with glucocorticoid excess (Cushing syndrome) may have atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck, clavicles, abdomen, and face.

The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system?

Diuretic

Corticosteroid

Benzodiazepine

Calcium channel blocker

Corticosteroid

Corticosteroids can have unwanted integumentary side effects such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.

An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne?

Ulcers

Wheals

Vesicles

Pustules

Pustules

Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.

When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system?

Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails

Decreased extracellular water, surface lipids, and sebaceous gland activity; decreased scalp oil; and decreased circulation

Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient?

It is used for a superficial lesion.

It provides a full-thickness of skin.

It is used for good cosmetic results.

It is used because the lesion is too large to remove.

It provides a full-thickness of skin.

The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide.

A patient is admitted to the acute care facility with purpura. Which laboratory test would be most important to check in the patient?

Urinalysis

Serum electrolytes

Coagulation studies

White blood cell count

Coagulation studies

Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore, it is most important for the nurse to assess the patient's coagulation studies.

The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis (select all that apply.)?

Select all that apply.

Patient's sclera

Patient's nail beds

Soles of the patient's feet

Palms of the patient's hands

Conjunctiva of the patient's eyes

Patient's nail beds

Conjunctiva of the patient's eyes

An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration?

The skin color over the nose and ears has a blue tint.

The skin of the extremities is warm and dry to touch.

Pressing the skin over the ankles causes pitting for 10 seconds.

Pinching the skin under the clavicle causes tenting for 10 seconds.

Pinching the skin under the clavicle causes tenting for 10 seconds.

Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool without edema or central cyanosis.

The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient?

Lips

Earlobe

Conjunctiva

Palm of hand

Conjunctiva

Cyanosis will appear ashen or gray color and is most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds of dark-skinned individuals. The nail beds, earlobes, lips, mucous membranes, and palms and soles of feet would be appropriate locations to assess for cyanosis in a light-skinned individual.

The nurse is assessing a white patient's skin color for cyanosis. The best place for the nurse to assess this is the

lips.

legs.

wrists.

sclera.

lips.

On light-skinned individuals, cyanosis or a grayish blue tone initially appears on the lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet.

A patient with hypothyroidism has developed carotenemia. The nurse should assess for improvement of this condition on which part of the patient's body?

Face

Chest

Sclera

Palms of hands

Palms of hands

Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet.

The nurse is assessing a patient's skin temperature, turgor, moisture, and texture. What is the best technique for the nurse to use to obtain the data?

Inspection of skin color

Examination for vascularity

Palpation of skin with the hand

Percussion of the skin on the back

Palpation of skin with the hand

Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin.

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as

petechiae.

erythema.

ecchymosis.

telangiectasia.

petechiae.

Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

The nurse is performing an assessment of a patient with obesity. Inspection reveals the presence of a foul odor that emanates from the patient's abdominal skin folds. What is most likely causing the odor?

Ecchymosis

Colonization by yeast or bacteria

Age-related integumentary changes

Atrophy of the skin under the abdominal folds

Colonization by yeast or bacteria

Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising. An unusual odor would not normally be attributed to age-related changes or skin atrophy.

The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching?

"A blood test will confirm the presence of abnormal antibodies."

"My skin cells will be stained and examined under the microscope."

"The rash will be scraped with a razor blade and the flakes cultured."

"I will return to have the substances removed and the areas evaluated."

"I will return to have the substances removed and the areas evaluated."

A patch test is used to determine skin reactions to certain allergens applied to the skin. The patient will return in 48 to 72 hours for allergen removal and return again in 96 hours for evaluation.

A patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient's integumentary system?

Warm, flushed skin; alopecia; thin nails

General hyperpigmentation and loss of body hair

Pale skin; pale mucous membranes; hair loss; nail dystrophy

Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

With hypothyroidism, the patient will manifest with cold, dry, pale skin; dry, coarse, brittle hair; and brittle, slow-growing nails. With hyperthyroidism, the patient will have warm, flushed skin; alopecia with fine soft hair; and thin nails. With Addison's disease, the patient will have loss of body hair and generalized hyperpigmentation, especially in folds. With anemia, the patient will display pallor, pale mucous membranes, hair loss, and nail dystrophy.

A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect?

Bursitis

Fasciitis

Sprained ligament

Achilles tendonitis

Bursitis

Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking. Plantar fasciitis occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not from repetitive motion.

When administered long-term, which medication requires ongoing musculoskeletal assessment?

Corticosteroids

β-Adrenergic blockers

Antiplatelet aggregators

Calcium-channel blockers

Corticosteroids

Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-Blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily for several years to prevent organ rejection. What is the most important assessment for the nurse to perform?

Staggering gait

Ruptured tendon

Back or neck pain

Tardive dyskinesia

Back or neck pain

Osteoporosis with fractures is a serious complication of corticosteroid therapy. The ribs and vertebrae fractures cause back and neck pain. Ataxic (staggering) gait is an adverse effect of phenytoin, an antiseizure medication. A rare adverse effect of ciprofloxacin and other fluoroquinolones is tendon rupture, usually the Achilles tendon. Antipsychotics and antidepressants may cause tardive dyskinesia, characterized by involuntary movements of the tongue and face.

A female patient with a history of rheumatoid arthritis complains of stiffness in her right knee and complete fixation of the joint. What problem does the nurse anticipate will be identified in the patient's history and physical examination?

Atrophy

Ankylosis

Crepitation

Contracture

Ankylosis

Ankylosis is stiffness or fixation of a joint, and contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a wasting of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies joint movement. Problem identification leads to determination of an appropriate treatment.

The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group (select all that apply.)?

Select all that apply.

Hinge joint of the knee

Ligaments joining the vertebrae

Gliding joints of the wrist and hand

Fibrous connective tissue of the skull

Ball and socket joint of the shoulder or hip

Cartilaginous connective tissue of the pubis joint

Hinge joint of the knee

Gliding joints of the wrist and hand

Ball and socket joint of the shoulder or hip

The nurse admits a 55-yr-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern?

Ataxic gait

Radicular pain

Severe fatigue

Urinary retention

Ataxic gait

An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability and visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis.

A 54-yr-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information?

"Only mild pain is associated with the procedure."

"Two additional follow-up scans will be required."

"The procedure takes approximately 15 to 30 minutes."

"You will need to drink increased fluids after the procedure."

"You will need to drink increased fluids after the procedure."

Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans are required. Only mild pain may be associated with bone scans related to 1 hour of lying supine.

An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond?

"You should go on a diet and exercise more to feel better about yourself."

"Something must be wrong with you because you should not have these problems."

"You have arthritis and need to take nonsteroidal antiinflammatory drugs (NSAIDs)."

"Decreased muscle mass and strength and increased hip rigidity are expected with aging."

"Decreased muscle mass and strength and increased hip rigidity are expected with aging."

The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." is untrue and will not be helpful to the patient's frustrations.

A 42-yr-old man who is scheduled for arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate?

"When would you like to reschedule the procedure?"

"Tell me what your concerns are about this procedure."

"The procedure is safe, so why should you be worried?"

"The procedure is not painful because an anesthetic is used."

"Tell me what your concerns are about this procedure."

The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to conclude the patient is concerned about pain or assume the patient is asking to reschedule the procedure.

A 57-yr-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by the patient indicates understanding of the procedure?

"The bone density in my heel will be measured."

"This procedure will not cause any pain or discomfort."

"I will not be exposed to any radiation during the procedure."

"I will need to remove my hearing aids before the procedure."

"This procedure will not cause any pain or discomfort."

DXA is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound evaluates bone density using ultrasound of the calcaneus (heel). MRI would require removal of objects such as hearing aids that have metal parts.