Exam 2 V2: NU 160 / NU160 (Latest 2026 / 2027) Mental Health Concepts | 100% Correct Questions & Answers – Galen

Exam 2 V2: NU 160 / NU160 (Latest 2026 / 2027) Mental Health Concepts | 100% Correct Questions & Answers – Galen Question : Which finding is expected when assessing an 11-year-old child? A. 5 lb weight gain and beginning of a growth spurt. B. development o f mature relationships and beginning of dating C. Loss of deciduous teeth and eruption of permanent teeth D. Acting out feelings during play A. 5 lb weight gain and beginning of a growth spurt. Which of the following is the most common exemplar of adherence? A. Medication taking behavior B. Prevention strategies C. Motivational Feelings D. Activity Guidelines A. Medication taking behavior A newborn should be given an influenza vaccine. A. True B. False B. False A 2-year-old becomes upset when her routine or environment changes, this; A. is abdominal for a toddler, they are adaptable. B. Means she is insecure and didn't develop trust in infancy. C. Means she is spoiled and needs punishment. D. Is normal for a toddler, they are ritualistic. D. Is normal for a toddler, they are ritualistic. When a 6 month old baby is sleeping, how should the physical exam proceed? A. Examine the hips while drowsy since it can be uncomfortable. B. Examine the eye movements and pupillary reaction first. C. Wake the infant to get most accurate results of body systems. D. Auscultate lungs and heart while baby sleeping. D. Auscultate lungs and heart while baby sleeping. Which is a development task of young adults? A. Putting aside resources for retirement B. Formulating gener role attitudes C. Getting an appropriate education D. Following social mores and customs C. Getting an appropriate education Normal growth and development task for a 5 year old A. Fear of being left alone B. Selecting a mate C. Accepting physical changes D. Hop on one foot D. Hop on one foot Which immunizations are NOT recommended for pregnant patients? Select all that apply. A. Influenza B. Tetanus C. MMR D. Varicella C. MMR D. Varicella Which tool assesses life stressors and social readjustment? A. AUDIT B. Beck C. Holmes D. Yesavage C. Holmes Two grams of fat has how many calories? A. 9 B. 4 C. 8 D. 18 D. 18 Where should you assess cyanosis in a client with dark skin? A. Sclera of eye B. palms of hands C. Ear lobes D. Oral mucous membranes D. Oral mucous membranes Which tool would be used to assess orientation, memory, judgement and recall? A. CAGE B. Denver C. Holmes D. MMSE D. MMSE Which skin lesion needs more follow up? A. Brown Freckle B. White Striae C. Multicolored Mole D. Tan Skin Tag C. Multicolored Mole Long-term, progressive, irreversible cognitive disorder with memory loss and language problems: A. Delirium B. Dementia C. Delterium D. Depression B. Dementia The nurse assesses the pupils, size, shape, response to light, accommodation and Documents normal findings as A. PEERLA B. PERRLA C. PERILLA D. PERLAA B. PERRLA While assessing the skin of a patient, the nurse notes decreased skin turgor, this could indicate A. Hyperthyroidism B. Hypothyroidism C. Malnutrition D. Dehydration D. Dehydration The nurse has assessed the nose and documents expected findings as A. Nose symmetrical with clear drainage B. Nose symmetrical and midline C. Nose symmetrical and proportional to face D. Nose symmetrical with yellow drainage B. Nose symmetrical and midline The cranial nerves involved with eye movement A. II, V, and VII B. IV, V, VIII C. III, IV, VI D. V, VI, VII C. III, IV, VI Main nutrients essential for optimal body function include A. Carbohydrates, Proteins, and Fats B. Folate, Vitamin B12, and Iron C. Vitamins A, D, E, and K D. Iron, Zinc, and Calcium A. Carbohydrates, Proteins, and Fats Which of the following is the best indicator of current 2-3 days nutritional intake? A. Transferrin B. Total Protein C. Albumin D. Prealbumin D. Prealbumin Which of the following measurements of waist circumference would lead the nurse to suspect that a female client is at an increased risk for cardiovascular disease and diabetes? 36 inches Women with 35 inches or greater waist circumference are at an increase risk for such disorders as diabetes, hypertension, hyperlipidemia, and cardiovascular disease. A college football player has been hospitalized with knee surgery. When discussing dietary choices, what nutrient would the nurse encourage increasing to promote muscle healing? Protein Athletes may require additional protein for muscle building and maintenance; this client also requires protein for muscle repair. Hospitalized athletes and post-surgical clients do not generally require extra servings of carbohydrates, grains, or fats. What is the most common indication of nutritional status in infants and children? Growth Growth charts are commonly used to indicate nutritional status. As an indication of nutritional status, appetite, number of wet diapers/day, and sleep pattern are generally not used. How can a nurse best assess a client's dietary habits? Obtain a 24 hour dietary recall of all foods and fluids consumed The nurse can best assess dietary habits by asking the client about an average daily intake of food and fluids, where and when food is consumed, and if there are any conditions or diseases that may affect intake or absorption of nutrients. A height and weight may not accurately reflect dietary intake. One meal will not provide the best assessment of overall dietary habits. A nurse assesses an older adult client who lives alone and is unable to drive a vehicle. Which of the following assessment areas of the nutritional history will most likely impact the client's nutritional status? Accessibility The older adult client who is unable to drive will have limited access to a range of foods that will promote nutritional health. The correct option is accessibility. Food preparation seeks to determine who does the cooking for the client and the way in which the foods are prepared. Finances refers to having access to sufficient funds to purchase foods that support nutritional health. Food preferences are personal for each client and refer to likes or dislikes. In addition, the client may report foods they find harmful or beneficial and cultural or religious preferences in this assessment area. Which of the following dishes should the nurse cite as an example of a way for clients to integrate more omega-3 fatty acids into their diets? Salmon pan-fried in canola oil Fatty fish, such as salmon, and canola oil are recognized sources of omega-3 fatty acids. Margarine, bread, spinach, fruit, olive oil, chicken, and French fries are not high sources of omega-3 fatty acids. How often would a nurse recommend a client eat or drink a source of vitamin C? Every day Vitamin C, a water-soluble vitamin, is usually not stored in the body. Deficiency symptoms are apt to develop quickly when intake is inadequate; a daily intake is recommended. A dietitian is providing an in-service for the nurses on a medical-surgical unit. During the in service, she informs the group that there are six classes of nutrients, and three supply the body with energy. What are the three sources of energy? Carbohydrates, protein, and lipids Of the six classes of nutrients, three supply energy (carbohydrates, protein, and lipids), and three are needed to regulate body processes (vitamins, minerals, and water). The obstetrical nurse should instruct the woman in the first trimester of pregnancy to Eat foods high in folic acid Folic acid deficiency in pregnant women can lead to neural tube deficits in the fetus. You are completing a health assessment on a new client. You note that the client has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate? Poor nutritional status Signs of poor nutrition include dry, dull, brittle hair and dry, flaky skin with poor turgor. These findings do not indicate excessive physical activity, poor personal hygiene or damage from an environmental cause therefore these options are incorrect. A home care nurse is teaching a client's daughter meal planning for her mother who is recovering from a hip replacement surgery. Which of the following meals indicates that the daughter understands the concept of a nutritionally complete choice based upon the Food Guide Pyramid? Ham sandwich with tomato on rye bread with peaches and yogurt The menu has a choice from each of the food groups from the Food Guide Pyramid. The other selections are incomplete choices. The nurse in a bariatric clinic is providing education to a client who wishes to lose weight. The nurse informs the client that she has a Body Mass Indicator of 45. What does this indicate? The client is extremely obese Body Mass Indicator is a ratio based on body weight and height. A BMI of 25 to 29 is considered overweight, a BMI of 30 to 39 obese and a BMI greater than 40 extremely obese. Options A,C and D are incorrect, they are not in the appropriate range on the BMI scale. What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors? Place the tape measure behind the client and measure at the umbilicus The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen, especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing, not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed off only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention. Of the following measurements, which one helps to determine if a client is underweight, normal weight, or obese? Body mass index. BMI18.5 is considered underweight. BMI between 25.0 and 29.9 is considered overweight and increases risk for health problems. A BMI of 30 or greater is considered obese and places the client at a much higher risk for type 2 diabetes, cardiovascular disease, osteoarthritis, and sleep apnea. A client asks for help with determining the amount and type of foods to consume to improve nutritional intake. What should the nurse recommend that this client use? My Plate The U.S. Department of Agriculture's (USDA's) Choose My Plate is a tool to help individuals analyze their diet and set goals for a healthier diet. A calorie counter will not necessarily help the client select healthful foods. An 1800 calorie diet may be too much or insufficient to meet the client's nutritional needs. Healthy People 2020 does not provide direction as to how to improve nutritional status. Which of the following is the most common exemplar for adherence? medication taking behavior Self- Management exists within a broad system of collaborative care that includes a partnership among patients, their caregivers, their health care providers, and the health care system? True or False True An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The client's appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these findings reflect? Depression Poor hygiene may be from paranoia of water, homelessness, severe depression, or incapacitation as a result of mental illness. Poor hygiene is not a result of mania, poor nutrition, or needing to recover from childbirth. The other options are distracters to the question. A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries? "Injuries like yours could have been caused by someone hurting you. Did someone hurt you?" The best option is "Injuries like yours could have been caused by someone hurting you. Did someone hurt you?" The other options are inappropriate questions to elicit information from the teenager. A nurse admits an older adult client to the ED. The client has bruises in various stages of healing; the client also is malnourished and severely dehydrated. The client lives alone with a grandchild who has been taking care of the client for the last 2 years. Of what type of abuse could these findings be an example? Elder abuse Types of family violence include child maltreatment, sibling violence, intimate partner violence (IPV), and elder abuse. This case is not an example of sibling abuse or IPV. Intimate partner abuse is a simple distracter for this question. When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider? The client's physical and emotional safety The first and foremost thing in every nurse's mind should be the client's physical and emotional safety. A universal rule is that client interviews be done in private-including without significant others or anyone who may be or could represent the perpetrator (e.g., friend, mother-in-law). Nurses should not assume who may or may not be a perpetrator or have power over the client and prevent the client from talking freely and safely. The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life? CAGE If alcohol use might be a problem, the CAGE is a quick first-step questionnaire to use as an assessment tool. The MMPI is the Minnesota Multiphasic Personality Inventory used to aide in diagnosing psychological problems. The ABCT is used for assessment of mental status. It includes Appearance (posture, movement, hygiene, and dress), Behavior (level of consciousness, eye contact, facial expressions, speech), Cognitive function (orientation, attention span, memory, judgment), and Thought processes and is not a tool. The HOPE tool is used for assessing spirituality. A nurse interviews a client who reports pain in the chest. The client is accompanied by her husband. During the interview which observation by the nurse may indicate that the client is abused by her partner? Partner attempts to speak for the client The nurse should suspect that the client has been abused if the partner attempts to speak for the client. If the client answers question independently and does not seem afraid of partner, and if the partner appears to be supportive, there is no indication of abuse. A nursing instructor is teaching about the first of Erikson's stages. The nursing student demonstrates understanding of this stage when she states: "Infants achieve trust when their caregivers consistently meet their needs." Erikson's first stage is trust vs. mistrust--this is achieved when the caregiver consistently meets the infant's needs. Autonomy is achieved during the toddler stage, while initiative is the main goal for preschoolers. Intimacy is not achieved until young adulthood. A 26-year-old client tells the nurse that she recently became engaged. She proceeds to inform the nurse that she has never had such a good and loving relationship. This commitment to marriage that the client has made mainly occurs during which stage of development? Intimacy vs. isolation Young adults (ages 18 to 25 years) are in the stage of intimacy vs. isolation, in which they strive to establish mature relationships and make a commitment to a partner. Infants (newborns to 18 months) experience trust vs. mistrust, trying to have their basic needs met. Toddlers during autonomy vs. shame strive to make choices and exert some independence. Middle adults during generativity vs. stagnation strive to share their knowledge with the younger generation. A mother brings her 3 year old to the clinic, concerned about her daughter's growth and development. She tells the nurse that her daughter can climb stairs, dress herself, and feed herself, but she cannot draw circles or rectangles like her 5-year-old brother. What should the nurse tell this mother? "This is normal for this age, because children do not master the fine motor skill of drawing until age 5 years." The client is right on target for her fine and gross motor skills. Climbing stairs, feeding herself, and dressing herself are normal skills for this age group. Drawing circles and rectangles are fine motor skills that are not accomplished until age 5 years. An older adult is admitted for altered cognition. The spouse indicates the client has becoming more forgetful over time. The nurse assesses the client's cognition using the Mini-Cog. The client is able to draw a clock correctly but is unable to recall the three words given at the beginning of the assessment. What do the results suggest to the nurse? Dementia Dementia is an irreversible state of confusion that develops over time. If the client is unable to recall the three words or draws an abnormal clock, dementia is indicated. The nurse would use the Geriatric Depression Scale to assess for depression in the older adult. Delirium is an acute reversible condition in any client across the lifespan and can be attributed to some underlying medical condition or substance abuse. A delusion is a false belief the person holds despite lack of supportive evidence. The nurse is assessing the cognitive functioning of an older adult. Which action by the client demonstrates intact episodic long-term memory? The older adult accurately describes the first date with his spouse of 50 years. The older adult demonstrates intact episodic long-term memory by accurately describing the first date with his spouse. Accurate recall of three unrelated words and what was served for breakfast assesses short-term memory. Accurate recall of the name of the President of the United States demonstrates intact semantic long-term memory. Which aspects of the mental status exam refer to data about how thoughts connect to one another? Thought process Thought process refers to data about how thought connect to one another. One of the most basic assessments of cognitive function is the client's orientation to person, place, and time. When the mental health nurse ask the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination? Orientation One of the most basic assessments of cognitive function is the client's orientation to person, place, and time. Judgment may be viewed as the action-oriented counterpart to insight. To assess abstract reasoning the nurse may ask the client to describe the meaning of well-known proverbs. Insight is the cognitive process of understanding. The mother of a 7 month old attempts to scoop cereal with his palm and reach his mouth, but drops several pieces of cereal on the floor. His mother asks if this feeding behavior is normal. What is the nurse's best response? "Fine grasp is just now starting to develop at this age." At age 7-13 months, an infant uses pincer grasp to pick up objects. A child is not expected to feed himself with a spoon and cup until age 10-14 months. The nurse notes a teen client to have multiple piercings and wears black clothing. The nurse understands the client is experiencing what stage of Erikson? Identity Autonomy is associated with the toddlers and is demonstrated when they can make simple choices and can exert some control. Initiative is associated with preschoolers and is demonstrated by cooperating with others. Identity occurs during adolescence and is demonstrated by establishing own views and ideas. Trust is at the infant level and they gain trust through consistency. The mother of an infant states he cries every times she leaves. She is concerned that there is something wrong. The nurse recognizes the infant is experiencing what stage of Erikson? Trust Autonomy is associated with the toddlers and is demonstrated when they can make simple choices and can exert some control. Initiative is associated with preschoolers and is demonstrated by cooperating with others. Identity occurs during adolescence and is demonstrated by establishing own views. Trust is at the infant level and they gain trust through consistency. A 50-year-old client tells the nurse that she enjoys babysitting her grandchildren while their parents are attending night classes at the local college. She also shares that on many days she volunteers at a neighborhood food bank. Erikson would most likely place this client as positively resolving a sense of generativity versus stagnation. The central task of generativity vs. stagnation is focused on the younger generation—often children (whether one's own or those of others), family, community, mentoring others, helping to care for others, discovering new abilities/talents, continuing to create, and "giving back." A nurse is preparing to conduct a community assessment. Upon completing the assessment, which of the following would the nurse expect as the primary outcome? A. Increase in the number of services provided B. Development of a common bond C. Identification of health-related concerns D. Creation of a health partnership C. Identification of health-related concerns A nursing instructor is describing the various models used for community assessment. The instructor determines that the teaching was successful when the students identify which model as being used to assist community agencies in meeting challenges of providing care to clients with declining resources? A. Mobilizing for Action through Planning and Partnerships B. Partners in Caring Model C. Community Readiness Model D. Partnership Model B. Partners in Caring Model A client asks the nurse if there are church services in the hospital because the client attends mass every Sunday. The nurse realizes that this client is demonstrating: A. Religion B. Spirituality C. Recreation D. Culture A. Religion A mother brought a child in to the Emergency Department stating that she thinks her child's appendix has ruptured. Before any diagnostic tests can be done, the father comes in and says, "I don't want anything done, we will take the child to our church where prayer will heal him." What is an appropriate action by the nurse at this time? A. Tell the father that if he takes the child from the Emergency Department, the police will be notified. B. Lock the father out of the Emergency Department. C. Notify the ethics committee immediately. D. Tell the mother and father that you will call social service if they do not allow treatment. C. Notify the ethics committee immediately. The nursing instructor is discussing the importance of spiritually assessing a client in order to be able to provide holistic care. What suggestion can she give to the student who is not sure of the correct questions to ask? A. " You may use the FICA spiritual assessment tool." B. "Ask the client questions that pertain to your religion." C. "Call the hospital chaplain and have them compile a list of questions for you to ask." D. "Apply COLDSPA for clinical symptoms." A. " You may use the FICA spiritual assessment tool." Participating in the community allows the nurse to be accepted as a member of it. This method of data collection allows the nurse to participate in the daily life of the community, obtain information about the structures and influences of the community, and also do which of the following? A. Facilitate immediate changes. B. Tell people what to do. C. Form judgements. D. Make observations. D. Make observations. The nurse is concerned with the rising unemployment rate of the community in which she lives. How will the nurse be affected by this problem? A. High unemployment rates are associated with higher morbidity and mortality rates. B. High unemployment rates mean that she could lose the job at the hospital. C. High unemployment rates mean there will be no raises for employees this year. D. There will be more suicides for the hospital to handle. A. High unemployment rates are associated with higher morbidity and mortality rates. The school nurse is in the talking to a group of students about sexually transmitted diseases. One of the students says, "I know that most of the 10th grade has already had sex. There's drinking and parties, and this is where a lot of it happens." What type of data is the nurse collecting? A. Objective B. Formulative C. Subjective D. Summative C. Subjective A client who is terminally ill with cancer is discharged from the hospital to home. The physician orders home health care for the client. For which other type of services in the community that might benefit this client should the nurse assess? A. hospice services B. types of grocery stores C. recreational areas D. types of churches A. hospice services In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers? A. Death rituals B. Body language C. Pregnancy and childbearing D. Pain B. Body language A nurse is assessing the level of social services available in a rural community. Which of the following is such a community most likely to be lacking in? A. Medicare B. Salvation Army C. Homeless shelters D. Medicaid C. Homeless shelters A nurse is completing a comprehensive assessment of a client who has been referred to the clinic. Which of the following would be most appropriate for the nurse to ask when beginning to assess the client's spirituality? A. "Would you like to speak to a chaplain?" B. "What gives you hope or peace?" C. "What religion are you?" D. "Do you believe in God?" B. "What gives you hope or peace?" A nurse's personal reflection reveals that the nurse tends to see their own culture as the "gold standard" to which all other cultures should aspire. This nurse should create learning goals to address what phenomenon? A. Unconscious incompetence B. Acculturation C. Ethnocentrism D. Stereotyping C. Ethnocentrism A nurse is caring for a 70-year-old client from a different culture whose breast cancer has metastasized. The nurse observes that the client tends to defer responsibility for decision making around treatment options to her eldest son. How should the nurse respond to this? A. Request a referral for a social worker. B. Confirm that the client wants her son to make these decisions. C. Attempt to dialogue with the client when her son is not present. D. Explain the disconnect between the client's practice and the principle of client autonomy. B. Confirm that the client wants her son to make these decisions. A nurse is relying heavily on gestures and simplified language during the assessment of a client from another culture who speaks minimal English. During the lengthy assessment, the nurse asks the client if she is "okay" by making a circle with his thumb and forefinger. The nurse should be aware of which of the following? A. In some cultures, this gesture denotes confusion. B. In some cultures, this gesture is offensive. C. This gesture has meaning only in American cultures. D. In some cultures, this gesture denotes pain. B. In some cultures, this gesture is offensive. A nurse is assessing a community's environmental protection. What would the nurse address? A. Local law enforcement agencies B. Major local employers C. Educational facilities D. Sewage treatment facilities D. Sewage treatment facilities A client asks how long the hospitalization will be since family and friends will not be able to visit because of the distance to travel. Which nursing diagnosis should be identified for this client's concern? A. Risk for social isolation B. RC: Depression C. Hopelessness D. Anxiety A. Risk for social isolation The nurse prepares to complete a community assessment. What should the nurse recall as the reason for this assessment? A. Plan strategies to improve participation in health promotion activities B. Identify the number of families in the community C. Determine health-related concerns of community members D. Assess primary health problems of individuals C. Determine health-related concerns of community members The nurse learns that a tornado has ravaged a local community. Which tool should the nurse suggest be used to complete this community assessment? A. The nursing process B. Community Assessment for Public Health Emergency Response C. Community as Partner model D. Triage and trauma score assessment B. Community Assessment for Public Health Emergency Response A health care organization is preparing posters about childhood mortality for a community health fair. What should be identified as the leading cause of mortality for children of all ages? A. Unintentional injuries B. Homicide C. Suicide D. Malignant neoplasms A. Unintentional injuries The leading cause of childhood mortality for ages 1 through 14 is unintentional injuries. Suicide is the 2nd cause of death for children ages 10 to 14. Homicide is the 3rd leading cause of death for children aged 1 through 4, 4th leading cause of death for children aged 5 through 9, and 5th leading cause of death for children aged 10 through 14. Malignant neoplasms are considered the 4th leading cause of death for children aged 1 through 4, 2nd leading cause of death for children aged 5 through 9, and 3rd leading cause of death for children aged 10 through 14. When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like. The nurse would interpret this finding as indicating which stage of pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV B. Stage II The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause? A. Inadequate circulation B. Continuous trauma C. Decreased subcutaneous tissue D. Excessive collagen formation D. Excessive collagen formation When preparing to examine a client's skin, which of the following would be most important for the nurse to do? A. Wear gloves when preparing to inspect the skin and nails B. Have the client remove clothing from the upper body C. Ensure that the room is warm to prevent chilling D. Expose only the body part that is being examined D. Expose only the body part that is being examined A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy? A. Melasma can be treated with Betadine ointment B. Melasma generally resolves postpartum C. Melasma is always permanent D. Melasma should be treated with antibiotics B. Melasma generally resolves postpartum An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of? A. Henna tattooing B. Body piercing C. Home remedy D. Coining D. Coining A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? A. Macule B. Vesicle C. Papule D. Nodule A. Macule A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCD" characteristic of malignant melanoma? A. Asymmetrical shape B. Diameter less than 6mm C. Color is uniform D. Borders well demarcated A. Asymmetrical shape A decrease in oxyhemoglobin will result in documentation of pallor. A. True B. False A. True Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash? A. Psoriasis B. Insect bites C. Urticaria or hives D. Purpura C. Urticaria or hives A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? A. Small pits in the surfaces of the nails B. Transverse white lines in the nails C. White spots, or leukonychia, on the nail surfaces D. Beau's lines A. Small pits in the surfaces of the nails The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs? A. Have a nurse who is the same sex as the client examine him B. Let the client remained fully dressed for the examination C. Avoid asking any questions regarding the client's lifestyle D. Allow the client to pray before the examination A. Have a nurse who is the same sex as the client examine him A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale? A. The client's current medication regimen B. The client's history of integumentary disorders C. The pigmentation of the client's skin D. The client's ability to change position D. The client's ability to change position A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? A. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." B. "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." C. Repeated sunburns in childhood may explain the presence of some of your moles. D. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." A. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." A nurse is providing care for a client who has decreased mobility secondary to a recent stroke. Which assessment finding would be indicative of a stage I pressure ulcer? A. There is a generalized rash on the client's lower back and buttocks. B. There is scant, frank blood present on the skin surfaces surrounding the client's coccyx. C. There is a non-blanching reddened area on the client's coccyx region. D. There is noticeable bruising on and around the client's coccyx region. C. There is a non-blanching reddened area on the client's coccyx region. Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what? A. Psoriasis B. Acne C. Varicella D. Herpes simplex B. Acne Which of the following scores on the Braden Scale signifies that the client is not at risk for a pressure sore? A. 13 to 18 B. 9 or lower C. 10 to 12 D. 19 to 23 D. 19 to 23 While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of A. anemia. B. trauma. C. infection. D. hypoxia. D. hypoxia. An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of A. erosion. B. scales. C. ulcers. D. fissures. D. fissures. A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? A. Hypothyroidism B. Cushing disease C. Diabetes mellitus D. Crohns disease A. Hypothyroidism A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? A. Defensive driving B. Fall prevention C. Correct use of firearms Domestic violence prevention B. Fall prevention The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A. Infraspinous B. Sternomastoid C. Platysma D. Trapezius B. Sternomastoid During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis? A. Vision acuity B. Lymph nodes C. Facial symmetry D. Temporomandibular joint A. Vision acuity A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? A. Bell's palsy B. Migraine headache C. Tension headache D. Temporal arteritis B. Migraine headache The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? A. In the midline, a few centimeters behind the tip of the mandible B. In front of the ear C. Superficial to the sternomastoid D. At the angle of the mandible A. In the midline, a few centimeters behind the tip of the mandible A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? A. Cushing's syndrome B. Myxedema C. Nephrotic syndrome D. Parkinson's disease D. Parkinson's disease A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment? A. Palpate the woman's parotid gland for enlargement. B. Assess for other signs and symptoms of Cushing's syndrome. C. Order tests to rule out an overactive thyroid gland. D. Assess the woman for hypothyroidism. D. Assess the woman for hypothyroidism. Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding? A. There is an inflammatory response in the musculature of the boy's neck. B. The tissue underlying the nodes is infected. C. There is an infection in the area that these nodes drain. D. The boy requires assessment of his thyroid gland. C. There is an infection in the area that these nodes drain. A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition? A. Migraine headache B. Meningeal inflammation C. Trigeminal neuralgia D. Parkinson's disease B. Meningeal inflammation A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? A. Trapezius B. Temporalis C. Masseter D. Sternocleidomastoid D. Sternocleidomastoid A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? A. Ask permission before palpating the head and neck B. Avoid asking the client to remove her clothes for the examination C. Have a nurse who is the same sex as the client perform the examination D. Palpate the client's feet before palpating the head A. Ask permission before palpating the head and neck When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? A. Cup of water B. Penlight C. Centimeter-scale ruler D. Tongue depressor A. Cup of water A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? A. Diameter: 0.75 cm B. Tender C. Discrete D. Mobile B. Tender A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? A. C3 B. C7 C. C5 D. T2 B. C7 A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? A. Referral for assessment of cranial nerve function B. Referral for assessment of lymphatic system function C. Referral for further assessment of thyroid function D. Referral for further assessment of swallowing ability C. Referral for further assessment of thyroid function A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? A. Arthritic changes of the cervical spine B. Muscle tension C. Cranial damage D. Bacterial thyroiditis A. Arthritic changes of the cervical spine During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? A. Look for involvement of other regions of the body B. Look for a source such as infection in the area that it drains C. Assess for dietary changes D. Assess for meningitis B. Look for a source such as infection in the area that it drains A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? A. Migraine B. Meningitis C. Measles D. Cervical fracture B. Meningitis A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? A. location B. onset C. relieving factors D. treatment C. relieving factors The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely? A. benign tumor B. Hashimoto thyroiditis C. thyroid cyst D. hyperthyroidism D. hyperthyroidism A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A. III B. XII C. VI D. VIII B. XII The frontal sinuses are the only ones readily accessible to clinical examination. A. True B. False B. False During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse would document this finding as being: A. Angioedema B. Actinic cheilitis C. Herpes simplex D. Angular cheilitis C. Herpes simplex You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? A. Encrusted mucous membranes B. Erosion of the trachea C. Noisy breathing D. Hardened secretions C. Noisy breathing The nurse is assessing an individual with facial injury following a motor vehicle accident. Which finding would suggest a fracture of the nose? A. turbinates B. crepitus C. polyps D. mucus B. crepitus The prenatal client asks the nurse why her gums are swollen. What is the best response by the nurse? A. "You have leukoplakia as a result of changes in your hormones with your pregnancy." B. "You have candidiasis as a result of changes in your hormones with your pregnancy." C. "You have herpes simplex virus as a result of changes in your hormones with your pregnancy." D. "You have gingival hyperplasia as a result of changes in your hormones with your pregnancy." D. "You have gingival hyperplasia as a result of changes in your hormones with your pregnancy." The client comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the client has? A. Leukoplakia B. Gingivitis C. Pharyngitis D. Strep throat D. Strep throat A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? A. Reddish B. Pallor C. Cyanotic D. Swelling C. Cyanotic A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? A. Enlarged, reddened B. Pink, moist, firm C. Red, bleeding D. A grey-white line D. A grey-white line A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? A. Cranial nerve I (olfactory) B. Cranial nerve VII (facial) C. Cranial nerve X (vagus) D. Cranial nerve XII (hypoglossal) D. Cranial nerve XII (hypoglossal) During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts? A. Buccal mucosa across from the second upper molars B. Right side of the frenulum at the base of the gums C. Posterior aspect of the tongue bilaterally D. Either side of the frenulum on the floor of the mouth D. Either side of the frenulum on the floor of the mouth A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? A. Reassure the mother that this is common in children B. Assess for allergies to antibiotic C. Inspect the nostrils with an otoscope D. Have the child blow the nose to assess drainage C. Inspect the nostrils with an otoscope A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? A. Self-Care Deficit B. Ineffective Health Maintenance C. Acute Pain D. Hopelessness C. Acute Pain A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client? A. Exposure to the sun B. Heavy alcohol use C. Asthma D. Chewing betel nuts C. Asthma A nurse is working with a client who has an impaired ability to smell. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? A. Cranial nerve VII (facial) B. Cranial nerve V (trigeminal) C. Cranial nerve IX (glossopharyngeal) D. Cranial nerve I (olfactory) D. Cranial nerve I (olfactory) A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? A. History of epistaxis (nosebleeds) B. History of allergies C. Prolonged tonsillar enlargement D. Incomplete immunization record B. History of allergies The nurse identifies this as trapping debris and propelling it toward the nasopharynx. A. Columella B. Turbinates C. Lacrimal duct D. Cilia D. Cilia The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the A. maxillary sinuses. B. ethmoidal sinuses. C. sphenoidal sinuses. D. laryngeal sinuses. A. maxillary sinuses. During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem? A. angioedema B. angular cheilitis C. actinic cheilitis D. herpes simplex D. herpes simplex Which of the following would the nurse document as an abnormal finding with lymph node assessment? Tender The nurse is preparing to teach a class to a group of clients with dysphagia. Which of the following would be most important for the nurse to include? Thoroughly chew only small amounts of food with each mouthful. When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition? Sun exposure A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment? This could be a sign of dehydration The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation? This could be a sign of cancer The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate? Inadequate hydration Which technique should the nurse use to properly assess a client's skin turgor? Pinch the skin on the sternum and observe its return to the original shape. Which of the following principles should guide the nurse's assessment of clients' oral health? Poor oral health has both physical and psychosocial implications. What is the rationale for asking the client whether he or she has noticed any new or changed moles? Changes in existing moles or the appearance of new moles can indicate melanoma. Parents of an Hispanic newborn express concern about the "bruise" they see on the lower back of their child. What explanation by the nurse can alleviate the parents' concern? "This is called a Mongolian spot and is common in infants of African, Hispanic, or Asian descent." A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? Cyanotic A nurse is examining a client's nose. Which characteristics of the nasal mucosa should the nurse expect to find if the client is healthy? Dark pink, moist, and free of discharge Which characteristic of the gums should a nurse expect to assess in a client who is healthy? Pink, moist, firm A nurse assesses a newborn and finds a yellow tinge to the skin. What underlying condition should the nurse most suspect based on this finding? Jaundice A nurse is collecting a thorough and accurate subjective history of a client's nail problems. The client asks why this is necessary. Which of the following should the nurse mention in response? Nail problems can be caused by an underlying systemic illness A nurse is interviewing a client regarding her lifestyle and health practices to obtain subjective information to assist in her assessment of her skin. She asks her, "Do you spend long periods of time sitting or lying in one position?" Which of the following is the best rationale for asking this question? To determine the clients risk for pressure ulcers A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? "Do you use tobacco, whether smoking or chewing?" A dark-skinned client visits the clinic because he "hasn't been feeling well." To assess the client's skin for jaundice, the nurse should inspect the client's sclera. A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristic of the client's symptom is the nurse assessing? relieving factors The nurse performs the action shown in this image during the assessment of a client. What is the nurse assessing? Skin turgor The nurse notes that a client has the rash shown on the forearm What should the nurse suspect as the cause for this client's rash? Allergic reaction A client seeks medical attention for the condition shown. For which health problem should the nurse plan care for this client? Herpes simplex Erikson's stages of psychosocial development. (1) Trust vs Mistrust Erikson's stages of psychosocial development. (2) Autonomy vs Shame and Guilt Erikson's stages of psychosocial development. (3) Initiative vs Guilt Erikson's stages of psychosocial development. (4) Industry vs Inferiority Erikson's stages of psychosocial development. (5) Identity vs Role Confusion Erikson's stages of psychosocial development. (6) Intimacy vs isolation Erikson's stages of psychosocial development. (7) generativity vs. stagnation Erikson's stages of psychosocial development. (8) Ego integrity vs despair Young adult also need what? Good Education Growth is tracked by what? (BABIES) Growth Chart Development is tracked by what? (BABIES) Pediatric Milestones Oriented x3 Oriented to person, place, and time Oriented x4 person, place, time, situation MMSE (what is assessed and what does it mean) many mental status exam (COGNITION) CAGE (what is assessed and what does it mean) cut down, annoyed, guilty, eye opener (Alcohol Abuse) Interpersonal violence also includes what? Bullying What is asked to assess violence "Do you feel safe at home?" Delirium temporary, short-term, reversible Dementia Long-term and irreversible Multidose vial has thimerasol (mercury HPV human papillomavirus - at age 11 MMR should be given at what age 1 year Tetnus shot is to be given every 10 years SQ injections are what needle length 5/8 Needle length for deltoid injection 1 inch what is the smallest needle gauge 25 What are the three primary macro nutrients Carb Protein Lipids/Fats How many cal/g in a protein? 4 cal/g How many cal/g in a fat? 9 How many cal/g in carbs? 4 cal/g what is the percent for carbs? 45-65% What is the percent for protein? 12-20% What is the percent for fats? 20-35% normal nail base (degrees) 160 degrees clubbing angle of nail base exceeds 180 (lack of oxygen) hirsutism increase in growth of facial, body, or pubic hair in women cyanosis conjunctiva (EYE), nail bed Jaundice yellowing of the skin (sclera of eyes and palms) Palor an unhealthy pale appearance () skin turgor (assessment on adults and ederly) under clavical skin turgor (infants) Abdomen Where should you NEVER assess skin turgor? On Hand What do we need to heal PROTEIN ABCDEs of melanoma asymmetry, border, color, diameter, evolution anterior fontanel closes by... 18 months posterior fontanel closes by... 2-3 months Adult lymph nodes that are normal should be soft, mobile and non-tender lymph nodes that are tender and warm suggest what? infection lymph nodes that are fixed, non-tender and one sided are..... cancerous prebyopia impairment of vision as a result of old age (loss of accommodation) PERRLA stands for pupils equal, round, reactive to light and accommodation consenital reaction works together (opposite pupil constricts along with the pupil being tested. accomidation the process by which the eye's lens changes shape to focus near or far objects on the retina close constrict distance dialate corneal light reflex assess the parallel alignment of the eye axes by shining a light toward the person's eyes. direct the person to stare straight ahead as you hold the light about 12 inches away. note the reflection of the light on the corneas, it should be in exactly the same spot on each eye six cardinal fields of gaze A test to evaluate extraocular muscle function; performed by having the patient visually track an object in six visual fields in an H pattern. (MOVEMENT) cover/uncover test Cover one eye; Watch the uncovered eye for a steady, fixed gaze. Uncover the first eye and observe the uncovered eye for any movement Snellen chart a chart used to determine visual acuity (distance) presbycusis age related hearing loss halitosis bad breath Epistaxis nosebleed BMI underweight less than 18.5 BMI normal 18.5-24.9 BMI overweight 25-29.9 BMI class 1 obesity 30-34.9 BMI class 2 obesity 35-39.9 BMI class 3 obesity 40+ IBW ideal body weight waist to hip ratio waist circumference / hip circumference Normal waist-to-hip ratio in men 1.0 or less Normal waist-to-hip ratio in females 0.8 or less