HESI Health Assessment Exam 2023/ 2024Test BankCorrect 100%

HESI Health Assessment Exam 2023/ 2024Test BankCorrect 100% Be sure of Passing your exam with this test bank because it covers All Hesi Health Assessment (The test bank is 100% Verified with all correct Answers) hesi health Assessment with Grade A+ Multiple Choices For which clinical indicator associated with a complication of portal hypertension would the nurse assess the client? A. liver abscess B. intestinal obstruction C. perforation of the duodenum D. hemorrhage from esophageal varices {{Ans- c. The increased pressure within the portal circulatory system causes increased pressure in areas of portal systemic collateral circulation (most importantly, in the distal esophagus and proximal stomach). Hemorrhage is a possible complication. Liver abscesses may occur as a complication of intestinal infections, not portal hypertension. Intestinal obstruction may be caused by manipulation of the bowel during surgery, peritonitis, neurological disorders, or organic obstruction, not portal hypertension. Perforation of the duodenum usually is caused by peptic ulcers; it is not a direct result of portal hypertension or cirrhosis. A client with schizophrenia takes ziprasidone. Which conditions in the client may indicate a need to discontinue the medication? Select all that apply. One,some, or all responses may be correct. A. leukopenia B. tachycardia C. hypokalemia D. hypomagnesemia E. prolonged QT interval {{Ans- a, c, e Ziprasidone is a second-generation antipsychotic medication indicated for schizophrenia. The medication may cause leukopenia, hypokalemia, and hypomagnesemia. This medication may cause a prolonged QT interval, which indicates torsades de pointes. Bradycardia may occur in torsades de pointes but not tachycardia. A client is prone to hyponatremia. Which factors would the nurse identifythat can precipitate hyponatremia? Select all that apply. One,some, or all responsesmay be correct. A. wound drainage B. diuretic therapy C. GI suction D. parenteral infusion of 0.9% sodium chloride E. inappropriate anti-diuretic hormone (ADH) secretions {{Ans- a, b, c, e Wound drainage can result in hyponatremia from loss of sodium ions. Most diuretics interfere with sodium reabsorption in the nephrons and have the side effect of hyponatremia. Gastrointestinal fluids are rich in sodium ions, which are lost by GI suction. With the syndrome of inappropriate antidiuretic hormone (SIADH), high levels of the antidiuretic hormone (ADH) are produced, causing the body to retain water instead of excreting it normally in the urine. Parenteral infusion of 0.9% sodium chloride, an isotonic solution, should be compatible with body fluids; if given in excess, it may lead to hypernatremia. Which statements made by the client identify regulatory functions of the kidney? Select all that apply. One,some, orallresponsesmay be correct. A. erythropoiesis B. acid base balance C. vitamin D activation D. blood pressure control E. fluid and electrolyte balance {{Ans- b, e Maintaining the acid-base balance of the body by selectively reabsorbing and secreting certain substances from the blood is a regulatory function of the kidneys. The kidneys also perform the regulatory function of electrolyte balance by regulating the reabsorption of certain electrolytes while eliminating others depending on their levels in the serum. The kidneys perform hormonal function by secreting a hormone called erythropoietin that aids in synthesis of red blood cells (erythropoiesis). Activation of vitamin D is a hormonal function of the kidneys. The kidneys perform hormonal function by secreting the hormone renin that assists in blood pressure control. Which signs would the nurse expect to observe in a client with small cell carcinoma of the lung who develops syndrome of inappropriate antidiuretic hormone (SIADH)? Select all that apply. One, some, or allresponsesmay be correct. 1 Oliguria 2 Seizures 3 Vomiting 4 Polydipsia 5 Polyphagia {{Ans- 1, 2, 3 Cancerous cells ofsmall cell lung cancer can produce antidiuretic hormone, which causes fluid retention, resulting in increased blood volume and decreased urine volume. Fluid retention associated with SIADH can cause cerebral edema, resulting in confusion and seizures. Fluid retention resulting in hyponatremia causes nausea and vomiting. The client will have nausea and vomiting, resulting in a decreased oral fluid and food intake. Which urinary diagnostic test does not require any dietary or activity restrictions forthe clie nt before or afterthe test? 1 Renalscan 2 Renal biopsy 3 Renal arteriogram 4 Concentration test {{Ans- 1 A renal scan does not require any dietary or activity restrictions. A renal biopsy requires bed rest for 24 hours after the procedure. A renal arteriogram requires the client to maintain bed rest with affected leg straight. A concentration test requires the client to fast after a given time in the evening. The nurse identifies that a client's urinary output is less than 40 mL/h over the past 3 hours. Which actionwouldthe nurse take? 1 Assess breath sounds and obtain vital signs. 2 Decrease the intravenous flow rate and increase oral fluids. 3 Insert an indwelling catheter to facilitate emptying of the bladder. 4 Check for dependent edema by assessing the lower extremities {{Ans- 1 The imbalance in intake and output, with a decreasing urinary output, may indicate kidney failure. The retention of excess body fluid can precipitate the development of heart failure. Assessing breath sounds and obtaining the vital signs are necessary when monitoring for these complications. In the presence of hypervolemia, oral and intravenous fluid intake should be decreased. There are no data to support a problem with the excretion of urine; the problem is with insufficient production. The insertion of a urinary retention catheter requires a health care provider's prescription. Checking for dependent edema by assessing the lower extremities is an appropriate assessment after respirations and vital signs are assessed. A client had a laparoscopic cholecystectomy. Postoperatively, the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What would the nurse include in the teaching plan when preparing this client for discharge? Select all that apply. One, some, or all responses may be correct. 1 Wash the puncture sites with strong soap and hot water daily. 2 Call the health care providerfor a fever of 100°F (37.8°C) or highermore for 2 days. 3 Remove the tape strips overthe puncture sites 1week aftersurgery. 4 Check the puncture sites daily forredness, tenderness, swelling, heat, or drainage. 5 Ease the discomfort from the gas used to insufflate the abdomen during surgery by applying a heating pad to the leftshoulder. {{Ans- 2, 4 Which complication is most likely to occurin the immediate postoperative period after a client has had a splenectomy? 1 Infection 2 Peritonitis 3 Hemorrhage 4 Intestinal obstruction {{Ans- 3 Because the spleen is highly vascular, hemorrhage may occur in the immediate postoperative period. Although risk for some types of infection is higher after splenectomy because of lower immunoglobulin levels, risk for immediate postoperative infection is not higher than usual after splenectomy. Peritonitis is possible after splenectomy, but it would not be apparent in the immediate postoperative period and is not a common complication. The incidence of intestinal obstruction is not higher than for other abdominal surgery, and symptoms would not be apparent in the immediate postoperative period. A high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. Which would the nurse instructthe studentto do? 1 Breathe into cupped hands. 2 Pant using rapid, shallow breaths. 3 Use a rapid deep-breathing pattern. 4 Hold the breath for as long as possible. {{Ans- 1 Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. Which major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula? 1 Amino acids 2 Gamma globulins 3 Essential electrolytes 4 Complex carbohydrates {{Ans- 2 The gamma globulin antibodies in human milk provide the infant with immunity against all or most of the pathogens that the mother has encountered. Amino acids and essential electrolytes are present in commercial formulas. Complex carbohydrates are notrequired by the infant. Which instruction on infection prevention would the nurse include when providing discharge education to a client who received a cadaveric renal transplant? Select all that apply. One, some, or all responses may be correct. 1 Avoid eating from buffets. 2 Obtain annual flu vaccinations. 3 Perform regular hand hygiene. 4 Stay away from crowded areas. 5 Report a temperature greaterthan 100.5°F. {{Ans- 1,2,3,4,5 Clients who receive an organ transplant need to take immunosuppressant medications for the rest of their lives to prevent organ rejection. These medications put the client at increased risk for infection. The nurse would provide infection prevention teaching to the client after renal transplant, which would include instructions to avoid eating from buffets, get an annual flu vaccine, practice regular hand hygiene, and avoid crowded areas. Clients would also be instructed to report a temperature greater than 100.5°F to their health care provider as it could indicate infection or organ rejection and requires treatment. Which malnourished condition may predispose a client to secondary immunodeficiency? 1 Cachexia 2 Cirrhosis 3 Diabetes mellitus 4 Hodgkin lymphoma {{Ans- 1 Cachexia is a nutrition disorder that may occur because of wasting of muscle mass and weight, resulting in a secondary immunodeficiency disorder. Cirrhosis, diabetes mellitus, and Hodgkin lymphoma also lead to secondary immunodeficiency disorder, but these are not malnutrition disorders. Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? 1 Refraining from consuming fatty foods 2 Refraining from consuming frequent meals 3 Refraining from consuming high-calorie foods 4 Refraining from consuming high-protein foods {{Ans- 1 Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. The client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity. Which statement describes a client's tidal volume? 1 Tidal volume is the volume of airinhaled and exhaled with each breath. 2 Tidal volume is the amount of air remaining in the lungs after forced expiration. 3 Tidal volume isthe additional airforcefully inhaled after normal inhalation. 4 Tidal volume is the additional airforcefully exhaled after normal exhalation. {{Ans- 1 Which hormone is released from the posterior pituitary gland? 1 Oxytocin 2 Prolactin 3 Growth hormone 4 Luteinizing hormone {{Ans- 1 Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland. Which clinical manifestation is associated with hypernatremia in burns? 1 Fatigue 2 Seizures 3 Paresthesias 4 Cardiac dysrhythmias {{Ans- 2 Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia. A client with laryngeal cancer is receiving chemotherapy. Which laboratory report is most important for the nurse to monitorwhen considering the effects of chemotherapy? 1 Platelets 2 Hemoglobin level 3 Red blood cell count 4 White blood cell count {{Ans- 4 Antineoplastic medications depress bone marrow, which results in leukopenia; the client must be protected from infection, which is a primary cause of death in the client with cancer. Platelets may decrease rapidly, but complications may be limited by infusions of platelets. Although the hemoglobin level diminishes, a transfusion with packed red blood cells (PRBCs) will alleviate the anemia. RBCs diminish slowly and may be replaced with a transfusion of PRBCs. Which type of hepatitis virus spreads through contaminated food and water? 1 HepatitisAvirus 2 Hepatitis B virus 3 Hepatitis C virus 4 Hepatitis D virus {{Ans- 1 Hepatitis A virus spreads through contaminated food and water. Hepatitis B, C, and D viruses spread through contaminated needles, syringes, and blood products. Which organism is a common opportunistic infection in a client infected with human immunodefici ency virus(HIV)? 1 Oropharyngeal candidiasis 2 Cryptosporidiosis 3 Toxoplasmosis encephalitis 4 Pneumocystis jiroveci pneumonia {{Ans- 1 Oropharyngeal candidiasis is the most common infection associated with HIV because the immune system can no longer control Candida fungal growth. Pneumocystis jiroveci pneumonia (PCP) is more common in a client infected with acquired immunodeficiency syndrome (AIDS). It causes tachypnea and persistent dry cough. Cryptosporidiosis, an intestinal infection caused by Cryptosporidium organisms, presents in clients with AIDS as does toxoplasmosis encephalitis, which is caused by Toxoplasma gondii and is acquired through contact with contaminated cat feces or by ingesting infected undercooked meat. Which effect has resulted in the avoidance of tetracycline use in children under 8 years old? 1 Birth defects 2 Allergic responses 3 Severe nausea and vomiting 4 Permanent tooth discoloration {{Ans- 4 Tetracycline use in children under the age of 8 years has been discontinued because it causes permanent tooth discoloration. Birth defects, allergic responses, and severe nausea and vomiting are not prevalent reasons for the discontinuation of tetracycline medications in children under 8 years old. The nurse understands which medication increases the risk of Reye syndrome in children? 1 Aspirin 2 Naloxone 3 Ibuprofen 4 Acetaminophen {{Ans- 1 Aspirin increases the risk of Reye syndrome in children. Naloxone, ibuprofen, and acetaminophen can be used, but the child should be assessed for renal and liver functioning before prescribing. Which immunomodulatory agent is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon {{Ans- 3 A normal calcium level is {{Ans- 9-10.5 A normal magnesium level is {{Ans- 1.8-2.6 Normal phosphate levels {{Ans- 3-4.5 Which foods would the nurse recommend to a client who is concerned with ensuring that her diet is not deficientin folic acid (folate)? Select all that apply. One,some, or all responsesmay be correct. 1 Lean ground beef 2 Milk and cheese 3 Chicken breast meat 4 Black and pinto beans 5 Enriched bread and pasta {{Ans- 4, 5 Which teaching would the nurse include for parents of an infant with phenylketonuria (PKU)? 1 Testing forPKU is done immediately afterbirth. 2 Cognitive impairment occurs if PKUis untreated. 3 Treatment for PKU includes lifelong medications. 4 PKU istransmitted by an autosomal dominant gene. {{Ans- 2 In PKU, the absence of the hepatic enzyme phenylalanine hydroxylase prevents metabolism (hydroxylation to tyrosine) of the amino acid phenylalanine. The increased fluid level of phenylalanine in the body and the alternate metabolic by-products (phenylketones) are associated with severe cognitive impairment if PKU is not identified and treated early. Testing for PKU cannot be done until after several days of milk ingestion. Medications are not part of therapy for PKU. PKU is transmitted by an autosomal recessive gene. A health care provider prescribes B-complex vitamins. Which information will the nurse teach the client? 1 The vitaminsmay turn the urine bright yellow. 2 The daily fluid intake should be increased. 3 The vitamins should be taken on an empty stomach. 4 Taking the vitamins with a high-fat meal will increase absorption. {{Ans- 1 Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the vitamins on an empty stomach may precipitate nausea; therefore they should be taken with food. Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine. Taking the vitamins with a fatty meal will not improve absorption. Chemotherapy via regional perfusion is the treatment of choice for a client's malignant sarcoma of the liver. Which reason would the nurse provide to explain to the client why this method of medication administration probably wasselected? 1 Medication therapy can be continued at home with little difficulty. 2 Larger doses of medications can be delivered to the actual site of the tumor. 3 Toxic effects of the chemotherapeuticmedications are confined to the area of the tumor. 4 Combinations of medications are used to attack neoplastic cells at various stages of the cell cycle. {{Ans- 2 Regional perfusion therapy permits relative isolation of the tumor area and saturation with the medication(s) selected. This method of medication administration requires medical and nursing supervision and cannot be continued at home. Although toxic effects are confined mainly to the treated area, some migration may still occur. Combinations of chemotherapeutic medications are administered via intravenous or oral rout es, not via regional perfusion. Which nursing actions best promote communication when obtaining a nursing history? Select all that apply.One,some, orallresponsesmay be correct. 1 Establishing eye contact 2 Paraphrasing the client's message 3 Asking "why" and "how" questions 4 Using broad, open-ended statements 5 Reassuring the client that there is no cause for alarm 6 Asking questions that can be answered with a "yes" or "no" {{Ans- 1, 2, 4 Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication. Which actions would the nurse take to help a client with obsessive-compulsive disorder discuss how anxiety influences feelings and the ability to function? Select all that apply. One, some, or all responses may be correct. 1 Identify manipulative behaviors. 2 Explore anxiety-provoking situations. 3 Introduce the client to socializing situations. 4 Assist the client in examining coping mechanisms. 5 Assessthe quality of interpersonal relationships. {{Ans- 2, 4 Which statement will the nurse include when teaching the family of a child with asthma about peak flow meters(PFMs)? 1 "This device measures the peak amount of airthat your child can inhale." 2 "This device will improve medication delivery to the lungs when it's used with an inhaler." 3 "Your child should make sure to use a short-acting bronchodilator before using the PFM." 4 "A PFM can help you identify when asthma is getting worse even before your child has symptoms." {{Ans- 4 The PFM is used to measure the maximal amount of exhalation. In doing this, it can identify when airway obstruction is occurring before the obstruction is sufficient to cause symptoms. PFMs are used to measure exhalation, not inhalation. PFMs are not used for medication administration. The use of a PFM should not be preceded by administration of a bronchodilator. Oral iron supplements patient education should include... {{Ans- - should be given on an empty stomach between meals for best absorption - if a child is old enough, the supplements should be offered with citrus fruit juice as vitamin C will increase absorption - milk and products and antacids also decrease absorption of oral iron and should be avoided for 2 hours after administration - iron supplements may cause constipation and dark green, tarry stools - liquid iron can stain teeth and so are administered with a medicine droppertoward the back of the infants cheek Cushing'striad {{Ans- Signs of increased intracranial pressure: 1. hypertension w/ widened pulsepressure 2. bradycardia 3. irregular respiration's Where is the nurse positioned when performing a Romberg test? 1 Sittingnextto the client 2 Standing behind the client 3 Standing in front of the client 4 Standing to the side of the client {{Ans- 4 The nurse would be standing to the side of the client when performing a Romberg test because the client is most likely to sway side to side. Sitting does not safely position the nurse to rescue an unbalanced client. Standing behind or in front of the client is not optimal for safety because the client is most likely to sway side to side. Which point requires correction regarding the use of restraints? 1 Less restrictive interventions must have been unsuccessful before applying restraints. 2 All other alternatives must have been tried and exhausted before applying restraints. 3 Restraints may be applied to ensure the physical safety of the resident or other residents. 4 A written orderforrestraintsis notrequired. {{Ans- 4 Restraints can be used only on the written order of a health care provider. Restraints can be used when less restrictive interventions are not successful. Restraints may be used after all available alternatives have been tried and exhausted. Restraints can be used only to ensure the physical safety of the resident or other residents. A child is prescribed intravenous mannitol. The nurse understands mannitol belongs to which classification of diuretics? 1 Loop 2 Osmotic 3 Potassium sparing 4 Carbonic anhydrase inhibitor {{Ans- 2 Osmotic diuretics, such as mannitol, increase the osmotic pressure of glomerular filtrate and thus decrease absorption ofsodium; they are used to treat cerebral edema and increased intraocular pressure. A medical-surgical nurse completes the admission assessment on a client diagnosed with a urinary tract infection. The client's admitting weight is 165 lb (74.8 kg). The vital signs are: temperature 96°F (35.6°C), pulse 110 beats per minute, respirations 20 per minute, and blood pressure 88/56 mm Hg. The client received 3 L of normal saline in the emergency department. The total urine output for the past 2 hours was 20 mL via a urinary drainage system. Which intervention would the nurse recommend to the primary health care provider? 1 Transferthe clientto a critical care unit. 2 Discontinue the urinary catheterimmediately. 3 Administer another 1 L bolus of sodium chloride. 4 Begin a dopamine hydrochloride drip forrenal perfusion. {{Ans- 1 The client has a known infection, is exhibiting signs ofsepsis, and is unresponsive to fluid therapy as evidenced by the low blood pressure. The client is showing signs of renal failure. The client is manifesting probable signs of septic shock requiring a higher level of care. This question requires the medical/surgical nurse to synthesize the client's manifestations and make an evaluation of the need for more invasive care than is available on the admitting unit. Giving another fluid is plausible, but this client weighs 75 kg, requiring a maximum of 3 L of fluid to be given before a diagnosis of severe sepsis. The client requires more invasive monitoring than can be done on a medical/surgical unit to determine if more fluid or vasopressors are required. The urinary catheter is necessary to continue monitoring the urine output in this acute client. A client has a blood pressure of 90/50 mm Hg during her first visit to the prenatal clinic. On a subsequent visit, at 34 weeks' gestation, her blood pressure is 120/76 mm Hg. Which would the nurse conclude might have caused the change? 1 The presence of chronic hypertension 2 The possible development of preeclampsia 3 An increased stroke volume during the third trimester 4 An expected increase in blood pressure as pregnancy progresses {{Ans- 2 During the second trimester the blood pressure usually decreases and stays lower for the remainder of the pregnancy; an increase in systolic pressure of 30 mm Hg and diastolic pressure of 15 mm Hg warrants close observation for preeclampsia. The client's baseline blood pressure is low, suggesting that the increase in blood pressure is pregnancy related (i.e., gestational hypertension). Increased stroke volume during the third trimester does not cause an increase in blood pressure. An increase in blood pressure of this amount at 34 weeks' gestation is not expected. A 2-year-old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most importantsafety measure forthe nurse to institute immediately afterthe child has a seizure? 1 Monitoring the child's vital signs 2 Padding the side rails of the toddler's crib 3 Placing the child in the side-lying position 4 Bringing suction equipment to the bedside {{Ans- 3 The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained. A blood transfusion is prescribed for a child with acute lymphocytic leukemia (ALL). Which intervention will the nurse implement during the administration ofthe blood product? 1 Infuse the blood over no more than 4 hours. 2 Take the vital signs 3 hours afterthe transfusion. 3 Check the vital signs 15 minutes afterstarting the transfusion. 4 Have the blood warm at room temperature for 1 hour before administration. {{Ans- 1 Blood should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature. Taking the vital signs 3 hours after the transfusion is too long to wait; the vital signs should be checked every 5 minutes during the absorption of the first 50 mL of blood and then routinely thereafter (every 15 minutes to 1 hour, depending on hospital policy). Vital signs must be checked every 5 minutes during the administration of the first 50 mL of blood to detect a transf usion reaction. Blood should be used within 30 minutes after its arrival from the blood bank; the risk for bacterial proliferation increases overtime and exposure to roomtemperature. Which clinical finding in a newly delivered client requires immediate investigation? 1 An inflamed episiotomy 2 A slow trickle of blood from the vagina 3 An estimated blood loss of half a liter during a vaginal birth 4 A boggy fundus that becomes firm after prolonged massage {{Ans- 2 Vaginal bleeding may be an early sign of hemorrhage; hypovolemic shock can develop. An inflamed episiotomy is an expected finding; ice packs help resolve the inflammation. Expected blood loss for a vaginal birth is 300 to 500 mL. A fundus that has been overstretched or is multiparous may require prolongedmassage until itbecomesfirm. The nurse is caring for a client with a 30% total body surface area burn. Which assessment finding indicatesthatthe client'sfluid replacementis adequate? 1 Increasing hematocrit level 2 Urinary output of 15 to 20 mL/h 3 Slowing of a previously rapid pulse rate 4 Central venous pressure progressing from 5to 1 mm Hg {{Ans- 3 The pulse rate is one indicator of optimum vascular fluid volume; the pulse rate decreases as intravascular volume normalizes. An increasing hematocrit level indicates hemoconcentration resulting from hypovolemia. Urinary output of 0.5 to 1 mL/kg/h indicates inadequate kidney perfusion; if adequate, output should be greater than 30 mL/h. Central venous pressure decreasing from 5 to 1 mm Hg indicates hypovolemia. Which intervention would the nurse implement for a client with Alzheimer disease who has become agitated and aggressive and isincontinentof urine and feces? 1 Manage the behavior. 2 Prevent further deterioration. 3 Focus on the needs of the spouse. 4 Establish an elimination rewards program {{Ans- 1 The nurse would manage the behavior. The client must be kept from harming self or others and needs a calm,supportive environmentthatmeets needs andmaintains dignity. After a thoracentesis for pleural effusion, a client returns to an outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the clientmakes which statement? 1 "Lately I can only breathe well if Isit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up large amounts of thicker mucus for the past several days." {{Ans- 3 Tension is placed on the pleura at the height of inspiration and causes pain. Which of the following statements from a patient's history is it most important to investigate further? a. "I have an allergy to peanuts." b. "I have lost 30 pounds overthe last 4 months." c. "I don't like many vegetables so I take multivitamins." d. "I drink 2 cups of coffee each morning." {{Ans- ANS: B The statement in option "b is most important to investigate further because any significant weight loss may indicate a serious problem. The statement about an allergy to peanuts is not the most important piece of information, although the nurse would want to investigate and document any food allergies. Option "c" is not the most significant statement; however, the nurse should investigate the types and amounts of vegetables the patient eats. Two cups of coffee is considered fairly typical and the patient is not consuming an excessive amount of caffeine. Your patient complains of pruritus. You should examine the patient for which of the following associated signs and symptoms? a. rash and edema b. coolness and pallor c. cyanosis and coolness d. ecchymosis and purpura {{Ans- ANS: A Pruritus or itching of the skin is associated with the following manifestations: rashes, lesions, edema, angioedema, anaphylaxis, excoriation or ulcers as a result of scratching, lichenification or thickening of the skin, and systemic disease. As a result of scratching the skin due to pruritus, the skin would most likely be warm and red, not pale, cool, or cyanotic. Ecchymosis is a violaceous discoloration, also called a black-and-blue mark. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis.Neitherof these is associatedwith pruritus. 3. Your patient asks you about the small, reddish purple discolorations of the skin, less than 0.5 cm in diameter. You informthe patientthatthisis known as which of the following? a. ecchymoses c. purpura b. petechiae d. spider telangiectasia {{Ans-ANS: B Petechiae are violaceous (red-purple) discolorations of less than 0.5 cm in diameter. Petechiae do not blanch. They can indicate an increased bleeding tendency or embolism; causes include intravascular defects and infections. Ecchymosis is a violaceous discoloration of varying size, also called a black-andblue mark. It is caused by extravasation of blood into the skin as a result of trauma; heparin or Coumadin use; or liver dysfunction. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis over any part of the body. Purpura is caused by hemorrhage into the skin and can be the result of decreased platelet formation. Spider angiomas, a type of telangiectasia, are bright red and star-shaped. Most often these lesions are found on the face, neck, and chest. There is often a central pulsation noted with pressure, and thisresultsin blanching in the extensions. Your patient expresses concern about a mole on her right leg that has recently started itching. Which accompanying findingmostlikely indicates adeveloping cancerouslesion? a. regular and distinct border c. edema in both feet b. multiple colorations d. inflammation of periungualtissue {{Ans- ANS: B Developing cancerous lesions may have multiple colorations such as brownish, tan, red, white, blue, pink, purple, or gray. Othersigns in potentially cancerous lesions include the following: 1) rapid change in size; 2) change in coloration; 3) irregular or butterfly-shaped border; 4) elevation in a previously flat mole; 5) multiple colorations in a lesion; 6) change in surface characteristics, such as oozing; 7) change in sensation, such as pain, itching, or tenderness; 8) change in surrounding skin, such as inflammation or induration; and 9) bleeding or ulcerative appearance in a mole. These lesions are not associated with edemaor inflammation of the areaaround the fingernails orthe toenails. After releasing the pressure of your thumb on your patient's lower legs, ankles, and feet, you observe a 4 mm depression of the skin that disappears in 10 to 15 seconds. You would report this finding as which of the following? a. 1+ pitting edema c. 3+ pitting edema b. 2+ pitting edema d. 4+ pitting edema {{Ans- ANS: B Edema is the accumulation of fluid in the intercellularspaces. Pitting edema is rated on a 4-pointscale: 0+ = no pitting edema. 1+ = mild pitting edema; 2mm depression that disappears rapidly. 2+ = moderate pitting edema; 4mm depression that disappearsin 10 to 15 seconds. 3+ = moderately severe pitting edema; 6 mm depression that can last more than 1 minute. 4+ = severe pitting edema; 8mmdepression that can last more than 2 minutes. The nurse checks the capillary refill of a new patient. The amount of time for the nail color to return afterthe pressure isreleased on the patient's nail should not exceed which of the following? a. 1-2 seconds c. 3-4 seconds b. 2-3 seconds d. 4-5 seconds{{Ans- ANS: B Capillary refill time is a measure used to examine arterial flow to the extremities and is an indicator of peripheral circulation. Normal capillary refill varies with age, but color should return to normal within 2- 3 seconds. Options "c" and "d" indicate prolonged capillary refill time and may indicate cardiovascular or respiratory dysfunction.Option "a"would be considered within normal limits. To locate the temporomandibular joint, the nurse would palpate with both index and middle fingers on both sides ofthe face a. anteriorto the tragus of the ear. c. overthe temporalis muscles. b. inferiorto the external meatus of the ear. d. posteriorto the tragus of the ear. {{Ans- ANS: A The temporomandibularjoint is just below the temporal artery and anteriorto the tragus of the ear. The tragus is a small extension of the auricular cartilage of the ear, anterior to the external meatus of the ear. The temporomandibular joint is not over the temporalis muscles. The nurse can examine this joint by palpating it as the patient opens and closes the mouth and notes normally smooth movement with no limitation ortenderness. Crepitation, limited range of motion, ortenderness are abnormal findings. To perform auscultation of a patient's thyroid gland, you would place the bell of your stethoscope over the a. thyroid isthmus, then the right and left lobes. b. right thyroid lobe, then the left lobe. c. left carotid artery first. d. right temporal artery, then the left temporal artery. {{Ans- ANS: B If the thyroid is enlarged, auscultation should be performed. The nurse stands in front of the patien t, places the stethoscope over the right thyroid lobe, auscultates for bruits, and finally repeats the procedure on the left lobe. The thyroid isthmus is the band of tissue connecting the right and left thyroid lobes; however, it is not involved in auscultation of the thyroid gland. Options "c" and "d" are included in auscultation ofthe thyroid gland. Legal blindness is most commonly considered to be a. blurred or double vision that cannot be corrected. b. corrected vision thatis 20/100 or worse. c. corrected vision thatis 20/200 or worse. d. inability to perceive any light. {{Ans- ANS: C Legal blindness is defined as the best-corrected vision in the better eye of 20/200 or worse. Total blindnessis defined asthe inability to perceiveany light. Normal visualacuity is 20/20. You observe that your patient's eyes move smoothly and symmetrically in each of the six fields of gaze and converge on the held object as it moves toward the nose. There are a few beats of nystagmus on extreme lateral gaze. This observation indicateswhich of the following? a. early stage of paralysis of horizontal gaze b. lesion in the brainstem or cerebellum c. normal findings d. weakness of the lateral rectus muscle {{Ans- ANS: C This observation indicates normal results in examining extraocular muscle movements by testing the six cardinal fields of gaze. Inability to move the eye in a given direction indicates weakness of an extraocular muscle (EOM) or dysfunction of the cranial nerve innervating it. Paralysis of horizontal gaze, the inability of both eyes to look to the contralateral side, is abnormal. This may be caused by damage to the motor areas of the cerebral cortex resulting in the loss of the ability of both eyes to look to the contralateral side. If one eye deviates down and the other eye deviates up, it is called skew deviation. A lesion in the brainstem or cerebellum on the same side asthe eye that is deviated down can cause skew deviation. Weakness of the lateral rectus muscle is demonstrated by failure of the eye to move outward. While assessing a patient's ability to consume food, the nurse recalls which types of foods are the easiestto chew and swallow? a. Thin liquids b. Soft foods c. Dry foods d. Chewy foods {{Ans- B. Soft Foods Which tool is the best choice for a nurse to use as a quick screening tool to assess a patient's dietary intake? a. Food diary b. Calorie count c. Comprehensive diet history d. 24-hour recall {{Ans- D. 24 hourrecall Nurses use which measurement as the most highly correlated with risk of morbidity and mortality? a. Waist-to-hip ratio b. Triceps skinfold measure c. Desirable body weight d. Body mass index (BMI) {{Ans- D. BMI When the patient's chart includes a notation that petechiae are present, what finding does a nurse expect during inspection? a. Purplish-red pinpoint lesions b. Deep purplish or red patches of skin c. Small raised fluid-filled pinkish nodules d. Generalized reddish discoloration of an area of skin {{Ans- A. Purple-red pinpoint leisons A nurse is inspecting the skin of a patient who has had skin problems after multiple piercings. How will the nurse recognize the characteristics of keloids? a. Roughened and thickened scales involving flexorsurfaces b. Hypertrophic scarring extending beyond the original wound edges c. Thin, fibrous tissue replacing normal skin following injury d. Loss of the epidermal layer, creating a hollowed-out or crusted area {{Ans- Hypertrophic scarring extendingbeyond the original wound edges A patient is visiting an urgent care center after being hit in the back with a baseball. Upon examination, the nurse notes a flat, nonblanchable spot 2.25 cm wide that is reddish-purple in color. How does the nurse documentthislesion? a. As an angioma b. As purpura c. As petechiae d. As ecchymosis {{Ans- Ecchymosis During a health fair, which recommendation is appropriate as a primary prevention measure to reduce the risk forskin cancer? a. Use a tanning booth instead of sunning outside if a tan is desired. b. Wear protective clothing while in the sun. c. Perform self-examination of skin monthly. d. Use sunscreen with a sun protection except on overcast days. {{Ans- Wear protective clothing while in the sun Which questions are appropriate to ask a patient when performing a symptom analysis for a rash? Select all that apply. a. "When did the rash first start?" b. "Do you have a family history of rashes?" c. "What makesthe rash worse?" d. "What do you do to make yourrash better?" e. "Describe the sensation from the rash, does it burn or itch?" f. "Describe what the rash looked like initially." {{Ans- Everyone except C! 1. The presence of jaundice in a dark-skinned individual appears as a yellow to orange coloration of the a. skin, mucous membranes, and palmar and plantarsurfaces. b. fingernails and skin. c. sclera, hard palate, and palmar and plantarsurfaces. d. sclera only. {{Ans- ANS: C The appearance of jaundice is abnormal. Jaundice in a dark-skinned individual appears as yellow staining in the sclera, hard palate, and palmar and/or plantar surfaces. In light-skinned individuals jaundice appears as yellow-green to orange coloration of the skin, sclera, mucous membranes, fingernails, and palmar and/or plantarsurfaces. A white cast to the skin resulting from a congenital inability to form melanin is known as a. vitiligo. c. jaundice. b. pallor. d. albinism. {{Ans- ANS: D A white cast to the skin as evidenced by generalized whiteness, including the hair and eyebrows, is abnormal. This lack of coloration is caused by albinism, a congenital inability to form melanin. Vitiligo is a condition marked by patchy symmetrical areas of white on the skin. This condition is caused by an acquired loss of melanin. Trauma can also lead to hypopigmentation, especially in dark-skinned individuals.Jaundice produces a yellow-green to orange cast or coloration ofthe skin. Your patient asks you about the small, reddish purple discolorations of the skin, less than 0.5 cm in diameter. You informthe patientthatthisis known aswhich of the following? a. ecchymoses c. purpura b. petechiae d. spidertelangiectasia {{Ans- ANS: B Petechiae are violaceous (red-purple) discolorations of less than 0.5 cm in diameter. Petechiae do not blanch. They can indicate an increased bleeding tendency or embolism; causes include intravascular defects and infections. Ecchymosis is a violaceous discoloration of varying size, also called a black-andblue mark. It is caused by extravasation of blood into the skin as a result of trauma; heparin or Coumadin use; or liver dysfunction. Purpura is a condition characterized by the presence of confluent petechiae or confluent ecchymosis over any part of the body. Purpura is caused by hemorrhage into the skin and can be the result of decreased platelet formation. Spider angiomas, a type of telangiectasia, are bright red and star-shaped. Most often these lesions are found on the face, neck, and chest. There is often a central pulsation noted with pressure, and thisresultsin blanching in the extensions. A nursing student informs you that the examination revealed ecchymoses on the face, breasts, and buttocks of a 14-year-old patient. Your best response is to inform the student that these findings are mostlikely related to whichofthe following? a. liver dysfunction c. trauma from physical abuse b. heparin or Coumadin use d. familial blood condition {{Ans-ANS: C Ecchymosis is a bruise or superficial bleeding under the skin or mucous membranes. Areas of ecchymosis are often signs of trauma that could be the result of physical abuse. In a 14-year-old, such a finding on the face, breasts, and buttocks would most l ikely be caused by physical abuse. Ecchymosis can also occur with heparin or Coumadin use or liver dysfunction; however, these would not typically be located onthe breasts and buttocks. Your patient complains of hoarseness yet denies smoking, alcohol use, and recent upper respiratory infection. Which question is appropriateto examinethe aggravating factors? a. "Does drinking fluids or warm drinks help alleviate the hoarseness?" b. "Do you have any pain in your neck or throat?" c. "Have you been singing, yelling, ortalking excessively recently?" d. "Is your hoarseness continuous, or does it come and go?" {{Ans- ANS: C Aggravating factors related to hoarseness include inhalation of chemicals or noxious fumes, smoking, overuse of voice, alcohol use, recent upper respiratory infections, recent head and neck surgery, intubation, and neck trauma; therefore, the appropriate question to ask is option "c." Manifestations associated with hoarseness include fever, sore throat, malaise, reflux, and vocal cord mass. Option "b" examines for associated manifestations. Option "a" is appropriate to examine for alleviating factors. The question in option "d" isrelated to the timingofthe hoarseness. An enlargement of the head without enlargement of the facial structures is known as a. acromegaly. c. craniotabes. b. craniosynostosis. d. hydrocephalus. {{Ans- ANS: D Hydrocephalus is an enlargement of the head without enlargement of the facial structures and is caused by an abnormal accumulation of cerebrospinal fluid within the ventricles ofthe brain. Acromegaly is an abnormal enlargement of the skull and bony facial structures resulting from an excessive secretion of growth hormone from the pituitary gland. Craniosynostosis is characterized by abnormal shape of the skull or bone growth at right angles to suture lines, exophthalmos, and drooping eyelids. It is caused by premature closure of one or more sutures of the skull in children before brain growth is complete. Craniotabes is a softening of the skull caused by hydrocephalus or demineralization of the bone due to rickets, hypervitaminosis A, orsyphilis. Individuals most at risk for thyroid cancer are which of the following? a. men age 20-30 years of age c. men age 40-50 years of age b. women age 20-30 years of age d. women age 40-50 years of age {{Ans- ANS: D Individuals most at risk for thyroid cancer include women between the ages of 40-50. Men ages 60-70 years are also at risk forthyroid cancer. A patient is complaining of a burning and gritty sensation in the eyes, with redness, itching, and crusting on the eyelids. Which question is most likely to assist in identifying the aggravating factors related to the patient's complaints? a. "Do eyedrops help relieve yoursymptoms?" b. "Do you wear eye makeup?" c. "Do you notice a change between outdoors and indoors?" d. "Have you noticed any change in your visual acuity?" {{Ans- ANS: B A burning and gritty sensation in the eye is an associated manifestation of the symptom of itching of the eye. Redness, itching, and crusting on the eyelids are associated manifestations of drainage or discharge of liquid from the eye. Aggravating factors related to drainage and itching are allergens, eye makeup, contact lens, chlorine, poor hygiene, and an upper respiratory infection; therefore, the question most likely to assist in identifying the aggravating factors related to her complaints would be about wearing eye makeup. Asking whether eyedrops relieve symptoms would be appropriate to identify alleviating factors. Option "c" refers to the setting in which symptoms occur. The question in option "d" is not appropriate to identify aggravating factors. When completing a measurement of the patient's visual acuity, which of the following would be appropriate? a. Snellen chart c. penlight b. visual field d. ophthalmoscope {{Ans- ANS: A The measurement of visual acuity includes the Snellen or Snellen E chart. The visual field evaluates movement in the extraocular eye muscles and the cranial nerves. The penlight and ophthalmoscope illuminateinnereye structures. 1. Asymmetry of the face occurs in _ palsy and in a cerebral {{Ans- ANS:Bell's Rationale: Asymmetry of the palpebral fissures, nasolabial folds, the mouth, and facial expression can indicate damage to the nerves innervating facial muscles (cranial nerve VII), as in a stroke (cerebral vascularaccident) or Bell'spalsy. The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumenis correct? a. Sticky honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary fortransmitting sound through the auditory canal. {{Ans- ANS: C The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protectsthe ear. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a. light pink with a slight bulge. b. pearly gray and slightly concave. c. pulled in at the base of the cone of light. d. whitish with a small fleck of light in the superior portion. {{Ans- ANS: B The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles. A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be importantforthe nurse to: a. speak loudly so he can hear the questions. b. assess for middle ear infection as a possible cause. c. ask the patient what medications he is currently taking. d. look forthe source of the obstruction in the external ear. {{Ans- ANS: C A simple increase in amplitude may not enable the person to understand words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxicdrugs, which affectthe hair cellsin the cochlea. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an importantquestion in thissituation? a. "Do you ever notice ringing or crackling in your ears?" b. "When was the last time you had your hearing checked?" c. "Have you ever been told you have any type of hearing loss?" d. "Was there any relationship between the ear pain and the discharge you mentioned?" {{Ans- ANS: D Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilt the person's head forward during the exam. b. Once the speculum is in the ear, release the traction. c. Pull the pinna up and back before inserting the speculum. d. Use the smallestspeculum to decrease the amount of discomfort. {{Ans- ANS: C Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure? a.Pull the pinna down. b.Pull the pinna up and back c.Tilt the child's head slightly toward the examiner. d.Have the child touch his chin to his chest {{Ans- ANS: A For an otoscopic examination, pullthe pinna down on an infant and a child under 3 years of age. The otherresponses are not part of the correct procedure. During an examination, the nurse notices that the patient stumbles a bit while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse noticesthat the patientis experiencing: a. objective vertigo. b. subjective vertigo. c. tinnitus. d. dizziness. {{Ans- ANS: A With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo;the personwho is dizzy may feel unsteady and lightheaded. A patient complains of right ear pain. What findings does the nurse anticipate on inspecting the patient's ears? a. Redness and edema of the pinna of the right ear b. Report of pain when the nurse manipulates the right ear c. Bulging and red tympanic membrane in the right ear d. Increased cerumen in the right ear canal {{Ans- ANS: C A Redness and edema of the pinna of the right ear is consistent with external ear pain that may be associatedwith otitis externa orswimmer's ear. B Report of pain when the nurse manipulates the right ear is consistent with external ear pain that may be associatedwith otitis externa orswimmer's ear. C Bulging and red tympanic membrane in the right ear is consistent with internal ear pain that may be associatedwith otitismedia. D Increased cerumen in the right ear canal is not consistent with internal ear pain. An adult patient comes to the clinic complaining of right ear pain. What technique does the nurse use to inspectthis patient's auditory canal? a. Position the otoscope speculum 1.0 to 1.5 cm (about 0.5 inches) into the ear canal. b. Remove cerumen from each canal before inserting otoscope. c. Choose the smallest otoscope speculum that will fit the patient's ear comfortably. d. Pull the pinna slightly downward and backward before inserting the otoscope speculum. {{Ans- ANS: A A Thisis the correct technique. B Removing cerumen is not necessary. C The largest speculum that comfortably fits in the ear canal is the one that should be chosen. D For adults, the pinna is pulled up and backward to straighten the ear canal. A nurse examines a patient's auditory canal and tympanic membrane with an otoscope and observes which finding as normal? a. Clear fluid lining the auditory canal b. A firm tympanic membrane without fluctuation with puffs of air c. A small hole within the cone of light d. A shiny, translucent tympanicmembrane {{Ans- ANS: D A Clear fluid or bloody drainage following a head injury may indicate a basilar skull fracture. B An expected response is that the tympanic membrane slightly fluctuates with puffs of air. C A cone of light is expected, but a hole indicates perforation. D A shiny, translucent tympanic membrane is an expected finding. A nurse observes a student using the whisper test to screen a patient with hearing loss. Which behavior by the studentrequires acorrective commentfromthe nurse? a. Instructing the patient to cover the ear not being tested b. Standing beside the patient on the side of the ear being tested c. Shielding the mouth to prevent the patient from reading lips d. Whispering one ortwo syllable words and ask the patient to repeat what is heard {{Ans- ANS: B A Thisis the correct technique. B The student nurse should stand 1 to 2 feet in front or to the side of the patient. C Thisis the correct technique. D Thisis the correct technique. A nurse reads in the history that a patient has a new onset of acute otitis media. Based on this information, how doesthe nurse expectthis patient'stympanicmembrane to appear? a. Dull b. Shiny c. Red d. Blue to deep red {{Ans- ANS: C A This indicates fibrosis or scarring. B This is normal forthe tympanic membrane. C This indicates infection in the middle ear, such as otitis media. D Thisindicates blood behind the tympanicmembrane, which may have occurred secondary to injury. The nurse is conducting a child safety class for new mothers. Which of these is a risk factor for ear infectionsin young children? a. Family history b. Air conditioning c. Excessive cerumen d. Passive cigarette smoke {{Ans- D. Exposure to passive and gestational smoke is a risk factor for ear infectionsin infants and children During a Weber test, a patient with right ear hearing loss reports hearing sound longer in the right ear than the left ear. What results should the nurse expect to find from this patient during a Rinne test? a. Air conduction will be twice as long as bone conduction (2:1 ratio). b. Air conduction will be 1.5 times as long as bone conduction (1.5:1 ratio). c. Bone conduction will be longer than air conduction. d. Bone conduction will be equal to air conduction. {{Ans- ANS: C A Thisis an expected finding. B This finding is consistent with a sensorineural hearing loss, but this patient has a conduction hearing loss based on the resultsofthe Webertest. C This finding from the Rinne test indicates a conduction hearing loss, which is consistent with the finding fromthe Webertest described in the question. D This finding is not consistent with the conductive hearing loss described. The nurse is testing the hearing of a 78-year-old man and keeps in mind the changes in hearing that occur with aging include which ofthe following? Select all that apply. a. Hearing loss related to aging begins in the mid 40s. b. The progression is slow. c. The aging person has low-frequency tone loss. d. The aging person may find it harder to hear consonants than vowels. e. Sounds may be garbled and difficult to localize. f. Hearing lossreflects nerve degeneration of the middle ear. {{Ans- ANS: B, D, E Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after age 50. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels. This makes words sound garbled. The ability to localize sound isimpaired also. What findings does the nurse expect when assessing the ears of a healthy adult? Select all that apply. a. Cerumen noted in the outer ear canal b. Pinna located below the external corner of the eye c. Cone of light located in the 5 o'clock position in the left ear d. Ratio of air conduction to bone conduction 2:1 e. Tympanic membrane pearly gray f. Whispered wordsrepeated accurately {{Ans- ANS: A, D, E, F Correct: These are all expected findings from an assessment of the ears of a healthy adult. Incorrect: The pinna should align with the outer canthus of the eye. Cone of light should be located in the 7 o'clock position in the left earand the 5 o'clock position in the right ear. The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicatorof pain in this clientis: The patient is reporting "6/10" pain. The patient is refusing to get out of bed. The patient is refusing to eat breakfast. The patient's heart rate is 90 beats per minute. {{Ans- A Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? Ensure the width ofthe BP cuff is equal to 80% of the arm circumference. Ensure the client's back is supported and feet are flat on the ground. Take two BP readings 20 seconds apart. Ensure that the patient's arm is above heart level. {{Ans- B The patient's arm should be supported at heart level. Separate BP readings may need to be taken, but not one right afterthe other. The length of the BP bladdershould equal 80% of the arm circumferen The nurse obtains which piece of data during the general survey? Clientis alert and calm. Client's heart rate is 80 beats per minute. Client's bodymassindex (BMI) is 30. Client's lung sounds are "clear" to auscultation. {{Ans- A A man is at the clinic for a complete physical exam. He statesthat he is "very anxious". Whatsteps can the nurse take to make himmore comfortable? Appear confident and unhurried during the exam. Measure vital signs at the end to allow the patient sufficient time to relax. Let himleave his clothes on during the examination. Obtain another nurse to examine the patient. {{Ans- A A father brings his 13 month-old child in for "fever" and he reports that the child has been "pulling on his left ear". Upon entering the exam room, the child is asleep in the father's arms. The nurse should performwhich assessmentfirst? Use the otoscope to look inside the ear. Use a penlight to check the eyes and nose. Auscultate the lungs, heart, and abdomen. Assess gross motorskills using the Denver II screening tool. {{Ans- C An 18 year-old presents to the emergency department with "headache." Which of these assessment findings alertsthe nurse to recent opioid use? Pupillary constriction Hallucinations. Fever. Tachypnea. {{Ans- A- constricted pupils are a sign of recent opioid use, the rest are withdrawals While collecting the pulse on a 26 year-old client, the nurse notes that the heart rate seems to speed up and then slow down in accordance with respirations. The pulse is counted at 80 beats per minute. What should the nurse do next? Obtain orthostatic vital signs. Notify the physician. Document "sinus arrhythmia." Use a dopplerto confirm the finding. {{Ans- C An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents hislevel of consciousness as: Manic. Demented. Drowsy. Delirious. {{Ans- D The nurse is assessing a newborn infant. How should the nurse measure the heart rate (HR)? Palpate the radial pulse for15 seconds and multiply by four. Palpate the brachial pulse for 30 seconds and multiply by two. Auscultate the apical site for 60 seconds. Apply a pulse oximeterto obtain both the HR and SpO2. {{Ans- C A 28 year-old is brought to the emergency department. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspectsthatthe patientis experiencing withdrawal symptoms from which substance? Alcohol. Cocaine. Cannabis. Opiates. {{Ans- A- hallucinations and delirium are commonly seen w alcohol withdrawal When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? Fever is a reliable sign of infection in older adults. The older adult's body temperature varies widely because of the thinner subcutaneous layer. There are no differencesin temperaturebetween ayoung and old adult. Older adults body temperature runs lower than that of an adult. {{Ans- D Which error may resultin a falsely low blood pressure (BP) reading? The patient has a full bladder. The arm is held above the level of the heart. The cuff size istoo small for the client. The BP cuff is wrapped loosely around the arm. {{Ans- B- at heart level During a general survey of a post-operative patient, the nurse notes that the patient's eyes are closed but they temporarily open with loud verbal stimulus and a gentle shake to the shoulder. The nurse documents hislevelof consciousness as: Alert. Somnolent. Stuporous. Obtunded. {{Ans-D A 46-year-old male presents to the Emergency Department with syncope. He says his cardiologist recently placed him on a new medication for his blood pressure (BP). What should the nurse do first? Obtain orthostatic vital signs. Educate the patient on homeopathic methods to control his BP. Administera fluid bolus. Advise the patient to stop taking this medication. {{Ans-A As a mandatory reporter, the nurse notifies the authorities with which of the following? Suspicion of child or elder abuse/neglect. Proof of substance abuse inminors. Any bruising on a child or older adult. Proof of intimate partner violence. {{Ans- A A 50 year-old patient is in the intensive care unit (ICU) with septic shock. The nurse receives an order to notify the provider if the patient's mean arterial pressure (MAP) is <60 mmHg. What does the nurse understand to be true? A MAP >60 is needed to maintain adequate tissue per