NSG 3160 Exam 1 Newest 2025/2026
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To obtain subjective data about a newly admitted client's sleep pattern, the nurse
should do what action?
1) Assess the client's alertness and short-term memory (objective)
2) Have the client describe how rested they typically feel in the morning
3) Document the client's affect and yawning (objective)
4) Determine how frequently the client naps. (objective) - Answer ✓✓Have the
client describe how rested they typically feel in the morning
Explanation:
The frequency of naps, alertness and observed affect are objective data. The
client's description of reeling rested is subjective.
The nurse conducts a health history on a client who has experienced a 7.5-pound
(3.5 kilogram) weight loss in the past 3 weeks. Which information would the nurse
gather to determine the client's nutrition pattern?
Weigh the client and measure the client's height.
Ask the client for a 24-hour diet recall.
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Examine the hygiene of the client's teeth.
Inspect the client's abdomen for symmetry. - Answer ✓✓Ask the client for a 24-
hour diet recall.
Explanation:
Interview questions that will focus on nutrition might include asking the client to
disclose what the individual has eaten in the last 24 hours. Weighing the client
would not provide good nutrition information because the nurse already knows
the client has experienced a significant weight loss. A 24-hour diet recall would
provide better information about the total nutritional pattern than merely
examining the client's teeth or inspecting the abdomen for symmetry.
The nurse pinches the skin under the clavicle and it tents. What conclusion should
the nurse determine from this assessment?
1) The skin is less elastic with aging. ( but the turgor should remain normal--less
than 3 seconds and not tent)
2) The client is dehydrated. (skin will tent more than 3 seconds)
3) The skin has normal turgor.
4) The client is overhydrated. ( present edema--taunt and shiny skin ) - Answer
✓✓The client is dehydrated.
Explanation:
The nurse assesses for skin turgor by gently pinching the skin under the clavicle.
This technique provides information about the client's hydration status as well as
skin mobility and elasticity.
Skin is less elastic with aging, but the turgor should remain normal (less than 3
seconds) and not tent, or remain in the pinched position. When a client is
dehydrated, the skin will tent for more than 3 seconds. When a client is
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overhydrated, edema will be present with the skin, and the skin turgor would be
normal, or taunt because of excess fluid.
The nurse is palpating the skin of a 30-year old client and documents that when
picked up in a fold, the skin fold slowly returns to normal. What would be the next
action of the nurse based on this finding?
1) Document a normal skin finding on the client chart.
2) Assess the client for cardiovascular disorders.
3) Report the finding as a positive sign for cystic fibrosis.
4)Assess the client for dehydration. - Answer ✓✓Assess the client for dehydration.
Explanation:
Turgor is the fullness or elasticity of the skin. The client should be further
assessed for signs and symptoms of dehydration because poor skin turgor is a sign
of dehydration. When the client is dehydrated, the skin's elasticity is decreased,
and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular
disease nor cystic fibrosis.
A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3
days ago. Her postoperative course has been uneventful except for a urinary tract
infection that developed yesterday for which she is receiving cefaclor 500 mg PO
bid. The client tells the nurse that the backs of her legs and buttocks are "itching
like crazy." Which action should the nurse take first?
Check her chart for allergy information.
Inspect the area of itchy skin.
Review her medical history.
Review her medication record. - Answer ✓✓Inspect the area of itchy skin.
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Explanation:
Inspecting the back of the client's legs and buttocks is the first step in determining
the nature of the client's problem. Checking the chart for known allergies and
reviewing the medical history and medication record may provide helpful
information, but assessing the skin gives firsthand information about the problem.
To assess subjective data related to a client's elimination pattern, the nurse should
perform which action?
1)Review culture and sensitivity results of urine (objective)
2)Ask the client about changes in voiding patterns.( subjective)
3)Document the frequency, amount, and time the client voids.( objective)
4)Palpate the abdomen for pain or distention. (objective) - Answer ✓✓Ask the
client about changes in voiding patterns.
Explanation:
Asking for the client's impressions and understanding of a situation yields
subjective data. Lab results, physical assessment findings and data such as time
and quantity are considered objective.
While assessing a 58-year-old client's near vision, the nurse can anticipate the
client will state that their vision is:
clear.
blurred.
clouded.
20/20. - Answer ✓✓blurred.
Explanation:
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