The nurse is completing a nutritional assessment on a client with hypertension (high BP). What
foods would be recommended for this client? - Answers Low sodium diet (low salt)
During a home visit the nurse is assessing an older adult client. Which assessment findings
support the nursing diagnosis (Imbalanced Nutrition: Less than Body Requirements)? Select all
that apply? - Answers - Client reports a problem with dentures slipping while chewing
- Client complains of occasional dry mouth and problems with feelings of nausea
- Clients is prescribed 15 medications
What is the primary prevention tool used for colon cancer screening? - Answers Occult blood
testing
The public health nurse is providing community education aimed at promoting nutritional habits
that decrease an individuals modifiable risks factors for heart disease. Which topic should the
nurse NOT include in this teaching? - Answers Importance of eliminating all fats
The process of digestion is important for every living organism for the purpose of nourishment.
Where does most digestion take place in the body? - Answers Small intestine
The nurse is providing teaching to a female client about dietary modifications to promote
weight loss. Which statement by the nurse is accurate? - Answers Your diet should consist of
1000-1200 calories per day and be low in fats, high in fiber and include a variety of foods
The home care nurse is assessing an older client diagnosed with mild cognitive impairment
(MCI) and is living alone. Which information is of concern? - Answers The client has lost 10
pounds (4.5 kg) during the last two night
During an assessment, the patient states that his bowel movements cause discomfort because
the stool is hard and difficult to pass. As the nurse you make which of the following suggestions
to assist the patient with improving the quality of his bowel movements? - Answers Increase
water intake, increase fiber intake
The nurse is planning a teaching seminar for a group of young adult clients who are at risk for
obesity. Which statement by the nurse best addresses their needs? - Answers Proper diet and
exercise programs can not only prevent obesity but also potentially improve the ability to think
and positivity of self perception
A nurse is working with an adolescent client who is attempting to lose weight. The client admits
having difficulty being compliant with the diet prescribed by the healthcare provider. Which
suggestion by the nurse might assist the client in being compliant with the diet in a way that is
sensitive to the client age? - Answers It can be difficult to avoid unhealthy food if that is what
your friends are eating, but try to choose healthier options when you can.
,A nurse is teaching environmental control to the parents of a child with asthma. Which
statements by the parents indicate effective teaching? - Answers We will replace the carpet in
our child's room with tile
The nurse is reviewing the results of lab tests conducted on a clients admitted respiratory
disorder. Which lab findings would be most significant for this client? - Answers Blood pH 7.32
The nurse is providing care to clients on a medical surgical unit. Which independent nursing
intervention are appropriate for a client who is experiencing an alteration in oxygenation? -
Answers - Encouraging deep breathing exercises
- Assisting with positioning
- Providing suctioning
- Monitoring activity intolerance
The nurse assigned to the newborn nursery is conducting shift assessments. While assessing
one newborn the nurse notes the respiratory rate is 52 breathes/minutes. Which action by the
nurse is appropriate? - Answers Continue to monitor the newborn per facility policy
Which clinical management prevention concept would the nurse identify as representative of
secondary prevention? - Answers Administering a Mantoux test to individuals at risk for
exposure of TB
The nurse is assessing a clients differential WBC count. What implications would this test have
on evaluating the adequacy of a clients gas exchange? - Answers An elevation of the WBC count
indicates generalized inflammation and presence of infection
The nursing is planning care for a client experiencing dyspnea and subsequent activity
intolerance. Which action by the nurse is most appropriate? - Answers Consult physical therapy
for endurance and musculoskeletal function
When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low pitched
sound that is continuous throughout inspiration. What does this lung sound indicate to the
nurse? - Answers Blocked large airway passages
Friends of a client hospitalized with asthma would like to bring the client a gift. Which gift would
the nurse recommend for the client? - Answers A book
The charge nurse is observing a newly licensed nurse conduct an admission assessment on a
client with asthma. Which action by the newly licensed nurse requires immediate intervention? -
Answers The newly licensed nurse is observed continuing to ask the client questions regarding
past medical history while the client is demonstrating difficulty breathing and signs of
respiratory impairment.
,An older client receiving medications for hypertension had a recent fall at home. Which
intervention should the nurse include in this client's plan of care? - Answers Assess postural
blood pressures
A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the
following findings should the nurse expect? - Answers Pallor on elevation of the limbs and rubor
(redness of the skin) when the limbs are dependent.
The nurse is conducting a patient assessment. The patient tells the nurse that he has smoked
two packs of cigarettes per day for 27 years. The nurse may find which data upon assessment?
- Answers Elevated blood pressure
Blood pressure is influenced by all except which factor? - Answers Heart rate
A patient diagnosed with hypertension asks the nurse how this disease could have happened to
them. What is the nurse's best response? - Answers Hypertension can happen from arterial
changes that block the blood flow
The nurse is planning care for a client with deep venous thrombosis (DVT). Which nursing
diagnosis would be a priority for this client? - Answers Ineffective tissue perfusion related to
obstructed venous return
The nurse is explaining to a student nurse about impaired central perfusion. The nurse knows
the student understands this problem when the student makes which statement? - Answers
Central perfusion involves the entire body
A client reports morning headache that extends into the neck and goes away as the day wears
on. Based on this initial data, which does the nurse suspect the client is experiencing? - Answers
A symptom of hypertension
The nurse is completing an assessment on a newly admitted client. What finding would suggest
that the client is experiencing a deep vein thrombosis (DVT)? - Answers Swelling in one leg with
pitting edema
The nurse is planning for a group of clients. Which client has the greatest risk for developing
deep veinous thrombosis (DVT)? - Answers The client recovering from knee replacement
surgery
The nurse is conducting a nutritional assessment for a 25-year-old patient and notes that the
individual appears overweight.
Which assessment tool should the nurse use to determine if the patient is overweight? -
Answers BMI
, A patient is scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. The patient asks,
"Why am I having this scan? Isn't it used to detect osteoporosis?"
Which response to the patient is accurate? - Answers "This scan is also used to measure body
composition and body fat."
The nurse is teaching a small group of patients about using over-the-counter vitamins and
supplements.
Which is the most important factor that the nurse should share during the training? - Answers It
is important to take supplements as recommended on the label.
A patient tells the nurse, "I don't eat much. Is there anything I can take to help get the nutrients I
need?"
Which collaborative intervention should the nurse consider in response to the patient? -
Answers Vitamin and mineral supplements
A 45-year-old patient presents with morbid obesity. Their gait has been disabled for more than 5
years, and since that time the patient has continued to gain weight due to their lack of exercise.
Which assessment should the nurse recognize as a starting point to understand the eating
pattern of the patient? - Answers Review of a food diary
Which term is defined as having no consistent access to sufficient nutritious food? - Answers
Food insecurity
The nurse has been treating an underweight patient for the past 3 months. The patient
demonstrates a weight gain of 1.5 kg this past month.
Which response by the nurse is most appropriate? - Answers "Your new meal plan is showing
positive results."
The nurse is identifying ways to assist community members with diabetes mellitus on weight
management.