Concept-Based Assessment Online
Practice A Level 2
A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's
parents tells the nurse that it is too difficult to cope any longer and has decided to move
out of the house. Which of the following responses should the nurse make? - answer A:
"Let's talk about a few ways you have dealt with stress in the past." Rationale: This
statement by the nurse combines two therapeutic responses, active listening and
focusing. Used together, these techniques facilitate communication by letting the parent
know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis.
Which of the following information should the nurse include in the teaching? - answerA:
"Maintain bone health by eating fruits, vegetables, and protein." Rationale: The nurse
should instruct the client that the best way to maintain bone health and bone remodeling
is by eating fruits, vegetables, and protein.
A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which
of the following statements should the nurse make? - answerB: "This medication causes
adverse effects if the dosage is too high or too low." Rationale: The nurse should
instruct the client that levothyroxine, in the right dosage, does not typically cause
adverse effects. If the dosage is too low, the manifestations of hypothyroidism will recur.
If the dosage is too high, the manifestations of hyperthyroidism will occur.
A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the
following findings should the nurse identify as an indication that the treatment is
effective? - answerD: Brisk skin turgor Rationale: The nurse should expect the child to
have brisk skin turgor if fluid replacement therapy is effective.
A nurse is caring for a client who has left hemiparesis following a stroke. Which of the
following actions should the nurse take? - answerB: Encourage the client to use wide-
grip utensils when eating with the right hand. Rationale: The nurse should encourage
the client who has hemiparesis to use wide-grip utensils when eating with the right
hand, which can accommodate a weak grasp and encourage independence in eating.
A nurse is teaching about herbal supplements with a group of newly licensed nurses.
Which of the following herbal supplements should the nurse include in the teaching for
treating hyperlipidemia? - answerD: Garlic Rationale: The nurse should include that
,garlic can help improve cholesterol levels, which then helps to reduce the buildup of
plaque in the arteries. For some clients, it can also help lower blood pressure
A nurse is admitting a client who has an acute bacterial wound infection and a
temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take?
- answerD: Set the temperature of the client's room to 22.2° C (72°). Rationale: The
nurse should set the temperature of the client's room at 21° C to 27° C (70° F to 80° F).
This promotes a reduction in the client's fever without causing shivering. By combining
nonpharmacological interventions with antipyretics, the nurse can reduce the client's
fever.
A nurse is planning care for a client who had surgery for osteomyelitis from a past
musculoskeletal trauma to the lower leg. Which of the following interventions should the
nurse include in the plan of care? - answerC: Check for paresthesia of the affected leg.
Rationale: The nurse should include in the interventions to check for paresthesia, such
as a tingling sensation of the leg and foot, which can indicate manifestations of
neurovascular compromise or compartment syndrome.
A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider? - answerB:
Presence of strabismus Rationale: The nurse should recognize that the presence of
strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not
corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should
report this finding to the provider.
A nurse is teaching a client who has atherosclerosis about self-care. Which of the
following instructions should the nurse include in the teaching? - answerC: Increase
fiber intake to at least 30 g per day. Rationale: The nurse should instruct the client to
increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and
minimizes the development of atherosclerosis.
A nurse is assessing a client who has as an ulcer due to peripheral vascular disease.
Which of the following findings should the nurse identify as an indication that the client
has a venous ulcer rather than an arterial ulcer? - answerB: Discoloration and edema of
the right ankle Rationale: The nurse should identify that manifestations of peripheral
venous disease include discoloration and edema of the ankle, resulting from venous
hypertension.
A nurse is providing discharge teaching to a client who is postoperative following a
transurethral resection of the prostate (TURP) for treatment of benign prostatic
hyperplasia. Which of the following instructions should the nurse include in the
teaching? - answerD: "Perform Kegel exercises several times throughout the day."
Rationale: The nurse should instruct the client on the performance of Kegel exercises,
or tightening and then relaxing the urinary sphincter, to assist the client in regaining
urinary control and eliminate dribbling or the leakage of urine. The nurse should
encourage the client to perform these exercises several times each day.
, A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect? (Select all the apply.) - answerA: Nocturia
C: Dyspnea
D: Hacking cough Rationale: Left-sided heart failure causes oliguria during the day and
nocturia during sleeping hours, pulmonary manifestations, such as dyspnea, orthopnea,
crackles, and wheezes, and a hacking cough that worsens at night and eventually
produces frothy sputum.
A nurse is assessing a client who is 1 hour postoperative following a transurethral
resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For
which of the following assessment findings should the nurse notify the provider? -
answerC: The catheter tubing has multiple red clots. Rationale: The nurse should
identify that the presence of multiple red clots in the catheter tubing or drainage that is
ketchup-like are manifestations of postoperative bleeding. The nurse should notify the
provider and provide hand irrigation of the bladder per provider prescription.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to
prevent reflux. Which of the following information should the nurse include in the
teaching? - answerD: Plan to finish eating at least 3 hr before bedtime. Rationale: The
nurse should encourage the client not to eat anything at least 3 hr before bedtime to
prevent reflux.
A nurse is providing teaching for a client who has a new diagnosis of benign prostatic
hyperplasia (BPH). Which of the following instructions should the nurse include to
promote elimination? - answerB: "Void as soon as you feel the urge." Rationale: The
nurse should instruct a client who has BPH on measures to prevent distension of the
bladder and urinary retention. Encouraging the client to void as soon as the urge
develops decreases the risk of bladder distension.
A nurse is assessing for manifestations of hyponatremia in a client who has been taking
twice the prescribed dose of a diuretic. Which of the following findings should the nurse
expect? - answerC: Decreased level of consciousness Rationale: The nurse should
expect a client who has hyponatremia to have cerebral edema and increased
intracranial pressure as fluid moves into the cells in the brain. This can manifest as
confusion, changes in level of consciousness, and seizures.
A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the
following statements should the nurse identify as an indication the client understands
the teaching? - answerC: "I will base my peak flow meter score on the best of three
attempts." Rationale: The client's peak flow rate should be based on the best of three
trials of the peak flow meter. The client should record this finding and share it with the
provider on the next visit.
A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose
level of 250 mg/dL. Which of the following findings should the nurse expect? - answerB:
Practice A Level 2
A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's
parents tells the nurse that it is too difficult to cope any longer and has decided to move
out of the house. Which of the following responses should the nurse make? - answer A:
"Let's talk about a few ways you have dealt with stress in the past." Rationale: This
statement by the nurse combines two therapeutic responses, active listening and
focusing. Used together, these techniques facilitate communication by letting the parent
know one's feelings are heard and taken seriously, which conveys acceptance and
respect. Therefore, the parent feels the nurse validates the concerns and becomes
comfortable asking the nurse sensitive questions about the child.
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis.
Which of the following information should the nurse include in the teaching? - answerA:
"Maintain bone health by eating fruits, vegetables, and protein." Rationale: The nurse
should instruct the client that the best way to maintain bone health and bone remodeling
is by eating fruits, vegetables, and protein.
A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which
of the following statements should the nurse make? - answerB: "This medication causes
adverse effects if the dosage is too high or too low." Rationale: The nurse should
instruct the client that levothyroxine, in the right dosage, does not typically cause
adverse effects. If the dosage is too low, the manifestations of hypothyroidism will recur.
If the dosage is too high, the manifestations of hyperthyroidism will occur.
A nurse in an emergency department is assessing a preschooler who has severe
dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the
following findings should the nurse identify as an indication that the treatment is
effective? - answerD: Brisk skin turgor Rationale: The nurse should expect the child to
have brisk skin turgor if fluid replacement therapy is effective.
A nurse is caring for a client who has left hemiparesis following a stroke. Which of the
following actions should the nurse take? - answerB: Encourage the client to use wide-
grip utensils when eating with the right hand. Rationale: The nurse should encourage
the client who has hemiparesis to use wide-grip utensils when eating with the right
hand, which can accommodate a weak grasp and encourage independence in eating.
A nurse is teaching about herbal supplements with a group of newly licensed nurses.
Which of the following herbal supplements should the nurse include in the teaching for
treating hyperlipidemia? - answerD: Garlic Rationale: The nurse should include that
,garlic can help improve cholesterol levels, which then helps to reduce the buildup of
plaque in the arteries. For some clients, it can also help lower blood pressure
A nurse is admitting a client who has an acute bacterial wound infection and a
temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take?
- answerD: Set the temperature of the client's room to 22.2° C (72°). Rationale: The
nurse should set the temperature of the client's room at 21° C to 27° C (70° F to 80° F).
This promotes a reduction in the client's fever without causing shivering. By combining
nonpharmacological interventions with antipyretics, the nurse can reduce the client's
fever.
A nurse is planning care for a client who had surgery for osteomyelitis from a past
musculoskeletal trauma to the lower leg. Which of the following interventions should the
nurse include in the plan of care? - answerC: Check for paresthesia of the affected leg.
Rationale: The nurse should include in the interventions to check for paresthesia, such
as a tingling sensation of the leg and foot, which can indicate manifestations of
neurovascular compromise or compartment syndrome.
A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit.
Which of the following findings should the nurse report to the provider? - answerB:
Presence of strabismus Rationale: The nurse should recognize that the presence of
strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not
corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should
report this finding to the provider.
A nurse is teaching a client who has atherosclerosis about self-care. Which of the
following instructions should the nurse include in the teaching? - answerC: Increase
fiber intake to at least 30 g per day. Rationale: The nurse should instruct the client to
increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and
minimizes the development of atherosclerosis.
A nurse is assessing a client who has as an ulcer due to peripheral vascular disease.
Which of the following findings should the nurse identify as an indication that the client
has a venous ulcer rather than an arterial ulcer? - answerB: Discoloration and edema of
the right ankle Rationale: The nurse should identify that manifestations of peripheral
venous disease include discoloration and edema of the ankle, resulting from venous
hypertension.
A nurse is providing discharge teaching to a client who is postoperative following a
transurethral resection of the prostate (TURP) for treatment of benign prostatic
hyperplasia. Which of the following instructions should the nurse include in the
teaching? - answerD: "Perform Kegel exercises several times throughout the day."
Rationale: The nurse should instruct the client on the performance of Kegel exercises,
or tightening and then relaxing the urinary sphincter, to assist the client in regaining
urinary control and eliminate dribbling or the leakage of urine. The nurse should
encourage the client to perform these exercises several times each day.
, A nurse is assessing a client who has left-sided heart failure. Which of the following
findings should the nurse expect? (Select all the apply.) - answerA: Nocturia
C: Dyspnea
D: Hacking cough Rationale: Left-sided heart failure causes oliguria during the day and
nocturia during sleeping hours, pulmonary manifestations, such as dyspnea, orthopnea,
crackles, and wheezes, and a hacking cough that worsens at night and eventually
produces frothy sputum.
A nurse is assessing a client who is 1 hour postoperative following a transurethral
resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For
which of the following assessment findings should the nurse notify the provider? -
answerC: The catheter tubing has multiple red clots. Rationale: The nurse should
identify that the presence of multiple red clots in the catheter tubing or drainage that is
ketchup-like are manifestations of postoperative bleeding. The nurse should notify the
provider and provide hand irrigation of the bladder per provider prescription.
A nurse is teaching a client who has gastroesophageal reflux disease about ways to
prevent reflux. Which of the following information should the nurse include in the
teaching? - answerD: Plan to finish eating at least 3 hr before bedtime. Rationale: The
nurse should encourage the client not to eat anything at least 3 hr before bedtime to
prevent reflux.
A nurse is providing teaching for a client who has a new diagnosis of benign prostatic
hyperplasia (BPH). Which of the following instructions should the nurse include to
promote elimination? - answerB: "Void as soon as you feel the urge." Rationale: The
nurse should instruct a client who has BPH on measures to prevent distension of the
bladder and urinary retention. Encouraging the client to void as soon as the urge
develops decreases the risk of bladder distension.
A nurse is assessing for manifestations of hyponatremia in a client who has been taking
twice the prescribed dose of a diuretic. Which of the following findings should the nurse
expect? - answerC: Decreased level of consciousness Rationale: The nurse should
expect a client who has hyponatremia to have cerebral edema and increased
intracranial pressure as fluid moves into the cells in the brain. This can manifest as
confusion, changes in level of consciousness, and seizures.
A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the
following statements should the nurse identify as an indication the client understands
the teaching? - answerC: "I will base my peak flow meter score on the best of three
attempts." Rationale: The client's peak flow rate should be based on the best of three
trials of the peak flow meter. The client should record this finding and share it with the
provider on the next visit.
A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose
level of 250 mg/dL. Which of the following findings should the nurse expect? - answerB:
