BSN 246 HESI HEALTH ASSESSMENT EXAM QUESTIONS AND VERIFIED ANSWERS WITH SUCCESS GUARANTEED

BSN 246 HESI HEALTH ASSESSMENT EXAM QUESTIONS AND VERIFIED ANSWERS WITH SUCCESS GUARANTEED “The nurse reviews the health record of a client with melasma. The nurse would anticipate that this client will exhibit: - CORRECT ANSWER Blotchy brown macules across the cheeks and forehead" "A client is admitted to the hospital with cellulitis of the lower leg. The nurse would anticipate which of the following therapies to be prescribed? - CORRECT ANSWER Warm compresses to the affected area" "The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. If the client were to examine the right breast, the nurse would tell the client to place a pillow: - CORRECT ANSWER Under the right shoulder" "The nurse would identify that which of the following foods should be increased in the diet to help decrease the risk of cancer development? - CORRECT ANSWER Broccoli" "The nurse would include which of the following in a list of the most helpful foods for the vegan client wishing to increase foods high in vitamin A? - CORRECT ANSWER carrots" "According to the American Cancer Society, fecal occult blood testing should be done annually after the age of _____ years. - CORRECT ANSWER 50" "The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of thyroid storm. Which of the following is an early indicator of this complication? - CORRECT ANSWER Hyperreflexia" "The client is undergoing an oral glucose tolerance test. The nurse interprets that the client's results are not compatible with diabetes mellitus if the glucose level is lower than which of the following cutoff values after 120 minutes (2 hours)? - CORRECT ANSWER 140 mg/dL" "A client who visits the physician's office for a routine physical reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse continues to assess for which of the following? - CORRECT ANSWER Complaints of weakness and lethargy" "The nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse determines that which of these findings will support the diagnosis? - CORRECT ANSWER Elevated serum levels" "A nurse is caring for a client postoperatively following creation of a colostomy. Which of the following nursing diagnoses should the nurse include in the plan of care? - CORRECT ANSWER Disturbed body image" "The client is experiencing blockage of the common bile duct. Which of the following food selections made by the client indicates the need to plan for further diet teaching? - CORRECT ANSWER Whole milk" "The nurse is preparing to take an apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope at which cardiac site? - CORRECT ANSWER Mitral Valve" "The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which of the following conclusions? - CORRECT ANSWER The cardiac output is below the normal range" "A nurse is caring for a client diagnosed with Ménière's disease. The nurse plans care, understanding that this disorder is characterized by: - CORRECT ANSWER Dizziness" "The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use by this client? - CORRECT ANSWER Walker" "The client has sustained damage to Wernicke's area in the temporal lobe from a brain attack (stroke). Which of the following should the nurse anticipate when caring for this client? - CORRECT ANSWER The client will have difficulty understanding language." "The nurse is preparing to administer a prescribed antibiotic to a client with bacterial meningitis. The nurse understands that the selection of an antibiotic to treat meningitis is based on which of the following? - CORRECT ANSWER It is able to cross the blood-brain barrier." "The client who is experiencing an inferior wall myocardial infarction has had a drop in heart rate into the 50 to 56 beats/min range. The client is also complaining of nausea. The nurse interprets that these symptoms are because of stimulation of which cranial nerve (CN)? - CORRECT ANSWER Vagus CN: X" "Tetanus toxoid is prescribed for a client who has sustained a foot laceration from a piece of metal while walking barefoot on the beach. The nurse understands that the toxoid is a(n): - CORRECT ANSWER Toxin produced by bacteria that has been altered so that it is no longer toxic" "The older adult client has been lying in a supine position for the last 3 hours. The nurse who is repositioning this client would be most concerned with examining which of the following bony prominences of the client? Select all that apply - CORRECT ANSWER Heels Elbows Sacrum Back of the head" "The client is having a diagnostic workup for colorectal cancer. Which of the following factors in the client's history will place the client at increased risk of this type of cancer? Select all that apply. - CORRECT ANSWER -A diet high in fats -A diet high in carbohydrates -A history of inflammatory bowel disease" "The nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven possible warning signs of cancer that is used by the American Cancer Society. What should this list include? Select all that apply. - CORRECT ANSWER -Sores that do not heal -Nagging cough or hoarseness -Indigestion or difficulty swallowing -Change in bowel or bladder habits" "A client is admitted to the hospital with a diagnosis of Addison's disease. The nurse would monitor for which of the following problems associated with this disease? Select all that apply. - CORRECT ANSWER Syncope Hypotension Muscle weakness" "The client has been diagnosed with Cushing's syndrome. The nurse would monitor this client for which of the following expected signs of this disorder? Select all that apply. - CORRECT ANSWER Hypertension Moon facies Truncal obesity" "The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which of the following actions are planned to promote client safety? Select all that apply. - CORRECT ANSWER -Provide the client with a soft toothbrush. -Instruct the client to use an electric razor. -Monitor all secretions for frank or occult blood." "The nurse is doing volunteer work in a homeless shelter. The nurse monitors the individuals in the shelter for which of the following initial symptoms of tuberculosis (TB)? Select all that apply. - CORRECT ANSWER Fatigue Lethargy Low-grade fever Morning cough" "The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity. Polydipsia. - CORRECT ANSWER Polydipsia. Rationale A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst." "The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) Native language. Education level. Type of lifestyle. Financial resources. Previous medical history. - CORRECT ANSWER Native language. Education level. Type of lifestyle. Rationale To ensure compliance the client's native language, education level, lifestyle, and financial resources should be considered when preparing the client's discharge instructions about the continuation of treatment for TB." "The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? Decreased pedal pulses. Edema in upper extremities. Loss of appetite for food. Stiffness in right ankle joint. - CORRECT ANSWER Stiffness in right ankle joint. Rationale Stiffness in joints is an early sign of contractures and muscle atrophy related to inactivity and immobility." "The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? Reduced pain and minimized brusing. Lowering of body core temperature. Increased circulation around injury. Reabsorption of edema at injury. - CORRECT ANSWER Reduced pain and minimized brusing. Rationale Cold applications produce a topical anesthetic effect to reduce pain as well as constricts blood vessels to minimize bruising." "The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? The development of resistant strains of TB are decreased with a combination of drugs. Compliance to the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but is less effective. The treatment time is decreased from 6 months to 3 months with this standard regimen. - CORRECT ANSWER The development of resistant strains of TB are decreased with a combination of drugs. Rationale Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy." "A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) Select all that apply Use simple sentences during the examination. Move to another question if the client seems confused. Reduce environmental detractors during the examination. Allow family to answer for the client to decrease frustration. Ask questions one at a time to decrease confusion. - CORRECT ANSWER Use simple sentences during the examination. Reduce environmental detractors during the examination. Ask questions one at a time to decrease confusion. Rationale Communication techniques for clients with cognitive impairments should be simple, withoutenvironmental distractions, and direct." "The registered nurse (RN) is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? Phlegm production and wheezing. Smoking history. Hemoptysis. Night sweats. - CORRECT ANSWER Phlegm production and wheezing. Rationale A chronic seasonal cough related to bronchitis is likely accompanied withphlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes." "The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). Select all that apply Hematemesis. Gastric pain on an empty stomach. Colic-like pain with fatty food ingestion. Intolerance of spicy foods. Diarrhea and stearrhea. - CORRECT ANSWER Hematemesis. Gastric pain on an empty stomach. Intolerance of spicy foods. Rationale Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance." "A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? Discontinue the antibiotic because original symptoms have subsided. Continue taking medication until finished until the symptoms subside. Consult with healthcare provider about another treatment for this effect. Use an over-the-counter (OTC) vaginal wash to flush out the secretions. - CORRECT ANSWER Consult with healthcare provider about another treatment for this effect. Rationale A superinfection with normal flora yeast may occur during antibiotic therapy. If suspected, the new onset of findings should be reported to the healthcare provider for another prescribed treatment to treat the superinfection." "An infant with heart failure receives a prescription, digoxin 35 mcg PO. The registered nurse (RN) calcuates the desired dose for administration using the available concentration of digoxin labeled, 0.05 mg/mL. How many millilitersshould the registered nurse (RN) prepare for administration?(Enter the numerical value only. If rounding is required round to the nearest tenth.) - CORRECT ANSWER 0.7 Rationale Desired dose, 35 mcg converts to 0.035 mg because the equivalent is 1 mg = 1,000 mcg Using the formula, D/H x A = 0.035 mg / 0.05 mg x 1 mL = 0.7 mL the ratio proportion method of: 35mcg/X ml :: 1000mcg/1mL = 0.035mg; 0.035mg/XmL :: 0.05mg/mL =0.035mg/0.7mL" "The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? Dry mucous membranes and lips. Rebound abdominal tenderness over right lower quadrant. Dizziness when client ambulates from a sitting position. Poor skin turgor over client's wrist. - CORRECT ANSWER Rebound abdominal tenderness over right lower quadrant. Rationale RLQ rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider." "While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). Select all that apply Type I diabetes mellitus (DM). Closed angle glaucoma. Chronic hypertension. Rheumatoid arthritis. Crohn's disease. - CORRECT ANSWER Closed angle glaucoma. Chronic hypertension. Rationale OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma. Decongestants also can increase the heart rate and elevate blood pressure which can impact the client's management of chronic hypertension." "The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? 140 mg/dl. 160 mg/dl. 180 mg/dl. 200 mg/dl. - CORRECT ANSWER 140 mg/dl. Rationale The two hour postprandial level should be less 140 mg/dl for a young adult client." "A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse (RN) identify in the client's history? Chronic bronchitis. Gastroesophageal reflux disease (GERD). Heart failure (HF). Chronic pancreatitis. - CORRECT ANSWER Heart failure (HF). Rationale Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema." "The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? Prepare the client for chest x-ray at the bedside. Review arterial blood gases after removal. Elevate the head of bed to 45 degrees. Assist with disassembling the drainage system. - CORRECT ANSWER Prepare the client for chest x-ray at the bedside. Rationale A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal." "The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001. Tented skin on dorsal surface of hands. - CORRECT ANSWER Urine output of 40 mL/hour. Rationale A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing." "The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? Triglycerides. Amylase. Creatinine. Uric acid. - CORRECT ANSWER Amylase. Rationale An elevated amylase level is associated with acute pancreatitis." "A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? African American women. Caucasian women. Asian women. Hispanic women. - CORRECT ANSWER African American women. Rationale Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000)." "A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? Withhold medication and report symptoms and vital signs to healthcare provider. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will alleviate the symptoms. Delay administration of ipratropium until next maintenance medication is scheduled. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. Reassure client that the ipratropium given will alleviate the symptoms. Delay administration of ipratropium until next maintenance medication is scheduled. - CORRECT ANSWER Withhold medication and report symptoms and vital signs to healthcare provider. Rationale Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication until the healthcare provider is notified should be initiated to maintain client safety." "The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? Exercise bicycle. Sphygmomanometer. Blood glucose monitor. Weekly medication box. - CORRECT ANSWER Sphygmomanometer. Rationale Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record." "A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? Select all that apply Establish trust by creating an safe atmosphere for sharing. Share personal stories about how other clients dealt with grief. Help the client identify ways to adapt lifestyle to accommodate loss. Assure the client that their grief will last a short period of time. Explore ways to assist the client to make new emotional investments. - CORRECT ANSWER Establish trust by creating an safe atmosphere for sharing. Help the client identify ways to adapt lifestyle to accommodate loss. Explore ways to assist the client to make new emotional investments. Rationale Interventions that could aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life should include creating a safe atmosphere for sharing, helping the client to identify ways to adapt to a life style without their spouse and exploring ways to make new emotional investments." "A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels. - CORRECT ANSWER Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels. Rationale Cirrhotic and fibrosed liver damage causes obstructed blood flow through portal vessels to the liver which increases the portal pressurecausing the blood flow through the liver to be shunted to the esophageal vessels. The result of this shunting of blood causes the esophageal vessels (veins) to balloon out and weaken. As the portal hypertension increases, these esophageal varices can rupture and cause bleeding resulting in bloody emesis and black tarry stools." "The registered nurse (RN) reviews the new prescription, phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? Consumptiion of any alcohol or tyramine-rich foods. Complaints of nausea or vomiting. Therapeutic serum drug levels. Blood pressure and pulse prior to taking each dose.Consumptiion of any alcohol or tyramine-rich foods. - CORRECT ANSWER Consumptiion of any alcohol or tyramine-rich foods. Rationale The consumption of any type of tyramine containing foods such as aged cheeses, fermented fruits and vegetables, smoked or cured meats, dark wines and other alcoholic products should be avoided when a client is prescribed a MAOIs due to the a food-drug interaction causing a hypertensive crisis which can lead to a hemorrhagic stroke." "A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? Select all that apply Face the client so the client can see the RN's mouth. Increase one's speech volume when interacting with the client. Repeat information to the client if misunderstood. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client. - CORRECT ANSWER Face the client so the client can see the RN's mouth. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client. Rationale A client with hearing loss can develop the ability to read "lips," so facing the client during conversation allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication. Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process. Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech. If a client shows signs of confusion, rephrasing the question, instead of repeating, should be done to decrease client anxiety and facilitate understanding." "The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? Select all that apply Tachycardia. Increased blood pressure. Rapid resolution of wheezing. Improved pulse oximetry values. Reduce fever airway inflammation. - CORRECT ANSWER Rapid resolution of wheezing. Improved pulse oximetry values. Rationale Beta 2 receptor agonist agents should provide immediate return of airflow and resolve wheezing and improve oxygenation." "The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? Check pH of aspirated stomach contents obtained from the NGT. Auscultate over the epigastrium while injecting air into the NGT. Disconnect and place the end of NGT in water to see if bubbles appear. Listen for hyperactive bowel sounds in all four quadrants of abdomen. - CORRECT ANSWER Check pH of aspirated stomach contents obtained from the NGT. Rationale Checking the pH of the aspirate is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid." "An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? Lower extremity edema. Orthostatic hypotension. Elevated blood pressure. Cheyne-Stokes respirations. - CORRECT ANSWER Orthostatic hypotension. Rationale Orthostatic hypotension can be a sign of fluid volume deficit in an older client who has experienced severe diarrhea." "The registered nurse (RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) 1. Older females. 2. School-age female. 3. Older males. 4. Adolescent males. - CORRECT ANSWER 1. Older females. 2. School-age female. 3. Older males. 4. Adolescent males. Rationale Hypoestrogenism and alkalotic urine are other age-related factors put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI.All individuals regardless of gender and/or age are at risk if the following conditions exist: vesicoureteral reflux, neuromuscular conditions, like Parkinson's disease, previous brain attacks, or the use of anticholinergic medications can all cause incomplete bladder emptying which can create bacterial overgrowth. Fecal and urinary incontinence contributes to poor perineal hygiene and bacterial growth." "Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? Ask closed-ended questions with the assistance of the interpreter. Maintain eye contact with the client while listening to the translation. Instruct interpreter to answer questions from interpreter's point of view. Protect the client's privacy by asking a limited number of questions. - CORRECT ANSWER Maintain eye contact with the client while listening to the translation. Rationale When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues." "The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the RN to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions. Avoid peripheral injections. - CORRECT ANSWER Maintain strict protective precautions. Rationale The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection." "After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? Position client on left side with pillow placed under the costal margin. Assist the client with voiding immediately after the procedure. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Ambulate client 3 times in first hour with pillow held at abdomen. - CORRECT ANSWER Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Rationale Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right sidewith a pillow or sandbag under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for several hours to decrease the risk of bleeding from the biopsy site." "The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? Lower back pain. Headache of 7 on scale 1 to 10. Blood pressure of 140/98. Dyspnea. - CORRECT ANSWER Dyspnea. Rationale A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately." "A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin. Ischemia modified albumin. - CORRECT ANSWER Serum troponin. Rationale Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB." "The registered nurse (RN) did not note that a prescription dose was recently changed and did not note the updated medication administration record (MAR). After giving the client the original dose, the RN reports the medication error to the nurse manager. What consequences will the RN experience due to this error in medication administration? The incident will be reported to the state's Board of Nursing (BON). A medication error report will be completed and risk management will be notified. The RN will be suspended from medication administration until the error is investigated. The incident will be documented in the RN's personnel file. - CORRECT ANSWER A medication error report will be completed and risk management will be notified. Rationale By reviewing quality of care internally, steps of care can be evaluated and staff can be educated where gaps are identified. The medication report and notification of management is the responsibility of the RN who made the mistake, so an internal review of the steps of the occurrence can be completed to determine further risk potentials." "The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? Irritable bowel syndrome. Diverticulitis. Crohn's disease. Ulcerative colitis. - CORRECT ANSWER Ulcerative colitis. Rationale The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration" "The registered nurse (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L. pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L. pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L. - CORRECT ANSWER pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. Rationale Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. An ABG of pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L represents a client with respiratory acidosis which is characterized by: low pH, pCO2higher than normal, and HCO3 within normal limits." "A client is newly diagnosed with diverticulosis. The registered nurse (RN)is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? Over use of laxatives for bowel regularity result in loss of peristaltic tone. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. Diverticulosis is the result of high fiber diet and sedentary life style. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. - CORRECT ANSWER Chronic constipation causes weakening of colon wall which result in out-pouching sacs. Rationale A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid." "The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? Recall of information. Orientation to surroundings. Attention to details. Ability to follow complex commands. - CORRECT ANSWER Attention to details. Rationale When conducting the MMSE and having the client count backwards by 7s; this evaluates their ability to do simple calculations and is specific to the client's attention to detail and staying focus and not getting distracted by external stimuli." "Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? Faint pedal pulses. Decrease in blood pressure. Lethargy. Slow breathing. - CORRECT ANSWER Lethargy. Rationale One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion." "The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? Fever related to infection. Weight loss and anorexia. Depressed mood. Break in tissue integrity. - CORRECT ANSWER Fever related to infection. Rationale Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately." "The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? The client cannot understand the nurse. The client is uncomfortable with the nurse. The client is treating the nurse with respect. The client is purposefully disrespecting the nurse. - CORRECT ANSWER The client is treating the nurse with respect. Rationale In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is being respectful by looking down while speaking with the nurse." "A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? Straignt fracture line that is also a simple, closed fracture. Nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin. A fracture that bends or splinters part of the bone. - CORRECT ANSWER A fracture that bends or splinters part of the bone. Rationale An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone." "While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy (EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction. - CORRECT ANSWER Monitor infusing IV fluids and any replacement blood products. Rationale Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products." "The client with cellulitis of the lower leg has had cultures done on the affected area. The nurse reviewing the results of the culture report interprets that which of the following organisms is not part of the normal flora of the skin? - CORRECT ANSWER Escherichia coli" "The client complains of chronic pruritus. Which of the following diagnoses would the nurse expect to support this client's complaint? - CORRECT ANSWER Renal Failure" "A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which of the following disorders? - CORRECT ANSWER Systemic lupus erythematosus (SLE)" "The nurse notes that the older adult client has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. The nurse correctly interprets the finding as alterations in blood vessels of the skin and defines them as: - CORRECT ANSWER Cherry angioma" "The client has been diagnosed with paronychia. The nurse understands that this is a disorder of the: - CORRECT ANSWER Nails" "The client is diagnosed with a full-thickness burn. The nurse understands that which of the following structural areas of the skin is involved? - CORRECT ANSWER Epidermis, entire dermis, and epithelial portion of subcutaneous fat" "A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse would anticipate observing which sign or symptom? - CORRECT ANSWER Flushing" "A 27-year-old female client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask the client whether the breast lumps seem to become more prominent or troublesome at which of the following times? - CORRECT ANSWER before menses" "The nurse is assigned to the care of a client scheduled for surgery for a right colon tumor. Which of the following is the most characteristic manifestation of cancer at this site? - CORRECT ANSWER Dull abdominal pain exacerbated by walking" "A client has undergone abdominal perineal resection for a bowel tumor. The nurse interprets that the client's colostomy is beginning to function if which of the following signs is noted? - CORRECT ANSWER The passage of flatus" "A nurse assessing a postoperative ureterostomy client will interpret that the stoma has normal characteristics if the stoma is: - CORRECT ANSWER Red and moist" "The nurse monitoring the oncological client for early signs of vena cava syndrome would include assessment for which of the following? - CORRECT ANSWER Periorbital edema" "The nurse understands that which of the following hormones is directly responsible for maintaining the free or unbound portion of serum calcium within normal limits? - CORRECT ANSWER parathyroid hormone" "The client with an endocrine disorder complains of weight loss and diarrhea, and says that he can "feel his heart beating in his chest." The nurse interprets that which of the following glands is most likely responsible for these symptoms? - CORRECT ANSWER Thyroid" "The client is experiencing an episode of hypoglycemia. The nurse understands that the physiological mechanism that should take place to combat this decrease in the blood glucose level is: - CORRECT ANSWER Increased glucagon secretion" "The client with diabetes experiences breakdown of fats for conversion to glucose. The nurse determines that this response is occurring if the client has elevated levels of which of the following substances? - CORRECT ANSWER Ketones" "The client with diabetes mellitus is being tested to determine long-term diabetic control. Which of the following results would the nurse expect to see if the client's long-term control is within acceptable limits? - CORRECT ANSWER Glycosylated hemoglobin of 6%" "The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which of the following nursing actions is focused on the consequence of low albumin levels? - CORRECT ANSWER Palpating for peripheral edema" "Discharge teaching for a client recovering from an attack of chronic pancreatitis should include which of the following instructions? - CORRECT ANSWER Avoid caffeine, because it may aggravate symptoms." "A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which of the following reflects appropriate intervention by the nurse? - CORRECT ANSWER Withhold oral fluids until the client's gag reflex has returned." "The nurse is assisting the physician during a colonoscopy procedure. The nurse helps the client to assume which of the following positions for the procedure? - CORRECT ANSWER Left Sims" "The client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse provides a list of foods from which diet type? - CORRECT ANSWER Fat Free" "In which of the following optimal positions should the nurse plan to place the client after bolus feeding using a nasogastric tube? - CORRECT ANSWER HOB elevated 30 to 45 degrees, with client in the right lateral position for 60 minutes" "The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions? - CORRECT ANSWER Clamp the tubing for 30 seconds, and restart the flow at a slower rate." "client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which of the following is the priority action taken by the nurse? - CORRECT ANSWER Take the vitals" "The client with frequent upper respiratory infections (URIs) asks the nurse why food doesn't seem to have any taste during illness. The nurse understands that this is because of which of the following? - CORRECT ANSWER Blocked nasal passages impair the senses of smell and taste." "The nurse providing instructions to the client using an incentive spirometer tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that the primary benefit is to: - CORRECT ANSWER Maintain inflation of the alveoli." "The nurse understands that increasing the flow of oxygen to more than 2 L/min in the client with chronic obstructive pulmonary disease (COPD) could be harmful because it: - CORRECT ANSWER Decreases the client's oxygen-based respiratory drive" "The nurse participating in a client care conference with other health team members is discussing the condition of a client with adult respiratory distress syndrome (ARDS). The physician states that because of fluid in the alveoli, surfactant production is falling. The nurse understands that the consequence of insufficient surfactant is: - CORRECT ANSWER Collapse of alveoli and decreased compliance" "The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which of the following arterial blood gas (ABG) findings? - CORRECT ANSWER pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L" "The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope: - CORRECT ANSWER Just under the left-sided clavicle" "The nurse would determine that tracheal suctioning is needed if which of the following is noted? - CORRECT ANSWER Congested breath sounds in the lung fields." "The client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which of the following documented in the client's record is an expected finding with this client? - CORRECT ANSWER Hyperinflation of lungs documented by chest x-ray" "The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which of the following assessment findings would be indicative of further fluid volume deficit? - CORRECT ANSWER Pulse rate increases from 100 beats/min to 136 beats/min" "The nurse is listening to a 56-year-old client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/min. Which of the following would be an appropriate course of action taken by the nurse? - CORRECT ANSWER Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity." "The nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which of the following vital signs? - CORRECT ANSWER Decreased heart rate and decreased blood pressure" "A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused around reduction of which specific problem associated with this type of heart failure? - CORRECT ANSWER Bilateral lung crackles" "A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, a nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? - CORRECT ANSWER Variant Angina" "A client's total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching? - CORRECT ANSWER The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught." "he ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control? - CORRECT ANSWER Instruct the client to limit protein intake." "The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which of the following results would be consistent with the observation? - CORRECT ANSWER Serum potassium level of 2.8 mEq/L" "The client who has had intracranial surgery is experiencing diabetes insipidus. The nurse understands that the client is experiencing which of the following problems? - CORRECT ANSWER Insufficient production of antidiuretic hormone (ADH)" "The client is admitted to the hospital with a tentative diagnosis of bladder cancer. The nurse expects the client history to reveal which of the following earliest manifestations of the disease? - CORRECT ANSWER Hematuria with no pain" "The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client's medical record? - CORRECT ANSWER Hypertension" "The client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client at risk for this disorder? - CORRECT ANSWER Diabetes mellitus" "The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique when implementing this procedure? - CORRECT ANSWER Ask the client to void, save the specimen, and note the start time." "The nurse who is collecting data from the client notes that the client's left-sided eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions? - CORRECT ANSWER Ptosis" "The nurse is attempting to inspect the lacrimal apparatus of the client's eye. Because of its anatomical location, the nurse should do which of the following? - CORRECT ANSWER Retract the upper eyelid, and ask the client to look down." "The nurse conducting an eye examination notes that the client exhibits rapid, involuntary, oscillating movements of the eyeball when looking at the nurse. The nurse documents this finding as: - CORRECT ANSWER Nystagmus" "The nurse who is assessing the client's eyes notes that the pupil gets larger when looking at an object in the distance and gets smaller when looking at a near object. The nurse documents this finding as: - CORRECT ANSWER Accommodation" "The nurse suspects the client may be experiencing dysfunction in the area of the semicircular canals of the ear if the client experiences: - CORRECT ANSWER Disturbance in balance" "A client is experiencing blockage of the eustachian tubes. Which of the following activities by the client may forcibly open the eustachian tube? - CORRECT ANSWER Performing the Valsalva maneuver" "The client is being scheduled for a positron emission tomography (PET) scan. The nurse provides which of the following explanations to the client? - CORRECT ANSWER "The test detects abnormal glucose metabolism in the brain."" "The nurse is caring for a client who is scheduled to have electroencephalography. The nurse determines that the client is ready for the procedure after noting which of the following? - CORRECT ANSWER The client's hair has been shampooed." "The nurse should ask the client to do which of the following when testing the function of the spinal accessory nerve (CN XI)? - CORRECT ANSWER Elevate the shoulders" "The nurse is assessing the client's muscle strength and notes that when asked, the client cannot maintain his or her hands in a supinated position with the arms extended and eyes closed. How would the nurse correctly document this finding on the medical record? - CORRECT ANSWER Client is exhibiting pronator drift." "The nurse is testing the client for graphesthesia and asks the client to close his eyes. Which of the following would the nurse have the client do? - CORRECT ANSWER Identify three numbers or letters traced in the client's palm." "The nurse plans care for the older adult female client with a diagnosis of osteoporosis knowing that the client is at greatest risk for which of the following? - CORRECT ANSWER Fractures" "The clinical picture of the client with osteitis deformans (Paget's disease) includes back and leg pain, a crouched forward posture, and legs that bow outward. The nurse plans care, knowing that these manifestations are caused by disturbances of which of the following? - CORRECT ANSWER Bone resorption and regeneration" "The nurse understands that the most significant rationale for the application of heat to an area of contusion 72 hours after the injury is to: - CORRECT ANSWER Reabsorb blood from the injured tissue" "The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which of the following would be an abnormal finding? - CORRECT ANSWER Presence of fasciculations" "The nurse explaining the procedure of indium imaging to a client with a bone infection would include which of the following? - CORRECT ANSWER Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone." "The client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which of the following changes in vital signs? - CORRECT ANSWER Tachycardia, hypotension" "Which of the following teaching points is the priority when the nurse is teaching the client about caring for a plaster cast - CORRECT ANSWER Immediately report any increase in drainage or interruption in cast integrity." "The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. The nurse understands that in cases in which the recipient rejects transplanted organs, the cells of the transplanted organs are seen by the body as a(n): - CORRECT ANSWER Foreign antigen" "A client is admitted to the hospital with a diagnosis of parasitic worms. The nurse understands that the primary cell type that will attack these foreign particles is: - CORRECT ANSWER Eosinophils" "The nursing instructor is questioning a nursing student about the organs of the immune system and asks the student where Kupffer's cells are located. The student responds correctly by stating that these types of cells are located in the: - CORRECT ANSWER Liver" "The nursing student understands that the primary purpose of neutrophils in the inflammatory response is to: - CORRECT ANSWER Phagocytize any potentially harmful agents." "The nursing student correctly describes the process of phagocytosis as: - CORRECT ANSWER A process whereby a particle is ingested and digested by a cell" "The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. The priority nursing action at this time is which of the following? - CORRECT ANSWER Elevate the foot of the bed." "The nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would plan to teach the client which of the following pieces of information about positioning in the postoperative period? - CORRECT ANSWER Avoid sleeping on the left side." "The nurse caring for a client following craniotomy who has a supratentorial incision understands that the client should most likely be maintained in which of the following positions? - CORRECT ANSWER Semi-Fowler's position" "The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching regarding positioning? - CORRECT ANSWER laying on his or her back" "The nurse is assisting the physician with insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse takes which of the following actions? - CORRECT ANSWER Document the accurate functioning of the tube" ". The physician is about to remove a chest tube from a client. After the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to: - CORRECT ANSWER Perform the Valsalva maneuver." "The nurse is assisting in caring for the client immediately after removal of the endotracheal tube. Which of the following findings should be reported to the health care physician immediately? - CORRECT ANSWER Stridor" "A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that are most likely to have this taste for the client? - CORRECT ANSWER Pork" "The client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should plan to include which of the following in a list provided to the client? - CORRECT ANSWER summer squash" "The client has been diagnosed with gout. In developing a teaching plan for this client, the nurse should include a list that identifies which of the following foods to be avoided? - CORRECT ANSWER Chicken Liver" "The client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are in which of the following diet types? - CORRECT ANSWER a low fiber diet" "The nurse is caring for the client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which of the following? - CORRECT ANSWER Pork" "102. The client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following? - CORRECT ANSWER Drinking liquid with meals" "The nurse notes that the client's serum calcium level is 6.0 mg/dL. Which of the following assessment findings would be anticipated in this client? Select all that apply. - CORRECT ANSWER Tetany Hypotension Prolonged QT interval Positive Chvostek's sign" "The nurse notes during assessment and history taking that the older client exhibits visual changes. Which of the following are normal age-related changes of the eye? Select all that apply. - CORRECT ANSWER -Decreased visual acuity -Decreased tolerance of glare -Decreased peripheral vision" "The nurse caring for a client admitted to the hospital with acute back pain understands that this problem can be most likely caused by which of the following? Select all that apply. - CORRECT ANSWER -Twisting of the spine -Hyperflexion of the spine -Herniation of an intervertebral disk" "The client who sustained a severe sprain of the ankle is told by the physician that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which of the following interventions should the nurse anticipate will be included in the client's plan of care? Select all that apply - CORRECT ANSWER -Ice bags -Elevation -Compression by an elastic bandage" "The nurse collecting data related to the client's risk factors associated with osteoporosis would include which of the following? Select all that apply. - CORRECT ANSWER -Thin body build -Smoking history -Postmenopausal age -Chronic corticosteroid use -Family history of osteoporosis" "The student nurse is assisting with an assessment of a client's level of consciousness using the Glasgow Coma Scale. The student understands that which of the following categories of client functioning are included in this assessment? Select all that apply. - CORRECT ANSWER -Eye opening -Best verbal response -Best motor response" "An adult client trapped in a burning house has suffered burns to the back of the head, upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what does the nurse determine the extent of the burn injury to be? (Enter the answer in the space provided.) Answer: __________% - CORRECT ANSWER 22.5" The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs Bruising on extremities Skin cool to touch Capillary refill less than 3 seconds Darkened skin on extremities - CORRECT ANSWER Diminished hair on legs Skin cool to touch Capillary refill less than 3 seconds Rationale Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other options are not indicators for impaired peripheral circulation." "The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) Diminished hair on legs. Bruising on extremities. Skin cool to touch. Capillary refill less than 3 seconds. Darkened skin on extremities. - CORRECT ANSWER Skin cool to touch. Capillary refill less than 3 seconds. Rationale Diminished hair on the