A client is reporting chest pain. What statement made by the client, helps the nurse to
understand this client has a naturalistic belief in the cause of
... [Show More] illness?
Answer - "My life is really out of balance."
2. A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.)
Answer - Be open to people who are different Have a curiosity about people.
Become culturally competent.
Which statement is accurate about assessing the spleen?
Answer - It must be enlarged at least three times normal size for it to be palpable.
What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope?
Answer - Posterior chest below the 3rd intercostalspace.
The nurse is assessing a client who has a history of mitral stenosis. How should the
nurse assess this client with a stethoscope to listen for this condition?
Answer - Place the bell on the 5th intercostal space, left midclavicular line.
The nurse is assessing a client who has a history of aortic regurgitation. Where should
the nurse place the stethoscope diaphragm to listen for this condition?
Answer - 2nd intercostal space along the right sternal border.
The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing?
Answer - The client works in a daycare setting that has had a scabies outbreak.
A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client?
Answer - Level of consciousness.
A client reports feeling increasingly fatigued for several months, and the nurse observes
that the client's lips are pale. Which additional data should the nurse collect based on
this presentation?
Answer - Use of vitamin and iron supplements .
The nurse is assessing a client who has experienced a sudden onset of hearing loss in
the right ear. Which finding should alert the nurse to a potentially serious medical
condition that requires further evaluation?
Answer - There is no sign of associated infection.
The client reports to the nurse a recent exposure to the mumps. Which assessment
finding suggests the client has contracted the mumps?
Answer - Swelling anterior to the ear lobe on one side of the face.
A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client?
Answer - Swelling of the left arm and non-pitting edema.
What is the best nursing response to an older client who has not mentioned
incontinence during a genitourinary assessment?
Answer - Ask the client specifically about any leakage of urine.
A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client?
Answer - Have you experienced sudden weight loss?
A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client?
Answer - Family history of colon cancer on mother's side. Correct
Which information should the nurse obtain to identify the client's self-perception of
health status?
Answer - Health history.
During the initial assessment, the nurse notes that a client has blurred vision with cloudy
lenses. Which condition should the nurse document?
Answer - Cataracts
While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition?
Answer - Fibroadenoma.
Which part of the body should the nurse examine when assessing for peripheral edema
in a client with heart failure?
Answer - Ankles.
Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a
Wood's lamp toexamine a client's skin lesions?
Answer - Fungal infection
The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? Answer - Have you ever felt guilty about your drinking?
A client has just returned from the recovery room and asks to get out of bed to go to the
bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse
position the client to begin this procedure?
Answer - Lying [Show Less]