A client is reporting chest pain. What statement made by the client helps the nurse to understand the client has a naturalistic belief in the cause of
... [Show More] illness?
A. "My life is really out of balance."
B. "I knew I should have changed my diet."
C. "I should have gone to church last week."
D. "I forgot to take my medicines last night." - ANS-A. "My life is really out of balance."
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.)
A. Be open to people who are different.
B. Have a curiosity about people.
C. Become culturally competent.
D. Interact with each person in the same way.
E. Request nurses take care of patients with the same ethnicity.
F. Always request an interpreter for people from other countries. - ANS-A. Be open to people who are different.
B. Have a curiosity about people.
C. Become culturally competent.
Which statement is accurate about assessing the spleen?
A. It must be enlarged at least three times normal size for it to be palpable
B. It is easily felt by reaching the left hand behind the 11th and 12th ribs.
C. It is normally felt by rolling the client on the right side and palpating.
D. It is a firm mass palpated slightly left of midline in the upper abdomen. - ANS-A. 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?
A. Posterior chest below the 3rd intercostal space
B. Posterior-axillary line at the 4th intercostal space C. Anterior chest at the level of the 4th intercostal space.
D. Anterior-axillary line at the 5th intercostal space. - ANS-A. Posterior chest below the 3rd intercostal space
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?
A. Place the bell on the 5th intercostal space, left midclavicular line.
B. Place the bell on the 2nd intercostal space, left midclavicular line.
C. Put the diaphragm on the 5th intercostal space, left sternal border.
D. Put the diaphragm on the 2nd intercostal space, left sternal border. - ANS-A. 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?
A. 2nd intercostal space along the right sternal border
B. 2nd intercostal space along the left sternal border.
C. 3rd intercostal space on the right midclavicular line
D. 5th intercostal space on the left midclavicular line - ANS-A. 2nd intercostal space along the right sternal border
The client is experiencing severe pruritis 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?
A. The client works in a daycare setting that has had a scabies outbreak.
B. The client has been using a chemical stripping agent for home remodeling.
C. The client has a family history of psoriasis in both parents and a sibling.
D. The client routinely works with clay and paint as a hobby. - ANS-A. 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?
A. Level of consciousness
B. Gait characteristics
C. Presence of trauma
D. Bladder control ability. - ANS-A. 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?
A. Current alcohol and tobacco use
B. A 24-hour dietary recall
C. Use of vitamin and iron supplements
D. Daily pattern of oral hygiene practices - ANS-C. 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?
A. The client works in a busy office setting
B. There is no sign of associated infection
C. The client has no prior history of hearing loss
D. The hearing loss involves high frequencies - ANS-B. 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?
A. Enlargement centered along the anterior lower neck region
B. Swelling anterior to the ear lobe on one side of the face
C. Generalized rounded shape of the face
D. Paralysis on one side of the face - ANS-B. 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?
A. Swelling of the left arm and non-pitting edema.
B. Bilateral swelling of the arms with weakened pulses.
C. Complaints of pain when taking the blood pressure on the affected side.
D. Metastasis of cancer due to cancer being in the lymph nodes. - ANS-A. 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?
A. Ask the client specifically about any leakage of urine.
B. Document that the client reports having no incontinence
C. Have the client cough and then check for urine leakage
D. Determine if the client has ever had urinary tract surgery. - ANS-A. 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?
A. What types of food do you like or dislike?
B. Have you experienced sudden weight loss?
C. Do you use dietary supplements every day?
D. Can you recall the last 24 hours of food intake? - ANS-B. 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?
A. Administration of rubeola vaccine at age 7.
B. Removal of gallbladder 5 years ago.
C. Family history of colon cancer on mother's side.
D. Family history of hypertension on father's side. - ANS-C. Family history of colon cancer on mother's side.
Which information should the nurse obtain to identify the client's self-perception of
health status?
A. Vital signs
B. Health history
C. Informed consent
D. Genetic predisposition - ANS-B. Health history [Show Less]