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Questions and Answers
A nurse is assessing a client for risk factors related to stress and coping. Which of the following factors is most likely to increase the client's risk for experiencing stress?
A nurse is assessing a client for risk factors related to stress and coping. Which of the following factors is most likely to increase the client's risk for experiencing stress?
A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination?
A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination?
A nurse is developing a care plan for a 45-year-old patient who has recently been diagnosed with hypertension. The patient has expressed interest in improving their overall health and reducing the need for medication. The nurse decides to implement a health promotion strategy that addresses primary, secondary, and tertiary prevention measures.
Which of the following interventions best demonstrates the nurse's use of health promotion across all three prevention levels?
A nurse is developing a care plan for a 45-year-old patient who has recently been diagnosed with hypertension. The patient has expressed interest in improving their overall health and reducing the need for medication. The nurse decides to implement a health promotion strategy that addresses primary, secondary, and tertiary prevention measures.
Which of the following interventions best demonstrates the nurse's use of health promotion across all three prevention levels?
A nurse is assessing a client and notes an irregular pulse of 120 beats per minute. Which of the following should be the priority nursing intervention?
A nurse is assessing a client and notes an irregular pulse of 120 beats per minute. Which of the following should be the priority nursing intervention?
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A nurse is assessing a healthy adult client’s skin and notes a mole with irregular borders, varying colors, and a diameter of 8 mm. What is the nurse’s best action?
A nurse is assessing a healthy adult client’s skin and notes a mole with irregular borders, varying colors, and a diameter of 8 mm. What is the nurse’s best action?
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A nurse is performing a skin assessment on a 50-year-old patient during a routine physical examination. The following findings are noted. Which of these findings should the nurse be concerned about and report for further evaluation?
Select all that apply.
• A) A round, flat mole on the patient's upper back, measuring 4 mm in diameter, with a uniform tan color and no changes in shape or size over the past 5 years.
• B) A new lesion on the patient's left thigh, with irregular borders, multiple shades of brown, and a diameter of 8 mm.
• C) A raised, scaly patch on the patient’s elbow that has been present for several months and is slightly itchy.
• D) A flat, circular birthmark on the patient’s chest that has remained unchanged in size and color for the last 20 years.
• E) A firm, non-tender nodule on the patient's scalp that is increasing in size over the past month.
A nurse is performing a skin assessment on a 50-year-old patient during a routine physical examination. The following findings are noted. Which of these findings should the nurse be concerned about and report for further evaluation? Select all that apply. • A) A round, flat mole on the patient's upper back, measuring 4 mm in diameter, with a uniform tan color and no changes in shape or size over the past 5 years. • B) A new lesion on the patient's left thigh, with irregular borders, multiple shades of brown, and a diameter of 8 mm. • C) A raised, scaly patch on the patient’s elbow that has been present for several months and is slightly itchy. • D) A flat, circular birthmark on the patient’s chest that has remained unchanged in size and color for the last 20 years. • E) A firm, non-tender nodule on the patient's scalp that is increasing in size over the past month.
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A nurse is caring for a 72-year-old patient who has been diagnosed with early-stage Alzheimer's disease. The patient’s spouse expresses concern about recent changes in the patient’s behavior and memory. Which of the following manifestations should the nurse recognize as an indication of impaired cognition in this patient?
A nurse is caring for a 72-year-old patient who has been diagnosed with early-stage Alzheimer's disease. The patient’s spouse expresses concern about recent changes in the patient’s behavior and memory. Which of the following manifestations should the nurse recognize as an indication of impaired cognition in this patient?
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A nurse is educating a 60-year-old client with newly diagnosed type 2 diabetes on self-management strategies. Which of the following statements by the client indicates the need for further teaching
A nurse is educating a 60-year-old client with newly diagnosed type 2 diabetes on self-management strategies. Which of the following statements by the client indicates the need for further teaching
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A nurse is conducting a head, neck, and neurological assessment on a 45-year-old client. Which of the following findings should the nurse recognize as abnormal and report to the healthcare provider?
A nurse is conducting a head, neck, and neurological assessment on a 45-year-old client. Which of the following findings should the nurse recognize as abnormal and report to the healthcare provider?
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A nurse is caring for a postoperative client who just had an appendectomy. The nurse understands there are several factors for the client to develop an infection. Which of the following factors most significantly increase the client's risk for developing an infection?
A nurse is caring for a postoperative client who just had an appendectomy. The nurse understands there are several factors for the client to develop an infection. Which of the following factors most significantly increase the client's risk for developing an infection?
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A 70-year-old client with a history of hypertension and Type 2 diabetes presents to the emergency department with complaints of sudden-onset weakness on the right side of the body, difficulty speaking, and a severe headache. On assessment, the nurse notes that the client’s right-sided facial droop, slurred speech, and inability to lift the right arm are present. The client is alert but disoriented to time. The nurse suspects a stroke. Which of the following interventions is the nurse's priority?
A 70-year-old client with a history of hypertension and Type 2 diabetes presents to the emergency department with complaints of sudden-onset weakness on the right side of the body, difficulty speaking, and a severe headache. On assessment, the nurse notes that the client’s right-sided facial droop, slurred speech, and inability to lift the right arm are present. The client is alert but disoriented to time. The nurse suspects a stroke. Which of the following interventions is the nurse's priority?
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A 65-year-old patient presents for a routine health assessment. During the cardiovascular examination, the nurse notes the following findings:
- Heart rate: 72 beats per minute, regular rhythm
- Blood pressure: 128/76 mmHg
- Peripheral pulses: 2+ and equal bilaterally in the upper and lower extremities
- Auscultation of heart sounds reveals S1 and S2 with no audible murmurs or gallops.
- The patient reports occasional "skipping" heartbeats.
Which of the following findings is considered abnormal and requires further assessment?
A 65-year-old patient presents for a routine health assessment. During the cardiovascular examination, the nurse notes the following findings:
- Heart rate: 72 beats per minute, regular rhythm
- Blood pressure: 128/76 mmHg
- Peripheral pulses: 2+ and equal bilaterally in the upper and lower extremities
- Auscultation of heart sounds reveals S1 and S2 with no audible murmurs or gallops.
- The patient reports occasional "skipping" heartbeats.
Which of the following findings is considered abnormal and requires further assessment?
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A nurse is teaching a group of patients about self-management strategies related to chronic illness. Which of the following approaches to self-care should the nurse emphasize to improve health perception and health management?
A nurse is teaching a group of patients about self-management strategies related to chronic illness. Which of the following approaches to self-care should the nurse emphasize to improve health perception and health management?
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A nurse is teaching a patient with newly diagnosed Type 2 Diabetes Mellitus about self-management of their condition. Which statement by the patient indicates a need for further teaching?
A nurse is teaching a patient with newly diagnosed Type 2 Diabetes Mellitus about self-management of their condition. Which statement by the patient indicates a need for further teaching?
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A nurse is assessing a 30-year-old patient’s cardiovascular system. Which of the following findings would the nurse identify as abnormal and requiring further investigation?
A nurse is assessing a 30-year-old patient’s cardiovascular system. Which of the following findings would the nurse identify as abnormal and requiring further investigation?
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A nurse is assessing a patient’s approach to self-care as part of the health perception and health management pattern. Which of the following statements by the patient would indicate a positive approach to self-care?
A nurse is assessing a patient’s approach to self-care as part of the health perception and health management pattern. Which of the following statements by the patient would indicate a positive approach to self-care?
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During a routine health assessment, a nurse evaluates a patient's peripheral and neurological systems. Which of the following findings should the nurse consider abnormal and require further investigation?
During a routine health assessment, a nurse evaluates a patient's peripheral and neurological systems. Which of the following findings should the nurse consider abnormal and require further investigation?
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A nurse is conducting a cardiovascular assessment. Match the findings to the appropriate category: Normal or Abnormal.
A nurse is conducting a cardiovascular assessment. Match the findings to the appropriate category: Normal or Abnormal.
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A nurse is performing an admission assessment for a client who recently had a stroke. Which question best evaluates the client’s functional ability?
A nurse is performing an admission assessment for a client who recently had a stroke. Which question best evaluates the client’s functional ability?
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A nurse is assessing a patient with a history of stroke. The patient’s family reports that the patient has become increasingly forgetful and disoriented, asking the same questions repeatedly and struggling to recognize familiar people. The nurse suspects the patient may be experiencing cognitive impairment. Which of the following findings would support the diagnosis of dementia rather than delirium?
A nurse is assessing a patient with a history of stroke. The patient’s family reports that the patient has become increasingly forgetful and disoriented, asking the same questions repeatedly and struggling to recognize familiar people. The nurse suspects the patient may be experiencing cognitive impairment. Which of the following findings would support the diagnosis of dementia rather than delirium?
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A nurse is performing a respiratory assessment on a patient with suspected pneumonia. Which of the following findings would be the most concerning and require immediate intervention?
A nurse is performing a respiratory assessment on a patient with suspected pneumonia. Which of the following findings would be the most concerning and require immediate intervention?
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A nurse walks past her four patient’s rooms after doing hourly round before going to chart. The patient in room 111 is a fall risk and is sitting upright in the chair with his chair alarm on and the call light near. The patient in 112 is independent and is sitting in a tripod position using her bedside table. The patient in 113 is lying in bed in semi-fowlers, independent, and calls appropriately. Patient 114 has shortness of breath and is sitting upright in bed with her oxygen nasal cannula on. Which patient should the nurse reassess?
A nurse walks past her four patient’s rooms after doing hourly round before going to chart. The patient in room 111 is a fall risk and is sitting upright in the chair with his chair alarm on and the call light near. The patient in 112 is independent and is sitting in a tripod position using her bedside table. The patient in 113 is lying in bed in semi-fowlers, independent, and calls appropriately. Patient 114 has shortness of breath and is sitting upright in bed with her oxygen nasal cannula on. Which patient should the nurse reassess?
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A 35-year-old female patient is in the hospital and has had an indwelling catheter for four days. She mentions that she is experiencing pain while urinating, and the UAP reports to the nurse that the patient has a fever. What other symptoms should the nurse assess for as a potential sign of CAUTI? Select all that apply.
A. Decreased appetite
B. Increased urgency to urinate
C. Increased thirst
D. Hematuria
E. Lower back pain
A 35-year-old female patient is in the hospital and has had an indwelling catheter for four days. She mentions that she is experiencing pain while urinating, and the UAP reports to the nurse that the patient has a fever. What other symptoms should the nurse assess for as a potential sign of CAUTI? Select all that apply.
A. Decreased appetite B. Increased urgency to urinate C. Increased thirst D. Hematuria E. Lower back pain
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A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess an older adult. Which patient behavior suggests full independence in this assessment tool?
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess an older adult. Which patient behavior suggests full independence in this assessment tool?
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A nurse is assessing a patient with complaints of abdominal pain. During auscultation of the abdomen, the nurse hears high-pitched, rushing bowel sounds in all four quadrants. What is the most appropriate interpretation of this finding?
A nurse is assessing a patient with complaints of abdominal pain. During auscultation of the abdomen, the nurse hears high-pitched, rushing bowel sounds in all four quadrants. What is the most appropriate interpretation of this finding?
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A nurse is assessing a client’s ability to perform basic and instrumental activities of daily living (BIADLs) during a home visit. Which findings indicate a problem requiring further evaluation and intervention? (Select all that apply)
- The client reports taking medication at the correct times but uses a family member to set up a weekly pill organizer.
- The client states, "I haven’t been cooking much lately because it feels too tiring, so I’ve been eating mostly canned soups."
- The client reports walking to a nearby grocery store once a week but mentions avoiding busier times due to unsteady balance.
- The client says, "I’ve been wearing the same clothes this week because my washer is broken, and I’m waiting for it to get repaired."
- The client reports losing track of bill payments recently, resulting in a utility shutoff notice, and states, "It’s been hard to keep up with everything
A nurse is assessing a client’s ability to perform basic and instrumental activities of daily living (BIADLs) during a home visit. Which findings indicate a problem requiring further evaluation and intervention? (Select all that apply)
- The client reports taking medication at the correct times but uses a family member to set up a weekly pill organizer.
- The client states, "I haven’t been cooking much lately because it feels too tiring, so I’ve been eating mostly canned soups."
- The client reports walking to a nearby grocery store once a week but mentions avoiding busier times due to unsteady balance.
- The client says, "I’ve been wearing the same clothes this week because my washer is broken, and I’m waiting for it to get repaired."
- The client reports losing track of bill payments recently, resulting in a utility shutoff notice, and states, "It’s been hard to keep up with everything
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A nurse is assessing a client during a routine health visit. Which of the following client statements should the nurse address as the highest priority?
A nurse is assessing a client during a routine health visit. Which of the following client statements should the nurse address as the highest priority?
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A nurse is assessing a client’s abdomen during a routine examination. Which of the following findings requires immediate follow-up?
A nurse is assessing a client’s abdomen during a routine examination. Which of the following findings requires immediate follow-up?
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A nurse is assessing a 72-year-old client who is recovering from hip surgery. The client is reporting some difficulty performing activities of daily living (ADLs) and expresses concerns about being able to live independently at home. Which of the following interventions should the nurse prioritize to support the client's functional status?
A nurse is assessing a 72-year-old client who is recovering from hip surgery. The client is reporting some difficulty performing activities of daily living (ADLs) and expresses concerns about being able to live independently at home. Which of the following interventions should the nurse prioritize to support the client's functional status?
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A nurse is caring for a 32-year-old client who sustained a tibial fracture in a motor vehicle accident. The client is in a cast and has been using crutches for mobility. Which of the following instructions should the nurse provide to help prevent complications associated with the use of crutches?
A nurse is caring for a 32-year-old client who sustained a tibial fracture in a motor vehicle accident. The client is in a cast and has been using crutches for mobility. Which of the following instructions should the nurse provide to help prevent complications associated with the use of crutches?
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A 45-year-old woman with a history of osteoarthritis is being assessed by the nurse. The following findings are noted during the assessment:
~The patient reports stiffness and joint pain in both knees, especially in the morning.
Swelling and mild warmth are noted in both knee joints.
~The patient has a positive Heberden’s node at the distal interphalangeal joint (DIP) of both hands.
~The patient has a normal gait but reports occasional difficulty with walking long distances.
~The patient denies any redness or fever.
Which of the following findings is abnormal for a patient with osteoarthritis?
A 45-year-old woman with a history of osteoarthritis is being assessed by the nurse. The following findings are noted during the assessment:
~The patient reports stiffness and joint pain in both knees, especially in the morning. Swelling and mild warmth are noted in both knee joints. ~The patient has a positive Heberden’s node at the distal interphalangeal joint (DIP) of both hands. ~The patient has a normal gait but reports occasional difficulty with walking long distances. ~The patient denies any redness or fever.
Which of the following findings is abnormal for a patient with osteoarthritis?
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A nurse is evaluating a patient's peripheral and neurological systems. Which of the following findings should the nurse consider a normal finding?
A nurse is evaluating a patient's peripheral and neurological systems. Which of the following findings should the nurse consider a normal finding?
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What are nursing interventions for a client receiving parenteral nutrition? Select all that apply.
a. Monitor electrolytes
b. Monitor vital signs
c. Weekly weight
d. Monitor blood glucose levels
e. Discard soultion every 48 hours
What are nursing interventions for a client receiving parenteral nutrition? Select all that apply. a. Monitor electrolytes b. Monitor vital signs c. Weekly weight d. Monitor blood glucose levels e. Discard soultion every 48 hours
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