1-A nurse is assessing an adult client. Which observations would the nurse include when documenting the general survey of the client? Client states.
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1-     A nurse is assessing an adult client. Which observations would

the nurse include when documenting the general survey of the client?
Client states. " I have a headache"
Strength of upper extremities is strong and equal bilaterally
Skin is warm to touch
Gait is smooth, steady, and well-balanced
 
2-     A nurse is completing the general survey portion of a physical assessment on a client recently admitted to the unit. which of the following best describes the purpose of the general survey?
It states an introduction and general plan of care.
it allows for vital signs to be taken prior to starting the exam,
It provides an opportunity for the client to relax before the exam
It yields information to guide the physical assessment.
 
3-     When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that m very indicates which of the following?
Venous insufficiency
Within the expected range
Thrombus formation in the vein
Arterial insufficiency
 
4-     A nurse is establishing health promotion goals for a female client who smokes cigarettes has hypertension and has at i . which of following goals should the nurse include?
The client will walk for 30 min 5 days a week
The client will increase calorie intake by 200 cal per day.
The client will list foods that are high in calcium. which should be avoided
The client will replace cigarettes with smokeless tobacco products
 
5-     The nurse educator is preparing an education module for the nursing on the functions of the skin. Which of these statements would be included in the module? Select all that apply?
Production of vitamin D
Temperature regulation
Protection from environment
Thin and nonstratified.
Psychological wellness
 
5. A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height a weight to calculate BMI, which of the following clients has a healthy BMI?
A client with a weight of 128 lb and height of 70 inches. BMI of 17.8
A client with a weight of 133 lb and a height of 60 inches. BMI of 17.61
A client with a weight of 200 lb and height of 72 inches. BMI of 27,18
A client with a weight of 150 lb and height of 68 inches, BMI of 22.85
 
11. A nurse is discussing active health promotion with a nursing student. Which activities) are examples of health promotion. SATA
Age-recommended immunization.
The county ruling in the use of seat belts in all moving vehicles.
Daily weight and diet regimen.
The state regulation regarding recycled and non-recycled materials.
An annual physical examination with a healthcare provider.
The city ordinance on public parking and smoking.
 
5. A nurse is assessing an adult client. Which observations would the nurse include when documenting the general survey of the client?
Strength of upper extremities is strong and equal bilaterally
Client states, "I have a headache."
Gait is smooth, steady, and well-balanced
Skin is warm to touch
6. The nurse is assessing the carotid arteries of an older patient with cardiovascular disease. What is the correct technique the nurse should use?
Instruct the patient to take slow deep breaths during auscultation.
Listen with the bell of the stethoscope to assess for bruits.
Simultaneously palpate both arteries to compare amplitude.
Palpate the artery in the upper one third of the neck.
 
7. A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should ex murmur
is a high-pitched sound due to a narrow valve.
is an extra sound due to blood entering an inflexible chamber.
means that there is some inflammation around the heart.
indicates turbulent blood flow through a valve.
 
16. A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the use to take?
Provide a schedule of visiting hours to the client's family.
Document the client's allergies in the electronic medical record.
Develop a plan of care for the client.
Instruct the client about the diagnosis.
 
8. A nurse is reviewing client assessment data. Which information found in the client chart is considered objective data select all that apply
Ultrasound result shows presence of stones in the gallbladder.
Blood pressure at 150/80 mmHg, right arm, sitting position.
Laboratory reports reveal the patient's blood sugar is increased than the normal value.
Client verbalizes, "For the past week, I have experienced morning pain in both knees. Always 8/10.
Grimace face and guarding position of the abdomen.
The mother claims the child has the fever for the past 24 hours.
 
9. What assessment information should the nurse the select all that apply.)
When did the rash first start?
Describe the sensation from the rash, does it burn or itch?
What do you do to make your rash better?
Do you have a family history of rashes?
Describe what the rash looked like initially.
10. A nurse is preparing to perform an assessment on a client with a rash. What assessment information should the nurse ask the client? SATA
When did the rash first start?
Describe the sensation from the rash, does it burn or itch?
What do you do to make your rash better?
Do you have a family history of rashes?
Describe what the rash looked like initially
What makes the rash worse?
 
11. The nurse who works on a cardiac unit is teaching the student nurse about heart sounds. The student nurse askes how the S2 heart sound is produced. Which of the following is the nurse's best response?
"It results from the closing of the tricuspid and mitral valves."
"It results from the closure of the pulmonic and aortic valve."
"By atrial contraction and ejection of blood into the ventricles."
"When the mitral and aortic valve opens"
 
12. A nurse is discussing the nursing process with a nursing student. Which statement best describes the nursing process?
The nursing process is a personalized plan of care that involves a dynamic process in meeting the client's holistic
The nursing process is focused on physiologic health concerns of those clients who have a medical diagnosis
The nursing process is an interprofessional written plan of care about the client's health problems and the providers metical dup
The nursing process is the general documentation of the nurse's actions to address the client's needs.
13. Unlicensed assistive personnel (UAP) reports a client's vital signs as tympanic temperature 37.1 C(P F pulse 12/in 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
Pulse rate
BP
Respiratory rate
Temperature
 
14. A nurse is caring for a client with depressive disorder and is assessing the client's ability to perform activities of daily living (ADLs) prior discharge. Which of the following activities should the nurse include in the assessment? (Select all that apply)
Ability to identify how often he should schedule his car for an oil change
Ability to dress himself
Ability to bathe himself
Ability to balance his bank account
Ability to perform oral hygiene
 
14. A client with coronary artery disease states a fear of dying from a heart attack. Which of the following responses should the nurse make?
"Of course you aren't going to die, at least not in the immediate future."
"Tell me more about these fears of dying from a heart attack."
"Perhaps you should discuss this with your physician."
"I recommend you exercise daily and avoid smoking to decrease your risk."
 
15. A nurse is completing a skin assessment. What information should be collected during this assessment?
Support systems
Psychological wellness
Circulatory status
Socioeconomic status
 
16. A nurse is assessing a client's pupillary light reflex. What assessment finding should the nurse anticipate?
Light is reflected at the same spot in both eyes.
The eyes focus the images in the center of the pupils.
The eyes converge to focus on the light.
Constriction of both pupils occurs in response to bright light.
 
18. A nurse auscultates a client's lungs and notes low pitched, soft breath sounds over
Vesicular breath sounds
Sounds normally auscultate over trachea
Bronchial breath sounds
Bronchovesicular breath sounds
 
19. nurse is assessing a client's pupillary light reflex. What assessment finding should the nurse anticipate?
Light is reflected at the same spot in both eyes.
The eyes focus the images in the center of the pupils.
The eyes converge to focus on the light.
Constriction of both pupils occurs in response to bright light.
 
20. A nurse t is brought to the emergency department with a preliminary diagnosis of dehydration. The client is agitated when the client to open his mouth for an oral exam, the client yells, "You don't need to look in my mouth to see what is wrong with met nurse's best rationale for looking in his mouth is:
To assess for oral lesions.
That a complete physical exam must be performed.
To assess mucous membranes.
To assess for cranial nerve damage.
 
21. During percussion, the nurse knows that resonance over a lung lobe would most likely indicate which of the following
Decreased adipose tissue
Increased density of lung tissue
Normal lung tissue
Shallow breathing
 
22. A nurse is caring fora client who has expressive aphasia following a cerebrovascular accident (CVAL which of the following parameters should nurse use first in order to assess the client's pain level?
behavioral indicators and effect
a self-report pain rating scale
scheduled treatments and client illness
pulse and blood pressure findings
 
 
 

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