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Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?
A. Ongoing assessment
B. Comprehensive assessment
C. Focused assessment
D. Emergency assessment
A. Ongoing assessment
The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?
A. Cognitive skill
B. Technical skill
C. Interpersonal skill
D. Ethical or legal skill
A. Cognitive skill
An older adult asks the nurse about the appearance of flat brown age spots on the hands. After examining the client's hands, the nurse recognizes these skin characteristics as a common skin variation in the older adult and documents the variations as:
A. Senile lentigines
B. Lanugo
C. Senile keratosis
D. Cherry angiomas
A. Senile lentigines
In which situation would the nurse be most justified in implementing trial-and-error problem solving?
A. The nurse is attempting to landmark the apical pulse for a client whose BMI higher than 30.
B. The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery.
C. The nurse is attempting to determine which as-needed analgesic to offer a client who is in pain.
D. The nurse is attempting to determine whether a client has a swallowing deficit after experiencing a stroke.
A. The nurse is attempting to landmark the apical pulse for a client whose BMI higher than 30.
A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process?
A. visual acuity
B. extraocular movements
C. peripheral vision
D. existence of cataracts
B. extraocular movements
Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?
A. Assessing
B. Planning
C. Implementing
D. Evaluating
C. Implementing
While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?
A. bronchial
B. bronchovesicular
C. vesicular
D. adventitious
B. bronchovesicular
A nurse interviews a pregnant adolescent client and documents the answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and prenatal care. Of which characteristic of the nursing process is this an example?
A. systematic
B. dynamic
C. outcome-oriented
D. universally applicable
B. dynamic
A nurse is preparing a client for a barium enema. What activity would the nurse include in preparing the client for the barium enema?
A. The nurse writes the order for the barium enema.
B. The nurse delegates care during the barium enema to other personnel.
C. The nurse ensures the result of the barium enema is recorded.
D. The nurse provides emotional and physical preparation to the client.
D. The nurse provides emotional and physical preparation to the client.
Which step in the nursing process is most closely associated with cognitively skilled nurses?
A. Assessing
B. Planning
C. Implementing
D. Evaluating
B. Planning
The nurse is preparing to assess a client's cranial nerves. Which technique should a nurse use to assess cranial nerve III?
A. Shine a bright light in the client's eyes and observe for bilateral pupillary response.
B. Ask the client to close the eyes, occlude a nostril, and then identify the smell of different substances.
C. Determine visual acuity using a Snellen chart.
D. Occlude the client's right ear, whisper a word into the left ear, and ask the client to repeat it.
A. Shine a bright light in the client's eyes and observe for bilateral pupillary response.
To assess cranial nerve III (oculomotor), shine a bright light in the client's eyes and observe for bilateral pupillary response
A nurse is asked to perform a skill for which the nurse is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation?
A. Purpose of thinking
B. Adequacy of knowledge
C. Potential problems
D. Helpful resources
A. Purpose of thinking
During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is being tested by this action?
A. Cranial nerve I
B. Cranial nerves II and III
C. Cranial nerve VII
D. Cranial nerve VIII
C. Cranial nerve VII
Which interpersonal skill is essential to the practice of nursing?
A. Performing technical skills knowledgeably and safely
B. Maintaining emotional distance from clients and families
C. Keeping personal information among shared clients confidential
D. Promoting the dignity and respect of clients as people
D. Promoting the dignity and respect of clients as people
While giving a client a bath, the nurse observes the color of the client's skin as having a yellowish tinge. Which question would the nurse ask the client?
A. "How much caffeine do you drink per day?"
B. "Have you had diarrhea or constipation lately?"
C. "Do you use acetaminophen or drink alcohol?"
D. "How long have you had these spots?"
C. "Do you use acetaminophen or drink alcohol?"
Which nursing actions are potential errors in the decision-making process? Select all that apply.
A. Placing emphasis on the first data received
B. Avoiding information contrary to one's opinion
C. Selecting alternatives to maintain status quo
D. Being predisposed to multiple solutions
E. Prioritizing problems in order of importance
A, B, C
A nurse is teaching a client at risk for melanoma about what to look out for when checking the skin. The nurse determines that the teaching was successful based on which client statement(s)? Select all that apply.
A. "Different colors appearing in a mole is something to report."
B. "A mole that is bigger than 1/4 in (6 mm) is a problem."
C. "Any change in the mole's size or color is a danger sign."
D. "If I see a mole and it is completely round, I should get it checked out."
E. "Moles with irregular edges are nothing to worry about."
A, B, C
The client has experienced a fasting blood sugar in excess of 300 mg/dl (16.65 mmol/l) and is now diagnosed as having diabetes. The nurse plans care for this client based on the nursing concern of the client's knowledge deficit. Place in order the actions of using the nursing process for this client. Use all options.
A. The nurse addresses the client's learning needs by writing outcomes and education plans that involve disease process, self-monitoring of blood glucose, medications, diet, and checking the feet daily.
B. The client's blood sugar is over 300 mg/dl (16.65 mmol/l). The client is diagnosed as having diabetes. The nurse assesses the client's understanding as having no previous exposure to diabetes or care to manage health problems.
C. The nurse teaches the client addressing all domains—affective, cognitive, and psychomotor.
D. The nurse evaluates the client as achieving or not achieving each outcome.
E. The nurse analyzed the data and determined this client has multiple problems requiring education. The nurse writes one of the nursing concerns is a knowledge deficit related to client's lack of exposure as evidenced by verbalizing inaccurate information.
B, E, A, C, D
A school nurse will perform a hearing screening test for a group of elementary grade school students. What equipment will be needed for this examination?
A. no equipment
B. percussion hammer
C. speculum
D. ophthalmoscope
A. no equipment
The nurse is using the nursing process when providing care to a client. Place in order the nurse's actions. Use all options.
A. The nurse evaluates that vital signs are within normal limits; oxygen saturation level is 94% (0.94); pupils are equal and reactive; client's speech, swallowing, and eye drooping have not worsened. Cerebral perfusion is maintained. Continue with the plan.
B. The nurse writes the outcome "Cerebral perfusion will be maintained prior to discharge" and plans interventions that include monitoring vital signs, pulse oximetry, and pupil response; completing a stroke scale; keeping head of bed elevated to 30 degrees; and administering an antihypertensive medication.
C. The nurse assesses the client as having difficulty with speech, swallowing, and right eye drooping. A computed tomography scan indicates decreased perfusion to the brain.
D. The nurse intervenes by administering an antihypertensive medication.
E. The nurse analyzes the data and identifies the nursing concern as altered perfusion of cerebral tissue related to ischemia.
C, E, B, D, A