Question 1

The night nurse is reviewing the vital signs of a client in an extended care facility.The nurse notes the client's oral temperature at 6 a.m.was 98.0°F,but that evening,the client's oral temperature was 99.2°F.The nurse suspects that this variation in temperature is indicative of:

Accepted Answer

Diurnal variations refer to the normal fluctuations in body temperature throughout the day, with temperatures typically being lower in the early morning and higher in the late afternoon or evening. The change from 98.0°F in the morning to 99.2°F in the evening falls within the expected range of these variations.

Question 2

The nurse is doing a general survey on an infant for a well-child check.During the survey,the baby has a liquid stool.The mother becomes very angry and asks the nurse to change the diaper because she just can't "deal with the odor." This response is important to the nurse because:

Accepted Answer

The mother's response of being unable to "deal with the odor" may indicate a potential issue with the mother-child relationship, as she is exhibiting a lack of tolerance for a normal bodily function of her infant. It is not necessarily indicative of an illness or poor diet. However, the nurse should still investigate further to ensure the infant's health and well-being.

Question 3

The nurse is conducting a class on hypertension,when a client asks what the numbers in the blood pressure mean.Which of the following statements would the nurse correctly use to answer the client's question?

Accepted Answer

The answer of The nurse is conducting a class on...

Question 4

During a physical assessment the client asks the nurse repeatedly,"Is everything ok?" The nurse believes this client is demonstrating:

Accepted Answer

The client's repetitive questioning suggests anxiety, as they are seeking reassurance about their well-being.

Question 5

A client presents to the primary care clinic and is disheveled in appearance,with stained,dirty clothing,body odor,and uncombed hair.Based on this observation,which of the following should the nurse assess during the history and physical exam?

Accepted Answer

The answer of A client presents to the primary care...

Question 6

The nurse in interviewing a client observes changing of position frequently,wringing hands,and laughing at inappropriate times.Which of the following would be appropriate for the nurse to include in the assessment based on this information?

Accepted Answer

The client's behaviors, such as changing positions frequently, wringing hands, and laughing inappropriately, are indicative of anxiety. Therefore, an anxiety assessment would be appropriate.

Question 7

The nurse is admitting a client with a fractured hip.The client points to the painful hip and describes it as a constant throbbing.The nurse would include which of the following when continuing the pain assessment on this client?

Accepted Answer

The answer of The nurse is admitting a client with...

Question 8

The nursing staff is admitting a client diagnosed with diabetic ketoacidosis (DKA).The LPN asks the RN if the pulse oximeter needs to be placed on the client.What is the nurse's best response to the LPN?

Accepted Answer

The nurse should complete a thorough assessment before determining if the pulse oximeter needs to be placed on the client. It's important to gather baseline vital signs and assess the client's respiratory and cardiovascular status to determine the need for oxygenation monitoring. Therefore, the nurse's best response is to inform the LPN that they will let them know after the assessment is complete.

Question 9

The nurse is assessing a client who has had a cerebral vascular accident (CVA or stroke)and has difficulty with verbal expression,but no other deficits.What approach should the nurse use to assess this client's level of pain?

Accepted Answer

Since the client has difficulty with verbal expression, the Wong-Baker "FACES" pain rating scale would be the most appropriate approach. This scale uses a visual representation of faces to help the client indicate the level of pain they are experiencing. It does not rely on verbal expression or the observation of behavior and vital signs.

Question 10

The nursing assistant brings the nurse the following vital signs for an older adult client: Temperature 97.4ºF (oral),BP 165/70,Pulse Rate 84/min,and Respirations 28.After reviewing the vital signs,the nurse should do which of the following?

Accepted Answer

The vital signs indicate some abnormalities, such as high blood pressure and high respiratory rate, but they do not necessarily require immediate intervention. The nurse should continue to monitor the client and assess for any signs of distress or changes in condition, and report any concerns to the healthcare provider. Rechecking the temperature may not be necessary, as it falls within the normal range. Ordering medications or oxygen therapy without further assessment and evaluation would be premature and potentially harmful.

Question 11

The nurse is obtaining the height and weight of an older adult client.The client asks why the height is 1 inch less than last year.What is the best response by the nurse?

Accepted Answer

This response is the most accurate and informative. It explains that it is common for older adults to experience musculoskeletal changes that can lead to a decrease in height. The nurse can also provide additional education about these changes and ways to maintain bone health. Option A is incorrect and can cause unnecessary concern and fear for the client. Option B is dismissive and does not address the client's concern. Option D is not a good response as it can potentially affect the accuracy of the measurements.

Question 12

An older adult client has edema of the lower extremities despite being prescribed medication for this symptom.Which of the following should the nurse do first to assist this client?

Accepted Answer

Reviewing the client's current medications is the first step in identifying if any medications are causing the edema or if medication adjustments need to be made. This information can then be discussed with the healthcare provider and documented in the medical record. Support hose can be helpful in managing edema, but it is not the first intervention to address the underlying cause.

Question 13

A nurse has been asked to present a program on blood pressure for a group of adults at a community center.Which of the following true statements should the nurse incorporate into the presentation?

Accepted Answer

Both B and C are true statements that are important for the nurse to incorporate into the presentation. B highlights the importance of considering demographic factors when assessing blood pressure, while C emphasizes the impact of lifestyle factors such as stress on blood pressure. A, D, and E are all incorrect statements that could potentially confuse or misinform the audience.

Quiz 7: General Survey