Nokea
The nurse is performing an assessment on a pregnant client with a history of cardiac disease. Which body area will venous congestion most commonly be noted in?
- A. Vulva
- B. Around the eyes
- C. Fingers of the hands
- D. Around the abdomen
Correct Answer: A
Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, the vulva, or the rectum. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. It would be difficult to assess for edema in the abdominal area of a client who is pregnant.
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Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
- A. Nausea and vomiting
- B. Fever and exertional dyspnea
- C. An arterial blood gas pH of 7.40
- D. A respiratory rate of 20 breaths per minute
Correct Answer: B
Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.
An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question should the nurse ask first?
- A. Do you have a history of a recent brain abscess?
- B. Do you have a chronic hearing problem in the left ear?
- C. Do you successfully obtain pain relief with acetaminophen?
- D. Do you have a history of a recent upper respiratory infection (URI)?
Correct Answer: D
Rationale: Otitis media in the adult is typically one-sided and presents as an acute process with earache; nausea; and possible vomiting, fever, and fullness in the ear. The client may report diminished hearing in that ear during the acute process. The nurse takes a client history first, assessing whether the client has had a recent URI. It is unnecessary to question the client about a brain abscess. The nurse may ask the client if anything relieves the pain, but ear infection pain is usually not relieved until antibiotic therapy is initiated.
The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?
- A. Fetal heart rate
- B. Maternal heart rate
- C. Fetal scalp sampling
- D. Maternal blood pressure
Correct Answer: A
Rationale: Fetal well-being must be confirmed before and after amniotomy. Fetal heart rate should be checked by Doppler or with the application of the external fetal monitor. Although maternal vital signs may be assessed, fetal heart rate is the priority. A fetal scalp sampling cannot be done when the membranes are intact.
A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper and lower GI series and endoscopies. Upon return to the long-term care facility, which priority assessment should the nurse focus on?
- A. The comfort level
- B. Activity tolerance
- C. The level of consciousness
- D. The hydration and nutrition status
Correct Answer: D
Rationale: Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although the remaining options may be components of the assessment, the correct option is the priority.