Adhi Exam 1 Nclex Questions

D. Health Management Pattern

Rationale: The nurse’s assessment covers the health perception– health management pattern, which is a patient’s self-report of how he or she manages his or her health and his or her knowledge of preventive health practices. The coping–stress tolerance pattern includes questions focused on how a patient manages stress and sources of support. An assessment covering the value belief pattern leads a patient to describe patterns of values, beliefs, and life goals. An assessment of the cognitive-perceptual pattern includes questions that focus on the patient’s language adequacy, memory, and decision-making ability.

An inference is your judgment or interpretation of cues such as the shuffling gait and reduced leg strength. Any information gathered through your senses is a cue. Probing is a technique used in interviewing. Reflection is an internal process of thinking back about a situation.

This is an example of a problem-focused approach. The nurse focuses on assessing one body system (cardiovascular) to determine the nature of the patient's pain and other presenting symptoms.

The gathering of information is the working phase of a patient-centered interview.

This is the only assessment approach that is not biased or does not show judgment about the patient's weight or occupational status. With the other options, the nurse is reacting to the patient on the basis of personal stereotypes and biases.

The best interview question for initially determining why a patient is seeking health care is by asking an open-ended question that allows the patient to tell his or her story. This is also a more patient-centered approach. Probing questions are asked after data are gathered to seek more in-depth information. Problem-oriented and confirmation are not types of interview questions.

Observing a patient perform activities physical, socially, psychologically, and developmentally assesses his or her level of function. In the case of this question the nurse assesses physical functional level. Observation does not measure willingness to perform self-care but the ability to do so. Observing physical performance of self-hygiene is not a measure of level of consciousness nor does it reveal a patient's values.

This is an example of assessment of a patient's feelings about his worth and body image, which is the self-perception- self-concept health pattern.

2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of

questions to gather your health history."

4. "Tell me what brought you to the hospital." 1. "You say you've lost weight. Tell me how much weight you've lost in the last month."

5. "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor—correct?"

3. "I have no further questions. Thank you for your patience."

An open-ended question that probes such as "Tell me what makes your headaches begin" encourages a fuller description of a situation. The statement "So you've had headaches periodically in the last week, and sometimes they cause you to feel nauseated—correct?" is a summative statement. Asking whether the patient has taken anything for the headaches is a closed-ended question. Saying "Uh huh, tell me more" is an example of back channeling.

B Recognition that further observations are needed to clarify information

C. Comparison of data with another source to determine data accuracy

Assessment includes collection of data from secondary sources such as the patient's family. Recognizing that more observation is needed is an example of validation of data. Comparing data to determine accuracy is a feature of interpretation. Although complete documentation is an important step in communicating assessment data, it is not an assessment step.

C. The care recommendations of a physical therapist

D. The results of a diagnostic x-ray film

There are many sources of data for an assessment, including the patient through interview, observations, and physical examination; family members or significant others, health care team members such as a physical therapist, the medical record (which includes x-ray film results, and the scientific and medical literature.

D. Patient has drainage from surgical wound.

E. Body temperature is 38.3° C (101° F).

F. Patient states, "I'm worried that I won't be able to return to work when I planned."

Tender skin around the wound, drainage from the surgical wound, and a temperature of 38.3° C (101° F) indicate a wound infection. Fluid intake of 800 mL over 8 hours and a heart rate of 78 beats/min and regular are normal assessment findings. A patient's expressed concern about returning to work is his or her subjective response about a separate issue and is insufficient to form a pattern.

B. Use gestures that reinforce your questions or comments.

C. Maintain direct eye contact.

E. Ask questions quickly to reduce the patient's fatigue.

Approaches for collecting an older-adult assessment include listening patiently, using nonverbal communication when a patient has a hearing deficit, and maintaining patientdirected eye gaze. Leaning forward, not backward, shows interest in what the patient has to say.

D. The nurse assesses the patient's lower-limb strength.

Validation of assessment data is the comparison of data with another source to determine its accuracy. The nurse compares data reported by the previous nurse with data collected directly with the patient, including assessing pain on the rating scale and assessing the patient's lower limb strength. Asking the patient what caused his fall and about past back pain and experience with pain medications would offer the nurse new information about the patient.

from primary source (client) and secondary sources

Obtain objective data

A. Ataxia.

Ataxia is a lack of coordination of movement, possibly caused by lesions of sensory or motor pathways, cerebellum disorders, or certain medications. Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them related to a cerebral cortex lesion. Anisocoria is inequality of pupil size from an optic nerve injury. Anosognosia is the inability to recognize a bodily defect or disease related to lesions in the right parietal cortex.

The spinal accessory nerve is tested by asking the patient to shrug the shoulders against resistance and to turn the head to either side against resistance while observing the sternocleidomastoid muscles and the trapezius muscles. Assessing the gag reflex and saying “ah” are used to assess the glossopharyngeal and vagus nerves. Asking the patient to push the tongue to either side against resistance is used to assess the hypoglossal nerve.

Downward drifting of the arm or pronation of the palm is identified as pronator drift. Athetosis is a slow, writhing, involuntary movement of the extremities. Hypotonia is flaccid muscle tone, and hemiparesis is weakness of one side of the body.

Allergies to shellfish, iodine, or dyes contraindicate the use of contrast media in CT. The patient’s immunization history is not a central consideration, and the presence of metal in the body does not preclude the use of CT as a diagnostic tool. The need to assess for allergies supersedes the need for tranquilizers or antiseizure medications in the majority of patients.

Among the most important descending tracts are the corticobulbar and corticospinal tracts, collectively termed the pyramidal tract. These tracts carry volitional (voluntary) impulses from the cortex to the cranial and peripheral nerves. Dysfunction of the pyramidal tract is likely to manifest as impaired movement because of hypertonicity. Diseases affecting the pyramidal tract do not result in changes in level of consciousness, impaired reflexes, or decreased sensation.

The Romberg test is an assessment of position sense in which the patient stands with the feet together and then closes his or her eyes while attempting to maintain balance. The other cited tests of neurologic function do not directly assess position sense.

Because the frontal lobe is responsible for higher cognitive function, this patient may have difficulty with memory retention, voluntary eye movements, voluntary motor movement, and expressive speech. The lack of reflexes would occur if the patient had problems with the reflex arcs in the spinal cord. Endocrine problems would be evident if the hypothalamus or pituitary gland were affected. Respiratory, vasomotor, and cardiac dysfunction would occur if there were a problem in the medulla.

Using a transsphenoidal approach to remove the pituitary gland includes a risk of damage to the olfactory cranial nerve because the cell bodies of the olfactory nerve are located in the nasal epithelium. With damage to this nerve, the sense of smell would be altered. Increased heart rate, loss of coordination, and impaired swallowing will not be potential deficits from this surgery.

With an EMG, pain may occur when needles are inserted to record the electrical activity of nerve and skeletal muscle. The patient is not tilted on a table during a myelogram. The electroencephalogram is noninvasive without a danger of electric shock. The magnetoencephalogram is done with a passive sensor that does not make contact with the patient.

Older adults are more likely to experience orthostatic hypotension related to altered coordination of neuromuscular activity. Other neurologic changes in older adults include atrophy of taste buds with decreased sense of taste, below-average reflex score (and diminished deep tendon reflexes), and slowed reaction times.

Cognition is one component of the mental status examination to determine cerebral functioning. Cognition is assessed by determining orientation, memory, general knowledge, insight, judgment, problem solving, and calculation. A question often used to determine cognition for adults living in the United States is, “Who were the last three presidents?” General appearance and behavior are additional components and include level of consciousness, body posture, and facial expressions. Mood and affect are assessed by observing for agitation, anger, or depression. Cerebellar function is determined by assessing balance and coordination, and may include testing rapid alternating movements of the upper and lower extremities.

The glossopharyngeal and vagus nerves innervate the pharynx and are tested by the gag reflex. It is important to assess the gag reflex in patients who have a decreased level of consciousness, brainstem lesion, or disease involving the throat musculature. If the reflex is weak or absent, the patient is in danger of aspirating food or secretions.

After a lumbar puncture, the nurse should monitor the puncture site for drainage or bleeding. Other assessments include headache intensity, meningeal irritation (nuchal rigidity), signs and symptoms of local trauma (e.g., hematoma, pain), neurologic signs, and vital signs. A lumbar puncture does not affect bowel or bladder function or upper extremity muscle strength. Bed rest until lower extremity movement returns is indicated for the patient after spinal anesthesia.

Patients with type 1 diabetes mellitus must have insulin administered the day of the PET if glucose metabolism is the focus of the PET. Diuretics should not be administered before the PET unless a urinary catheter is inserted. The patient must remain still during the procedure (1 to 2 hours). Sedatives and tranquilizers (e.g., alprazolam) should not be administered before a PET of the brain because the patient may need to perform mental activities, and these medications may affect glucose metabolism. Prophylactic antibiotics are not necessary. Patients are NPO before a PET of the brain and should not receive oral medications (alprazolam and ciprofloxacin).

C. Motor function deficit

F. Central nervous system changes

Normal changes of aging in the nervous system decrease the sensory function that leads to poor ability to maintain balance and a widened gait. The motor function deficit decreases muscle strength and agility. The central nervous system changes in the brain lead to a diminished kinesthetic sense or position sense. These changes all contribute to an increased risk of falls for the older adult. Memory deficits, normal changes of cranial and spinal nerves, and the reticular activation system do not increase the risk for falls.

Male gender

Use of physical restraints

Pain (especially untreated)

Emotional stress

Prolonged sleep deprivation

 Vascular disorders

o Head trauma

o Obesity

o Smoking

o Cardiac dysrhythmias

o Hypertension

o Hypercholesterolemia

o Coronary artery disease

 Memory loss

 Mild disorientation

 Trouble with words and/or numbers

Sex (1 pt)

Age (<19 or >45) (1 pt)

Depression/Hopelessness (2 pt)

Previous suicide attempt (1 pt)

Excessive alcohol/drug use (1 pt)

Rational thinking loss (2 pt)

Separated/Divorced/Widowed (1 pt)

Organized or serious Attempt (2 pt)

No social supports (1 pt)

Stated future intent (2 pt)

9 or more points, immediate hospitalization

o Difficulty performing familiar tasks

o Problems with language

o Disorientation to time and place

o Poor or ↓ judgment

o Problems with abstract thinking

o Misplacing things

o Changes in mood or behavior

o Changes in personality

o Loss of initiative

o ↓Concentration and attention

o Unpredictable behavior in 90% of patients with AD

Aggression

Some long-term memory loss

Wandering

o Distraction (Ways to distract the agitated patient may include providing snacks, taking a car ride, sitting on a porch swing or rocker, listening to favorite music, watching videotapes, looking at family photographs, or walking.)

o Reassurance

o Use of repetitive activities, songs, poems, music, massage, aromas, or a favorite object can be soothing to patients.

o Do not threaten or restrain patient if frustrated.

o Ingesting dangerous substances

o Wandering

o Injury to others and self

o Fire or burns

o Inability to respond to crisis

o Cannot perform activities of daily living (ADLs)

o Patient becomes unresponsive and incontinent.

o Total care is required.

SSRIs used to treat both depression and Alzheimers associated depression, also may improve cognitive ability

Anti-psychotic drugs used to address behavioral problems in Alzheimer's patients.

o Self-neglect

o Risk for injury

o Wandering

o Risk for trauma

 Have personal care needs met.

 Have dignity maintained.

Face (drooping)

Arms (weakness in one side)

Speech (slurred)

Time (call 911 IMMMEDIATELY if you see any one of these signs)

D. Instruct the client to swallow after the tube has passed the pharynx.

Only the unconscious or obtunded client should be placed in a left side-lying position. The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process. The neck should only be extended back prior to the tube passing the pharynx, and then the client should be instructed to position the neck forward.

Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having.

Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name.

To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.

The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client.

Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement.

The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one

School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted.

D. Ask the client to describe the routine he is currently following.

Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading

His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her.

This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. This age-related change can put the older adult at risk for falls. Options A, B, and D are age-related changes but are not high safety concerns.

Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the health care provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.

A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed. The client may interact with peers and staff and sit attentively in groups without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening is not an indication of improvement.