Fundamentals Of Nursing NCLEX Quiz 41

1. Tywin has come to the nursing clinic for a comprehensive health assessment. Which statement would be the best way to end the history interview?

“What brought you to the clinic today?”

“Would you describe your overall health as good?”

“Do you understand what is happening?”

“Is there anything else you would like to tell me?”

By asking the client if there is anything else. the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.

Explanation

By asking the client if there is anything else. the nurse allows the client to end the interview by discussing feelings and concerns. Asking about what brought the client to the clinic is an ambiguous question to which the client may answer “my car” or any similarly disingenuous reply. Asking if the client describes his overall health as good is a leading question that puts words in his mouth. Asking if the client understands what is happening is a yes-or-no question that can elicit little information.

2. Miggy. a 6-year-old boy. received a small paper cut on his finger. his mother let him wash it and apply small amount of antibacterial ointment and bandage. Then she let him watch TV and eat an apple. This is an example of which type of pain intervention?

Pharmacologic therapy

Environmental alteration

Control and distraction

Cutaneous stimulation

The mothers actions are example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. Pharmacologic agents for pain analgesics — were not used. The home environment was not changed. and cutaneous stimulation. such as massage. vibration. or pressure. was not used.

Explanation

The mothers actions are example of control and distraction. Involving the child in care and providing distraction took his mind off the pain. Pharmacologic agents for pain analgesics — were not used. The home environment was not changed. and cutaneous stimulation. such as massage. vibration. or pressure. was not used.

3. Which assessment data should the nurse include when obtaining a review of body systems

Brief statement about what brought the client to the health care provider

Client complaints of chest pain. dyspnea. or abdominal pain

Information about the client’s sexual performance and preference

The client’s name. address. age. and phone number

Client complaints about chest pain. dyspnea. or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client’s perceptions of major body system functions. including cardiac. respiratory. and abdominal. The client’s name. address. age. and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client’s sexual performance and preference addresses past health status.

Explanation

Client complaints about chest pain. dyspnea. or abdominal pain are considered part of the review of body systems. This potion of the assessment elicits subjective information on the client’s perceptions of major body system functions. including cardiac. respiratory. and abdominal. The client’s name. address. age. and phone number are biographical data. A brief statement about what brought the client to the health care provider is the chief complaint. Information about the client’s sexual performance and preference addresses past health status.

4. For which time period would the nurse notify the health care provider that the client had no bowel sounds?

2 minutes

3 minutes

4 minutes

5 minutes

To completely determine that bowel sounds are absent. the nurse must auscultate each of the four quadrants for at least 5 minutes; 2. 3. or 4 minutes is too short a period to arrive at this conclusion.

Explanation

To completely determine that bowel sounds are absent. the nurse must auscultate each of the four quadrants for at least 5 minutes; 2. 3. or 4 minutes is too short a period to arrive at this conclusion.

5. Christine Ann is about to take her NCLEX examination next week and is currently reviewing the concept of pain. Which scientific rationale would indicate that she understands the topic?

Pain is an objective sign of a more serious problem

Pain sensation is affected by a client’s anticipation of pain

Intractable pain may be relieved by treatment

Psychological factors rarely contribute to a client’s pain perception

Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Psychological factors contribute to a client’s pain perception. In many cases. pain results from emotions. such as hostility. guilt. or depression.

Explanation

Phases of pain experience include the anticipation of pain. Fear and anxiety affect a person’s response to sensation and typically intensify the pain. Intractable pain is moderate to severe pain that cannot be relieved by any known treatment. Pain is a subjective sensation that cannot be quantified by anyone except the person experiencing it. Psychological factors contribute to a client’s pain perception. In many cases. pain results from emotions. such as hostility. guilt. or depression.

6. When evaluating a client's adaptation to pain. which behavior indicates appropriate adaptation?

The client distracts himself during pain episodes.

The client denies the existence of any pain.

The client reports no need for family support.

The client reports pain reduction with decreased activity.

Distraction is an appropriate method of reducing pain. Denying the existence of any pain is inappropriate and not indicative of coping. Exclusion of family members and other sources of support represents a maladaptive response. Range-of-motion exercises and at least mild activity. not decreased activity. can help reduce pain and are important to prevent complications of immobility.

Explanation

Distraction is an appropriate method of reducing pain. Denying the existence of any pain is inappropriate and not indicative of coping. Exclusion of family members and other sources of support represents a maladaptive response. Range-of-motion exercises and at least mild activity. not decreased activity. can help reduce pain and are important to prevent complications of immobility.

7. Beginning in their 20s. women should be told about the benefits and limitations of breast self-exam (BSE). Which scientific rationale should the nurse remember when performing a breast examination on a female client?

One half of all breast cancer deaths occur in women ages 35 to 45

The tail of Spence area must be included in self-examination

The position of choice for the breast examination is supine

A pad should be placed under the opposite scapula of the breast being palpated

The tail of Spence. an extension of the upper outer quadrant of breast tissue. can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides. above head. and on the hips is also recommended. A pad is placed under the ipsilateral (e.g.. same side) scapula of the breast being palpated.

Explanation

The tail of Spence. an extension of the upper outer quadrant of breast tissue. can develop breast tumors. This area must also be included in breast self-examination. One half of all women who die of breast cancer are older than age 65. The correct position for breast self-examination is not limited to the supine position; the sitting position with hands at sides. above head. and on the hips is also recommended. A pad is placed under the ipsilateral (e.g.. same side) scapula of the breast being palpated.

8. Mr. Lim. who has chronic pain. loss of self-esteem. no job. and bodily disfigurement from severe burns over the trunk and arms. is admitted to a pain center. Which evaluation criteria would indicate the client's successful rehabilitation?

The client remains free of the aftermath phase of the pain experience.

The client experiences decreased frequency of acute pain episodes.

The client continues normal growth and development with intact support systems.

The client develops increased tolerance for severe pain in the future.

Even though the client may experience an aftermath phase. progress is still possible. as is effective rehabilitation. Aftermath reactions may occur but need not interfere with rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably would produce less pain tolerance.

Explanation

Even though the client may experience an aftermath phase. progress is still possible. as is effective rehabilitation. Aftermath reactions may occur but need not interfere with rehabilitation. Acute pain is not expected at this stage of recovery. Conditioning probably would produce less pain tolerance.

9. Evaluating the apical pulse is the most reliable noninvasive way to assess cardiac function. Which is the best area for auscultating the apical pulse?

Aortic arch

Pulmonic area

Tricuspid area

Mitral area

The mitral area (also known as the left ventricular area or the apical area). the fifth intercostal space (ICS) at the left midclavicular line. is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.

Explanation

The mitral area (also known as the left ventricular area or the apical area). the fifth intercostal space (ICS) at the left midclavicular line. is the best area for auscultating the apical pulse. The aortic arch is the second ICS to the right of sternum. The pulmonic area is the second intercostal space to the left of the sternum. The tricuspid area is the fifth ICS to the left of the sternum.

10. Which statement represents the best rationale for using noninvasive and non-pharmacologic pain-control measures in conjunction with other measures?

These measures are more effective than analgesics.

These measures decrease input to large fibers.

These measures potentiate the effects of analgesics.

These measures block transmission of type C fiber impulses.

Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. They potentiate the effect of analgesics. No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Decreased input over large fibers allows more pain impulses to reach the central nervous system. There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures.

Explanation

Noninvasive measures may result in release of endogenous molecular neuropeptides with analgesics properties. They potentiate the effect of analgesics. No evidence indicates that noninvasive and nonpharmacologic measures are more effective than analgesics in relieving pain. Decreased input over large fibers allows more pain impulses to reach the central nervous system. There is no connection between type C fiber impulses and noninvasive and nonpharmacologic pain-control measures.