Physiological Adaptation Assessment

A client sustained a shoulder injury after falling from a stepladder.

What nursing assessment finding is the best indication that the shoulder has been dislocated?

A 23-year-old client is admitted to the hospital with a tentative diagnosis of meningitis. 

If the diagnosis is accurate, what nursing assessment findings support the diagnosis? Select all that apply.

A high school chemistry student is splashed in the eyes with a chemical. The school nurse is immediately called to the lab and meets the client at the eye wash station.

What information is most important for the school nurse to obtain from the client initially?

After suffering head trauma, a client develops signs and symptoms of diabetes insipidus. 

What characteristic symptom of the client’s disorder would the nurse expect to find during an assessment?

A client has been recording blood pressure readings for the health care provider to review. The client asks the nurse why it is important to control hypertension and if there is anything that can be done.

When obtaining a health history from a person at the clinic, what finding strongly suggests that the person is hypertensive? Select all that apply.

While helping a client onto the examination table, the nurse notes that the client has several large protruding leg veins.

What client statement can the nurse attribute to varicose leg veins?

The client returns to the health care provider’s office and the nurse updates the medical record.

What symptom reported by the client to the nurse is the best indicator that complications are developing from this cold?

A client who has been taking an antibiotic for the past 2 weeks reports difficulty in eating and swallowing.

Upon completion of an oral assessment to provide to the health care provider, which objective data would indicate a candidal infection is causing the oral symptoms?

A client is admitted to the hospital with signs and symptoms suggesting cholecystitis. As the nurse takes the client’s admission history, dietary preferences are discussed.

When the nurse performs a pain assessment, if the client’s symptoms are due to gallbladder disease, where is the client likely to report experiencing referred pain?

A client with type 1 diabetes mellitus reports having urinary problems.

When the nurse interviews the client, what symptom(s) will the client most likely report if a bladder infection has been acquired? Select all that apply.

During a presurgical assessment, a 67-year-old woman tells the nurse that she has felt a lump in her left breast for the past 6 months.

What characteristic of the breast anomaly suggests to the nurse that the lump may be cancerous?

A client with a persistent upper respiratory infection develops acute bronchitis.

Aside from the characteristics of the client’s cough, what other pertinent assessment finding should the nurse document?

A 67-year-old client has developed venous stasis injuries on the lower leg.

When managing the nursing care for the client with stasis injuries, what intervention is essential in promoting venous circulation?

A surgical repair of the myelomeningocele is successfully completed. 

Unless the health care provider prescribes otherwise, in what position should the nurse place the infant during the postoperative period?

A 7-year-old child is admitted to the hospital with possible rheumatic fever.

Upon reviewing the child’s history with the parents, what is most closely correlated with an increased risk of rheumatic fever?

An adolescent parent brings the 6-month-old infant to the clinic. The parent tells the nurse that the infant cries a lot, and the parent is concerned that the infant is not eating well. 

What information about the infant’s well-being is most important for the nurse to collect initially?

An anonymous caller phones the emergency department and asks the nurse how to tell if someone has been smoking marijuana within the past few hours. 

What physical sign(s) of recent marijuana use should the nurse identify for the caller? Select all that apply.

The shoulder dislocation will be treated by a closed reduction.

Which physical change is anticipated when the closed reduction is successfully completed?

A spinal tap will be performed to confirm a diagnosis of meningitis.

What nursing intervention is most appropriate after a spinal tap has been performed?

The school nurse prepares to irrigate the student’s irritated eye. 

What solution is best for the school nurse to use when irrigating the student’s eye at this time?

After suffering head trauma, a client develops signs and symptoms of diabetes insipidus.

When the nurse collects a specimen of urine, what urine characteristic does the nurse anticipate?

The nurse advises a person at the clinic to seek medical attention immediately following blood pressure readings of 206/110 mm Hg and 198/104 mm Hg.

When a person with hypertension is assessed, what finding is the best indication that the client’s heart has been affected by sustained high blood pressure?

The client is scheduled for a ligation and vein-stripping procedure as treatment for varicose veins.

The client asks the nurse how the blood in the lower legs will circulate after surgery. What nursing response is accurate?

The client is advised to undergo allergy skin testing and grading for level of response. Weekly injections for desensitization are prescribed.

What nursing assessment is an early indication that the client is developing anaphylaxis?

The client asks the nurse about the source of the oral infection.

The nurse correctly explains that most individuals acquire candidiasis (thrush) by what means?

A 45-year-old client is suspected of having cholecystitis. 

When obtaining a history from a client with cholelithiasis, when can the nurse expect the client to report experiencing pain?

A client with type 1 diabetes mellitus reports having urinary problems.

What nursing information best explains to a client with diabetes the reason why the client is at higher risk for acquiring a bladder infection?

A 1-week-old newborn who was born with hydrocephalus is scheduled for surgery. 

When assessing the client preoperatively, what finding is anticipated?

Twenty-four hours after surgery, the health care provider writes prescriptions to discontinue the morphine epidural, I.V. therapy, and indwelling catheter, and to administer the combination drug oxycodone and acetaminophen two tablets P.O. every 3 to 4 hours p.r.n. for pain. The health care provider also removes the abdominal dressing and says the client may shower and ambulate as tolerated.

What assessment finding is the best indication that an infection is present in the abdominal incision line?

A 7-year-old child is admitted to the hospital with possible rheumatic fever.

When communicating the results of the assessment data with the health care provider, what finding is stressed as most indicative of a client with rheumatic fever?

A client arrives at the emergency room with a right shoulder injury, which occurred during aggressive training at the gym.

When preparing the client for a medical assessment, which characteristic indicates a torn rotator cuff?

The client with Guillain-Barré syndrome begins to have difficulty swallowing food.

What nursing measure should the nurse anticipate for providing adequate nutrition for the client at this time?

The nurse re-evaluates the student’s eye 48 hours later. The student still reports eye discomfort, and redness is noted across the sclera.

When a small foreign body becomes embedded in a client’s eye, what nursing action should be taken first before referring the client for emergency treatment?

The nurse is assessing a client who is experiencing signs and symptoms of acromegaly. 

During physical assessment, what documented finding does the nurse identify as a clinical manifestation of acromegaly?

To reduce a client’s hyperlipidemia, a client is advised to follow a low-cholesterol diet.

When the client asks the nurse how cholesterol acts as a cardiac risk factor, the best explanation is that excess fat in the blood:

A 67-year-old client has developed venous stasis injuries on the lower leg. 

When assessing the client’s lower leg, what findings characteristic(s) of venous stasis injuries is the nurse most likely to find? Select all that apply.

The client is advised to undergo allergy skin testing and grading for level of response. Weekly injections for desensitization are prescribed.

The client experiencing a severe allergic reaction becomes pulseless. The nurse shakes the client, shouts the client’s name but gets no response, and activates the emergency medical response system. What nursing action becomes the next priority?

A 70-year-old client is referred for suspected oral cancer after a routine dental examination.

If the client is typical of others with this diagnosis, what contributing factor is the nurse most likely to find when reading the medical history?

A 45-year-old client is suspected of having cholecystitis.

If gallstones obstruct the flow of bile, how would the nurse expect the client’s stools to appear?

A client with type 1 diabetes mellitus reports having urinary problems.

When the nurse reviews the results of the client’s urinalysis, what substance in the urine is most suggestive of a bladder infection?

A 16-year-old client confides to the school nurse that she has cramps that accompany the onset of menstruation.

What nursing recommendation is best for initially validating that the client is experiencing premenstrual syndrome (PMS)?

When reviewing the client’s medical records, the nurse notes that the client’s rubella titer is low (<1:10) and the client is scheduled to receive the rubella vaccine before discharge.

What finding by the nurse is most suggestive of cystitis in the postpartum client?

A ventriculoperitoneal (V/P) shunt is placed on the right side of the infant’s head.

What sign is the best indication that the infant is developing increased intracranial pressure?

The parents question how their child got rheumatic fever and ask if the child can get it again. The nurse teaches the parents the disease process and potential consequences in the future.

If the child develops shortness of breath when ambulating to the bathroom in the hospital, what intervention should the nurse add to the care plan?

A 15-year-old girl is being treated for bulimia in an eating disorder unit.

When reviewing the assessment data, the nurse would recognize what finding to be a characteristic physical finding of this eating disorder?

An x-ray of the injured teenager’s leg reveals a comminuted fracture of the distal tibia. 

What nursing explanation can best help this client understand the injury that has occurred?

A 23-year-old client who experienced a generalized seizure while at work is admitted to the hospital for diagnostic testing.

What nursing assessments indicate an autonomic nervous system manifestation of a seizure?

An unlicensed assistive personnel confides to the nurse that a family member needs eyeglasses. 

When a nurse assesses a client with astigmatism, what statement aligns most closely with the diagnosis?

Because medical treatment was unsuccessful, the client with acromegaly is scheduled for a transsphenoidal hypophysectomy. 

The night before surgery, the nurse provides the client with information about what to expect during the postoperative period. What statement by the client indicates a misunderstanding of the expected surgical outcome?

A client with coronary artery disease (CAD) experiences periodic chest pain and is diagnosed with angina pectoris.

If the client is typical of others who have angina pectoris, the nurse would expect the client to report that chest pain is best relieved by what nonpharmacological measure?