The nurse is assisting in performing a neurovascular check on a client. Which is the BEST method to use when checking a client’s pupillary reaction to light?

• Turn the light on directly in front of the eye and watch for a response.

• Ask the client to follow the light through the six cardinal positions of gaze.

• Check the people response and then have the client alternate between watching the light and watching the examiner’s finger.

• Instruct the client to look straight ahead and then shine the light on the client, moving it from the temporal area to the eye.

Answer explanation

Option 4 Identifies the correct procedure for checking the clients pupillary reaction to light. Option 1 relates to the pupillary response to light, but shining light directly into the clients eyes without asking the client to focus on a distant object is not an appropriate technique. Option 2 Assesses for eye-movement related to cranial nerves lll, lV, Vl. Option 3 Assesses the accommodation of the eye rather than the eye’s response to light.

A client is asked to describe how she performs breast self examination (BSE). Which statement by the client would indicate the client requires further instruction regarding BSE?

• “ I do the exam usually about 7 days after the start of my period.”

• “I concentrate the exam on my nipples and around it.”

• “ I avoid doing the exam during my period.”

• “I do the exam while taking a shower.”

Answer explanation

The nurse is auscultating the breath sounds of a client. Which technique, if used by the nurse, would indicate a need for further teaching in the use of the stethoscope?

• Using the bell of the stethoscope.

• Asking the client to sit straight up

• Placing the stethoscope directly on the client’s skin

• Having the client breathe slowly and deeply through the mouth

Answer explanation

Which assessment data suggest that the client is at risk for coronary artery disease ( CAD) ?

• Age of 39 years old

• A total cholesterol level of 180 mg/dL

• Fasting blood glucose level of 80 mg/dL

• Resting blood pressure of 139/89 mmHg

Answer explanation

The nurse reviewing the health records of the prenatal clients determines which client as being at risk for gestational hypertensive disorder? SELECT ALL THAT APPLY.

• An Asian client pregnant with twins

• A client diagnosed with a hydatidiform mole

• A client with a past medical history of hypertension

• A client who is 20 years old, gravida 2, weighing 115 pounds

• A client who was diagnosed with diabetes mellitus 10 years previously

Answer explanation

A mother asked the nurse about the safety of attenuated or inactivated vaccines. The nurse should provide which statement BEST address for mother’s concerns?

• “All bacterial toxins have been made inactive by being exposed to high heat”

• “This form a vaccine contains pathogens that have been made inactive by either chemicals or heat.”

• “These vaccines have their virulence (potency) diminished so that they do not produce a full-blown clinical illness”

• “ Such vaccines I’ve been obtained from the pools blood of many people and that provides antibodies to a variety of diseases”

Answer explanation

Killed or inactivated vaccines contain pathogens that have been made inactive by either chemicals or heat. These vaccines, which are noninfectious, cause the body to produce antibodies. Their disadvantage is that they elicit a limited immune response from the body, so several doses are necessary. Examples of this type o vaccine include the Salk polio vaccine, the rabies vaccine, and the pertussis vaccine. Option 1 identifies the toxoids. Option 3 indemnifies human immunoglobulin.

A client is diagnosed with pernicious anemia. The nurse understands that which data collection question will best identify a risk factor associated with the development of this type of anemia?

• “Have you ever had gastric resection surgery?”

• “How much iron do you recommend to get in the diet?”

• “Have you ever been diagnosed with a musculoskeletal disorder?”

• “What, if any, central nervous system disorders have you experienced?”

Answer explanation

The nurse is planning to assist with testing The function of a clients vestibulocochlear nerve. The nurse should gather which items to assist with the performance of the test? SELECT ALL THAT APPLY

• Flashlight

• Audiometer

• Tuning fork

• Cotton wisp

• Ophthalmoscope

Answer explanation

The nurse is assisting with evaluating the deep tendon reflexes of a pregnant client who is receiving magnesium sulfate intravenously. The nurse exposes the woman’s lower leg, places one hand under the woman’s name to raise it slightly off the bed, and uses the percussion hammer to strike the patella tendon just below the patella. The nurse identifies the response as 4+. How should the nurse document this response?

• Normal

• Diminished

• Very brisk or hyperactive

• Increased or brisker than average

Answer explanation

In order to accurately determine the developmental skills of a 1-year-old born two months prematurely, The nurse should anticipate that the child should be able to perform what activity?

• Sit independently

• Walk independently

• Build a tower of three blocks

• Indicate wants by pointing or grunting

Answer explanation