N391 Summer Exam 2 391-900 Pierre - Adelphi University
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Free N391 Summer Exam 2 391-900 Pierre - Adelphi University Questions
During a comprehensive assessment, the nurse identifies that the client is at risk for pressure injuries using the Braden Scale. What findings did the nurse identify? Select all that apply.
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Poor nutrition
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Moisture
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Pain
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Altered sensory perception
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Warmth
Explanation
The Braden Scale assesses six risk factors for pressure injury development: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Poor nutrition, excess moisture (e.g., incontinence, perspiration), and altered sensory perception (inability to feel/respond to pressure-related discomfort) are all direct components of this standardized risk assessment tool.
Why the other options are incorrect:
C. Pain — Pain is not one of the six subscales included in the Braden Scale.
E. Warmth — Skin warmth/temperature is not a Braden Scale risk factor category.
Physical Exam:
- Alert & oriented X 4, appears slightly anxious
- Skin warm, dry & intact
- Heart rate regular @ 102 beats/minute
- Respirations unlabored, 14 breaths/minute, crackles at bases bilaterally
- Abdomen soft, non-tender, bowel sounds active x 4 quadrants
- 4+ pitting pedal and pretibial edema
- Weight 188 lbs (documented weight gain of 8 pounds since last visit 2 weeks ago)
Which of the assessment findings listed below are most concerning and require priority nursing follow up? Select four (4) answers that apply.
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4+ pitting pedal & pretibial edema
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Awakening at night with shortness of breath
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Weight gain
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Crackles in bilateral lung bases
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States he is anxious
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Heart rate
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Change in appetite
Explanation
Correct Answer:
(B, C, D, F) Tenderness upon palpation/percussion of the sinuses; Purulent nasal discharge; Swollen and red nasal mucosa; No transillumination of the sinuses. These four findings together reflect the classic presentation of acute sinusitis: tenderness reflects inflamed sinus tissue, purulent discharge indicates active infection, swollen and red nasal mucosa reflects local inflammation, and reduced or absent transillumination occurs because inflamed, fluid- or mucus-filled sinuses block the normal passage of light.
Why Other Options are Incorrect:
A. Shortness of breath is not a localized finding associated with acute sinus inflammation and instead suggests a lower respiratory or cardiopulmonary process.
E. Clear, watery nasal discharge is more typical of allergic rhinitis or a viral upper respiratory infection, not the purulent discharge characteristic of acute bacterial sinusitis.
A nurse is performing a neurologic assessment. The client states that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as an abnormal finding?
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Sensory function
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Position sense
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Balance
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Motor function
Explanation
This scenario describes stereognosis, the ability to identify an object by touch alone. The client's inability to correctly identify a familiar object placed in the hand indicates an abnormality in sensory function, specifically the tactile/discriminative sensory pathway.
Why the other options are incorrect:
B. Position sense — Position sense (proprioception) refers to awareness of joint and limb position in space, tested differently (e.g., moving a finger up or down with eyes closed), not object identification.
C. Balance — Balance relates to vestibular and cerebellar function, tested with gait and Romberg testing, not tactile object recognition.
D. Motor function — Motor function refers to muscle strength and movement, not the client's ability to identify an object by touch.
A nurse is assessing a patient who has heart failure. Which of the following findings should the nurse be alert for during assessment? Select ALL that apply.
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Dyspnea.
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Excessive body hair growth.
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Dependent edema.
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Thin upper and lower extremities.
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Orthopnea.
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Distended jugular veins with the patient sitting up 45 degrees.
Explanation
Correct Answer: (A, C, E, F) Dyspnea occurs in heart failure because the heart cannot pump effectively, leading to fluid buildup in the lungs and impaired gas exchange. Dependent edema develops due to fluid retention and increased hydrostatic pressure in the venous system from reduced cardiac output, causing swelling in areas affected by gravity, such as the legs and ankles. Orthopnea, difficulty breathing while lying flat, occurs because lying down redistributes fluid to the lungs, worsening respiratory symptoms in heart failure. Distended jugular veins, especially when observed with the patient sitting up at 45 degrees, indicate elevated central venous pressure and fluid overload associated with right-sided heart failure.
Why the other options are incorrect:
B. Excessive body hair growth. This finding is not associated with heart failure and is more indicative of endocrine disorders such as Cushing's syndrome or hormonal imbalances.
D. Thin upper and lower extremities. Heart failure is more commonly associated with edema and fluid retention in the extremities rather than thinning, which may instead suggest muscle wasting from other chronic conditions.
The nurse cares for a 19-year-old wheelchair-bound male who has come to the clinic with his mother for a routine checkup.
Nurses Note: 1000: Client received for routine checkup accompanied by mother with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x3. Denies pain or any problems. Mother is concerned about "red area on his left heel."
Complete from the choices below to specify what condition the client is most likely experiencing. Choose two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action To Take options: Administer Vitamin A topically / Elevate heels / Perform wound care / Apply compression stockings
Potential Condition options: Venous stasis ulcer / Skin rash / Pressure injury / Skin cancer
Parameter to Monitor options: Signs of infection / Depth of wound / Distribution of rash / Lower extremity edema / Extent of scaling of lesions
Correct selections:
- Potential Condition: Pressure injury
- Action To Take: Elevate heels; Perform wound care
- Parameter to Monitor: Signs of infection; Depth of wound
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Potential Condition: Pressure injury
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Action To Take: Elevate heels; Perform wound care
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Parameter to Monitor: Signs of infection; Depth of wound
Explanation
This client has paraplegia with absent sensation below the waist and is wheelchair-bound, placing him at high risk for pressure injuries since he cannot feel prolonged pressure on bony prominences like the heel and cannot reposition himself in response to discomfort. Elevating the heels off the bed or surface relieves pressure on the affected area and prevents further tissue breakdown, while performing appropriate wound care supports healing and reduces infection risk. Monitoring for signs of infection is essential given the open wound, and tracking the depth of the wound helps the care team assess whether the injury is worsening or healing over time.
Venous stasis ulcer, skin rash, and skin cancer do not fit this presentation, since there is no evidence of chronic venous insufficiency findings, a rash, or a lesion consistent with malignancy. Administering topical Vitamin A and applying compression stockings are not appropriate interventions for a pressure injury, and distribution of rash, lower extremity edema, and extent of scaling of lesions are not the relevant parameters to track for this wound.
An adult client has come into the walk-in clinic with a two-day history of stool that is "black and sticky." Which of the following should the nurse consider as a potential etiology/cause for this change in stool color and consistency? Select all that apply.
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The patient may have taken an over-the-counter medication containing bismuth subsalicylate.
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The patient may have a gastrointestinal bleed.
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The client may be taking oral iron supplements.
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The patient may have possible vitamin B12 deficiency.
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The patient may have added too much fiber to their diet.
Explanation
Correct Answer: (A, B, C) Bismuth subsalicylate, found in medications like Pepto-Bismol, is well known to cause black stools as a harmless side effect. A gastrointestinal bleed, particularly from the upper GI tract, causes melena, which presents as black, tarry, sticky stool due to the digestion of blood. Oral iron supplements are also a common cause of black stools due to the way iron is metabolized in the digestive tract.
Why the other options are incorrect:
D. The patient may have possible vitamin B12 deficiency. Vitamin B12 deficiency does not cause changes in stool color and is not associated with black, sticky stools.
E. The patient may have added too much fiber to their diet. Increased fiber intake affects stool bulk and frequency but does not cause black or sticky stool changes.
A 54-year-old truck driver reports "chest burning" after meals and when lying down. He has a history of working long hours on the road, is divorced, smokes 1 PPD for 17 years, drinks 3 beers nightly and eats meals from highway rest stops. He has a BMI of 36, takes Eliquis 10mg everyday for atrial fibrillation and has obstructive sleep apnea. He reports not being compliant with the CPAP machine. Which of the following increase the risk of gastroesophageal reflux disease? Select all that apply.
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Alcohol use.
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Smoking.
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Obesity.
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Regular physical activity.
Explanation
Correct Answer: (A, B, C) Alcohol use relaxes the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus more easily. Smoking similarly weakens the lower esophageal sphincter and reduces saliva production, which normally helps neutralize acid, increasing GERD risk. Obesity, reflected by this client's BMI of 36, increases intra-abdominal pressure, which promotes reflux of stomach contents into the esophagus.
Why the other options are incorrect:
D. Regular physical activity. Regular physical activity is generally protective and associated with a lower risk of GERD, as it supports healthy weight management and digestion, rather than increasing risk.
A client reports a three (3) day history of productive cough, shortness of breath, fatigue, and intermittent wheezing.
Objective findings include heart rate of 110, oral temperature of 102.5°F, respiratory rate of 24.
The nurse plans a focused assessment. Which system should the nurse plan as a priority?
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Mouth and Throat
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Cardiovascular
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Neurologic
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Thorax and Lungs
Explanation
Correct Answer:
D
Why the other options are incorrect:
A. While a mouth and throat assessment may be part of a broader exam, it is not the priority given this client's primary respiratory symptom cluster.
B. Although the elevated heart rate warrants monitoring, it is most likely a compensatory response to the underlying respiratory illness and fever, making the lungs the priority system to assess first.
C. There are no neurologic symptoms described in this scenario, making this a lower priority than the respiratory assessment.
For each nursing action, indicate whether it is appropriate or inappropriate when assessing the carotid arteries.
Ask the client to hold their breath briefly while listening for a bruit. A. Appropriate. B. Inappropriate.
Palpate one carotid artery at a time. A. Appropriate. B. Inappropriate.
Palpate both carotid arteries simultaneously. A. Appropriate. B. Inappropriate.
Auscultate with the bell of the stethoscope for a bruit. A. Appropriate. B. Inappropriate.
Use the diaphragm of the stethoscope to assess for a bruit. A. Appropriate. B. Inappropriate.
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Appropriate
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Appropriate
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Inappropriate
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Appropriate
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Inappropriate
Explanation
Correct Answers: Appropriate, Appropriate, Inappropriate, Appropriate, Inappropriate. Asking the client to hold their breath briefly while listening for a bruit helps eliminate breath sounds that could interfere with hearing the turbulent flow of a bruit. Palpating one carotid artery at a time is the correct technique, as it prevents simultaneous compression of both arteries. Palpating both carotid arteries simultaneously is inappropriate because it risks significantly reducing cerebral blood flow. Carotid bruits are low-pitched sounds best detected using the bell of the stethoscope lightly placed against the skin, making diaphragm use inappropriate for this specific assessment.
A nurse is performing a comprehensive HEENT assessment on a 62-year-old patient who recently immigrated to the US. The patient is from a culture that strongly emphasizes holistic health practices, including herbal remedies, spiritual balance, and ancestral healing traditions.
During the assessment, the patient mentions using several natural treatments before seeking medical care.
The patient expresses a preference for approaches that "treat the whole person rather than just the illness."
Which action by the nurse demonstrates culturally competent assessment?
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Use medical terminology to ensure the patient understands the clinical terminology used during the exam.
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Ask the patient to describe their traditional healing practices and explore how these beliefs may influence their perception of symptoms and treatment choices.
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Document the patient's statements but continue the exam focusing only on physical findings and diagnostic indicators.
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Explain that Western medical treatments are more effective and should take priority over cultural practices.
Explanation
Correct Answer:
(B) Ask the patient to describe their traditional healing practices and explore how these beliefs may influence their perception of symptoms and treatment choices. Culturally competent care requires the nurse to actively explore and understand the patient's health beliefs and traditional practices, since these beliefs directly shape how the patient perceives illness, communicates symptoms, and engages with treatment recommendations.
Why Other Options are Incorrect:
A. Using clinical jargon does not demonstrate cultural competence and can create a communication barrier rather than fostering understanding.
C. Documenting but disregarding the patient's beliefs fails to integrate this important context into the overall assessment and care plan.
D. Dismissing the patient's cultural practices as inferior is disrespectful and directly undermines culturally competent, patient-centered care.
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