A nurse is performing a cultural assessment using the LEARN mnemonic for communication. Which area will the nurse assess for the "L" portion of the mnemonic?

Leave

Leverage

Listen

Look

Liken

Answer and Explanation

The Correct Answer is C

A. "Leave" is not a part of the LEARN mnemonic.
B. "Leverage" is also not included in the LEARN mnemonic.
C. "Listen" is the correct answer; it encourages active listening to understand the client’s cultural needs and perspectives.
D. While "Look" may imply observation, it is not a component of the LEARN mnemonic.
E. "Liken" is not part of the LEARN mnemonic and is not relevant here.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.
B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.
C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.
D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.
E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.

A. barrel chest B. respiratory rate of 22 per minute C. Oral cyanosis D. decreased lung sounds on expiration E. Pursed-lip expiration

Correct Answer is C

Explanation

A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.

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A nurse is performing a cultural assessment using the LEARN mnemonic for communication. Which area will the nurse assess for the "L" portion of the mnemonic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed with peripheral arterial insufficiency to the right leg. Which of these findings would the nurse expect to find with this condition?

Correct Answer is A

Explanation

Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

Correct Answer is C

Explanation

A nurse is preparing to suction a client. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?

Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

In which position would the nurse place a 20 year old adult with asthma who is short of breath?

The nurse is caring for a client admitted with pneumonia. The patient has a history of smoking 10 cigarettes per day for 30 years. What is the pack year amount? Use numbers only in your answer. No letters.