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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Correct Answer is B

Explanation

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

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 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?

The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?

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?

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?

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.

When teaching a health promotion class at a retirement home for individuals 65 or greater, which information would the nurse include about ways to decrease the spread of respiratory infections?

The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.