EAQs Unit one that I missed
Which available staff member would be best for the nursing manager to assign to take frequent vital signs for a client with suspected shock? 1. registered nurse 2. nursing student 3. licensed practical nurse 4. unlicensed assistive personnel
1. registered nurse
which disorder would the nurse suspect in the client who has blue nail beds? Thrombocytopenia Polycythemia vera Iron-deficiency anemai Cardiopulmonary disease
CD
Which questions would the nurse initially ask to conduct a culturally competent assessment interview? Select all that apply. Can you tell me about the reasons for coming here today? What do you believe is the cause of your depression? Does religion have a role in your perception of health and wellness? DO you believe that we can help you with mental health issues? Have you ever sought treatment for mental health problem before?
Can you tell me about the reasons for coming here today? What do you believe is the cause of your depression? Does religion have a role in your perception of health and wellness? Have you ever sought treatment for mental health problem before?
When obtaining a health history from a newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include in this initial assessment? Pain history including location, intensity, and quality Clients purposeful body movement in arranging papers on the bedside table Pain pattern including precipitating and alleviating factors vital signs, such as increased BP and HR The client's family statement about increases in pain with ambulation
Pain history including location, intensity, and quality Pain pattern including precipitating and alleviating factors (not vital signs bc they are physiological responses to pain and not a direct evaluation. pain is a subjective experience)
Which person is at the greatest risk for a mental health crisis? The individual who has no family and very few friends The individual who has had many losses over a lifetime the individual who has a highstress job with many responsibilities The individual who has limited coping skills and stress is ongoing
The individual who has limited coping skills and stress is ongoing
Which component is important in a neurovascular assessment performed by the nurse? select all that apply orientation capillary refill pupillary response respiratory rate pulse and skin temperature movement and sensation
capillary refill pulse and skin temperature movement and sensation
Which information would the nurse document in the medical record regarding a client's reported allergies? Select all that apply. Medication names Date of allergic reaction Type of allergic reaction family history of allergies Epinephrine used for allergic reaction
medication names type of allergic reaction epinephrine used for allergic reaction
an RN is caring for an older client who has been admitted to the hospital. The RN allocates several tasks to the unlicensed assistive personnel. To evaluate the understanding of the UAP, the RN asks the UAP to describe what tasks have been allocated. Which response by the UAP indicate effective understanding of the tasks? Select all that apply. I must assist the client with oral care I must assess the client's health status I must administer intravenous mediation I must give a sponge bath to the client every morning I must record the blood pressure of the client at regular intervals
oral care sponge bath vital signs
Which communication technique is part of therapeutic communication? asking for explanations showing sympathy to the client asking personal questions of the client providing relevant information to the client
providing relevant information to the client
Findings expected when assessing the skin of older adults? select all that apply scaly skin tenting of skin transparent skin increased wrinkles pigmented lesions
tenting of skin transparent skin increased wrinkles pigmented lesions
What possible causes could a nurse associate with dry skin? select all that apply. use of hard soap frequent bathing using of tanning pills presence of an allergy use of petroleum products
use of hard soap frequent bathing
Which symptoms indicate hyperthermia? select all that apply vasodilation dry and flushed skin pale and cyanotic skin decreased capillary refill decreased urinary output
vasodilation dry and flushed skin decreased urinary output
Which client does the nurse suspect as having an iron deficiency? A: clubbing (nail base is spongy) B: koilonychia (flattening of the nail plate C: beau's grooves (caused by growth arrest) D: pitting (small, multiple pits)
B: flattening of the nail plate with an increased smoothness of the nail surface
Which statement made by the client would indicate to the nurse that teaching has been effective regarding the management of lower back pain? Select all that apply I should sleep in a prone position I should sleep with my legs out straight I should keep a check on my body weight I should stop exercising if the pain becomes severe I should exercise by leaning forward without bending the knees
I should keep a check on my body weight I should stop exercising if the pain becomes severe
The nurse is caring for a child who has undergone laparoscopic appendectomy. What interventions would the nurse document on the child's clinical record? Select all the apply Intake and output Measurement of pain tolerance of low-residue diet frequency of dressing changes presence or absence of bowel sounds
intake and output measurement of pain presence or absence of bowel sounds