Exam 2
The nurse is documenting client care. Which nursing assessment note would be appropriate? "Client sleeping." "Client voices concerns about being able to change abdominal dressings at home." "Client does not like her new baby." "Client is a drug seeker."
"Client voices concerns about being able to change abdominal dressings at home."
The mother of a 7 month old attempts to scoop cereal with his palm and reach his mouth, but drops several pieces of cereal on the floor. His mother asks if this feeding behavior is normal. What is the nurse's best response?
"Fine grasp is just now starting to develop at this age."
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this aspect? "My mom's still alive but my dad died 10 years ago of heart failure." "I have a brother with leukemia and a sister with hypertension." "I had surgery 5 years ago to repair an inguinal hernia." "I have been having some pain when I urinate for the last several days."
"I had surgery 5 years ago to repair an inguinal hernia."
A nursing instructor is teaching about the first of Erikson's stages. The nursing student demonstrates understanding of this stage when she states:
"Infants achieve trust when their caregivers consistently meet their needs."
A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries?
"Injuries like yours could have been caused by someone hurting you. Did someone hurt you?"
A elderly, diabetic client comes into the rural community clinic with a foul smelling, old dressing on her foot. The client tells the nurse that it has been on since she was in the hospital 2 weeks ago but she had to miss her follow-up appointments. What is the best response by the nurse? "You are going to have to have an amputation of that foot if you keep missing your appointments" "We will be unable to adequately treat you if you do not follow-up with the doctor." "Is transportation a problem for you? If so, let's find out what we do to get you here for your follow-up visits" "Call someone to come and get you. You have to be here on your next scheduled visit."
"Is transportation a problem for you? If so, let's find out what we do to get you here for your follow-up visits"
A nursing assistant working in a small rural hospital, states to the charge nurse, "The Jewish client in room 124 says that they are not able to eat the food because it is not kosher. That is ridiculous. There is nothing wrong with this food, I eat it!" What is the best response by the nurse? "You are right. If the client is hungry enough they will eat what is given to them." "It is important that we are culturally sensitive to other beliefs. Let's see how we can accommodate the client's food preferences." "You can get in a lot of trouble for saying things like that. You need to be educated on Jewish people and their beliefs." "I will take the client a menu and have them pick food from what we have in the cafeteria."
"It is important that we are culturally sensitive to other beliefs. Let's see how we can accommodate the client's food preferences."
A student nurse says, "I will not be able to do a good spiritual assessment, because I am not very religious." The instructor addresses this issue with which of the following statements? "The client is the focus of the spiritual assessment." "Pretend you are spiritual." "You cannot be a nurse if you are not spiritual." "You should discuss this issue with a chaplain yourself."
"The client is the focus of the spiritual assessment."
A mother brings her 3 year old to the clinic, concerned about her daughter's growth and development. She tells the nurse that her daughter can climb stairs, dress herself, and feed herself, but she cannot draw circles or rectangles like her 5-year-old brother. What should the nurse tell this mother?
"This is normal for this age, because children do not master the fine motor skill of drawing until age 5 years."
The nurse is performing an admission assessment with a client and is questioning the client about religious preference. The client says that they have no religious or spiritual preference. What statement by the nurse demonstrates a non-judgmental attitude? "Religion is very important to me. I don't know what I would do if I were ill and did not have my religion." "Don't you believe in something?" "What provides you strength in dealing with stress or illness in your life?" "I will call the hospital chaplain to talk with you. Maybe they will be able to help you."
"What provides you strength in dealing with stress or illness in your life?"
The nurse is admitting a client to the hospital following a motor vehicle collision in which alcohol may have been a contributing factor. What tool might the nurse use to assess whether alcohol is a problem in this client's life?
CAGE
This type of assessment includes a health history and physical assessment. Comprehensive Focused Ongoing Emergency
Comprehensive
A nurse admits an older adult client to the ED. The client has bruises in various stages of healing; the client also is malnourished and severely dehydrated. The client lives alone with a grandchild who has been taking care of the client for the last 2 years. Of what type of abuse could these findings be an example?
Elder abuse
The nurse notes a teen client to have multiple piercings and wears black clothing. The nurse understands the client is experiencing what stage of Erikson?
Identity
A 26-year-old client tells the nurse that she recently became engaged. She proceeds to inform the nurse that she has never had such a good and loving relationship. This commitment to marriage that the client has made mainly occurs during which stage of development?
Intimacy vs. isolation
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data? Patient centered Subjective Unconfirmed Objective
Objective
When the mental health nurse ask the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination?
Orientation
A nurse interviews a client who reports pain in the chest. The client is accompanied by her husband. During the interview which observation by the nurse may indicate that the client is abused by her partner?
Partner attempts to speak for the client
The nurse in an elevator on the way to the cafeteria shares with a friend information about a client under care. The nurse has violated Patient confidentiality Verbal handoff principles Patient safety Qualities of effective reporting
Patient confidentiality
A teenage girl comes to the clinic with abdominal pain. She is accompanied by her mother. During the interview, the nurse gets the impression that the client wants to talk but is afraid to with her mother in the room. What action by the nurse would best facilitate communication with the adolescent client? Politely ask the mother to wait in the waiting room Try to coax the information from the client without asking the mother to leave Ask the client to write her answers down so that the nurse can read them after the girl and her mother leave Ask the mother to get the information at home and call it in to the clinic
Politely ask the mother to wait in the waiting room
A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process? Wearing casual, neat, and comfortable clothes Ensuring that there are no periods of silence Portraying a neutral and friendly expression Sitting back with crossed arms during the interview
Portraying a neutral and friendly expression
A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this? Primary prevention Secondary prevention Tertiary prevention
Primary prevention
The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing? Situation Background Assessment Recommendation
Recommendation
When taking a telephone order from a physician, the nurse verifies that he or she understands the order by Repeating the order back to the physician. Faxing the written order to the physician's office. Asking the physician to summarize the orders given. Confirming the order with the nurse manager.
Repeating the order back to the physician
A nurse is interviewing a 16-year-old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says, "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "So, you're concerned that you may have a sexually transmitted infection?" Which verbal communication technique is the nurse using here? Open-ended question Rephrasing Laundry list Well-placed phrase
Rephrasing
The client states, "I cannot believe I have breast cancer. I am a good person; I don't know why God is punishing me." The nurse suspects the client is experiencing: Spiritual distress Readiness for enhanced spiritual well-being Impaired social interaction Social isolation
Spiritual distress
A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify the expression's meaning from the client? Tell me what you mean by ________? I think that expression means ____________ That expression is unclear to me Where did you hear that expression?
Tell me what you mean by ________?
When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider?
The client's physical and emotional safety
The nurse is assessing the cognitive functioning of an older adult. Which action by the client demonstrates intact episodic long-term memory?
The older adult accurately describes the first date with his spouse of 50 years.
Which aspects of the mental status exam refer to data about how thoughts connect to one another?
Thought process
What is the primary purpose of health assessment? To gather information about the health status of the client To make judgments about the client's lifestyle and behaviors that contribute to the client's illness To decide on the best way to manage a client's illness based on the nurse's own views and beliefs To help the physician diagnose illness without further testing
To gather information about the health status of the client
"Tell me about your pain" is an example of an open-ended question. True False
True
T or F The experienced nurse understands that active listening is the key element when interviewing a client.
True
The mother of an infant states he cries every times she leaves. She is concerned that there is something wrong. The nurse recognizes the infant is experiencing what stage of Erikson?
Trust
The nurse is performing a health history on a client with mild chest pain who came to the Emergency Department. When asked about his allergies, the client states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a client states an allergy? How many doses did the client take of codeine? What type of reaction did the client experience? Who prescribed the codeine? Who administered the codeine to the client?
What type of reaction did the client experience?
The culturally competent nurse defines culture as which of the following? a demonstration of the characteristics shared by a group of people a shared system of values, beliefs, and learned patterns of behavior a group of individuals characterized by shared biological traits the basic unit of society
a shared system of values, beliefs, and learned patterns of behavior
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is continuous. completed on admission. linear. performed only by nurses.
continuous.
A 50-year-old client tells the nurse that she enjoys babysitting her grandchildren while their parents are attending night classes at the local college. She also shares that on many days she volunteers at a neighborhood food bank. Erikson would most likely place this client as
positively resolving a sense of generativity versus stagnation.
Caitlyn was about 50 cm (20 in.) long at birth and weighed 3 kg (7 lb, 8 oz). At her 1-year well-child checkup, the nurse determines that Caitlyn is 66 cm (26 in.) and weighs 7 kg (16 lb). The nurse's reaction to these assessment findings is to be a. concerned; Caitlyn should have quadrupled her birth weight by now. b. unconcerned; Caitlyn is growing in height and weight at an expected pace. c. concerned because Caitlyn should have tripled her birth weight by now. d. unconcerned because Caitlyn has slightly more than doubled her birth weight.
what do you want from me
Jasmyn, who has just had her second birthday, comes to the well-child clinic for an assessment. The nurse reviews her records and discovers that Jasmyn weighed 3.1 kg (7 lb) at birth. Today, the nurse expects that Jasmyn's weight should be a. 9.5 kg (21 lb). b. 12.7 kg (28 lb). c. 15.9 kg (35 lb). d. 19 kg (42 lb).
what do you want from me
The nurse's response to Emily's length, which is 66 cm (26 in.) now at age 12 months and was 51 cm (20 in.) at birth, is to be a. concerned because Emily should have grown 25 to 30 cm (10 to 12 in.) by now. b. unconcerned because Emily should have grown 15 cm (6 in.) by now. c. concerned because Emily should have doubled her birth length by now. d. unconcerned because Emily should have grown 7.6 to 10 cm (3 to 4 in.) by now.
what do you want from me
