Focused assessment 2 Prep U
A client, who attempted suicide 5 years ago with an overdose, was brought to the emergency department (ED) by a friend. The client states, "I just don't feel like living anymore. No one would care if I lived or died." What question should the nurse ask next? a."Do you have a plan for suicide at this time?" b."What major losses have you experienced in the past 6 months?" c."Have you experienced any major life crises in the past 6 months?" d."Do you feel angry, overwhelmed, or hopeless?"
a
A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods? a.Listen with the stethoscope at the fifth intercostals space left mid-clavicular line b.Listen with the stethoscope at the fifth intercostals space at the sternum c.Listen with a stethoscope at the neck to the right of the cricoid process d.Listen with a stethoscope at the second intercostal space left sternum
a
A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's: a. peripheral pulses. b.liver. c. lymph nodes. d.thyroid gland.
a
During which of the following assessments should the nurse use the bell of the stethoscope during auscultation? a. Auscultation of a patient's heart murmur b.Auscultation of a patient's apical heart rate c.Auscultation of a patient's breath sounds d.Auscultation of a patient's bowel sounds
a
The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? a. Each lub-dub is one beat. b.Each lub-dub is two beats. c.Heart sounds are caused by the opening of heart valves. dThe lub-dub sounds occur within 2 seconds of each other.
a
The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of? a. Crackles b.A friction rub c.Sonorous wheeze d.Sibilant wheeze
a
Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? a.Wheezes b.Fine crackles c.Pleural friction rub d.Stertorous breathing
a
When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following? a.Crackles b.Vesicular c.Wheezes d.Rales
a
Which statement correctly explains a person's interactions with basic human needs? a. As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier. b. Basic human needs and responses to stress are generalized. c. Basic human needs and responses to stress are unaffected by sociocultural backgrounds, priorities, and past experiences. d. Stress affects all people in their attainment of basic human needs in the same manner.
a
Which type of chest configuration is typical of the patient with COPD? a.Barrel chest b.Pigeon chest c.Flail chest d.Funnel chest
a
While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? a.bronchial b.bronchovesicular c.vesicular d.adventitious
b
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears? a.increased decisiveness b.problem-focused coping style c.increase in social interactions d.disturbance in his sleep patterns
d
A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs? a."It must have been a frightening experience to be in an accident." b."Accidents can result in all kinds of feelings. It must have been scary." c."I'll stay with you in case you would like to share your feelings with me." d."There is nothing physically wrong with you. You need to stop breathing so rapidly."
d
An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care? a.Determine whether the adolescent has had trouble adjusting to a stressful event. b.Determine whether the adolescent has had intermittent episodes of euphoria. c.Determine whether the adolescent's mood is related to a lack of sun exposure. d.Determine whether the adolescent has developed a plan for committing suicide.
d
The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation? a.By hemodynamic monitoring b.By checking for cardiac dysrhythmias c.By observing the patient for bleeding d.By checking peripheral pulses
d
