HA, Quiz 1 Exam 1

How many generations back should you collect medical history?

3

A nurse is caring for a group of patients. Which patient will the nurse see first? -A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74. -A 17-year-old male who has just returned from outside "for a smoke" who needs a temperature taken. -A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 -An 87-year-old male suspected of hypothermia whose temperature is below normal

A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 Post-op change in BP, focus on ABC's

A nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? -Intervenes based on priorities of patient care. -Identifies pertinent nursing diagnoses. -Determines whether outcomes have been achieved -Completes a comprehensive database.

Completes a comprehensive database. The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase) and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process

T/F: Aunts and uncles and cousins are part of assessing a pts family health history

False, only blood relatives and aunts and uncles are considered too far removed

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?

Implementation During the implementation step, the nurse carries out the interventions developed in the plan of care, which will assist the nurse and other members of the health care team to monitor the client's progress. Implementation is when the nurse puts the plan of care into action.

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?

Inspection

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Maintain a fair distance between self and client. The nurse should maintain a personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take? -Use the soft end of a cotton swab over the abdomen. -The nurse should apply the soft end of the cotton swab to different points on the skin to assess light touch. The nurse should perform the palpation before completing this action. -Auscultate the tender areas of the abdomen through clothing. -The nurse should not auscultate any areas of the body through clothing because this can cause artifact noises that will interfere with the assessment. -Palpate the tender areas of the abdomen last. -Use a two-point discrimination with a paper clip on the client's abdomen.

Palpate the tender areas of the abdomen last. The client reported abdominal tenderness, so the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client.

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply.) Penlight Tape measure Tongue depressor Needle and syringe Electrocardiogram (ECG) monitor

Penlight is correct. The nurse should use a penlight to inspect the client's pupils and test for pupillary reflexes during the inspection part of the physical examination. Tape measure is correct. The nurse should use a tape measure to measure the size of wounds, bruising, or other abnormalities of the skin during the inspection part of the physical examination. Tongue depressor is correct. The nurse should use a tongue depressor to view the client's uvula and posterior soft palate during the inspection part of the physical examination.

A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take? -The nurse should include factual, accurate, and objective information. -If there are no changes to the client's status, record "status unchanged" in the medical record. -The nurse should use complete descriptions of assessments and care. This type of documentation is subjective and is not reflective of the client's assessment. -After making a documentation error, leave it as is and begin a new entry. -The nurse should correct errors as soon as they occur; information should be accurate and complete.

Record the client's most recent assessment results. -The nurse should include factual, accurate, and objective information. -If there are no changes to the client's status, record "status unchanged" in the medical record. -The nurse should use complete descriptions of assessments and care. This type of documentation is subjective and is not reflective of the client's assessment. -After making a documentation error, leave it as is and begin a new entry.

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture, and abnormalities

What aspect of life is assessed with the FICA approach?

Spirituality- (Faith, Influence, Community, Address)

A nurse has instructed a patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? 'The patient: -The focus of the teaching was on a deficient knowledge related to never using crutches -The patient went up and down stairs -The patient used crutches with no difficulties -The nurse demonstrated the use of crutches

The nurse demonstrated the use of crutches