Health Assessment PrepU Ch. 29

Which general survey question focuses on the common "fifth vital sign"?

"Are you experiencing any pain right now?"

When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician?

"I am a registered nurse caring for your client."

Which statement made by a student nurse concerning how to conduct the retrograde filling (Trendelenburg) test indicates that the nurse needs further teaching?

"Observe for normal saphenous vein refill to take 30 seconds."

Which statement represents a clanging speech pattern?

"Peas are good. Trees are wood. I'd leave if I could."

The nurse is preparing an educational program on effective hygiene methods for a group of highschool teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

The nurse is assessing for pain. What should be included in the assessment? Select all that apply.

Location Intensity Alleviating factors Quality

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action?

Enter the room and auscultate the client's lung sounds.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

Fall

The nurse finds the client's abdomen to be distended. The nurse recognize distention may be caused by what? Select all that apply.

Feces Fluid Fetus Gas

What type of assessment would the nurse perform when assessing pain after medicating?

Focused

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action?

Instruct the nursing assistant to obtain a manual blood pressure.

A hospitalized client who suffered a recent stroke hasn't started a diet yet and has referrals in to speech therapy, occupational therapy, and physical therapy. What is the nurse's best action at

Keep the client NPO until speech therapy has seen client.

The nurse suspects the client has increased intracranial pressure due to meningitis. What should the nurse assess?

Neck mobility

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify the healthcare provider.

The nurse is testing for Brudzinski's sign in a newly admitted client. What would indicate meningeal inflammation?

Pain and flexion of the hips and knees

The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client?

Pneumonia

The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound?

Pulmonic

The client presents with pain, swelling, redness and warmth in his left leg. Based upon the assessment, the nurse suspects the client has what?

Venous thromboembolism

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

Venous thromboembolism

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

Venous thromboembolism

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

1+ pulses

The nurse assesses the client's pulses to be normal. These would be documented how?

2+

Which of the following changes in a hospitalized patient's status should prompt you to perform an urgent assessment?

A new onset of confusion

When planning an assessment of an older adult in a hospital setting, you should prioritize which of the following variables?

Age-related physiologic changes

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what?

Anemia

Which questions asked by the nurse demonstrate an understanding of the various coexisting conditions that contribute to the mental status of a client? Select all that apply

Are you using any substances to help manage your panic attacks?" "Could your anxiety be a result of the verbal abuse you are experiencing?" "Would you say that your diabetes has contributed to making you depressed?" "You seem very angry today; are you particularly anxious about something?"

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question

The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what?

Aura

A hospitalized client is prescribed a short course of corticosteroids. The client is placed on sliding scale regular insulin. The nurse should routinely assess which laboratory value while the client is hospitalized?

Capillary blood glucose

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness.

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what? Hypoxia Amnesia Delirium Dementia

Delirium

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply.

Difficulty following instructions Slurred speech Impaired vision

Which of the following would put the client at risk for falls? Select all that apply.

Dizziness Hypotension Confusion

Which of the following assessment findings should the nurse interpret as increasing a patient's risk for falls?

Recent decline in cognitive status

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?

Severe sepsis

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

When deciding whether to delegate a task to another care provider, you should prioritize what factor?

The other person's level of skill and education

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

Which of the following nursing actions best protects patient safety?

Using two separate identifiers with each patient

An auditory hallucination is considered an alteration in which component of the mental health assessment?

perceptions

Which situations should the nurse identify as being risk factors of the development of pressure sores? Select all that apply.

pressure that impairs capillary blood flow to the skin friction created by dragging the skin against bedlinen shearing that occurs when sliding down in bed moisture being allowed to accumulate on the skin

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries