Unit 1

When assessing a client's blood pressure, obtained via the client's unsupported left arm, which reading error would the nurse expect?

False high reading

Biographical info

-Client's age -Type of insurance -Occupation status

To access the status of circulation to the foot, which site would the nurse monitor for a pulse?

-Dorsalis pedis artery -Posterior tibial artery

Importance of nursing documentation for risk management

-A nurse's documentation is the evidence of care that a client receives -The nurse would note assessments & significant changes in the client's health -Nurses would always document the primary health care providers responses whenever they are contacted

Chronic back pain. Nursing considerations that would be made to determine client's plan of care.

-Ask the client about the acceptable level of pain -Administer pain medications regularly around the clock

The nurse is performing a neurologic assessment of an adolescent w/a seizure disorder. Which action would the nurse take to test cranial nerve XI?

By telling the adolescent to shrug the shoulders

Nurse expect when completing a health history & physical assessment for a client who has myasthenia gravis

Double vision Difficulty swallowing saliva Drooping of the upper eyelids

Assessing ulnar pulse

Evaluating the arterial insufficiency

Which cranial nerves assist with both sensory & motor functions?

Facial, Trigeminal

During a physical examination, which assessment would the nurse anticipate when a client is placed in a lithotomy position?

Female genitalia

High BP risk when

HR is decreased & STROKE volume is increased

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue?

Hypoglossal

Which finding would the nurse expect when assessing a client who has a verbal fracture at the T1 level?

Normal biceps reflexes in the arms

Which nursing intervention would the nurse use to encourage the client to verbalize their personal health problem?

The nurse leans forward attentively during discussion

Upon entering an examination room for assessment of a confused client, which action would the nurse take?

Plan a focused physical assessment

Assessing for damage to glossopharyngeal & vagus nerve

Swallow

Describes the percussion technique?

Tapping the skin with the fingertips to vibrate underlying tissue

While assessing a client who sustained a road traffic accident, the nurse notices that the client is unable to clench teeth. Which cranial nerve might have been affected?

Trigeminal nerve