342 Kahoot Questions #1
When performing a nutritional assessment, which technique would best screen for nutritional deficits?
24 hour recall
A nurse has just admitted a patient who has a wound infection to the unit. After assessing the patient, the next step of the nursing process the nurse should perform is:
Analyze the data
The nurse observes multiple red circular lesions with central clearing that are scattered all over the abdomen and thorax. How does the nurse document the shape and pattern of these lesions?
Annular & generalized
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?
Ask the client to bring all the medications and supplements to an interview
A patient states that he has experienced "a lot" of unintentional weight loss over the past 4 months. The nurse measures his height and weight (5 feet 11 inches, 170 pounds) and determines that his body mass index is 22.7. Which of the following is the most appropriate action to better evaluate his recent weight loss?
Ask, "what is your usual body weight?"
A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next?
Assess the client's pain using a mnemonic device (OLDCAARTS)
The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?
Assist the nurse in formulating appropriate subjective questioning
A 52-year-old office worker presents to your office for evaluation of a bump on his face. It appeared 1 month ago & is growing. He denies fever, chills, or itching. Physical examination reveals a 0.4-cm nodule with a depressed center and a firm, elevated border that is flesh-colored. Based on this information, what is the most likely diagnosis?
Basal cell carcinoma (flesh colored)
An older woman is 5 feet 2 inches tall and weighs 100 pounds. To best understand her dietary intake, which question is most appropriate?
Can you describe what you eat on a typical day?
You are a nurse working on a medical-surgical unit of the hospital. You receive report on your patient, George Feeny. Mr. Feeny is a 72 year old male, who is a retired school teacher. He is single, and lives alone. After receiving report, you go to check on your patients. When you get to Mr. Feeny's room, he tells you that he has a headache. You adjust the environment to block out some of the sunlight that he says makes it worse. You also provide him with a cool washcloth to place over his eyes. After finishing your assessment, you leave his room and go check on your other patients. What is important to remember?
Come back in 30-45 mins
A 72-year-old retired secretary is brought to the clinic by her daughter. The daughter is concerned because her mother seems to be more confused; she has gained more weight, but her appetite has decreased, and she seems to be more "swollen" in general. She is diagnosed with profound hypothyroidism. On examination of the skin, you would expect it to feel:
Cool (also dry) because all function is decreased with hypothyroidism
You are assessing an 80-year-old male patient admitted to your unit with the diagnosis of congestive heart failure (CHF). When assessing his skin, which finding would be considered normal, taking his age into account?
Decreased turgor (elasticity)
A pt is wearing a hospital gown & sitting on the exam table. What area should the nurse include in the general survey?
Facial Expression
A nurse at the local free clinic is collecting data on a 16-year-old boy who has come to the clinic. Under what component of the health history would the nurse place data on whether the teen routinely uses seat belts when in a vehicle?
Health Maintenance (safety measures-smoke alarms, seat belts, helmets)
The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement? a. I cant assure you secrecy if the information you tell me ...
I have to share the information if it is something that could hurt you
A 42-year-old receptionist presents to your office for evaluation of multiple moles (nevi). She used to sunbathe a lot when she was younger and went to tanning salons regularly until 2 years ago. You are educating her about melanoma. When evaluating a mol, all of the following characteristics are important to note EXCEPT:
If its less than 6 mm in diameter
You are working in a pre-natal clinic. As you assess your patients, what skin changes would you not expect to find?
Linea alba (you WOULD expect to find linea nigra)
You are caring for Sophia Petrillo, an 89 year old female. Her daughter, Dorothy, comes to the nurses' station and tells you that Sophia doesn't feel well. She is reporting feeling nauseated. You go to check on Sophia and find her vomiting at the bedside. The nurses' aide is already in the room making sure that Sophia stays safe. After checking the orders, you see that Sophia's doctor has placed an order for Zofran 4mg IVP Q4H PRN nausea (Anti-nausea medication, to be given intravenously every 4 hours as needed for nausea). You administer the medication. 15 minutes later, you return to Sophia's room to check on her, and she says that she still feels nauseated. What is your next action?
Notify the dr. that the Zofran didn't work and she needs something else
A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?
Nurses focus on the diagnosis of actual human responses to the disease not just the disease itself
You are preparing to assess the respirations of an alert adult pt. You should:
Observe for equal bilateral chest expansion of 2.54 to 5.08cm (1-2in)
The nursing assistant obtains VS & reports the monitor gave a reading of 125bpm for HR. What is the nurse's best action?
Obtain an apical pulse
What area is best for detecting color changes in patients with dark skin?
Oral mucosa
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal Health History
A 48-year-old woman asks the nurse how to best protect herself from excessive sun exposure while at the beach. Which response would be most appropriate?
Reapply every 2 hours and use waterproof sunscreen on exposed skin
A 60-year-old male patient states that he has a sore above his lips that has not healed and is getting bigger. The nurse observes a red scaly patch with an ulcerated center and sharp margins. These findings are commonly associated with which malignancy?
Squamous cell carcinoma
Mrs. Green, age 75 years, has a CVA with left side weakness. As you reposition her, you notice a reddened sacral area about 3cm in size. How would you document this?
Stage 1 pressure ulcer-NOT ON TEST
The nurse is preparing to assess vital signs. Which vital sign would the nurse assess first?
Temperature
Your new patient becomes visibly anxious during the nursing interview. You respond by telling her, "Don't worry, everything will be okay." What might this premature reassurance cause?
The blockage of further disclosures by the patient
Which area of the skin is best for assessing skin turgor?
Under the clavicle-not as exposed to the sun
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
What other symptoms occurred during the spell
A patient has multiple red, raised, irregularly shaped lesions on her legs and groin that she describes as "itchy insect bites." How does the nurse document these lesions?
Wheals
When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be
Why do you think you have (name of the specific symptom)
Which part of your hand is best for assessing skin temperature changes?
dorsal aspect