Chapter 29: Hospitalized Adult Assessment

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

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

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

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 mealtime?

Keep the client NPO until speech therapy has seen client.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?

None

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.

A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client?

Platelet count less than 100,000

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 assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action?

Prepare to obtain a urine specimen for culture.

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+

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria?

50 mL in past 2 hours

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

A new onset of confusion

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

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

Anemia

When caring for hospitalized clients, the nurse should recognize which potential safety hazards? (Select all that apply.)

Call bell on bedside table Multiple intravenous infusions Urinary catheter under leg Dim lighting

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

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?

Delirium

A client states, "I feel worse since the nurse gave me that medication." What is the nurse's best action?

Record the information as subjective data.

What finding upon assessment would indicate the client is experiencing shock?

Systolic blood pressure 50

Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency?

Ulceration is noted on the great toe of the affected foot.

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 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

Which terms are used to identify the lobes of the right lung? Select all that apply.

upper lobe middle lobe lower lobe