Focused Assessment #1 ADN 140

A client is prescribed tetracycline to treat peptic ulcer disease. Which of the following instructions would the nurse give the client?

"Be sure to wear sunscreen while taking this medicine."

A middle-aged client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client?

"Does your pain level change after taking medications?"

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. (2)

"How long have you experienced this pain?"

After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching?

"I need to drink 8 ounces of water before eating."

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. (1)

"Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain."

A client is prescribed flavoxate (Urispas) following cystoscopy. Which of the following instructions would the nurse give the client?

"This medication will relieve your pain."

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? (3)

"This system fits nicely into how we work."

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? (2)

"Using the system is highly intuitive."

An informatics nurse is discussing the implementation of a new documentation system with a group of staff nurses who are using the system. Which response by the group would indicate to the nurse that the system's usability is effective? (1)

"We've noticed that this system really helps to save us valuable time."

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. (3)

"What aggravates your chest pain?"

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?"

A nurse is conducting an interview with a patient who complains of abdominal distress. What is an appropriate interview question for this patient?

"What is your problem as you see it?"

A nurse is assessing an adult client with back pain. The client is unable to speak in English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?

0-10 Numeric rating scale

The nurse in making an entry on the client's chart: "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time?

0000

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? (3)

38-year-old man

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? (1)

A client feels nauseated after eating his breakfast.

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? (2)

A client reports being cold and requests an extra blanket.

Nurses collect objective and subjective data during the client interview. Which client data is subjective data? (3)

A client reports being cold and requests an extra blanket.

Which of the following are examples of objective data? (3)

A clients temperature

The nurse is conducting an interview with a newly admitted client. Which listening behavior guideline should the nurse implement in order to have a successful interview?

Avoid the impulse to interrupt

To assess subjective data related to a client's elimination pattern, the nurse

Asks the client about changes in elimination patterns

A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to

Assess the reason for the client's anxiety.

A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the abdomen. Which of the following would the nurse perform next?

Auscultation

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation

Assessment of a patient's bowel sounds is best obtained by performing which assessment technique?

Auscultation

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

After surgery, a postoperative patient has not voided for 8 hours. Where would the nurse assess the bladder for distention?

Between the symphysis pubis and the umbilicus

A nurse collects objective data on a client during a health assessment that includes the client's

Blood Pressure

Which of the following are examples of objective data? (1)

Breath sounds

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

Breathe deeply

Melinda reports to the nurse that her joint pain has gotten worse over the last year and she has gradually increased her doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?

Chronic pain

An assessment involves gathering pieces of information about a client's health status. Which piece of information is subjective?

Client has generalized myalgia or muscle pain.

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? (2)

Client states, "I am in pain."

The nurse is gathering subjective data from a client during an interview after a suicide attempt. Which assessment data gathered by the nurse would be documented as subjective data? (1)

Client states, "I feel so sad all of the time."

The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians?

Medical history and physical exam

A patient is being seen in the clinic for possible kidney disease. What major sensitive indicator of kidney disease does the nurse anticipate the patient will be tested for?

Creatinine clearance level

Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain?

Do not administer if respirations are less than 12 per minute

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care?

Documentation

Which of the following is the first portion of the small intestine?

Duodenum

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (2)

Encourage deep breathing.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

The nurse is instructing a 3-year-old's mother regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?

Enuresis

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following?

Fissure

A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

Focused

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

Focused

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

Greater than normal urinary volume

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? (2)

Height: 6' (1.82 m)

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

The nurse understands that which of the following physiologic changes that influence the pain response occur in the gerontologic population?

Increased sensitivity to medications

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

Inspection, auscultation, percussion, palpation

A nurse asks an adolescent female client to describe her pain using a number between 0 and 10 where 0 means no pain and 10 means severe pain. The nurse is assessing which of the following?

Intensity of pain

Before conducting a health assessment on a client, the nurse should first

Introduce herself/himself to the patient

A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last when conducting an abdominal assessment?

It disturbs normal peristalsis and bowel motility

Which of the following are examples of objective data? (2)

Lab results

The nurse collects a urine sample from a client for urinalysis. Which of the following would the nurse document as a normal characteristic?

Light yellow color

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?

Location, onset, alleviating factors, and aggravating factors

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

Loss of urine without any identifiable pattern or warning

The nurse examines the skin of a 29-year-old Irish woman who is reporting swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?

Maculopapular

Which of the following describes awakening at night to urinate?

Nocturia

Peptic ulcer disease occurs more frequently in people with which blood type?

O

At the end of the shift, the nurse documents that the patient has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective

A client is reporting her pain as "8" on a 0-to-10 pain intensity scale. Then, the client states the pain is "3." Before the nurse leaves the room, the client states her pain is "6." The best action of the nurse is to

Obtain a pain scale with faces for the client to measure her pain.

Which phase of pain transmission occurs when the one is made aware of pain?

Perception

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (1)

Play the client's favorite music.

Retention of which electrolyte is the most life-threatening effect of renal failure?

Potassium

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (3)

Promote a restful environment.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?

Rates pain 8/10, states nauseated for last 30 minutes.

A nurse is providing care for a client recovering from gastric bypass surgery. During assessment, the client exhibits pallor, perspiration, palpitations, headache, and feelings of warmth, dizziness, and drowsiness. The client reports eating 90 minutes ago. The nurse suspects:

Vasomotor symptoms associated with dumping syndrome

Which of the following is the most successful treatment for gastric cancer?

Removal of the tumor

A nurse is using inspection as an assessment technique. What does the nurse use during inspection?

Senses of vision, hearing, smell

Which of the following is a disadvantage to using the IV route of administration for analgesics?

Short duration

During the interview component of the health assessment, how does the nurse convey to the client that the information is important?

Sitting at eye level with the patient

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

Stop lifting the patient and reassure.

The nurse preparing to perform an abdominal assessment on a client places the client in which of the following positions?

Supine

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? (1)

Weight: 195 lb (89 kg)

What would a nurse ensure before beginning a health assessment?

That the room is private, quiet, warm, and has adequate light

Which organization audits charts regularly?

The Joint Commission

An unconscious client is brought to the emergency department. Which assessment should be implemented first?

The client's airway should be assessed.

Of the following individuals, who can best determine the experience of pain?

The person who has the pain

The nurse is caring for a client who is brought to the emergency department after being found unconscious outside in hot weather. Dehydration is suspected. Baseline lab work including a urine specific gravity is ordered. Which relation between the client's symptoms and urine specific gravity is anticipated?

The specific gravity will be high.

The wife of a client with cancer is concerned that her husband's breakthrough doses of morphine have recently needed to be larger and more frequent in order for him to achieve pain relief. The nurse would recognize that the client is likely showing the effects of:

Tolerance

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:

peripheral pulses.

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

stool softeners and increased fluid intake