NSG 2015 Exam 2 Fall 2024

A nurse is caring for a client who is reporting pain as 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain?

The client reports that the pain has been present for approximately 4 years; The client reports never feeling total relief form pain; The client reports that the pain is recurring and does not always originate in the same location.

A nurse is conducting a general survey on a client who is being admitted to a long-term care facility.. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding?

The client reports they feel sad and lonely most of the time

A nurse assess a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate?

The client takes a narcotic pain medication for chronic pain

The nurse is completing documentation in a client's medical record.

The client's abdomen is soft and nondistended.

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following info should the nurse include as factors that affect BP?

Time of day, obesity, diuretic medicine, and Smoking

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation.

Use of assistive device Height and weight Behavior and mood

Subjective

based on or influenced by personal feelings, tastes, or opinions

Levels of Consciousness

conscious, preconscious, unconscious

Abdominal Assessment

inspection, auscultation, percussion, palpation

Interpreter Use

make the patient comfortable and information is confidential if that patient wants it to be, make sure patient understands what is going on medically

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?

Inspection

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings?

Tachycardia

Palpation

to examine by touch

A nurse is preparing to irrigate a client's leg wound. which of the following pieces of personal protective equipment should the nurse wear while performing this task?

- Goggles - Gown - Gloves

Aspects of Cultural Diversity

-health insurance and health care access -racial and ethnic minority communities -mental health -elderly -bariatric/obesity

When conducting a general survey of a client, the nurse should assess

1) Level on consciousness 2) Speech 3) Gait

A nurse in the emergency department has received report on a child has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?

Assessment

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; i do not want to have this surgery." Which of the following ethical principles is the client using?

Autonomy

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse preforming?

Implementation

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Maintain an arm's length between self and client

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via cannula

A nurse has just received report on a newly admitted client who client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?

Request assistance from an interpreter during the assessment.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?

Show interest in the client's feelings by acknowledging that they are upset.

A nurse is performing an assessment on a client. the client states, "I have a dry cough every morning when i wake up." Which of the following is the type of data the nurse is collecting?

Subjective

Temperature Routes

oral, rectal, axillary, tympanic, temporal artery

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination?

- Penlight - Tongue Depressor - Tape measure

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps?

1) Place the client in a supine position and allow them to rest. 2) Take the client's BP in supine position 3) Keep the cuff in place and assist the client to a seated position. 4) Take the client's BP in a seated position. 5) Assist the client to stand and obtain their BP

A nurse is admitting a client who is 162.6 cm (64 in.) tall and weighs 68.2 kg (150 lb). Using the BMI table shown what is the client's BMI?

B. 25

Objective

Based off something you can actually observe

Religious Beliefs and Medical Care

Based on these reasons, a patient may refuse care or a nurse may refuse to provide said care.

Culturally Competent Care

Care based on beliefs, values and customs of a specific group of people and being open minded and acceptant towards such.

Expected Findings

Changes that are within a normal range based on a condition.

Spiritual Care Considerations

Communicate and show compassion. Understand that this is a reason that a patient may accept or deny treatment.

Health Care Disparities

Differences among populations in the availability, accessibility, and quality of health care services

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client?

Dirty clothing, unexplained physical injuries, malnourished appearance

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?

Do not expose any more of the client's body than required at a time.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole.

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe the involuntary movement?

Fasciculation

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?

Palpate the tender areas of the abdomen last.

Pain Assessment

Provocative or Palliative (what makes it worse/better) Quality or Quantity (For example, is the pain sharp or dull, throbbing?) Regian or Radiation(Location) Severity Scale (Numeric pain intensity scale) Timing (Onset) Understand Patient's Perception (Activities of Daily Living assessment)

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse ox reading?

Recent scan with contrast dye

A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take?

Record the client's most recent assessment results.

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temp of the client?

Rectal

A nurse is preparing to perform palpation on a client during a physical assessment. which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture, or unexpected findings

A nurse is performing auscultation during a client's physical assessment. which of the following tools should the nurse use for this part of the assessment?

Stethescope

A nurse is assessing a client's respiration and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings?

Tachypnea