NURS146 Midterm Studyguide
A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?
Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.
To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?
Carotid
A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?
. Refer the client to a healthcare provider for possible corrective lenses.
The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?
Allergies
Which factors are major components of a client's general background history?
Allergies and socioeconomic status
How does a nurse check the orientation of a patient?
Ask questions about time, place and person.
The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?
Below the cheekbones
During mental health assessments, how can a nurse collect subjective data?
By directly observing conversations of patients with friends and family.
How is the Weber test performed ?
By using a tuning fork to check conductive hearing
A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan?
Follow the formal written plan of action for coordinating the response of the hospital staff.
The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane?
Grasp the auricle with the non-dominant hand, and pull down and back.
How can a nurse assess the speech of a client who had a stroke?
Have a client read statements loud and clear.
What is a Rinnie's test ?
Hearing test done to check sensorineural hearing
What precautions does a nurse take when performing Romberg's tests?
Hold your hands surrounding the client without touching them.
A patient who walks in with unkempt appearance, unclean, bad smelling clothes in emergency room, seems homeless, might have possibility of ______.
Illicit Drug use associated with mental illness.
What are examples of objective data
Measurable data , vital signs, what you, the nurse, sees.
What is the confidentiality relationship of nurse and patient ?
Not to share any info with anyone other than health care providers related to patients
What is the name of the cranial nerve which helps in smelling coffee?
Olfactory
What does the inner ear membrane look like with otoscope examination
Pearly gray membrane with cone at 7 o'clock
A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?
Place a tongue blade lightly on the posterior aspect of the pharynx
A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?
Respect the adolescent's wishes and maintain her confidentiality.
What are signs of social isolation which may lead to depression?
Sleeping too much, losing interest in work and hobbies, living alone without getting involved with any friends.
What is the stage of the pressure ulcer when the nurse could see the bone in the wound?
Stage IV
Which cranial nerve helps in hearing and balancing?
Vestibulococlear
What is subjective data ?
What patient says. Ex: pain
A community health nurse is planning to address the primary health needs of older adults living in their homes. What areas would the nurse assess first?
exercise patterns, nutrition, mobility, and safety
In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?
health habits, family relationships, affect, and thought patterns
What are important nursing responsibilities when a referral to other health team members has been made for a client?
sharing assessment information, information on the client's capability and level of participation in meeting activities of daily living
A client tells a nurse about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions?
vesicles
A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client?
Check the extremities for circulation based on hospital protocols
