ADN140 - PrepU - Focused Assessment 2

A chronically ill school-age child is most vulnerable to which stressor?

Anxiety over school absences.

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?

Bronchovesicular

A nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation?

By checking peripheral pulses.

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment finding that should be documented and reported to the physician?

Decreased heart rate.

An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care?

Determine whether the adolescent has developed a plan for committing suicide.

A client with breast cancer is concerned that their spouse is depressed by their diagnosis. Which change in their spouse's behavior may confirm their fears?

Disturbance in sleep patterns.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat.

To assess for peripheral edema, the nurse will examine which of the following areas of the body?

Feet, ankles

A 62-year-old client reports being tired all the time, having trouble sleeping, and having trouble thinking. What action should the nurse take?

Further assess the client's mental status and health history.

During an interview, the client states, "When my stress is really high, I have diarrhea." The physiologic response affects:

Gastrointestinal status.

"Guiding me to view the ocean's calming waves is not working for me," replies the client. Based on this comment, the nurse was attempting which relaxation technique?

Guided imagery

When approaching health care holistically, which of the following would the nurse do?

Include physical, emotional, and social elements.

A client admitted to the unit is visibly anxious. When assessing this client, the nurse should expect to see which cardiovascular effect produced by the sympathetic nervous system?

Increased heart rate.

A nurse admits a client with a preliminary diagnosis of acute stress disorder to the mental health unit. Which assessment requires the nurse's immediate action?

The client states she has a desire to not live anymore.

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation.

A nurse can most accurately asses a client's heart rate and rhythm by which of the following methods?

Listen with the stethoscope at the fifth intercostals space left mid-clavicular line.

An elderly client who lives in a retirement community is having a mild depressive episode over the past few weeks. The nurse intervenes by recommending

Participation in a social activity.

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

Peripheral pulses.

A client, who attempted suicide 5 year ago with an overdose, was brought to the emergency department (ED) by a friend. The client states, "I just don't feel like living anymore. No one would care if I lived or died." What question should the nurse ask next?

"Do you have a plan for suicide at this time?"

The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the toenails. Which is the best reply by the nurse?

"I can see how quickly the blood returns to assess blood flow."

The nurse is assessing the client's cardiovascular system. The client asks the nurse why she presses on his toenails. Which is the best reply by the nurse?

"I can see how quickly the blood returns when I press and release on your toenail. This tells me how well your peripheral blood is flowing."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. Which of the following is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting the client's relief behavior rather than the client's needs?

"There is nothing wrong physically with you. You need to stop breathing so rapidly."

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if they can have the same nurse care for them every day. How should the charge nurse respond?

"We will try to assign you the same nurse as often as possible."

Which statement correctly explains a person's interactions with basic human needs?

As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier.

A middle-aged adult discusses with the nurse the loss of his job due to frequent illness. The nurse recognizes the patient's loss of his income as which of the following?

A stressor.

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Auscultation of the patient's heart murmur.

A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment?

Auscultation.

Which type of chest configuration is typical of the patient with COPD?

Barrel chest.

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles

When the client demonstrates soft, high-pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles

A client is admitted to the emergency department after being found in a daze walking away from her burning car after an accident. She was not injured in the accident, but the other driver died. She states, "I can't handle it anymore. There's no point to it all." The crisis nurse recommends hospital admission based on the identification of which concern?

The client is expressing helplessness and hopelessness and is at risk for suicide.