Ch 29: Hospitalized Adult Assessment

"It's acceptable for a client to be admitted for observation." Explanation: Assessment is one of the primary reasons a client is hospitalized. It is not uncommon that a client is hospitalized entirely for observation. The healthcare provider does not need to change the diagnosis. Telling the client that insurance will not pay for observation is not a true statement for all insurance companies.

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response? "Call the healthcare provider to change the admitting diagnosis." "It's acceptable for a client to be admitted for observation." "Refuse to admit the client without a proper medical diagnosis." "Tell the client that insurance will not pay for observation."

Airway patent, breathing quiet, denies dyspnea Explanation: For a client experiencing respiratory distress, a respiratory related outcome is most appropriate such as patent airway, quiet breathing, and denying dyspnea. An appropriate client outcome for oxygen saturation is to maintain levels above 92%. Fall safety and pain are not respiratory-related outcomes.

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care? Gas exchange with oxygen saturation greater than 85% Pain level stabilized at client goal Airway patent, breathing quiet, denies dyspnea Client maintains safety; no falls

Keep the client NPO until speech therapy has seen client. Explanation: The client should remain NPO until evaluated by speech therapy. Occupational therapists do not specialize in swallowing assessments. Physical therapy does not need to be cancelled and should be continued. The nurse, not the nursing assistant, is responsible for assessment.

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? Cancel the physical therapy referral when client begins to tolerate meals. Ask the nursing assistant to offer sips of water to test swallowing. Keep the client NPO until speech therapy has seen client. Request the occupational therapist to remain with client during meal.

"Staff nurses report at the bedside so I can hear the information." Explanation: Beside reports build the client's trust, enhance teamwork, and protect safety. The nurse should ensure confidentiality and provide privacy, which sometimes necessitates closing doors. The nurse manager should round daily, but staff nurse should be seeing clients much more often than daily. Best communication practices to develop rapport with a client includes asking open ended questions.

A quality control nurse is reviewing client satisfaction survey comments. The nurse is most likely to read which positive remark? "The nurses kept the room doors open at all times." "I felt safe because staff nurses made daily rounds." "Staff nurses report at the bedside so I can hear the information." "Most nurses asked me yes or no questions when seeking information."

Platelet count 90,000 Pulse 104 beats/minute PaCO2 30 mmHg Explanation: Initial signs of severe sepsis include: heart rate greater than 90 beats/min; platelet count less than 100,000; temperature less than 36 or greater than 38.3 degrees Celsius; PaCO2 less than 32 mmHg; white blood cells greater than 12,000 or less than 4,000 mm3.

An older client is hospitalized with pneumonia. The nurse suspects the client is developing severe sepsis based on which assessment findings? (Select all that apply.) Pulse 104 beats/minute PaCO2 30 mmHg White blood cell count 10,000/mm3 Temperature 37.8 degrees Celsius Platelet count 90,000

Assess for bleeding. Explanation: A weak pulse can be the result of hypovolemia, so the nurse should assess for possible bleeding. A bounding or forceful pulse may be the result of hyperthyroidism, anemia, or a fever.

A client has a pulse that suggests diminished pulse pressure. What nursing action is most appropriate to determine the cause of this condition? Assess for bleeding. Ask about a history of hyperthyroidism. Assess for physical signs of anemia. Assess for an elevated temperature.

Falls Explanation: The client is at risk for falls due to impaired mobility and decreased movement of his lower extremities. There is no evidence to support the client is at risk for a stroke or pressure ulcers.

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what? Stroke Pressure ulcers Falls Impaired mobility

deep vein thrombosis Explanation: Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues.

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder? acute cellulitis acute lymphangitis compartment syndrome deep vein thrombosis

Aura Explanation: The nurse should assess the client about an aura that forewarns the client of an impending seizure. Lightheadedness, hallucinations and delusions are not associated with seizures.

The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what? Delusions Hallucinations Lightheadedness Aura

Antihypertensive medications Stiffness Wide gait Explanation: Risk factors for falls include a wide, unsteady gait, medications that may decrease the blood pressure, confusion and stiffness. Urinary frequency and abnormal heart sounds would not increase the client's risk for falls.

The nurse is assessing the client's risk for falls. What data identifies the client as having a fall risk? Select all that apply. Urinary frequency abnormal heart sounds Wide gait Stiffness Antihypertensive medications

Delirium Explanation: Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over a time, amnesia is a loss of memory and hypoxia may be a cause of delirium.

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? Amnesia Hypoxia Dementia Delirium

Tumor Cyst Abscess Adhesions Explanation: A mass in palpated in the abdomen could be due to a tumor, cyst, abscess, or adhesions. Flatulence does cause a mass like feeling.

The nurse is palpating the abdomen and notes a harden area in the left lower quadrant. The nurse understands that this could be related to what? Select all that apply. Tumor Cyst Flatulence Adhesions Abscess

Client stands erect with minimal swaying Explanation: The Romberg test is negative is the client stand erect with minimal swaying with eyes both opened and closed. Balance when walking is not part of the Romberg test.

The nurse is performing the Romberg test. Which of the following indicate a normal finding? Client stands erect with minimal swaying Client sways when eyes are closed Client prevents himself from falling Client maintains balance when walking

Cyanotic left lower extremity Explanation: An acutely cold, cyanotic, or pulseless extremity should be reported to the healthcare provider immediately. A temperature below 39.0 Celsius, bright red bleeding, and a heart rate greater than 120 beats per minute or less than 50 beats per minute are not considered urgent findings.

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? Cyanotic left lower extremity Moderate amount dark blood on dressing Temperature 37.5 Celsius Heart rate of 105 beats per minute

The other person's level of skill and education Explanation: The RN uses critical thinking and professional judgment when following the Five Rights of Delegation to be sure that the delegation or assignment is 1. The right task; 2. Under the right circumstances; 3. To the right person; 4. With the right directions and communication; 5. Under the right supervision and evaluation.

When deciding whether to delegate a task to another care provider, you should prioritize what factor? The other person's level of skill and education The other person's present workload The demands of your current workload The client's preferences

Skin Explanation: Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift. These devices do not affect breath sounds, blood sugar or body temperature.

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess? Breath sounds Skin Temperature Blood sugar

Age-related physiologic changes Explanation: Geriatric medical clients have an increased risk of falls and associated fractures as well as delirium, nosocomial infections, and medication interactions. In addition, any elderly person, particularly a frail elderly person, experiences a great risk of deconditioning and loss of function during a hospital stay.

When planning an assessment of an older adult in a hospital setting, you should prioritize which of the following variables? Decreased expectations for recovery Patient expectations for care The presence of family members at the bedside Age-related physiologic changes

3 Explanation: A Glasgow Coma Scale score indicates the client is in a deep coma. All other scores indicate some impairment with a score of 15 being no impairment.

Which Glasgow Coma Score indicates the client is in a deep coma? 14 8 15 3

"Client was alert and cooperative during the assessment." Explanation: Alertness or state of awareness of the environment is associated with level of consciousness. Inattentiveness is related to attention or ability to focus on tasks. Thought processes are evaluated through logical and coherent responses. Memory involves the ability to recall facts.

Which assessment notation describes a client's level of consciousness? "Client was alert and cooperative during the assessment." "Client answered questions both logically and coherently." "Client was inattentive to the questions being asked." "Client demonstrated difficulty with recalling events occurring this morning."

In coma Explanation: A Glasgow Coma Score of 3 indicates a deep coma. A score of 7 indicates the client is in a coma. Higher scores indicate minimal or no impairment.

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what? To have minimal impairments To have no impairments In coma Is in a deep coma

2+ Explanation: Normal pulses are 2+. Absent pulses are 0. Weak pules are 1+. Increased pulses are 3+.

The nurse assesses the client's pulses to be normal. These would be documented how? O 1+ 2+ 3+

Pulmonic Explanation: The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum.

The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound? Right ventricular Aortic Left ventricular Pulmonic

50 mL in past 2 hours Explanation: Acute oliguria is decreased or no urinary output. It is defined as urine output less than 0.5 mL/kg/hr for at least 2 hours. Convert 161 pounds to kg by dividing by 2 = 73 kg. 0.5 X 73 = 36.5 mL. In 2 hours output should be at least 73 mL.

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria? 100 mL in past 2 hours 50 mL in past 2 hours 80 mL in past 2 hours 120 mL in past 2 hours

Severe sepsis Explanation: The client is experiencing severe sepsis, the blood pressure is low, with an elevated heart rate and an elevated lactate level. There is no evidence of increased intracranial pressure, cardiac dysrhythmias or a surgical site infection.

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what? Surgical site infection Increased intracranial pressure Severe sepsis Cardiac dysrhythmias

Recent decline in cognitive status Explanation: Assess for falls. Items to consider include history of falling, medical diagnosis, use of ambulatory aids, presence of an IV/heparin lock, difficulty with gait/transferring, and impaired mental status.

Which of the following assessment findings should the nurse interpret as increasing a client's risk for falls? New onset of localized infection Recent decline in cognitive status Persistent fatigue Obesity

Medication reconciliation Explanation: Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being. SBAR is a communication tool to ensure appropriate information is given to the healthcare provider to care for the client. High-alert labeling is utilized to identify many sound alike medications. The teaching of side effects is crucial to informed care, yet is not the most likely cause of omission of medication from home.

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse? Reconcile current medications. Collect client's health history. Record the client's allergies. Place on cardiac monitor.

Notify the healthcare provider. Explanation: The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action? Encourage early ambulation. Assist the client to turn, cough, and deep breathe. Discontinue the indwelling urinary catheter. Notify the healthcare provider.

Fall Explanation: Because of decrease peripheral sensation in the legs, the client is at increased risk for falls. There is no data to support increased risk for sepsis, bloodstream or surgical site infections for this client.

The client has decreased sensation in his legs. What additional assessment should the nurse include? Surgical site Bloodstream infection Sepsis Fall

Capillary refill greater than 2 seconds Explanation: The client experiencing septic shock would have a capillary refill greater than 2 seconds. The temperature may or many not be normal, blood pressure would be low and extremities would be cool.

The client is experiencing septic shock. What assessment finding would the nurse expect to find? Capillary refill greater than 2 seconds Warm extremities Normal temperature Blood pressure 128/76

1+ pulses Explanation: The blood pressure, heart rate, and respiratory rate are all within normal limit. Weak pulses would be expected.

The client is experiencing severe sepsis. What assessment finding would the nurse expect? Respiratory rate 14 Heart rate 88 1+ pulses Blood pressure 140/80

inflammation of the parietal pleura Explanation: Inflammation of the parietal pleura produces pleuritic pain with deep inspiration, e.g., in pleurisy, pneumonia, and pulmonary embolism. The visceral pleura lies next to the lung, and the parietal pleura lines the inner rib cage and upper surface of the diaphragm. The visceral pleura lacks sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? ineffective innervation of the of the parietal pleura by the phrenic nerve an accumulation of fluid between the lungs and the visceral pleura inflammation of the parietal pleura an increase of sensory stimulation in the visceral pleura

Ineffective coping Explanation: Ineffective coping would be most appropriate. Anticipatory grieving occurs prior to change. There is no evidence of fear or mental status change.

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate? Anticipatory grieving Mental status change Ineffective coping Fear

None Explanation: A Glasgow Coma Score of 15 would indicate no impairments. All other scores indicate some degree of impairment up to and including deep coma.

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment? None Minimal Coma Deep coma

Ask permission to talk to the client in front of visitors. Explanation: The nurse should ask permission if visitors are present to find out whether the client wishes them to know information about his condition and treatment. The visitors do not necessarily have to leave the room. If visiting hours are not over, the nurse should not tell visitors they have to leave. Best communication practices include making eye contact with all persons the nurse is speaking to.

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? Make eye contact solely with the client. Ask permission to talk to the client in front of visitors. State that the visiting hours are over. Politely tell the visitors to leave.

Ask the client to repeat the statement or question. Explanation: The nurse should ask clients to repeat questions or statements if the nurse is unable to understand what the client said. The nurse can also paraphrase client responses to verify understanding.

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action? Refer all questions to the client's family member in room. Change the subject to put the client at ease. Turn the television on for distraction. Ask the client to repeat the statement or question.

Enter the room and auscultate the client's lung sounds. Explanation: The client's oxygen saturation level is low. Urgent situations warrant immediate assessment and intervention. The nurse should assess first to determine the need for interventions such as diuretic administration. The nurse then may need to contact the healthcare provider. After the client has been cared for, the nurse should document the situation.

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? Document the oxygen saturation level in the client's medical record. Enter the room and auscultate the client's lung sounds. Notify the healthcare provider immediately of the finding. Administer the scheduled diuretic as prescribed.

Hypovolemia Explanation: A weak pulse can indicate hypovolemia, shock or decreased cardiac output. Pulse inequality may indicate a constriction or occlusion. Hypervolemia would be manifested by bounding pulses.

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? Hypervolemia Hypovolemia Occlusion Constriction

fainting Explanation: Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency. None of the remaining options present responses directly associated with pallor.

What abnormal physical response should the nurse be prepared to manage after noting pallor in a client? diarrhea vomiting diaphoresis fainting

the reduction of red pigment in the arteries Explanation: Oxyhemoglobin, a bright red pigment, predominates in the arteries and capillaries. An increase in blood flow through the arteries to the capillaries causes a reddening of the skin (e.g., with blushing), whereas the opposite change usually produces pallor. Hemoglobin circulates in the red cells and carries most of the oxygen of the blood. An increased concentration of deoxyhemoglobin in cutaneous blood vessels gives the skin a bluish cast known as cyanosis. The loss of blood from the circulatory results in hemorrhage and hypotension.

What role does oxyhemoglobin play in the physiological process that results in pallor? the circulation of oxygen in the blood the reduction of red pigment in the arteries the loss of this component from the circulatory system the increase of blue pigment in the venous system

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection Explanation: Documented or suspected infection, a temperature less than 96.8 °F (36 °C) or greater than 101 °F(38.3 °C), respiratory rate greater than 20 breaths per minute, and altered mental state could be signs of sepsis. Pallor would not initially be associated with sepsis. The heart rate of 75 beats per minute and the blood pressure are within normal range.

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply. Documented or suspected infection Blood pressure 124/72 Altered mental state Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Heart rate 75 beats per minute

Focused Explanation: The focused assessment concentrates on assessing for anticipated problems specific to the client's problems. A comprehensive assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay. The shift assessment is performed at the beginning of the shift and includes an abbreviated exam.

What type of assessment would the nurse perform when assessing pain after medicating? Comprehensive Urgent Focused Shift

underarms Explanation: The apocrine glands are found chiefly in the axillary and genital regions, usually open into hair follicles, and are stimulated by emotional stress. This type of gland does not secret on locations identified by the other options.

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body? palms of the hands underarms face soles of the feet

Systolic blood pressure decreases from 140 mm Hg to 127 mm Hg during inspiration. Explanation: A decrease in systolic pressure greater than 10 mm Hg during inspiration results in what is referred to as a paradoxical pulse. This situation is found in pericardial tamponade. A bigeminal pulse is caused by a normal beat alternating with a premature contraction. The pulse alternates in amplitude from beat to beat even though the rhythm is regular when pulsus alternans is present and is indicative of left ventricular failure. A bounding pulse is caused by an increase in pulse pressure that can be a result of a variety of conditions. None of the remaining options are indicators of pericardial tamponade.

Which assessment finding would support the diagnosis of pericardial tamponade? A normal heartbeat alternates with a premature contraction. Systolic blood pressure decreases from 140 mm Hg to 127 mm Hg during inspiration. The pulse pressure is increased, making the pulse feel unusually strong. Pulse amplitude alternates from beat to beat.

Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line. Explanation: Using exterior landmarks picture the lungs and their fissures and lobes on the chest. Anteriorly, the apex of each lung rises approximately 2 cm to 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line. Posteriorly, the lower border of the lung lies at about the level of the T10 spinous process. On inspiration, it descends farther.

Which description of exterior landmarks indicates normal positioning of the lungs? Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line. Posteriorly, the lower border of the lung ascends to the level of T8 during inspiration. Posteriorly, the lower border of the lung lies at the level of T9. The anterior baseline of the lungs cross the midaxillary line at the 7th rib.

The thoracic cavity enlarges. Explanation: The diaphragm is the primary muscle of inspiration. When it contracts during inhalation, it descends in the chest and enlarges the thoracic cavity. At the same time, it compresses the abdominal contents, pushing the abdominal wall outward. Intrathoracic pressure decreases, drawing air through the tracheobronchial tree into the alveoli, or distal air sacs, and expanding the lungs. It is during expiration that the diaphragm relaxes.

Which observation confirms to the nurse that the client is experiencing a normal inspiration? The thoracic cavity enlarges. Air can be heard moving out of the tracheobronchial tree. The abdominal wall is pushed inward. The diaphragm is seen relaxing.

Absent bowel sounds, vomiting undigested food Explanation: Absent bowel sounds, vomiting undigested food is abnormal and may indicate a bowel obstruction. Constipation, Chest fullness, heartburn and nausea after eating. diarrhea and flatus do are not as high of a priority.

Which of the following assessment findings would need to be reported the physician immediately? Diarrhea and flatus Absent bowel sounds, vomiting undigested food Chest fullness, heartburn and nausea after eating Constipation

A new onset of confusion Explanation: Acute and urgent situations warrant immediate attention and interventions to include confusion, agitation, or delirium.

Which of the following changes in a hospitalized client's status should prompt you to perform an urgent assessment? Increase in heart rate from 80 beats per minute (BPM) to 110 BPM A newly developed rash accompanied by pruritus A new onset of confusion Expressed dissatisfaction with the quality of care

Dizziness Hypotension Confusion Explanation: Dizziness, hypotension and confusion may put the client at risk for falls. Palpitations and diaphoresis does not increase fall risk.

Which of the following would put the client at risk for falls? Select all that apply. Hypotension Dizziness Confusion Palpitations Diaphoresis

Difficulty following instructions Slurred speech Impaired vision Explanation: Signs and symptoms of a stroke that would be found during a neurological assessment include difficulty following instructions, slurred speech and impaired vision. The client may or may not be oriented x 3 and the nurse would expect to find the client hypertensive.

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply. Slurred speech Hypotension Impaired vision Orientation x 3 Difficulty following instructions