Focused assessment week 6

you are caring for Lou, an 82-year-old patient who is struggling to adapt to hearing loss as he ages. You preform which of the following interventions to assist Lout in adapting to this sensory deficit? Choose all that apply. A. Make sure he wares his hearing aid B. Keep his environment clear of clutter C. Speak so he can observe your lip movement D. Speak in a lower tone of voice E. Orient to person, place, and time frequency

A. Make sure he wares his hearing aid C. Speak so he can observe your lip movement D. Speak in a lower tone of voice

A nurse is making a follow-up phone call to a client who reported being raped. The client answers the phone and states, "I don't know what you are talking about. I have never been raped." What action should the nurse take?

Offer support, recognize that the client may be using repression as a defense mechanism.

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

Phantom pain

The nurse is conducting an admission interview with an adult mental health client. The client begins to talk in a childish voice about riding a bike and playing outside. What defense mechanism is this client demonstrating?

Regression

A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record?

Scoliosis

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

a stressor

When the home care nurse visits a female client age 78 years who is recently widowed, the nurse finds that the home if cluttered with trash. The client appears sad and disheveled. The nurse should assess the client for symptoms of:

depression

Which of the following describes a muscle that is limp and without tone?

flaccid

The nurse is assessing a client suffering from stress and anxiety. The most common psychologic response to stress an anxiety is:

gastrointestinal upset

A young woman who has just started college is 6 weeks into the semester and has several tests and assignments due in approximately 3 days. She has developed a sore throat and fever. The development of illness if related to:

immunosuppression with stress.

To assess a client's visual accommodation, the nurse has the client

look at a close object, then at a distant object

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "orientated x3"

oriented to person place and time

The most common affective or mood disorder of old age is

depression

Which of the following conditions most likely occur when a patient is experiencing stress related to scheduled surgery?

Anxiety

As a component of a head-to-toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?

Ask the client to follow the nurse's finger as the nurse slowly moves it toward the client's nose

The nurse would include which of the following in a neurological assessment?

Ask the client to plantar flex the toes. Pham

Which of the following are effects of immobility on the body? Select all that apply. A. Cerumen buildup B. Decreased muscle strength C. Urinary stasis, infection D. Impaired circulation and skin breakdown E. Diminished saliva production F. Decreased anal tone and sensation

B. Decreased muscle movement C. Urinary stasis, infection D. Impaired circulation and skin breakdown

A nurse is assessing a patient's knee. The area has grating sensations. This would be documented as which of the following?

Crepitus

A nurse is assessing a client's eyes by testing the cardinal fields of vision for coordination and alignment. Which eye characteristic is being assessed by this process?

Extraocular movements

The nurse observes the client as he walks into the room. What information will this provide the nurse?

Information regarding the client's gait

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following intervention would be the most appropriate?

Stay with the client, emphasizing that the client is safe and that the nurse will remain with the client.

A nurse is preforming eye assessments at a community clinic. Which assessment would the nurse document as normal?

The patient's pupils are black, equal in size, and round and smooth

A nurse is assessing the spine of a client with kyphosis. Which of the following would the nurse expect to observe about the client's posture?

The shoulder and upper back curves forward

A nurse is preparing to assess a middle-aged client who was brought to the emergency department by the client's spouse. The spouse reports that the client has been "extremely depressed lately." When assessing the client, which would be a priority assessment?

Thoughts of self harm

Which nursing intervention is focused on the primary goal of anxiety management and treatment?

assessing the client's ability to implement stress management techniques effectively

A client who responds to bad news concerning laboratory results by crying uncontrollably is handling stress by using: defense mechanism withdrawal behavior adaption technique coping mechanism

coping mechanism

A client who has used IV heroin every day for the past 10 years says, "I don't have a drug problem. I can quit whenever I want." Which defense mechanism is being used by the client?

denial

A 60-year-old client who has been fighting cancer for more than 20 years has just been diagnosed with metastases to the brain. The client finds it difficult to get out of bed in the morning, has no interest in eating, and no longer finds fulfillment in favorite hobbies. Within which emotional reaction is the client functioning?

depression