Hospitalized Adult Assessment PrepU

Which assessment notation describes a client's level of consciousness?

"Client was alert and cooperative during the assessment."

Which Glasgow Coma Score indicates the client is in a deep coma?

3

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria?

50 mL in past 2 hours

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation

The nurse identifies during assessment that the client is at risk for the development of pressure ulcers. What findings did the nurse identify? Select all that apply.

Moisture Poor nutrition Altered sensory perception

Which of the following assessment parameters should you prioritize in an urgent assessment?

Patency of the patient's airway

What finding upon assessment would indicate the client is experiencing shock?

Systolic blood pressure 50

The nurse is caring for a client hospitalized for surgical repair of a foot fracture. How should the nurse assess the muscle strength in the client's feet?

Tell client to push feet against resistance.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

fall

Which statement made by a student nurse concerning how to test a client for a paradoxical pulse would indicate that the nurse needs further education?

"The difference between the pressures at the two levels is normally no greater than 5 mm Hg."

The client is experiencing severe sepsis. What assessment finding would the nurse expect?

1+ pulses

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630

The nurse assesses the client's pulses to be normal. These would be documented how?

2+

Which of the following changes in a hospitalized patient's status should prompt you to perform an urgent assessment?

A new onset of confusion

When planning an assessment of an older adult in a hospital setting, you shouldprioritize which of the following variables?

Age-related physiologic changes

The nurse is assessing the client's risk for falls. What data identifies the client as having a fall risk? Select all that apply.

Antihypertensive medications Stiffness Wide gait

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors.

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?

Ask the client to repeat the statement or question.

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.

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

Aura

A hospitalized client is prescribed a short course of corticosteroids. The client is placed on sliding scale regular insulin. The nurse should routinely assess which laboratory value while the client is hospitalized?

Capillary blood glucose

The client is experiencing septic shock. What assessment finding would the nurse expect to find?

Capillary refill greater than 2 seconds

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness.

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?

Cyanotic left lower extremity

The nurse is performing an assessment on a client that is on postop day 2. The abdominal wound has pulled apart and the contents are spilling out. The nurse recognizes this as a what?

Dehiscence

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?

Delirium

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.

Difficulty following instructions Slurred speech Impaired vision

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Drooping of the left eye

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia

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?

Enter the room and auscultate the client's lung sounds.

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

Hypovolemia

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma

The nurse is observing the abdominal respiratory movements of a patient who is lying supine in bed. Why is the nurse using this method to assess breathing in the patient?

In the supine position, the thoracic movements are slight.

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

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?

Keep the client NPO until speech therapy has seen client.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action?

Notify the healthcare provider.

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

Place on cardiac monitor.

A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client?

Platelet count less than 100,000

The nurse assesses a client's indwelling urinary catheter bag and observes cloudy urine. The client also complains of lower back pain. What is the nurse's best action?

Prepare to obtain a urine specimen for culture.

The client has been admitted with pneumonia. What should the nurse assess?

Sputum

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

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

The nurse assesses the urine output (UOP) of several assigned clients. Which finding is priority for the nurse to address?

UOP 50 mL in 5 hours

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

When you enter the room of a hospitalized patient, you note that the patient is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization?

Venous thromboembolism

The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action?

Verify positioning of the catheter.

The nurse should implement which technique when assessing for jaundice in a dark-skinned patient diagnosed with liver disease?

assessing the client's hard palate with a bright light

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis

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

fainting

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?

falls

What type of assessment would the nurse perform when assessing pain after medicating?

focused

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?

none

An auditory hallucination is considered an alteration in which component of the mental health assessment?

perceptions

When assessing for apocrine gland function, the nurse would assess for moisture where on the client's body?

underarms

Which terms are used to identify the lobes of the right lung? Select all that apply.

upper, middle, lower lobe