nursing first set

identify a nursing diagnosis of Ineffective Health Maintenance

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic". How should the nurse best respond to this assessment finding?

continuous

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is:

1 1/2 inch diaphragm

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a:

sinuses

For which assessment would the nurse plan to use direct percussion?

up and back

How should the nurse place the ear of an adult when using the otoscope?

focused or problem- oriented assessment

an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health Conner is referred to as a(n):

-skin texture -skin temp -skin rash

for which of the following assessments would the nurse plan to use light palpitation?

functional status

the nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?

assess the status of the health problem

the nurse notes that an intervention provided to a client for a specific health problem was not effective. Which action should the nurse take next?

collecting date regarding the nature of the pain

what will the nurse initial role when conducting a health assessment with a client reporting abdominal pain?

-bowel sounds -heart sounds -breath sounds

The nurse is assessing a client. Which body area will the nurse use the diaphragm of the stethoscope to assess? Select all that apply

"I feel so tired sometimes" client complains of a headache "my father died of a heart attack"

The nurse is reviewing a clients health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.

"are you experiencing any pain at this time" "are you feeling dizzy now?" "do you know what your blood pressure is usually?"

The nurse performing a health assessment with a client who presented to the ED after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply.

palmar surface

a nurse is palpating a clients chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

the middle finger of one hand is placed on the body surface and the other middle finger strikes

a nurse is performing indirect percussion of the lungs on a young women with pneumonia. Which of the following Is the correct hand placement for this technique?

evaluation

a nurse provides care for a client with an elevated temp. The client is given the prescribed medication and the nurse checks the clients temp at repeated intervals. What top of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment?

measure the clients VS, ht, and wt

a nurse recognizes the it is best to begin the objective data collection with which procedure?

release of epinephrine , cortisol, norepinephrine

a nursing instructor is teaching students about the pain experience. The instructor informs the students that a client experiencing pain will have a stress response. The students are aware that this stress response causes the following:

the diaphragm should be held firmly against the body part

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

braden scale

A nurse is preparing to evaluate an elderly clients risk for developing pressure sores after a 2 wk stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

coin or key

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

tympany

A nurse performing percussion over the stomach should anticipate hearing which type of sound?

- identify ways to ensure client privacy - obtain and check needed equipment - wash hands

Which of the following should the nurse do before conducting a physical examination of a client? Select all that apply

low-frequency sounds

You should use the bell of the stethoscope when auscultating what type of sounds?

it is often the source of the most physical sings

which of the following statements is true of the role of inspection in the physical examination?

to determine any changes from the baseline data

A nurse provides care to a client with impaired respiratory function. The nurse frequently assesses the clients skin color and temp of the extremities. What is the purpose of this ongoing or partial assessment?

ask the client to rate the pain on a scale of 0 to 10

a client reports pain and rates it as a 9 on a scale of 0 to 10. The nurse administers medication as ordered and returns 20 mins later to assess the severity of the clients pain. To assess the severity, the nurse would:

snellen chart

a client with an inability to read billboards while driving arrives at the health care facility for an eye exam. Which piece of equipment should the nurse use to check the clients distant vision?

nursing diagnosis

after completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

it is ongoing and continuous

the nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the clients care. What principle should the nurse apply when using the nursing process?

lower the HOB

the nurse has completed the physical exam of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the MOST important thing the nurse should do prior to leaving the room?

"what were you doing when the pain first started?"

the nurse is assessing a clients pain. Which of the following questions would be MOST appropriate to ask the client to identify precipitating factors that might have exacerbated the pain?

provoking and alleviating factors

the nurse is assessing hospitalized post-op pain and has asked the client to rate his pain, describe it, state the location and onset of when it started. What other question should the nurse include in this pain assessment?

performing a physical examination

the nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

comprehensive

when a client first enters the hospital for an elective surgical procedure, the nurse should perform an easement termed?

collect subjective data

when performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

- the nurse notes crackling over the individuals thorax - the nurses notes a rhythmic Lub-dub over the clients anterior thorax -the nurse notes gurgling sounds over the individuals abdomen

which an example of auscultation? Select all that apply

-the nurse detects foul odor of the urine - the nurse notes symmetry of the individuals thorax - the nurse notes a Fien rash covering the individuals thorax

which is an example of inspection? Select all that apply.

pt's state of hygiene

which of the following is a component of the general survey?