PrepU ch 1

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to A. healthy lifestyle B. absence of disease C. stress reduction D. changes in the environment

A

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? A. Comprehensive B. Ongoing C. Focused D. Emergency

C

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? A. functional B. focused C. head to toe D. body system

C

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? A. Identify the most appropriate forms of medical intervention for the client. B. Determine the most likely prognosis for the client's health problem. C. Identify the status of the client's airway, breathing, and circulation. D. Establish a baseline for the comparison of future health changes.

D

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first? A. review the client's medical record B. obtain basic biographic data C. consult clinical resources explaining the client's diagnosis D. validate information with the client

A

A client requires soft wrist restraints. What assessments should the nurse perform to ensure the client's safety? Select all that apply. A. Hydration status B. Skin integrity C. Elimination D. Circulation E. gait

A, B, C, D

The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply. A. the client's medical diagnosis B. Recent abnormal lab findings C. the client's recent divorce D. the client's tonsillectomy 45 years ago E. Recent changes in the client's BP readings

A, B, E

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? A. Nursing intervention B. Nursing goal C. Nursing Evaluation D. Nursing assessment

A

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client? A. physical B. environmental C. social well being D. developmental level

B

The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process? A. develop a nursing diagnosis B. Implement an intervention C. evaluate an outcome D. perform an assessment

C

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is A. Primary Prevention B. secondary prevention C. tertiary prevention

A

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? A. Initial B. Focused. C. Ongoing D. emergency

C

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take? A. perform an emergency assessment B. Develop a nursing dx C. conduct a partial assessment D. review the clients chart

A

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's A. physiologic status B. holistic wellness status C. developmental history D. level of functioning

A

A nurse is conducting a health assessment. How will the information collected from the client be used? A. basis for the nursing process B. to illustrate nursing competence C. to facilitate nurse-client caring D. as one component of medical care

A

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to A. arrive at conclusions about the client's health. B. document any physical symptoms the client may have. C. contribute to the medical diagnosis. D. validate the data collected.

A

The nurse reviews a 70-year-old client's labs: sodium (Na+) 134 mEq/L (135-145 mEq/L), potassium (K+) 5.8 mEq/L (3.5-5 mEq/L), BUN 40 mg/dL (10-20mg/dL), creatinine 2.5 mg/dL ( 0.5-1.5 mg/dL), hematocrit 33% (35%-45%), hemoglobin 10 g/dL (12-15 g/dL). The nurse is concerned about renal function. What action should the nurse take? Select all that apply. A. assess urine output B. assess client's weight C. Determine client's 24-hour intake D. notify the health care provider E. perform a comprehensive assessment

A, B, C

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 concern is referred to as a(n) A. ongoing or partial assessment B. focused or problem-oriented assessment C. emergency assessment D. initial comprehensive assessment

B

How does a nurse best facilitate the nursing health assessment? A. Maintaining privacy B. Asking the appropriate questions C. Formulating a nursing diagnosis D. creating a nursing care plan

B

How does a nurse decide what health-promotion activities are necessary for a particular client? A. Nurses address areas associated with healthy behaviors only B. Nurses collaborate with clients to identify areas in which clients are willing to make changes C. Nurses assess areas in which clients are willing to make changes only D. Nurses construct their own theories to identify perceptions, barriers, and positive outcomes

B

Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first? A. perform a comprehensive head to toe assessment B. Conduct a focused assessment C. notify the health care provider D. alert the critical assessment team

B

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client would the nurse most likely expect to facilitate a referral? A. An 80-year-old client who lives with their daughter B. A 50-year-old client newly diagnosed with diabetes C. An adult presenting for an influenza vaccination D. A teenager seeking information about contraception

B

The nurse is reviewing the medical record of a newly admitted client to the rehabilitation center. Which subjective question should the nurse confirm with the client? A. "What would you like for lunch today?" B. "Are you aware of any allergies that you may have?" C. "Do you have family coming to visit today?" D. "Would you prefer a bed by the window or a bed by the door?"

B

A client admitted with a pulmonary embolism has been receiving continuous IV Heparin for the past 48 hours. The nurse reviews the client's chart containing the following information: ● 0800 VS: temperature 98.7F, blood pressure 120/74, heart rate 88, SpO2 95% 2L NC ● 1200 VS: temperature 98.6F, blood pressure 100/60, heart rate 99, SpO2 94% 2L NC ● Laboratory values on admission: hemoglobin 15 g/dL, hematocrit 40%, platelets 275,000 mm3 ● Laboratory values today: hemoglobin 11 g/dL, hematocrit 33%, platelets 175,000 mm3 What step of the nursing process should the nurse perform next? A. Intervention B. Assessment C. Diagnosis D. Planning

C

Which part of the nursing process includes the formulation of goals? A. Assessment B. Diagnosis C. planning D. evaluation

C

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment? A. Inspection B. Palpation C. sympathy D. empathy

D

The nurse working in the emergency room has been assigned the following clients. Which client requires an ongoing assessment? A. a client admitted with acute atrial fibrillation who has a heart rate of 150 bpm and irregular heart rhythm. B. a client admitted with a leg fracture who is reporting sudden shortness of breath and a rash C. a newly admitted client who was involved in a motor vehicle incident with a head injury and reports a headache of 3 on a scale of 1-10 D. a client admitted 2 days ago with exacerbation of chronic obstructive pulmonary disease with an oxygen saturation of 90% on 2L nasal cannula who reports ease of breathing

D

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next? A. assessment B. diagnosis C. planning D. evaluation

D

Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing? A. Diagnosing B. Intervening where necessary C. formulating a discharge plan D. Assessing

D