adn 140 week 4 quiz
The nurse is taking care of a client on the second postoperative day who asks about wound dehiscence. Which response by the nurse is most accurate?
"Dehiscence is when a wound has partial or total separation of the wound layers."
A female client is crying and states that everyone thinks she is a "drug addict," and that no one will listen to her. She states she has abdominal pain and must have something for the pain. What is the best response of the nurse?
"Tell me more about your pain"
A client states. "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
"What does the pain feel like?"
Which question or statement would be an appropriate termination of the health history interview?
"can you think of anything else you would like to tell me?"
which of the following can a nurse assess by palpitaiotn
A. Heart sounds, lung sounds, blood pressure B. temperature, turgor, moisture C. vision, hearing, cranial nerves D. tissue density, gait, reflexes B. temperature, turgor, moisture
Which of the following scale is used for systematic assessment and qualification of a patients risk for pressure ulcer
Braden scale
Melinda reports to the nurse that her joint pain has gotten worse over the last year and she has gradually increased her doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?
Chronic pain
the nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse do first?
Complete a comprehensive assessment
upon assessment of an older adult, the nurse notes the patient's skin to have a yellow color. The nurse recognizes and documents the skin color as which of the following?
Jaundice
According to The Joint Commissions pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?
Location, onset, alleviating factors, and aggravating factors
The nurse is performing an initial admission assessment from a client. What subjecting data gathered from the client will the nurse document? Select all that apply.
Reports of abdominal pain of a 4 on a 0 to 10 point scale The client states. "I feel nauseated." Client informs the nurse there is a floater in the left eye
of the following individuals, who can best determine the experience of pain?
The person who has the pain
When documenting subjective data, the nurse should do which of the following?
Use the patients own words placed in quotation marks?
Which assessment data cue does the nurse recognize as subjective data?
a paint rating of 7
the nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces?
a patient sitting in a chair who slides down
a patient with terminal cancer is taking high doses of narcotic for pain. The nurse will teach the patient or family about what common side effect of opioids?
constipation
the nurse is developing a plan of care for a client in acute pain. WHich of the following should the nurse include? Select all that apply
encourage deep breathing play the client's favorite music
A nurse asks an adolescent female client to describe her pain using a number between 0 and 10 where 0 means no pain and 10 means severe pain. The nurse is assessing which of the following?
intensity of pain
The nurse is caring for an infant who will have surgery. What type of pain assessment would the nurse use?
observation of facial and body actions
a medicalsurgical nurse is assisting a wound care nurse with the debridement of a patients coccyx wound. what is the primary goal of these nurse's action?
removing dead or infected tissue to promote wound healing
when conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?
symmetry (comparison of bilateral body parts)
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. the nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing?
the nurse asking is the client is having pain.
the nurse is conducting an assessment of a 74-year old patient's integumentary system. Which os the following finding should the nurse document as an anomaly that may warrant follow up?
the patient states that a mole on his forehead has become larger in recent months
the nurse is preparing to being a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment?
the room is private, quiet, warm and has adequate light.
