Ch.29 Hospitalized Adult Assessment

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

"Client was alert and cooperative during the assessment."

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 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.

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

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.

The analysis of a client's arterial blood indicates a normal level of arterial oxygen, but the client's skin is cyanotic. What is a likely cause of this condition?

The cyanosis may be a result of a prolonged period of exposure to the cold.

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

underarms

Which of the following would put the client at risk for falls? Select all that apply.

- Dizziness - Hypotension - Confusion

The nurse needs to assess the abdomen of a hospitalized client post gastrointestinal surgery. Place the following assessment steps in order as the nurse enters the client's room.

- Perform a general survey of safety hazards. - Inspect the abdomen. - Auscultate all four quadrants. - Palpate for tenderness. - Document the findings.

Which activities are focused on the assessment of chronic venous insufficiency of the lower extremities? Select all that apply.

- assessing for brownish pigmentation of the skin - assessing for pitting edema - assessing for a history of incompetent venous system valves

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 client's status should prompt you to perform an urgent assessment?

A new onset of confusion

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

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

Cyanotic left lower extremity

The nurse performing an admission assessment on an older adult. What would be an expected finding?

Decreased vision

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

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.

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

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

Focused

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 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 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

Which of the following assessment findings should the nurse interpret as increasing a client's risk for falls?

Recent decline in cognitive status

What intervention will the nurse implement initially for a client who has reported experiencing unexplained, severe neck pain for more than 2 months?

Screen for possible depression.

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin

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 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

Upon assessment, the nurse finds the left calf to be red and warm. The client states it only "aches". The nurse would suspect what?

Venous thromboembolism

When you enter the room of a hospitalized client, you note that the client 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 client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura

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

perceptions

What role does oxyhemoglobin play in the physiological process that results in pallor?

the reduction of red pigment in the arteries