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

1630

Which of the following changes in a hospitalized client's status should prompt you to perform an urgent assessment? Increase in heart rate from 80 beats per minute (BPM) to 110 BPM Expressed dissatisfaction with the quality of care A new onset of confusion A newly developed rash accompanied by pruritus

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

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

Client stands erect with minimal swaying

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find?

Cold fingers & hands

The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? Temperature 37.5 Celsius Cyanotic left lower extremity Moderate amount dark blood on dressing Heart rate of 105 beats per minute

Cyanotic left lower extremity

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 Orientation x 3 Hypotension

Difficulty following instructions Slurred speech Impaired vision

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.

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

Fainting

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition? ineffective innervation of the of the parietal pleura by the phrenic nerve an accumulation of fluid between the lungs and the visceral pleura inflammation of the parietal pleura an increase of sensory stimulation in the visceral pleura

Inflammation of the parietal pleura

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 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

Which of the following would the nurse consider to be an urgent situation? Blood pressure 122/76 Heart rate 88 New onset chest pain Oxygen saturation of 92%

New onset chest pain

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

Patency of the client's airway

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

The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output?

Tachycardia; hypotension

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.

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

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

deep vein thrombosis

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action? Politely tell the visitors to leave. State that the visiting hours are over. Ask permission to talk to the client in front of visitors. Make eye contact solely with the client.

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 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

When planning an assessment of an older adult in a hospital setting, you should prioritize which of the following variables? Patient expectations for care Age-related physiologic changes The presence of family members at the bedside Decreased expectations for recovery

Age-related physiologic changes

The client is experiencing septic shock. What assessment finding would the nurse expect to find? Blood pressure 128/76 Capillary refill greater than 2 seconds Warm extremities Normal temperature

Capillary refill greater than 2 seconds

When orienting a new staff nurse to the hospital unit, the charge should include which information? Geriatric medical clients have an increased risk of falls while hospitalized. Geriatric trauma clients have less risk than younger clients of developing wound infections. Almost all geriatric clients are unable to return home and require nursing home placement. Geriatric surgical clients are at less risk for major behavioral problems than younger clients.

Geriatric medical clients have an increased risk of falls while hospitalized.

The nurse is providing discharge teaching to a client who underwent a hip fracture repair. The nurse should instruct the client to report which findings that indicate surgical site infection? (Select all that apply.) Pain at incision site Tenderness at incision site Redness over hip area Diffuse hives over body Surgical site warm to touch

Pain at incision site Tenderness at incision site Redness over hip area Surgical site warm to touch

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

An older client is hospitalized with pneumonia. The nurse suspects the client is developing severe sepsis based on which assessment findings? (Select all that apply.) Platelet count 90,000 Pulse 104 beats/minute Temperature 37.8 degrees Celsius PaCO2 30 mmHg White blood cell count 10,000/mm3

Platelet count 90,000 Pulse 104 beats/minute PaCO2 30 mmHg Explanation: Initial signs of severe sepsis include: heart rate greater than 90 beats/min; platelet count less than 100,000; temperature less than 36 or greater than 38.3 degrees Celsius; PaCO2 less than 32 mmHg; white blood cells greater than 12,000 or less than 4,000 mm3.

The nurse places a hospitalized client at risk for complications when performing which procedures? (Select all that apply.) Preparation for surgery Medication administration Participating in time-out Assisting with a cast application Monitoring intracranial pressure

Preparation for surgery Medication administration Assisting with a cast application Monitoring intracranial pressure Explanation: Surgery, medication administration, cast application, and intracranial pressure monitoring all place the client at increased risk for complications.

Which of the following nursing actions best protects client safety?

Use two separate identifiers with each client

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