Health Assessment final

"Would you like me to consult with our Chaplin or social worker for support?"

Patient and family values, beliefs, and cultural backgrounds are incorporated into the planning and delivery of care.

A nurse in a community health clinic is interviewing a couple who just lost their house in a fire. Using the priority framework of Maslow's hierarchy of needs, which category should the nurse identify for the client's situation? Safety Esteem Self-Actualization Physiological

Physiological

a nurse is assisting an older adult client who sometimes loses her balance while walking. which of the following devices should the nurse use when helping the client ambulate? Gait belt jacket harness four wheel walker cane

gait belt

a client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur. Is a high pitched sound due to a narrow valve. Is an extra sound due to blood entering an inflexible chamber. Means that there is some inflammation around the heart. Indicates turbulent blood flow through a valve.

Indicates turbulent blood flow through a valve.

A nurse is assessing a client who has a score of 6 on the glasgow coma scale. the nurse should expect which of the following outcomes based on this score? The client needs total nursing care The client is alert and oriented The client is in a deep coma Indicates stable neurologic status

The client needs total nursing care

"Your husband is currently stable. We will be giving him pain medications frequently to keep him comfortable."

this demonstrates caring if the report is unsolicited and tit also engenders trust.

A nurse is caring for a client 1 day posteroperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? Apnea Dysphagia Hypoxemia Pleural effusion

Hypoxemia

A nurse is performing a cardiac assessment on a client an auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? Atrial gallop. Ventricular gallop. Closure of the mitral valve. Closure of the pulmonic valve.

Ventricular gallop

"We welcome any and all questions you may have about this hospital stay."

This recognizes that patients and families are essential allies for health care quality and safety.

Implementation

is the fourth of the interventions can be completed by the patient, the family, or members of the health care team. The interventions should clearly relate to the nursing diagnosis and the planned goals. The interventions are individualized for each patient and will be modified as the patient's status or environment changes to support positive outcomes.

Assessment

is the subjective and objective data gathered during the initial health history and physical examination and collected on each patient encounter. This data is instrumental in devising a plan of care for the patient. Therapeutic communication is essential to elicit pertinent information about the patient, the family, and the community in order to provide the best care for the patient. As you document your findings, cluster key points and relevant pieces of information together. This will help you formulate the preliminary problem list. The phase continues throughout the entire patient encounter, which provides the potential for updates in the plan of care based on new assessments and data.

Planning

is the third element and is devising the best course of action to address the patient's diagnoses. During this phase, the nurse and patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the nursing diagnosis. There should be a short-term goal (STG) and a long-term goal (LTG) with realistic timeframes incorporated. Developing a successful plan requires good interpersonal skills and sensitivity to the patient's goals, economic means, competing responsibilities, and family structure and dynamics. Interventions are then developed for each goal.

A braden scale of 16, would put a patient at ______ risk for developing a pressure sore during their hospitalization.

mild

After calculating the heart rate, select how you would objectively document regular heart sounds. Heart rate ________ rate and rhythm. ____, ____ heard at the _________ area.

regular S1 S2 Mitral

After you reconcile an accurate medication list, the next most important data to gather would be to confirm if the patient is _________ with all his at home prescription medications.

compliant

Location

"Is it directly over the left side of your head?"

A nurse is providing education on priority setting framework to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the acute vs. chronic priority setting framework? "This framework helps clients to establish order in their individual environment." "This framework guides care by recognizing conditions that can worsen rapidly." "This framework follows a specific algorithm for prioritizing care" "This framework recognizes when client conditions have less time to adapt." "This framework will guide your care using a sequential process."

"This framework guides care by recognizing conditions that can worsen rapidly." "This framework recognizes when client conditions have less time to adapt."

Onset

"When did this pain start?"

To gather a full skin assessment, it is necessary to determine if your patient is at risk of developing a pressure sore during his hospital stay. During questioning, your new admission reports that he does not have sensory impairment, which you confirm with a sharp/dull sensation test. He also reports he is usually a "sweaty guy" especially since he hasn't been feeling well, so he changes his clothes about once a day. He only walks occasionally and the pain causes his overall mobility to be very limited once in bed. Due to his recent GI issues, he rarely has eaten a complete meal and reports "it's likely inadequate". You conclude he has a potential problem with friction and shearing as you have repositioned his twice since his arrival. Using the Braden Scale, calculate the total score your new patient would receive and document your numeric answer.

16

You want to get a sense of how much fluid the patient is vomiting a day. The wife guestimates about "1/2 liter each time he throws up." Based off of his report of "vomiting the past 3 days; 1-2 emesis per day'", the maximum amount of fluid loss from vomiting would be at most ________ mL.

3000

While in bed, H.S. is restless and trying to reposition frequently. After one attempt of pushing himself up in the bed, you observe he is short of breath with shallow breaths and an irregular breathing pattern.For how long should the nurse count H.S.'s respirations? Enter your numeric answer in seconds.

60 seconds

A nurse has received a change of shift report on a group of clients and is preparing her assignment. which of the following clients should the nurse assess first? A client who had a blood glucose reading 0650 of 70 mg/dL after receiving a 50% dextrose for a hypoglycemic episode. A client who has admitted for chest pain and is reporting a new onset of indigestion. A client who has pneumonia and was treated for a temperature at 38.9 (102 F) at 0400. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800.

A client who has admitted for chest pain and is reporting a new onset of indigestion.

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? Symmetrical convex sphere shape Concave umbilicus Bilateral bowel sounds in lower quadrants Ecchymosis

Ecchymosis

A nurse on a medical unit is planning care for several clients. which of the following clients should benefit most from the nurse acting as an advocate. A client who has previously undergone a procedure that is to be performed for a second time A client who has been educated on treatment options and chooses alternative treatments. A client who makes an informed decision not to participate in chemotherapy treatment. An older adult client who has no family and is uncertain about moving to assisted living.

An older adult client who has no family and is uncertain about moving to assisted living.

a nurse is assessing a client's cranial nerves. which of the following methods should the nurse use to assess cranial nerve II? ask the client to read the snellen chart listen to client's speech. ask the client to identify scented aromas. ask the client to clench their cheeks.

Ask the client to read the snellen chart.

A nurse is caring for a client of chinese heritage. which of the following actions should the nurse take to demonstrate cultural competence? Make sure the dietary department does not serve the client pork. Ask the client's permission to add ice to drinking water Maintain direct eye contact with the client Place a hand on the client's head

Ask the client's permission to add ice to drinking water

Before getting your admission, you want to make sure your other four patients you are assigned to are settled and don't require your immediate assistance. In planning your rounds, which patient should you, the nurse, assess first? A. A postoperative client preparing for discharge with a new medication B. A client with asthma who requested a breathing treatment during the previous shift C.A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client requiring daily dressing changes of a recent surgical incision

B. A client with asthma who requested a breathing treatment during the previous shift

When questioned about consistency of medication administration, the patient reports that although he is prescribed a "water pill", he has not taken it in six days because he has been "too sick to drive" to the pharmacy.What four assessment skills are you going to complete to assess the patient's overall fluid status? A. Assess skin color B. Assess sputum sample C. Assess Turgor D. Assess cranial nerves E. Assess for palpable liver F. Assess JVD G. Assess abdomen shape H. Assess pitting edema I. Assess for crepitus J. Assess Lung Sounds

C. Assess Turgor F. Assess JVD H. Assess pitting edema J. Assess Lung Sounds

Medication errors are common and often occur when patients move between healthcare settings. Around half of hospital medication errors occur on admission, transfer and discharge. Medication reconciliation is the process of identifying the most accurate list of all medications that the patient is taking at home, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider. Which of the following actions should the nurse take when performing the medication reconciliation? A. Place the client's home medications bottles in a secure location B. Call the pharmacy to determine whether the client's medications are available C. Compare the client's home medications with the provider's prescriptions D. Verify the client's name on their ID bracelet with the medication administration record

C. Compare the client's home medications with the provider's prescriptions

Below are the findings of the GI assessment: SUBJECTIVE DATA: "I haven't had a poop in 4 or 5 days, but I am farting a little." Describes pain as intermittent cramping that has been getting worse the past 3 days. Reports constant pain at 6/10 but upon any palpation, specifically RLQ, reports 8/10 pain. Experience nausea and vomiting the past 3 days; 1-2 emesis per day. OBJECTIVE DATA: Abdomen distended, rounded and is soft. Small scars on upper left side of abdomen. Last bowel movement "4 or 5" days ago. Some flatus per patient report. +Belching. Last emesis in the ED prior to arrival to the floor. Per patient, emesis usually green or whatever he just drank. Moderate to large amounts. Poor fluid intake due to nausea. You are documenting the client's assessment. Which of the following documentation provides the most accurate and concise information to include in the medical record? A. Client reports pain and not pooping for a few days. Vomiting. Cramping pain that gets worse when I palpate the abdomen. B. Client reports abdominal pain, nausea and vomiting for 2-3 days. Hasn't worked. Gallbladder was removed a couple years ago and has small scars on the abdomen. Reports no "good" bowel movement for several days. Pain increases with palpation. C. The client says he has been vomiting a lot and not moving their bowels. Abdomen is bigger than it should be. Says she has had pain for a couple of days. D. Client reports a 3 day history of nausea, vomiting and cramp abdominal pain at a level of 6/10. Abdomen distended and soft. Palpation of RLW increases to pain level 8/10.

D. Client reports a 3 day history of nausea, vomiting and cramp abdominal pain at a level of 6/10. Abdomen distended and soft. Palpation of RLW increases to pain level 8/10.

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply.) Decreased gastric motility Decreased skin elasticity Increased pain threshold Increased metabolic rate Increased cardiac output

Decreased gastric motility Decreased skin elasticity Increased pain threshold

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? Speak using his usual tone of voice. Stand directly in front of the client. Rephrase statements the client does not hear. Determine if the client uses hearing aids.

Determine if the client uses hearing aids.

You understand Mr. S. is at an increased risk for skin breakdown due to certain aspects of his past medical history. Which two medical conditions would be the cause in delaying wound healing? A. +Smoker B. BPH C. COPD D. CHF E. Arthritis F. DM II G. HTN H. PVD

F. DM II H. PVD

"Welcome, Mrs. S. to our unit. Let me take some time to tell you what all of these wires and monitors are for."

Familiarity with them might make them seem less intimidating.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.) Loosen restrictive clothing Insert a bite stick into the client's mouth. Place the client into a supine position. Place a pillow under the client's head. Apply restraints.

Loosen restrictive clothing Place a pillow under the client's head.

A nurse is teaching a class about pain management in older adult clients. which of the following information should the nurse include? Older adult clients frequently underreport pain. Opioids should not be used in older adult clients, Pain perception decreases with aging. clients who are cognitively impaired do not feel pain.

Older adult clients frequently underreport pain.

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (select all that apply?) Provide a suction setup at the bedside Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside. Furnish restraints at the bedside.

Provide a suction setup at the bedside Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside.

"H.S. and Mrs. H., there are going to be a lot of tests that are going to happen. First is an EKG, this looks at the heart's electrical impulses."

Providing education empowers the patient, and family, to involve them in their case.

A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching? SpO2 95% BP 148/72 mm Hg Temp 36 C (96.8 F) Radial pulse regular 68/min

Radial pulse regular 68/min

A nurse is completing the 8-hour I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

STEP 1: What is the unit of measurement to calculate? mL STEP 2: Set up an equation and solve for X. 1 cup/240 mL = 1/2 cup/X mL X = 120 mL STEP 3: Reassess to determine whether the fluid volume makes sense. If 1 cup = 240 mL, it makes sense that 1/2 cup = 120 mL. After converting all fluid amounts to mL, add them to calculate the client's total fluid intake. 120 + 360 + 240 + 120 + 300 (IV) = 1,140 mL

Drag and drop the body system into a head to toe sequence to complete a systematic approach to gather objective data.

Skin, head, eyes, ears, nose, throat, respiratory, cardiovascular, GI, peripheral vascular, musculoskeletal

A nurse is teaching a newly licensed nurse about gynecological examination. which of the following information should the nurse include in the teaching? A speculum is used to assess the perineum. The cervix is assessed by spreading the labia majora. The anal opening is assessed to visualize the bartholin glands. The urethral orifice is assessed by separating the labia minora.

The urethral orifice is assessed by separating the labia minora.

Characteristic

"On a scale of 0-10, 0 being no pain and 10 being the worst pain you've ever felt, what would you rate your pain?"

A nurse is preparing to collect health history data during a client's admission. which of the following questions should the nurse use to promote this discussion? "what brought you to the hospital?" "would you tell me about all of your medical issues?" "do you want to talk about your health concerns?" "would it help to discuss your feelings about this hospitalization?"

"What brought you to the hospital?"

Duration

"When the pain comes, how long does it last?"

A general survey assessment is a component of a patient assessment that observes the entire patient as a whole. Cues obtained during a general survey assessment are used to guide additional focused assessments in areas of concern. As your new admission is wheeled into the room via wheelchair and is transferred to the bed, what general assessment findings can the nurse gather in this time period? Select all that apply. A. Actual age vs. state age B. Posture C. Cranial nerve assessment D. ADL assessment E. Hygiene/Grooming F. Swallow screen G. Bowel sounds H. Obvious signs of distress I. Motor movements J. Height K. Past medical history L. Weight M. Immunization status N. Heart sounds O. Lung sounds Feedback

A. Actual age vs. state age B. Posture E. Hygiene/Grooming H. Obvious signs of distress I. Motor movements J. Height L. Weight

A nurse is reviewing communication styles. which of the following characteristics should the nurse identify as being exhibited by a passive communicator? Use sarcasm when responding to others. Rarely interrupt others during conversation Tend to blame others for misunderstandings Avoid standing up for themselves when boundaries are crossed. Respond in agreement to avoid conflict. Use "I" statements rather than "you" statements when communicating.

Avoid standing up for themselves when boundaries are crossed. Respond in agreement to avoid conflict.

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.) Contractures of the extremities Polyuria Diarrhea Crackles in the lungs Pressure ulcers

Contractures of the extremities Crackles in the lungs Pressure ulcers

A nurse is caring for an older adult client who has left sided heart failure. Which of the following assessment findings should the nurse expect? Frothy sputum Dependent edema nocturnal polyuria jugular distention

Frothy sputum

A nurse is assessing a client who has left sided heart failure. Which of the following findings should the nurse expect? Jugular venous distension Abdominal distension Dependent edema Hacking cough

Hacking cough

A nurse is evaluating the documentation of a newly licensed nurse. The nurse should identify that which of the following entries requires intervention? Client assisted OOB, instructed to splint ABD 12 units o regular insulin administered subcut Prescription received for MSO4 4.0 mg PRN pain Urine collected for UA and C & S

Prescription received for MSO4 4.0 mg PRN pain

A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision? The client's FBS was 95 mg /dl The client seems to be more comfortable performing self-administration of insulin The client demonstrated proper technique when drawing up 8 units of insulin. The client stated, I struggle to see those little lines on the syringe."

The client seems to be more comfortable performing self-administration of insulin

a nurse is caring for a client who is 3 hr postoperative following abdominal surgery. which of the following assessment data should the nurse report to the provider? Postoperative laboratory results are Hgb 15% and Hct 40% The client's pain level has decreased since the administration of morphine Serosanguioneous drainage noted on the abdominal dressing. The client urine output has been 50 mL since surgery.

The client urine output has been 50 mL since surgery.

Evaluation

The fifth and final element is ... This final phase is a continuing process to determine if the goals have been attained. The nursing care plan is revised based on the patient's condition and whether the goals are realistic or appropriate for the patient. The intervention and evaluation process is ongoing and confirms that the nursing care is relevant. This process is continuously assessed as the patient's health condition changes.

Diagnosis

The second element is ... and has a nursing focus and is based on real or potential health problems or human responses to health problems. The nurse uses clinical reasoning to formulate this phase based on the assessment data and the patient's problem list. The phase sets the stage for the remainder of the care plan.

A nurse is teaching a classes about documenting blood pressure. The nurse should include to document which of the following information. The site where the blood pressure was obtained. Interventions implemented in response to a client's BP. A client's position when the blood pressure was obtained The frequency in which a blood pressure is taken. A client's response to interventions implemented.

The site where the blood pressure was obtained. Interventions implemented in response to a client's BP. A client's position when the blood pressure was obtained A client's response to interventions implemented.

A nurse is reinforcing teaching with a client who has low health literacy. Which of the following actions should the nurse take? Use the teach-back method Encourage questions Speak Slowly Use medical terminology Provide written materials is incorrect

Use the teach-back method Encourage questions Speak Slowly