Health Assessment: Rashid Ahmed Pre-Simulation Quiz
An older patient is admitted with a diagnosis of gastroenteritis and dehydration. What assessment data documented by the nurse support this diagnosis? (Select all that apply.)
Produces dark yellow urine Reports feeling dizzy when standing up Reports experiencing diarrhea for last 48 hours Reports vomiting after taking "even a little drink of water" Rationale: Symptoms associated with dehydration include: diarrhea that has lasted a few days or longer; vomiting triggered by attempting to eat or drink; infrequent urination that produces dark yellow or brown urine; and feeling dizzy, especially when standing from a sitting or lying position. Flushed (ruddy), moist skin is not associated with dehydration.
Hydration status is being monitored for a patient being treated for dehydration. Which statements made by the nurse to the patient accurately reflect the assessment of fluid intake and output? (Select all that apply.) Liquid stool and vomitus will be assessed as well as urine. Your urine will be stored in the bathroom and measured twice a shift The amount of IV fluids you receive will also be recorded as part of your fluid intake. Do you remember how to use the urine hat to save your urine? When may I talk with your family about helping us keep track of your fluids?"
Liquid stool and vomitus will be assessed as well as urine. When may I talk with your family about helping us keep track of your fluids?" The amount of IV fluids you receive will also be recorded as part of your fluid intake. Do you remember how to use the urine hat to save your urine? Rationale: Fluid output includes urine, liquid stool, vomitus, blood, and drainage from tubes (such as chest tubes), ileostomies, nephrostomy tubes, suction devices, and surgical drains. IV fluids are considered when monitoring fluid intake. Urine can be collected and measured using a bedpan or a urine hat placed on the commode. The nurse should explain to the patient and the family that the nurse will be measuring intake and output, and ask for their help. Instruct the family to measure fluids that they give to the patient, to place output in a urinal or bedpan in the bathroom, and to call the nurse to have it measured. Urine is discarded after it is measured and recorded, unless it is being saved as a part of a 24-hour urine specimen.
Which reaction requires immediate notification of the health care provider when a patient is receiving the antibiotic ciprofloxacin? Hiccups lasting more than an hour Feelings of elevated mood Eyes becoming sensitive to sunlight Numbness in any extremity
Numbness in any extremity Rationale: Peripheral neuropathy may develop from ciprofloxacin therapy and must be reported to the health care provider. The other symptoms are not generally associated with administration of this medication.
A patient is admitted reporting diarrhea, nausea, vomiting, dizziness, and abdominal pain. Diagnoses of hypokalemia, dehydration, and gastroenteritis are pending. Intravenous access has been established for this patient. Which nursing intervention has priority considering the patient's symptoms and expected diagnoses? Managing the patient's pain through IV medication Introducing fluids to treat dehydration Administering potassium chloride in a timely, effective manner Minimizing the impact of nausea and vomiting on medication administration
Administering potassium chloride in a timely, effective manner Rationale: Hypokalemia, a condition characterized by insufficient potassium levels, places the patient at risk for a variety of health concerns, including cardiac arrhythmia and arrest. Managing this condition is a priority.
A patient has been admitted for treatment of abdominal pain, nausea, and diarrhea. Which finding identified during the nursing assessment is most associated with a bacterial or viral infection? Oral temperature of 38.1°C (100.6°F) Respiratory rate of 16 breaths per minute Blood pressure of 112/72 mm Hg Radial pulse rate of 76 beats per minute
Oral temperature of 38.1°C (100.6°F) Rationale: An elevated temperature (higher than 38.0°C or 100°F) may be seen in both viral and bacterial infections. Although the pulse and respiratory rates can be elevated as a result of a fever, all the remaining options are within normal limits.
A patient being admitted to a medical unit is receiving a general assessment by the nurse. What is the priority action for the nurse to take when the patient says, "I've been so nauseous"? Determine when the patient initially began experiencing the nausea Identify whether the patient has a history of chronic nausea Note the patient's comment in the medical record Conduct a focused assessment of the patient's abdomen
Conduct a focused assessment of the patient's abdomen Rationale: When an abnormality or concern is identified, the nurse will need to perform an in-depth focused assessment on the body area that appears to be affected, in this case the abdomen. The remaining options do not have priority over the abdominal assessment
An older adult diagnosed with gastroenteritis has an admission potassium level of 2.9 mEq/L. Of the following admission orders, which has initial priority for the nurse caring for this patient? Notify provider if heart rate is greater than 100 beats per minute Insert saline lock Strict I&O with totals recorded q. 24 hours Reassess potassium level in a.m.
Insert saline lock Rationale: This patient's potassium level is below the normal range of 3.5 to 5 mEq/L (hypokalemia), so the patient is in danger of experiencing cardiac complications such as arrhythmias or arrest. The establishment of intravenous access is necessary for the administration of potassium to elevate the electrolyte level back to within the normal range. Hypokalemia can cause bradycardia, not tachycardia. The remaining options are appropriate but do not have priority over initiating the steps necessary to introduce potassium into the vascular system of this patient.
The nurse is assessing a patient's abdomen during a physical assessment. What will be the focus of the nurse's inspection? (Select all that apply.) Overall skin color Location and contour of the umbilicus Aortic pulsations Abdominal reflex Symmetry and contour
Overall skin color Location and contour of the umbilicus Aortic pulsations Symmetry and contour Rationale: Inspection of the abdomen includes the following: notice of the overall skin color; location, color, and contour of the umbilicus; symmetry and contour of the abdomen; and aortic pulsations and/or peristaltic waves. Assessment of the abdominal reflex requires light palpation of the abdomen, and thus is not included in the inspection phase of the assessment.
The nurse is preparing to conduct a head-to-toe examination on a patient being admitted with a tentative diagnosis of gastroenteritis. What equipment will the nurse require to effectively perform the portion of the physical examination directly associated with the patient's affected physical system? Doppler ultrasound device Reflex hammer Stethoscope Water-soluble lubricant
Stethoscope Rationale: The system that is the focus for gastroenteritis would be the abdomen. The stethoscope would be necessary to assess bowel sounds; they would likely be hyperactive in this patient. A reflex hammer is associated with the neurologic system. Water-soluble lubricant is used in examining both the male and female genitalia and the rectum. The Doppler ultrasound is used to examine the peripheral vascular system.
An older patient is being treated for an infection that has resulted in a diagnosis of gastroenteritis. Which statement made by the nurse indicates an understanding of how the signs of this condition may appear in an older patient? The normal temperature range in an older adult is lower than that of a younger adult. The bowel sounds tend to be more active in an older adult. Diarrhea is a more serious concern in children than in older adults. Older adults tend to have a lower tolerance for gastric pain and so it is a major concern.
The normal temperature range in an older adult is lower than that of a younger adult. Rationale: Research has shown that for older adults, normal body temperature values for all routes are consistently lower than in younger adults. None of the remaining options presents a true statement.