NUR 220 case scenarios

A patient is on a large number of medications, and the nurse is concerned about the patient's personal ability to manage taking all the medications at home. Which questions would the nurse ask to assess the patient's potential safety risk? A.) "Do you take your medications consistently?". B.) "Do any young children live in the home who know about your medications?" C.) "Do you know how to take these prescriptions?" D.) "Do you know when to take your drugs?" E.) "Do you know why the health care provider has prescribed these medications?"

A.) "Do you take your medications consistently?"Asking a question about whether the patient takes the medications consistently is important in determining the patient's potential safety risk and whether the patient can manage taking all the medications at home. C.) "Do you know how to take these prescriptions?"Asking a question about the patient's understanding of how to take prescriptions is important in determining the patient's potential safety risk and whether the patient can manage taking all the medications at home. D.) "Do you know when to take your drugs?"Asking a question about the patient's understanding of when to take the drugs is important in determining the patient's potential safety risk and whether the patient can manage taking all the medications at home. E.) "Do you know why the health care provider has prescribed these medications?"Asking a question about the patient's understanding of why the healthcare provider has prescribed the medications is important in determining the patient's potential safety risk and whether the patient can manage taking all the medications at home.

Which vital sign measurements of adult patients would require the nurse to immediately notify the health care provider? A.) 158 pulse rate B.) 8 respirations C.) 99.5°F (37.5°C) temperature D.) 98% oxygen saturation E.) 50/30 blood pressure

A.) 158 pulse rate This is an extremely elevated pulse rate and would require the nurse to immediately notify the health care provider; the expected rate is 60 to 100. B.) 8 respirations This is an extremely low respiratory rate and would require the nurse to immediately notify the health care provider; the expected rate is 12 to 20. E.) 50/30 blood pressure This is an extremely low blood pressure and would require the nurse to immediately notify the health care provider; expected is 90 to <120/60 to <80.

Which principles would the nurse recall about pain signaling when caring for a patient with pain from stepping on a nail? A.) A nail pricking a foot is changed into an electrical impulse in transduction. B.) Trying to pull the foot away from the nail occurs during transmission. C.) The patient first translates the pain during modulation. D.) When the patient's brain sends inhibitory messages to the spinal cord, this is perception. E.) Release of endogenous opioids causes the pain to decrease.

A.) A nail pricking a foot is changed into an electrical impulse in transduction.Transduction is changing the painful stimulus (nail pricking foot) into an electrical impulse. Correct B.) Trying to pull the foot away from the nail occurs during transmission.During transmission, a healthy motor reflex will try to protect the body (pull the foot away from nail). E.) Release of endogenous opioids causes the pain to decrease.During modulation, release of endogenous opioids (natural pain killers) will cause the pain to decrease.

Which hypothesis would the nurse select for a postoperative patient who has increasing abdominal pain, a blood pressure of 142/92, and pulse of 110? A.) Acute Pain B.) Chronic Pain C.) Reduced Pain D.) Arthritis Pain

A.) Acute Pain Increasing abdominal pain postoperatively, elevated blood pressure, and pulse rate indicate Acute Pain.

Which actions would the nurse take after completing the interview and physical examination? A.) Document collected data. B.) Discuss what to expect next. C.) Encourage the patient to ask questions. D.) Place the call bell on the bedside table. E.) Assist the patient to a comfortable position.

A.) Document collected data. At the completion of the interview and physical examination, the nurse should document collected data. B.) Discuss what to expect next. The nurse should explain next steps to the patient at the conclusion of the assessment. C.) Encourage the patient to ask questions. Patients should be given a chance to ask questions or add any additional information that may have been forgotten earlier at the conclusion of the assessment. E.) Assist the patient to a comfortable position. On completion of the assessment, the patient should be assisted to settle back in bed or assisted to the front office, as appropriate.

How frequently would the nurse assess vital signs for a patient with a head injury who suddenly reports a severe headache and whose blood pressure rises from 118/62 to 170/94? A.) Every 5 minutes B.) Every 30 minutes C.) Every 4 hours D.) Every 8 hours

A.) Every 5 minutes The nurse would monitor the patient's vital signs every 5 minutes because this patient has experienced a sudden, severe change in condition as evidenced by the severe headache and blood pressure changes. These findings would be reported to the health care provider.

Which types of abnormalities can the nurse identify when percussing the abdomen? A.) Gas: Gas is found by percussing the intestines, and tympany will be heard. B.) Fluid: Fluid, or ascites, is suspected when periumbilical tympany and dullness in the flanks are heard. C.) Masses: For an abdominal mass, dullness will be heard when percussing the abdomen. D.) Organs: Dullness is a sound heard in percussion that may be a normal finding over solid organs. Identification of organ placement is not a type of abnormality. E.) Wounds: Percussion uses tapping to create sound vibrations based on the density of tissue beneath the skin. Percussion would not be necessary to identify a wound, which generally involves cut or broken skin.

A.) Gas: Gas is found by percussing the intestines, and tympany will be heard. B.) Fluid: Fluid, or ascites, is suspected when periumbilical tympany and dullness in the flanks are heard. C.) Masses: For an abdominal mass, dullness will be heard when percussing the abdomen.

Which prescribed medications would the nurse administer to a patient whose pain level is 3/10? A.) Ibuprofen B.) Naproxen C.) Acetaminophen D.) Morphine E.) Oxycodone

A.) Ibuprofen The nurse would administer ibuprofen. Ibuprofen, a nonopioid, nonsteroidal antiinflammatory drug, is given for mild (1 to 3) to moderate pain (4 to 7). B.) Naproxen The nurse would administer naproxen. Naproxen, a nonopioid, nonsteroidal antiinflammatory drug, is given for mild (1 to 3) to moderate pain (4 to 7). C.) Acetaminophen The nurse would administer acetaminophen. Acetaminophen, a nonopioid, is given for mild (1 to 3) to moderate pain (4 to 7).

Which factors influence the interpretation of a patient's vital signs? A.) Patient statusInterpretation of vital signs depends on patient status being stable, improving, or worsening. B.) Length of time the nurse is on duty C.) Consideration of patient's baseline vital signs D.) Standard range for vital sign values E.) Patient's unique medical condition

A.) Patient status Interpretation of vital signs depends on patient status being stable, improving, or worsening. C.) Consideration of patient's baseline vital signs Consideration of the patient's baseline vital signs assists in identifying trends. D.) Standard range for vital sign values The standard range is a guide the nurse uses to interpret vital sign measurements. E.) Patient's unique medical condition The patient's unique medical condition may explain vital signs being higher or lower (e.g., increased blood pressure in hypertension diagnosis).

Which cues would a nurse closely monitor to determine a patient's pain level who is intubated and can have nothing by mouth? A.) Pulse B.) Blood pressure C.) Eating habits D.) Restlessness

A.) Pulse A nonverbal patient's pain measurement can be determined by closely monitoring a patient's pulse because it will increase. B.) Blood pressure A nonverbal patient's pain measurement can be determined by closely monitoring a patient's blood pressure because it will increase. D.) Restlessness A nonverbal patient's pain measurement can be determined by closely monitoring a patient's restlessness because it will increase.

Which information to help decrease the pain would the nurse share with a postoperative abdominal patient who states that it is hard to move because the incision hurts? A.) Teach the patient about splinting. B.) Teach the patient about guarding. C.) Teach the patient about transmission. D.) Teach the patient about differences in acute and chronic pain.

A.) Teach the patient about splinting. Splinting (supporting the painful area with a pillow or blanket) will help decrease the pain when moving.

Match the process to its function for signaling pain. A.) Impulse crosses over in the spinal cord. B.) Inhibitory messages from the brain are sent to the spinal cord. C.) Painful stimulus is changed into an electrical impulse. D.) Impulse signal is received by the cortex. word bank: Transduction, modulation, transmission, perception

A.) transmission B.) modulation C.) transduction D.) perception

A 90-year-old patient taking multiple medications is being discharged to home. Which members of the interprofessional team would the nurse consult with to evaluate fall risk? A.) Pharmacist B.) Physical therapist C.) Unlicensed assistive personnel D.) Occupational therapist

A.)Pharmacist The pharmacist can help evaluate medications and make recommendations to the health care provider for alternative medications to minimize side effects that may result in a fall. B.) Physical therapist The physical therapist will evaluate the patient's ability to perform and maintain balance, which can help identify fall risks. D.)Occupational therapist The occupational therapist will evaluate the patient's ability to safely perform activities of daily living such as bathing or dressing, which can help identify fall risks.

Which response indicates a nurse has a correct understanding about the components of a vital sign assessment? A.) "Oxygen saturation is the measurable intake of oxygen and release of carbon dioxide." B.) "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." C.) "Respiration is the measurable amount of oxygen available to the tissues." D.) "Blood pressure is the measurable pressure of blood within the systemic veins."

B.) "Pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart." This is a correct statement because pulse is the detectable rhythmic expansion of an artery from the pumping action of the heart and is measured as the number of beats per minute.

Which vital sign measurements are unexpected? A.) 99.5°F (37.5°C) temperature for a newborn B.) 60 pulse rate for a 1-year-old C.) 35 respirations for a 6-year-old D.) SpO2 90% for a 15-year-old E.) 110/68 blood pressure for an older adult.

B.) 60 pulse rate for a 1-year-old 80 to 150 (awake) or 70 to 120 (asleep) pulse rate is expected for a 1-year-old; thus this pulse rate is unexpected. C.) 35 respirations for a 6-year-old 20 to 24 respirations are expected for a 6-year-old; thus this patient's respirations are unexpected. D.) SpO2 90% for a 15-year-old Greater than 95% is expected for a 15-year-old; thus this patient's SpO2 is unexpected.

Which classification would the nurse document the patient is experiencing when reporting the pain at a 7/10? A.) Mild B.) Moderate C.) Maximal D.) Severe

B.) Moderate Moderate pain is ranked as 4 to 7.

Which term describes subjective indications of a disease or a change in condition as perceived by the patient? A.) Signs B.) Symptoms C.) Conditions D.) Assessments

B.) Symptoms: Symptoms are a subjective indication of a disease or a change in condition. Examples include patient statements of headache or nausea.

Which expected outcome would the nurse develop for a patient suffering with acute pain? A.) Patient will report a pain level less than the previous rating. B.) Patient will ambulate up to 2 feet after surgery without pain. C.) Patient will report a pain level of less than 3/10 within 45 minutes of receiving pain medication. D.) Patient will meet with the health care provider to outline a plan for adjusting pain medication dosages within the next 3 days.

C.) Patient will report a pain level of less than 3/10 within 45 minutes of receiving pain medication. This is an appropriate patient outcome because it provides reasonable outcome criteria within a reasonable amount of time.

Which action would the nurse take when the unlicensed assistive personnel (UAP) reports the patient's pulse increased from 74 beats/min to 100 beats/min and the temperature increased from 99° to 101.8°F (37.2° to 38.8°C)? A.) Advise the UAP to wait 1 hour and repeat vital signs. B.) Compare the findings to the expected values. C.) Reassess the patient. D.) Tell the UAP to give fluids to the patient.

C.) Reassess the patient. The nurse verifies the vital signs since this is a significant change and notifies the health care provider.

Which finding is unexpected for a 15-year-old patient? A.) Pain level 0 B.) Pulse rate 88 C.) Respirations 30 D.) O2 sat 97%

C.) Respirations 30 This is an unexpected (abnormal) finding; respirations within expected ranges are 14 to 20.

Which concept describes the process in which the nurse collects information related to a patient problem by speaking with the patient? A.) Focused assessment. B.) Objective data collection C.) Subjective data collection D.) Comprehensive assessment

C.) Subjective data collection Subjective data collection is the process in which the nurse collects information related to a problem by speaking with the patient.

Which patient would the nurse assess first? A.) A patient with arthritis reporting joint pain B.) A patient with an open airway C.) A patient with a pain rating of 3/10 D.) A recent head injury patient who is reporting head pain

D.) A recent head injury patient who is reporting head pain A recent head injury with head pain would be assessed first because it is an acute situation. An acute situation is addressed before chronic situations.