PrepU: Exam 1

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?

Airway

Which assessment finding should the nurse document as objective data?

Body Functions

The nurse is conducting an initial interview with a client. During the introductory phase, it is essential that the nurse perform which of the following actions? Select all that apply.

Build rapport. Provide a comfortable environment. Explain the purpose of the interview. Ensure confidentiality

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tread on a car tire to determine whether it is time to replace it

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?"

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?

rephrasing

During an interview with an adult client for the first time, the nurse can clarify the client's statements by

rephrasing the client's statements

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to

use very basic lay terminology

The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment? Select all that apply.

"Are you experiencing any pain at this time?" "Are you feeling dizzy now?" "Do you know what your blood pressure is usually?"

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

"Have you ever had a problem with mental or emotional illness?"

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

"What is your major health concern at this time?"

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?

Assess the nasogastric tube for proper functioning

One technique of therapeutic communication is silence. What does silence allow the client to do?

Decide how much information to disclose

A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?

Develop a plan of care with the client

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize?

Establishing a trusting relationship

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing

A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?

The client may not want the sister to know their private information

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

emergency

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

head to toe

The nurse is assigned the following clients. Which client requires an emergency assessment?

the client who underwent a hysterectomy yesterday and is now reporting shortness of breath and has decreased oxygen saturations

Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview?

Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of Ineffective Health Maintenance

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

To clarify

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?

To determine any changes from the baseline data

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?

unable to go to the gym since having back surgery

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan."

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview

A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Click to highlight the findings that will require follow-up. Client is awake, alert, and oriented. Client walks with a cane. Abdomen is soft and nontender, last bowel movement was charted 7 days ago. No urine output has been charted in the last 24 hours. Skin is warm, dry, pink, and intact. Vital signs: temperature, 97.9°F (36.6°C); heart rate 120 beats/min and irregular; oxygen saturations 88% on room air.

last bowel movement was charted 7 days ago No urine output has been charted in the last 24 hours heart rate 120 beats/min and irregular oxygen saturations 88% on room air

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgments or diagnoses

A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?

Evaluate outcome

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?

Identify in what areas the client needs the most care