Exam 1 Prep U Quiz

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden Scale

A nurse obtains a pulse rate on an adult client of 56 beats per minute. What is the correct term that the nurse should use to document this finding?

Bradycardia

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

Continuous

The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain?

Facial grimacing, leaning forward

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of

Hypoxia

When entering a client's room, the nurse washes her hands and asks the client for his name. What is the nurse's next best action?

Introduce self and explain what will be done.

When documenting that a client has freckles, the appropriate term to use is

Macules

A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care?

Maintaining the privacy and confidentiality of clients' medical records.

While assessing the vital signs, the nurse notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my spouse. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon?

Mental

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

Orthostatic hypotension

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

Wash hands before examination in the examination room.

A client who has had a recent below-knee amputation tells the nurse that he feels as though his toes are cramping. What would the nurse say in return?

"That is called phantom pain, and it is not unusual."

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth of specific issues, unlike a comprehensive assessment.

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to

A healthy lifestyle