Focused Assessment #2 ADN 140

A client, who attempted suicide 5 years ago with an overdose, was brought to the emergency department (ED) by a friend. The client states, "I just don't feel like living anymore. No one would care if I lived or died." What question should the nurse ask next?

"Do you have a plan a plan for suicide at this time?"

The nurse is assessing the client's cardiovascular system. The client asks the nurse why she presses on his toenails. Which is the best reply by the nurse?

"I can see how quickly the blood returns when I press and release your toenail. This tells me how well your peripheral blood is flowing."

A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. Which of the following is the most appropriate response by the nurse?

"Is that a new shirt you're wearing?"

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly."

An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit to the telemetry unit. The client asks the charge nurse if he can have the same nurse care for him every day. How should the charge nurse respond?

"We will try to assign you the same nurse as often as possible."

A middle-aged adult discusses with the nurse the loss of his job due to frequent illness. The nurse recognizes the patient's loss of his income as which of the following?

A stressor

A chronically ill school-age child is most vulnerable to which stressor?

Anxiety over school absences

All People Enjoy Time Magazine (APETM)

Aortic, Pulmonic, Erb's Point, Tricuspid, Mitral(apical)

Which statement correctly explains a person's interactions with basic human needs?

As a person strives to meet basic human needs at each level, stress can serve as either a stimulus or barrier.

A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment?

Auscultation

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Auscultation of a patient's heart murmur

Which type of chest configuration is typical of the patient with COPD?

Barrel chest

A nurse assesses patient breath sounds for patients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? (3)

Blowing, hollow sounds; auscultated over the larynx and trachea

The nurse is caring for a patient who has undergone peripheral arteriography. How should the nurse assess the adequacy of peripheral circulation?

By checking the peripheral pulses

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment finding that should be documented and reported to the physician?

Decreased heart rate

An adolescent at a mental health clinic tells the nurse about feeling an overwhelming sadness and isolation for several months. The adolescent states a lack of interest in school and family life and proclaims, "No one cares about me. I wish I were dead." Which information would be most important for the nurse to obtain in order to plan appropriate care?

Determine whether the adolescent has developed a plan for committing suicide.

A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears?

Disturbance in his sleep pattern

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat.

To assess for peripheral edema, the nurse will examine which of the following areas of the body?

Feet, ankles

During an interview, the client states, "When my stress is really high, I have diarrhea." The physiologic response affects

Gastrointestinal status

"Guiding me to view the ocean's calming waves is not working for me," replies the client. Based on this comment, the nurse was attempting which relaxation technique?

Guided imagery

When approaching health care holistically, which of the following would the nurse do?

Include physical, emotional, and social elements

A client admitted to the unit is visibly anxious. When assessing this client, the nurse should expect to see which cardiovascular effect produced by the sympathetic nervous system?

Increased heart rate

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Listen with the stethoscope at the fifth intercostals space left mid-clavicular line

A nurse assesses patient breath sounds for patients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? (2)

Medium-pitched, medium-intensity, blowing sounds; auscultated over the first and second interspaces anteriorly and the scapula posteriorly

6Ps of Peripheral Vascular Assessment

Pain: Passive motion Pallor(perfusion): pallor, cyanosis, color, coolnesss of skin Peripheral pulses: Pulse presence, rate, quality Parasthesia(sensation): Numbness and tingling Paralysis: Compression or irreversible muscle damage Pressure: Tightness or pressure

An elderly client who lives in a retirement community is having a mild depressive episode over the past few weeks. The nurse intervenes by recommending

Participation in a social activity

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's

Peripheral pulses

Edema

Pitting or non pitting

Anasarca

Severe generalized edema

A nurse assesses patient breath sounds for patients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? (1)

Soft, low-pitched, whispering sounds heard over most of the lung fields

A client is admitted to the emergency department after being found in a daze walking away from her burning car after an accident. She was not injured in the accident, but the other driver died. She states, "I can't handle it anymore. There's no point to it all." The crisis nurse recommends hospital admission based on the identification of which concern?

The client is expressing helplessness and hopelessness and is at risk for suicide.

A nurse admits a client with a preliminary diagnosis of acute stress disorder to the mental health unit. Which assessment requires the nurse's immediate action?

The client states she has a desire to not live anymore.

Edema scale

Trace 1+: 2mm depression, immediate rebound 2+: 4mm deep pit, a few seconds to rebound 3+: 6mm deep pit, 10-12 seconds to rebound (may last around a minute) 4+: 8mm very deep pit, greater than 20 seconds to rebound(up to 2 minutes or greater)

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?

bronchovesicular

A 62-year-old client reports being tired all the time, having trouble sleeping, and having trouble thinking. The nurse should:

further assess the client's mental status and health history.