Fund- Chap 10-13

What role is the nurse who diligently works for the protection of patients' interests playing?

Advocate

How can the nurse help reduce the stress of a hospital admission? (Select all that apply.)

1. Involve the patient in the plan of care. 2. Give simple explanation of policies. 3. Show the patient how bedside equipment works.

When the nurse ambulates with a patient who has left-sided weakness, what actions should the nurse take? (Select all that apply.)

1. Keep the leg nearest the patient behind the patient's knee. 2. Use a gait belt

When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data. What does this data help to establish?

Appropriate interventions

What site should be selected if a peripheral pulse needs to be assessed quickly?

Carotid pulse

A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?

Complains of pruritus.

What is the pulse—the expansion and contraction of an artery— produced by?

Contraction of the left ventricle

What type of body temperature remains relatively constant?

Core

When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?

Deep palpation

When assessing factors that may influence the patient's pulse rate, what should the nurse take into consideration? (Select all that apply.)

Emotion Sex Temp Age

What should the nurse do when offering a cup of hot coffee to a frail, older adult patient?

Fill the cup half full

A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require?

Focused

What part of the body maintains a balance between heat production and heat loss, regulating body temperature?

Hypothalamus

Upon admission, the nurse notes that a patient without family members present has a billfold filled with cash. Where can the nurse suggest the money be placed?

In the hospital safe

The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation?

Inflammation is a protective response.

The nurse manager is providing an in-service regarding a "safe hospital environment." What will this education mainly focus on preventing?

Injury

What is the term for the exchange of carbon dioxide and oxygen that takes place at the alveolar level?

Internal respiration

What does the nurse use the diaphragm of the stethoscope to best assess?

Lung Sounds

If a patient has an order for an interagency transfer, where does the nurse explain that the patient will be moved?

One facility to another

A patient is admitted to a medical surgical unit. What factors will determine how frequently vital signs will be assessed? (Select all that apply.)

Orders of the health care provider Judgment of need by the nurse Patients condition

What type of disease results in a structural change in an organ that interferes with its functioning?

Organic Disease

The home health nurse is preparing to educate a patient regarding electronic self-blood pressure measurement. What information should the nurse provide regarding this procedure? (Select all that apply.)

Proper measurement techniques are necessary. Cuff fits over clothing. Stethoscope is not required.

The patient should be assessed as soon as possible after admission. Who performs this initial assessment?

RN

What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease?

Remission

What is the term for a fever that rises and falls but does not return to normal until the patient is well?

Remittent

The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method?

Review systems

When should discharge planning begin?

Shortly after admission

The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective?

Sign

Where can a nurse refer the family of a patient to find a source of financial aid to meet medical expenses?

Social Services

What are the universal guidelines that define appropriate measures for all nursing interventions?

Standard of care

As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient?

Symptoms

When assessing vital signs on a 40-year-old male, the nurse identifies a pulse rate of 120 beats/min. What is this pulse interpreted as by the nurse?

Tachycardic

What does the nurse recognize as the initial step in conducting an assessment of a patient?

The nursing health hx

The health care provider orders daily weights on a patient residing in a long-term care setting. What actions should the nurse implement to assess weight accurately? (Select all that apply.)

Weigh patient at the same time each day. Encourage patient to void before being weighed. Ensure same amount of clothing is worn by patient.

A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:

an individualized plan of care.

A long-term care facility is committing to a restraint-free environment. What will the health care workers implement to encourage this environment? (Select all that apply.)

1. Maintain toileting routines 2. Frequent orientation surroundings 3. Explain all procedures and treatments

The emergency department nurse quickly assesses the temperature of an unconscious patient who has been outside all night in below-freezing temperatures. What temperature is the nurse aware of that can lead to death?

93.2F (34C)

When a patient demands to be discharged without a health care provider's order and is leaving the unit with his belongings, what should the nurse ask the patient to sign?

A discharge against medical advice form

The nurse must be sensitive to an older adult patient experiencing separation anxiety when admitted to the hospital. When a child experiences separation anxiety, they will usually cry. What will an older adult often demonstrate when experiencing separation anxiety?

Depression

The best defense against malpractice claims associated with nursing care is accurate __.

Documentation

How should the nurse position the ear pinna when using the tympanic thermometer on a child?

Downward and back

During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated?

During inspiration

The nurse assesses respirations of a patient demonstrating pursed-lip breathing, flared nostrils, and retractions. How will the nurse describe these respirations?

Dyspnea

What should the nurse begin by assessing when performing a head-to-toe assessment?

Neurologic status

A nurse assesses a patient's dorsalis pedis pulse. The pulse is easily felt but not palpable when moderate pressure is applied. How should the nurse document this finding?

Normal pulse

A patient who is alert and oriented is threatening to leave the hospital against medical advice (AMA). What action should the nurse take?

Notify the health care provider that the patient is threatening to leave AMA.

What document identifies the roles and responsibilities of the LPN/LVN?

Nursing Practice act

The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?

Nursing assessment

During the nursing interview, several histories are taken. What is the history that involves data concerning habits and lifestyle patterns?

Past health hx

A patient is suspected of having a cardiac arrhythmia. The nurse is concerned with the findings of an apical rate of 88 and a radial rate of 80. What is the term for the difference between these two rates?

Pulse deficit

A new patient is being admitted to a long-term care facility. Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified?

RN

There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these factors?

Risk factors

A nurse needs to auscultate a patient's lung sounds. In what position should the nurse place the patient?

Sitting

A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data?

The patient expectorates red-tinged sputum.

Before the actual discharge occurs, what must the nurse ensure?

The patient understands the discharge instructions.

How should the nurse position the earpieces on a stethoscope to ensure optimum reception?

Toward the face