QUIZ #4

Orthopnea

Must sit upright or stand in order to breathe comfortably

Vomit

Expel the contents of the stomach out of the mouth

Pruritus

Itching and an uncomfortable sensation leading to an urge to scratch

The nurse is interviewing an older patient and notices that the patient is slumping and irritable and frequently sighs. Which questions would the nurse ask to validate the most likely interpretation of the patient's behavior?

"Are you feeling tired?" The nurse recognizes that the patient is tired. Shortness of breath is visible as the patient's respiratory rate increases and the focus of attention is on breathing; usually the facial expression conveys anxiety. Licking lips or dry lips would signal need for water. There many ways that pain manifests, but restlessness, shifting weight, or expiratory grunting would be a few of the nonverbal behaviors that the nurse might observe.

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Neurologic:

"Are you having headaches?" "Have you ever had a serious head injury in the past?" "Have you experienced any changes in sensation or coordination?"

A nurse instructing an assistive personnel (AP) about caring for a client who has a low platelet count as result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client?

"Do not measure the client's temperature rectally." The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client.

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Genitourinary:

"Do you have any discomfort when you urinate?" "Have you noticed any changes in frequency of urination?" "Do you suspect that you may have been exposed to a sexually transmitted infection?"

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Gastrointestinal:

"Do you have any trouble swallowing?" "Is there any change in your appetite?" "Have you had nausea, vomiting, diarrhea, or constipation?"

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Respiratory:

"Do you have difficulty breathing?" "Have you ever been exposed to tuberculosis?" "Do you smoke?"

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Endocrine:

"Has your weight changed recently?" "Do you have a personal or family history of diabetes?" "Have you noticed any change in your tolerance to heat or cold?"

A 40-year-old man comes to the clinic. He desires a general physical check-up and repots, "not feeling quite 100%." This is the patient's first visit to the clinic, so there are no medical records available for comparison. Provide examples of questions that the nurse could ask to obtain information during a review of systems. Cardiac:

"Have you had any chest pain?" "Do you have a personal or family history of hypertension?" "Have you experienced any palpitations?"

The LPN is assisting the RN with a newly admitted female patient. What is the most appropriate way to address the patient?

"Hello, Ms. Green, my name is..." All patients need to be addressed by Mr., Mrs., Ms., and the last name unless otherwise directed. It is not appropriate to use Honey, Sweetie, or Dear when addressing patients.

The nurse is assessing an older patient. Which explanation should the nurse use?

"I am going to listen to your heartbeat' The nurse should use terminology that is familiar to the average person.

The nurse is placing an ID band on a patient who was admitted through the emergency department. What is the best thing to say as the band is applied?

"The primary purpose of the band is to maintain safety." Explaining that the band is for safety reassures the patient that the band is for his/her benefit and not just a standard method of classification, and that he/she is not viewed as just an assigned number. Joking with patients is often appropriate, but first the nurse should establish rapport with the patient; otherwise he/she may believe that there is real possibility of getting lost or displaced.

A patient with Alzheimer's disease is being transferred from a long-term care facility to an acute care hospital for possible sepsis and change in mental status. Which question is most important to ask the nurse who is giving the report?

"What is the patient's baseline mental status and behavior?" For any patient who has change of mental status, knowing baseline behavior is important. For a patient with dementia, knowledge of baseline behavior is especially important, because delirium and dementia can have some similarities. The other information is also relevant, but not as critical as meeting the patient's immediate physical needs.

The patient's oral temperature is 101.2F (38.4C). The patient tells the nurse that he doesn't feel well, but has no known health conditions. What question would the nurse ask first to try to localize the source of infection?

"What other symptoms are you having?" If the patient can identify other symptoms, this helps the health care team to locate the source of the infection. For example, back pain or problems with urination suggest a urinary tract infection. A sore throat with difficulty swallowing suggests pharyngitis. Allergies can cause some people to have low-grade temperatures, but fever is not typically associated with allergic reactions. Asking about previous similar episodes could be a follow-up question to try to narrow the search; for example, tuberculosis or AIDS could cause episodes of respiratory infections that recur. Onset of fever is also a follow-up question that could be used if a pattern of infection is currently noted; for example, a number of people have developed febrile illness after attending the same event.

The patient is newly admitted and seems anxious, but also appears very tentative about asking questions. Which statement by the nurse best demonstrates empathy?

"You seem a little uncertain; do you have some questions?" First the nurse reflects the patient's feelings of anxiety and then directly invites the patient to ask questions. Indicating when to call and willingness to help is a good thing to say after the patient appears to be comfortable and settled in his/her new surroundings. Telling the patient "not to worry" does not address his/her specific concerns. "I know I would" switches the focus to the nurse.

Which task(s) related to admitting a new patient can be delegated to the UAP? (Select all that apply) 1. Obtain personal care-items, such as water pitcher or packaged cleansing cloths. 2. Position the bed for transfer from the stretcher or wheelchair. 3. Hang signs above the bed related to care, such as NPO status. 4. Ask the patient if he/she needs special equipment, such as a walker. 5. Store belongings, such as jewelry, watch, or wallet, in bedside table. 6. Assist patient to arrange desired items, such as eyeglasses within reach.

1. Obtain personal care-items, such as water pitcher or packaged cleansing cloths. 2. Position the bed for transfer from the stretcher or wheelchair. 6. Assist patient to arrange desired items, such as eyeglasses within reach. The UAP can assist by making the room more comfortable and welcoming. Needs should be assessed by the nurse and then signs, equipment, or other items can be obtained. Items of value should not be stored in the bedside table.

During the admission of a patient to a health care facility, what are the responsibilities of the admission department representative? Select all that apply. 1. Obtaining the identifying information 2. Giving information on Health Insurance Portability and Accountability Act (HIPPA) 3. Suplexing the patient off the second-story flight of stairs 4. Placing the correct ID band on the patient's wrist 5. obtaining a list of current medications 6. Placing the patient in a chokehold 7. Obtaining a emergency contact information 8. Gathering insurance information

1. obtaining the identifying information 2. Giving information on HIPPA 4. Placing the correct ID band on the patient's wrist 7. obtaining emergency contact information 8. gathering insurance information When the admission is conducted through the admissions department, efforts are made to obtain demographic, insurance, and emergency contact information. The identification band is immediately placed, so that all health care team members can correctly identify the patient for appropriate care. Health Insurance Portability and Accountability Act and Patient's Bill of Rights can be explained by the admissions representative. Discussions about medication and other health-related matters should be done by the nursing staff. DO NOT suplex or place anyone in a chokehold unless you're frustrated about Ms. Lori.

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. Which the client's pulse deficit?

16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to peripheral pulse points (84 - 68 = 16).

The patient is being transferred from the medical-surgical unit to a long-term care center. What tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Change the soiled dressings 2. Bathe an incontinent patient 3. Assist to collect personal items 4. Take a final set of vital signs 5. Review transfer details with family

2. Bathe an incontinent patient 3. Assist to collect personal items 4.Take a final set of vitals UAP can bathe the patient, assist the patient to collect personal items and take a set of vital signs. Dressing change should be performed by the nurse to include a final assessment of wound site. The nurse should discuss the transfer with the patient and family and answer questions as needed.

While assessing a patient's lower extremities, the nurse notes edema around the feet and ankles. When the area is depressed, it lasts for more than 1 minute before the shape returns. How would the nurse document this edema?

3+ pitting edema 3+ pitting edema is noticeably deep pitting, full and edematous extremity, with depression lasting more than 1 minute. 4+ pitting edema is very deep pitting, very edematous and distorted extremity, with depression lasting as long as 2 to 5 minutes. 2+ pitting edema is somewhat pitting edema, no marked change in shape of the extremity, and depression disappears in 10 to 15 seconds. 1+ pitting edema is slight pitting, with no visible change in the shape of the extremity and in which depression disappears rapidly.

The nurse hears in report that the patient has had occasional episodes of cyanosis and dyspnea. Which physical assessment does the nurse plan to frequently perform during the shift?

Assess respiratory effort Cyanosis and dyspnea indicate that oxygenation of tissues is inadequate and that the patient is having trouble breathing, so frequent assessment of respiratory effort is required.

Which newly admitted patient is mostly likely to need and benefit from an individualized explanation of the bathroom facilities?

A 65-year-old man who is from a rural farming region of China While all patients benefit from an individualized approach, the farmer from rural China is most likely to be unfamiliar with plumbing conditions in a Western hospital. The patient with Alzheimer's disease is not going to remember any new information. Children who are just starting to toilet train are likely to need diapers during hospitalization, because the stress may cause them to revert to earlier behavior. The woman with stress incontinence needs interventions to help tighten the pelvic musculature.

Which patient is likely to have the most complex discharge plan?

A 73-year-old man with chronic disease who has no family in the area An older patient with chronic disease and fewer personal resources is likely to have the most complex discharge plan, which may include social services, nursing, physical therapy, and home health aides. He is more likely to need help with issues such as transportation, shopping, preparing food, and assistance with activities of daily living. He is also likely to be taking more medications and have more ongoing health problems.

What would be considered a normal finding when assessing the patient's spine?

A gentle inward curvature of the lumbosacral curve An inward curvature of the lumbosacral area is normal. An exaggerated posterior curvature of the thoracic spine is kyphosis. An increased lumbar curvature is lordosis. A lateral curvature is scoliosis.

A male patient has his call light on. As the nurse enters the room, the patient is fully dressed and ready to leave. He begins yelling and asking to remove his IV because he is going home. What term best describes a patient's intent to leave a health care facility without a health care provider's order?

AMA When a patient leaves a long-term care or acute care setting without a health care provider's order, it is considered "leaving AMA" (against medical advice). A form acknowledging that the patient is choosing to leave against the health care providers advice is usually signed by the patient prior to leaving the health care facility.

Edema

Abnormal accumulation of fluid in interstitial spaces

Tachypnea

Abnormally rapid rate of breathing

Which method would be best to assess an older patient's ability to accomplish activities of daily living?

Accompany the patient during ambulation to the bathroom Watching the patient as he/she performs an activity is the best method for assessing abilities to accomplish activities of daily living (ADLs). Asking the patient who does the shopping and cooking would be a better question than asking him what he eats. (He may rely on others to obtain and prepare the food.) A full set of vital signs gives some indirect information about the patient's abilities; for example, a rapid respiratory rate would suggest that activity intolerance would be a factor in performing ADLs. Level of consciousness and orientation are important, but a person can be fully conscious and oriented, yet be unable to get to the bathroom.

The patients tells the nurse that he would like to be transferred to hospital X, because his cardiologist doesn't come to hospital Y. What should the nurse do?

Advise the patient that a transfer requires an order from the health care provider A transfer requires an order from the provider, and the provider must speak directly to accepting provider at the receiving hospital. The receiving hospital must be contacted and accept the transfer and the nurse must give a report to the nurse who will be caring for the patient.

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family?

Any difficulty swallowing The greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life-threatening.

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

Ask the client if she is having any pain (first nursing process of assessment) The first action that should be taken using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefor, the priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, report this finding to the provider.

A new nurse documents PERRLA in the patient's chart. When the preceptor nurse asks her to describe the findings, the new nurse is unable to explain. What should the preceptor nurse do first?

Ask the new nurse how she knew to document PERRLA The preceptor would try to determine what process the new nurse is using to assess and to document. There is a possibility that the new nurse knows what to do but is not able to describe the findings. Thus there is either a knowledge deficit or a communication problem. There is also the possibility that the new nurse copied the assessment from a previous entry. This is falsification of documentation, but probably occurs more often than it should. After assessment, the preceptor could decide to use the other options.

The nurse hears in report that a patient who has cancer is experiencing anorexia. Which assessment does the nurse plan to conduct during the shift?

Assess need for supplement nutrition A patient who is anorexic has a poor appetite with a subsequent poor intake of nutritious foods, so the nurse would assess need for supplemental feedings, which could include high-calorie, high-protein oral supplements, tube feedings, or intravenous nutrition.

The nurse is giving instructions to a family caregiver of an older patient who will need help after discharge from the hospital. The nurse tenses tension, resentment, and unwillingness from the caregiver. What should the nurse do first?

Assess the caregiver's attitude toward the patient and the circumstances The nurse would first attempt to assess the caregiver's attitude. Based on the assessment findings, the nurse could use the other options.

The nurse is almost finished doing a routine head-to-toe assessment on a newly admitted patient. Suddenly, the patient starts coughing and reports "trouble breathing." What should the nurse do first?

Assist the patient to sit upright and give oxygen per mask or nasal cannula The patient's immediate need for oxygenation is the priority. In addition to positioning and oxygen, the nurse could encourage coughing (to expel foreign matter in the airway), deep breathing, or purse lipped breathing as appropriate. When the patient recovers his breath, the nurse would conduct the focused respiratory assessment and notify the provider as needed. The nurse stays with the patient until he is stabilized but avoids giving false reassurance. (Note to student: a provider's order is required for oxygen, however in an emergency situation, apply oxygen and obtain an order as soon as possible.)

What is the role of the LPN when a patient is admitted to a health care facility?

Assist with the plan of care and recommend revisions as necessary As an LPN, you can assist with the plan of care and recommend any revisions as necessary. The initial health history and assessment is to be performed by an RN. Evaluation and implementing the plan of care are the responsibilities of both the RN and LPN, and they are done after the admission process is completed.

An older adult woman walks into the interview room. She smiles at the nurse and looks around the room. The nurse says, "Please take a seat," and the women takes a brochure from the display case. The nurse says, "Why have you come to see us today?" The women says, "Yes dear, tea is fine. Thank you." Based on this interaction, what assessments will the nurse perform first?

Auditory sensory perception and cognitive function Patient is in no apparent distress, but she is not responding appropriately to commands or to questions. The nurse assesses the patient's hearing first: moves closer to patient; uses gestures, such as pointing to the chair, while inviting the woman to sit; uses white board or paper and pencil to give commands. If hearing is not the problem, then the nurse would check cognitive functioning by assessing orientation, ability to move and follow commands. Vital signs, pulse oximeter and blood glucose should be performed on patients with sudden or unknown etiology of mental status decline. Decreased cerebral perfusion, low oxygenation or blood glucose levels require emergency intervention. Head-to-toe assessments are appropriate for new patients and for those who are unable to verbalize focused complaints. Assessment of the family support and structure are routinely done, especially for elderly patients. Culture, age and gender are important factors for this patient's behavior.

The process of listening to sounds produced by the body is which physical assessment technique?

Auscultation Auscultation is the process of listening to sounds produced by the body, which include the cardiovascular, respiratory, and gastrointestinal systems. Inspection is where the nurse visually inspects the patient's body and observes moods, including all responses and nonverbal behaviors. Palpation is where the nurse uses his or her hands and senses of touch to gather data. Percussion is the use of fingertips to tap the body's surface to produce vibration and sound.

A patient tells the nurse that she is "afraid of the doctor." How could this affect the objective data?

Blood pressure could be higher than expected Fear activates the sympathetic nervous system, so the blood pressure will rise and the pupils will dilated (fight or flight response). Pain and nausea are subjective symptoms.

Cyanosis

Bluish discoloration of the skin and mucous membranes

A patient is being transferred to a long-term care facility for rehabilitation. What is the nurse's responsibility in providing continuity of care for this patient?

Call the admitting nurse at the facility and give a brief summary of the patient's medical diagnosis, treatment care plan, and medications Documentation and communication between the health care staffs are very important to provide this patient with continuity of care from one facility to another.

The patient has an old head injury and demonstrates occasional intermittent episodes of belligerence and confusion interspersed with appropriate behavior. He is currently angry and wants to leave AMA. The nurse is unable to reach the provider. What should the nurse do first?

Call the supervising RN, because the patient now has acute needs. A patient with an old head injury can be considered a chronic care case that could be assigned to the LPN/LVN; however, it would be appropriate for the LPN/LVN to notify the supervising RN because the patient's change in status and needs should be assessed by the RN. Explaining the AMA form to the patient could be done, but the question is whether the patient can legally assume responsibility for his own actions. Contacting the family is a possibility, but the hospital/nurse could still be held liable if the patient were to injure himself or others in a confused state. Calling the risk manager is an option, but it is unlikely that the manager will make the decision to detain the patient, because the decision has to be based on whether the patient is rational and able to make safe judgments.

The nurse is admitting a new patient to the diagnostic and surgical center. What should the nurse do first?

Check Identification Band This patient is in no apparent distress, so the nurse should check the identification first. Identifying the patient is necessary to give correct information about procedures, plan of care, etc. Checking identification could be done simultaneously as the nurse is introducing self. The other actions are also necessary. If the patient was in apparent distress, the nurse would quickly assess needs and intervene.

The patient is admitted through the emergency department for an exacerbation of a chronic respiratory disorder. When the patient arrives at his room on the medical-surgical unit, he appears very tired. He has oxygen per nasal cannula and demonstrates labored breathing. He is able to speak, but his sentences are short and he takes a breath after every few words. How would the nurse modify the nursing actions related to the admission to meet the needs of this particular patient? Checking and verifying the identification band:

Checking and verifying the identification band (ID) must be performed. The nurse might say, "I need to check your ID band and check a few things related to your breathing, but I will do the work and you can put your energy towards breathing."

Nurses today care for patients from many different cultures and backgrounds. Which ideas/beliefs from the Japanese culture are accurate related to causing illness?

Contact with skin disease, lack of sleep, improper care of the body, and contact with blood Japanese culture believes that coming in contact with blood and skin disease, and improper care of the body including lack of sleep are some of the causes of illness. Japanese culture does not consider ingestion of alcohol or lack of prayer to be causes of illness.

Purulent drainage (pus)

Creamy, viscous, pale yellow or yellow-green exudate; liquefied necrosis of tissues

While performing a physical assessment, which findings would indicate a deviation from normal?

Cyanosis of the fingers and toes, erythema of lower extremities, jaundice, and apical heart rate of 110 Cyanosis indicates a peripheral vascular problem; jaundice indicates a problem with the liver; a 110 beats/min heart rate is tachycardia or a cardiac problem; and erythema indicates redness or inflammation of the skin or mucous membranes. Afebrile is an example of a normal finding that indicates no problems. A capillary refill of less than 3 seconds is normal.

The nurse observes jugular venous distention on a patient who is sitting in the interview chair. What other signs or symptoms would the nurse check to validate suspicion if heart failure?

Dependent edema in legs The most likely finding would be dependent edema in the lower extremities.

Constipation

Difficulty passing stools or infrequent passage of hard stools

The nurse is unable to palpate the popliteal pulse. Which pulse would the nurse assess before informing the provider?

Dorsalis pedis pulse The popliteal pulse is hard to find, and the patient may have difficult assuming the prone position which is optimal for this assessment. Prior to calling the provider, the nurse would assess pulses and tissues that are distal to the popliteal area; thus if the dorsalis pedis pulse and/or the posterior tibial pulse are palpable, the blood is flowing through the popliteal area to the distal tissues.

To effectively assess and plan for a patient's continuing needs, when should the nurse begin the discharge process?

During hospitalization Discharge planning occurs during hospitalization, beginning shortly after a patient is admitted.

A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehab center. Which of the following tasks are the responsibility of the nurse at the transferring facility?

Ensure that the client has possession of his valuables. (Account for all of the client's valuables at the time of transfer). Confirm that the rehab center has a room available at the time of transfer. (On the day of the transfer, confirm that the receiving facility is expecting the client and that the room is available). Give a verbal transfer report via telephone. (Provide the nurse at the receiving facility with a verbal transfer report in person or via telephone). Complete a transfer form for the receiving facility. (Completely any documentation for the transfer, including a transfer form and the client's medical records).

A patient has arrived at the outpatient surgery department before a scheduled surgery. What must the nurse accomplish before the patient goes to surgery?

Ensure the operative consent is signed The patient must sign the operative permit before surgery. Most patients are required to be NPO for 6 to 8 hours not 12 hours and pain medication is usually not administered before surgery. The patient's belongings are usually given to the patient's family.

A nurse is admitting a client who has acute cholecystitis to a med-surge unit. Which of the following actions are essential steps of the admission procedure?

Explain the roles of other care delivery staff. (The client's hospitalization is likely to be more positive if the client understands who can perform which care activities). Begin discharge planning. (Unless the client is entering a long-term care facility, discharge planning should begin on admission). Document the client's wishes about organ donation. (Upon hospital admission, required request laws direct providers to ask clients older than 18 years if they are organ or tissue donors). Introduce the client to their roommate. (Any action that can reduce the stress of hospitalization is therapeutic. Introductions to other clients and staff can encourage communication and psychological comfort).

Ecchymosis

Extravasation of blood into the subcutaneous tissues

Patient appears anxious as he enters the exam room for the first time. He nervously begins to ask the nurse a series if questions about what will will happen to him.

Fear of the unknown Patient is manifesting fear of the unknown, which causes insecurity, and relates to the need for safety according to Maslow.

A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary?

Follow up care. (It is essential to include the names and contact information of providers and community resources the client will need after they return home). Instructions for diet and medications. (The client will need written information detailing home medication and dietary therapy. A client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications, like constipation). Contact info for the home health care agency. (It is essential to include the names and contact information of providers and community resources the client will need after returning home. For example, a client who had a knee arthroplasty might require physical therapy at home until able to travel to a physical therapy department or facility.

Tachycardia

Heart rate greater than 100 beats per minute.

Bradycardia

Heart rate less than 60 beats per min

The patient is admitted through the emergency department for an exacerbation of a chronic respiratory disorder. When the patient arrives at his room on the medical-surgical unit, he appears very tired. He has oxygen per nasal cannula and demonstrates labored breathing. He is able to speak, but his sentences are short and he takes a breath after every few words. How would the nurse modify the nursing actions related to the admission to meet the needs of this particular patient? Assessing immediate needs:

Immediate needs must be assessed and addressed. In this case, the patient's respirations and breathing are the priority. The nurse would check respiratory rate, get a pulse oximeter reading, and initiate interventions such as assisting the patient to sit in an upright position, encouraging slow purse-lipped breathing, discouraging excessive talking and obtaining an order for oxygen if needed.

A 30-year-old woman comes to the emergency department. She reports pain in the lower abdomen. She appears very much uncomfortable and is walking in a slightly bent-over position. Her hands are supporting her lower abdomen as she moves toward the examination room. Describe how the nurse performs on the physical assessment of the abdomen:

In assessing the abdomen, first inspect for shape, contour, lesions, and skin color. Listen for bowel sounds for 1 minute in all four quadrants. Next use light to moderate palpation and check for texture, temperature, and moisture of the skin. Also note distention, firmness, tenderness, or guarding.

The nurse is taking care of a patient with a leg wound. The nurse notices redness, swelling, and purulent drainage while completing the assessment and recognizes that these are cardinal signs of what process?

Infection These are all part of the cardinal sign of an inflammation and infection. Pain is one of the cardinal signs of infections and inflammation. Ecchymosis is a discoloration of an area of the skin or mucous membrane. Asthenia is a condition of debility and loss of strength and energy.

While assessing the patient, the nurse observes that the patient experiences orthopnea. What instruction will the nurse give the unlicensed assistive personnel (UAP) about assisting the patient?

Keep the head of the bed elevated at all times In orthopnea, the patient has difficulty breathing in a flat position, so is likely to be more comfortable sitting in a chair or having the head of the bed elevated.

Anorexia

Lack of appetite resulting in the inability to eat

The nurse needs to assess a patient who had a head injury. Which neurologic assessment would the nurse perform first?

Level of consciousness Level of consciousness is the first thing that the nurse will assess. The other assessments are also important.

An older adult woman who has just moved into an assisted-living facility seems to need a lot of social interaction. She becomes very talkative when the nurse tries to leave the room.

Loneliness Patient is showing loneliness, which is a reaction that reflects the needs Maslow identified as belongingness and love.

An adolescent is admitted to the hospital, but refuses to take off his clothes and put on a hospital gown.

Loss of identity The adolescent feels that his clothes are a part of his identity. His behavior reflects a need that Maslow identified as self-esteem.

The nurse hears in shift report that an older patient has "tenting" over the sternum. Based on this information, what is most important for the nurse to monitor and assess?

Monitor intake and output and check electrolyte values On elderly patients to test for skin turgor, the skin over the sternum is gently pinched between the thumb and forefinger. Tenting is noted when the lax skin very slowly returns to the original position. This is a sign of dehydration, so the nurse would monitor intake and output and electrolytes.

Which term is described as an abnormal growth of new tissue, either malignant or benign?

Neoplastic disease Neoplastic disease is an abnormal growth of new tissue that is either malignant or benign. Deficiency disease results from the lack of a specific nutrient. Metabolic disease is caused by a dysfunction that results in a loss of metabolic control of homeostasis in the body. An infectious disease results from the invasion of microorganisms into the body.

A rational patient wishes to leave the hospital against medical advice (AMA), despite the nurse's best attempt at therapeutic communication. What is the nurse's first responsibility?

Notify the provider The nurse should notify the provider, who ideally will come immediately and talk to the patient and have the patient sign the AMA form. The incident should be documented in the nurse's notes. An incident report may also be completed as needed. It is inappropriate to detain a rational patient if he/she wants to leave.

A 45-year-old woman was admitted to the hospital for chronic infection of a stasis ulcer on her leg. She will be discharged after completing antibiotic therapy and consultation with the would care specialist. Discuss the importance of discharge instructions for patients who have chronic conditions.

Nurses and other health care professionals take very good care of patients in health care facilities, but once patients leave the facility they must manage their own health conditions at home. Patients with chronic conditions, such as this patient with a stasis ulcer may need additional information about topics, such as lifestyle modification or strategies to prevent reoccurrence or complications.

A 30-year-old woman comes to the emergency department. She reports pain in the lower abdomen. She appears very much uncomfortable and is walking in a slightly bent-over position. Her hands are supporting her lower abdomen as she moves toward the examination room. Use the OPQRSTUV method to elicit information about the abdominal pain:

O - Onset When did the pain start? P - Precipitating-Provocative-Palliative What causes it? What makes it better? What makes it worse? Q - Quality-Quantity How does it feel? How would you describe the pain? How often, when, how long does it last? R - Region-Radiation Where is it? Does it spread? S - Severity scale Does it interfere with activities? How does it rate on a severity scale of 0 to 10? T - Treatments What helps? For how long? U - Understanding What do you think is causing it? How does it affect you? V - Values Goals of care; on a scale of 1 to 10, what would you consider a tolerable level of pain?

What is the UAP's role is assessing the respiratory system?

Observe and report changes in rate and depth The UAP can observe and report on respiratory rate and depth, but the nurse should give the UAP parameters for reporting, especially if the patient is at risk for respiratory problems or if the UAP is inexperienced. The other tasks are nursing responsibilities.

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C(101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take?

Obtain culture specimens before initiating antimicrobials. (The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before initiating antimicrobial therapy to prevent any interference with the detection of the infection). Encourage the client to rest and limit activity. (Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production). Assist the client with oral hygiene frequently. (Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips).

The nurse is trying to explain the bed controls and the call button and other items related to hospitalization, but the elderly patient keeps telling the nurse to "wait for my son to get here." What should the nurse do first?

Offer comfort measures and ensure patient safety This elderly patient is refusing information that the nurse believes is necessary; however, the nurse can spend the time making the patient safe and comfortable and then return when the son arrives. At that time the nurse can assess the family dynamics to determine if the patient relies on the son for decision-making or information retention and filtering.

An experienced LPN/LVN is working on a medical-surgical unit. The LPN/LVN sees that a new RN has not completed the admission assessment on a patient who arrived 20 hours ago. What should the LPN/LVN do first?

Offer to collect data so that the new nurse can complete the admission assessment The assessment should be completed and documented within 24 hours of admission. An experienced nurse recognizes that new personnel need support and assistance, so gently offering help would be the first action. The other options are also possible, but less constructive and more likely to make the new nurse feel isolated.

The patient is admitted through the emergency department for an exacerbation of a chronic respiratory disorder. When the patient arrives at his room on the medical-surgical unit, he appears very tired. He has oxygen per nasal cannula and demonstrates labored breathing. He is able to speak, but his sentences are short and he takes a breath after every few words. How would the nurse modify the nursing actions related to the admission to meet the needs of this particular patient? Explaining hospital routines, such as visiting hours, mealtime, and morning wake-up:

Ordinarily, the nurse would explain hospital routines such as visiting hours, mealtime, and medication times; however, based on the assessment of the patient, the nurse may opt to temporarily delay long explanations. The nurse might say, "Sir, when you are feeling more relaxed and breathing easier, I can explain more about the hospital routines and what you can expect."

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse?

Orient the client to his room The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside.

A 45-year-old woman was admitted to the hospital for chronic infection of a stasis ulcer on her leg. She will be discharged after completing antibiotic therapy and consultation with the would care specialist. Identify examples of health care disciplines other than nursing that are involved in referrals and explain their role in the discharge process.

Other health care professionals involved in the discharge process include: Social worker—counseling, determination of community and financial resources Wound care specialist—advice about cleaning wound and changing dressings Physical therapist—rehabilitation plan of exercise Occupational therapist—activities of daily living, vocational skills

The nurse hears in report that the patient had a Glasgow Coma Scale score 15 during the night shift. What is an early sign that indicated a deterioration in neurologic status?

Patient knows his own name, but does not recognized his spouse A Glasgow Coma score of 15 during the night was the highest possible score. Change in level of consciousness and orientation is an early sign of change in neurologic status (see Table 12-4 for additional information). Cushing's triad: widening pulse pressure, bradycardia and irregular breathing occurs late in cases of increased intracranial pressure.

The patient sprains his ankle. During the inflammatory response, damaged tissue releases chemicals that increase the permeability of the capillary walls, which allows white blood cells and plasma to move into the area. What does the nurse expect to be included in the subjective and objective data?

Patient reports pain and obvious swelling around ankle Pain and edema are expected with an inflammatory response. Numbness, cool pale skin and decreased peripheral pulse indicate decreased tissue perfusion. Pruritus (itching) and rash could be caused by: allergy, infection, jaundice, elevated serum urea, and skin irritation.

During discharge planning, which discipline of the health care team assists in rehabilitating and restoring a patient's musculoskeletal function to its highest potential?

Physical therapy Physical therapy works with a patient's musculoskeletal function to regain strength and to attain its highest functioning level. Speech therapy assists with disorders affecting normal oral communication. A clinical nurse specialist provides instruction to the patient and family who will assume the patient care. Occupational therapy teaches how to adapt to physical handicaps by learning ADLs.

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include?

Place the client in semi-Fowler's position. (Having the client sit upright facilitates full ventilation and gives the assistive personnel a clear view of chest and abdominal movements). Have the client rest an arm across the abdomen. (With the client's arm across the abdomen or lower chest, it is easier for the AP to see respiratory movements). Observe one full respiratory cycle before counting the rate. (Observing for one full respiratory cycle before starting to count assists the AP in obtaining an accurate count).

The nurse is assessing the patency of the nostrils. What is the best method to use?

Press against one nostril and ask the patient to breathe Press against one nostril and have patient breathe. If the nostril is patent, air should flow freely; then switch and occlude the other nostril. Using a penlight only allows visualization of the opening of the nostril. Having the patient blow the nose first would be appropriate if the patient is having rhinorrhea (runny nose). Having the patient breathe quietly is an opportunity to observe respiratory effort, but air will enter the unobstructed nostril if the other is obstructed.

Diaphoresis

Profuse sweating

When documenting assessment findings, which of the following are examples of objective data?

Redness and swelling of feet Redness and swelling are both observed signs of objective data. The other examples are subjective data that would be expressed by the patient.

Erythema

Redness or inflammation of the skin or mucous membranes

The patient is diagnosed with sickle cell trait. Based on the nurse's knowledge of pathophysiology, which intervention is most likely to be recommended for the patient?

Referral for genetic counseling Sickle cell trait is hereditary; thus, genetic counseling may be considered.

While the nurse is performing a physical assessment, the patient complains of dyspnea. This symptom indicates a problem with which body system?

Respiratory Dyspnea is the term for shortness of breath, which indicates a problem with the respiratory system.

A young child is being admitted to an acute care setting. He has never been hospitalized before. As the nurse enters the room, the child begins to cry and cling to his mother. According to Maslow's hierarchy of needs, what need is the child is exhibiting?

Safety and Security Fear of the unknown, a common reaction to hospitalization, is related to what Maslow identified as the need for safety and security.

The provider tells the nurse that the patient has pruritus. Which objective finding is the nurse most likely to observe?

Scratch marks on skin Patient is likely to have scratched self to relieve the sensation of itching.

Nausea

Sensation often leading to the urge to vomit

A preschooler who is admitted to the hospital is happily engaged in playing with the toys that the nurse has provided, but when her parents prepare to leave, she begins to cry and clings to them.

Separation anxiety Separation anxiety is a reaction that reflect the needs Maslow identified as belongingness and love.

The nurse reads in the patient's chart that the patient has crackles in the posterior lower lobes. What does the nurse expect to hear during auscultation if the patient's conditioning is unchanged?

Short, discrete, bubbling sounds on inspiration Crackles (produced by fluid in the bronchioles and the alveoli) are short, discrete, interrupted, crackling, or bubbling sounds that are most commonly heard during inspiration. Sibilant wheezes have a high-pitched, squeaking, musical quality and are produced by airflow through narrowed airways. Sonorous wheezes have a lower-pitched, coarser, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and the large airways. Pleural friction rubs are produced by inflammation of the pleural sac; the nurse will hear a rubbing, grating, or squeaky sound upon auscultation.

Dyspnea

Shortness of breath or difficulty breathing

The nurse realizes that an older adult who resides in a long-term care facility can become confused and upset during hospitalization. Which intervention would be most appropriate when caring for this patient?

Sit face to face with the patient, conversing slowly and clearly It takes longer for older adults to process information. They are easily confused in a new environment. Sitting at eye level and talking slowly allows the patient time to process and respond correctly.

Lethargy or lethargic

State or quality of being indifferent, apathetic, or sluggish

To decreases the risk for lung disease, which lifestyle medication is the most important to recommend to patient?

Stop smoking All the options are recommended to patients for overall good health; however, smoking cessation is the single most important intervention for lung disease. Participation in cancer screening is recommended, but currently there is no reliable screening test for lung cancer.

Mr. S is complaining of pain in his chest, difficulty breathing, and a cough. What are these reports by the patient considered?

Subjective data Subjective data are symptoms that the patient describes that may indicate illness. Objective and observable data are signs that a caregiver notes about a patient. Disease process is a disturbance of a structure or functions of the body.

The nurse is most likely to use the Glasgow Coma Scale for which patient?

Sustained a serious head injury The Glasgow Coma Scale is used for patients who have potential for neurologic abnormalities related to brain injury. The other patients have potential for brain injury related to poor tissue perfusion secondary to a disease state, but there are many other interventions that the nurse would use to prevent coma from happening to patients with cardiac, infection, or respiratory problems.

While obtaining the vital signs of an adult, the nurse observes that the patient is diaphoretic and flushed. Which change in vital signs would the nurse expect to accompany this observation?

Temperature of 101F (38.3C) Diaphoresis and flushing can be seen in a variety of disorders and circumstances, but are frequently associated with hypermetabolic states, such as fever or exercise. The other vital signs are lower than expected for the average adult. Hypodynamic states (e.g., low BP, low pulse) are more associated with cool, clammy skin.

An older adult patient is postoperative for hip surgery. He is transferred by ambulance from the hospital to a rehabilitation (rehab) unit. One hour after he is assisted into bed at the rehab unit, he dies in his sleep. Which documentation provided the BEST legal protection for the transferring nursing staff?

The discharge assessment that was performed just before the patient left the hospital When a patient is discharged or transferred, the nurse is the last professional team member to assess/see the patient, so it is important that the nurse's documentation reflects that the patient left in stable condition. The other pieces of documentation are also likely to be reviewed in case of a lawsuit. Even if no lawsuit occurs, this death is likely to be investigated as a "sentinel event".

The patient is admitted through the emergency department for an exacerbation of a chronic respiratory disorder. When the patient arrives at his room on the medical-surgical unit, he appears very tired. He has oxygen per nasal cannula and demonstrates labored breathing. He is able to speak, but his sentences are short and he takes a breath after every few words. How would the nurse modify the nursing actions related to the admission to meet the needs of this particular patient? Orienting the patient to the room:

The information that is generally included in the orientation for the patient includes location of the room (proximity to nurses' station), location of bathroom, how to call for assistance, how to adjust the bed and lights, how to operate the phone and television, and policies that apply to the patient (e.g., smoking, visiting hours). For this patient, the nurse may decide to explain how to call for assistance and how to adjust the bed, but delay all additional information. The nurse should make a plan, inform the patient, and then follow through. For example, the nurse might say, "Sir, I am going to let you rest for about an hour. Use the call button before then if you need anything, but in an hour I will come back and finish telling you about hospital procedures."

How does the nurse generate subjective and objective data when the patient says, "I have a really bad headache"?

The nurse must have knowledge of normal body function and pathophysiology in order to determine which questions to ask and investigate underlying physiologic disorders. If the patient has a headache, the logical place to start is to collect subjective data about the pain (e.g., "What does it feel like?" "Where is the pain located?" "Are you having pain at any other location besides your head?"). Ask about associated symptoms that are likely to accompany a severe headache (e.g., "Have you felt nauseated?" "Have you felt dizzy?" "Are you experiencing any problems with your vision?"). Based on the nurse's knowledge of pathophysiology, the nurse would obtain objective data; for example, hypertension could cause headaches. Intracranial bleeding could cause a change in pupil size and reaction. Meningitis could cause an elevation of body temperature.

One of the first steps in gathering data about a patient is to establish the "nurse-patient relationship." What are appropriate ways to establish this relationship?

The nurse shows professionalism and competence to patients, introduces herself/himself to patients and answers questions the patients may have, and communicates trust and confidentiality to patients All of these answers are appropriate actions and responses for a nurse to use to encourage a nurse-patient relationship. Answer D is an inappropriate way for a nurse to gain a nurse-patient relationship. It is intrusive and nontherapeutic. The nurse must be faithful in fulfilling promises made to a patient to best establish the nurse-patient relationship.

The LPN/LVN is working on a medical floor and assisting the RN with patient assessments. A new patient is admitted to the floor and the RN takes a health history and performs an assessment. What is this considered the first step of?

The nursing process The data collected during the health history and assessment completes the first step in the nursing process. The nurse-patient relationship is ongoing throughout a patient's stay. The review of systems is a systematic method of collecting data. The chief complaint is the patient's main reason for seeking medical care.

the nurse is conducting an interview with a patient who was just admitted to the medical-surgical unit. The nurse stands at the bedside and initially smiles at the patient, but as she is asking the questions, the nurse frequently glances out the window and shifts restlessly back and forth. She diligently fills out the admission form while reading the questions from the form. When the patient tries to explain a point, she cuts him off and moves on to the next question. She checks the equipment necessary for the patient's care while the patient is trying to explain his symptoms. Discuss the nurse-patient interaction from the patient's point of view:

The patient might see the nurse as efficiently using the time, but is more likely to think that the nurse is very busy and focused on completion of tasks. The nurse's actions have blocked communication and created psychological distance between herself and the patient. The patient is less likely to give complete information to this nurse, because she doesn't appear to be interested in hearing what he has to say.

Inflammation

The protective response of the tissues of the body to irritation or injury

Which evaluation statement indicates that the antibiotic therapy has successfully resolved the patient's leg infection?

The wound site shows no signs of erythema; white cell count is normal A normal white cell count is the best indicator of the success of antibiotic therapy. A decrease in pain and increase in function are good indicators that the medication is working. However, subjective symptoms may improve after several days of antibiotic therapy, but the infection can still be present until antibiotic therapy is completed. Edema, redness, and elevated white count suggests that the antibiotic may need to be changed.

The nurse is examining the patient's eyes. Which finding is the most important to report to the provider?

There is similar puffiness and periorbital edema around both eyes Periorbital edema is abnormal and suggests fluid retention or it may occur with an infection. The shape of eyelids may or may not be symmetric, but the shape could be hereditary or congenital. White sclera, pink conjunctiva and reactive pupils are normal findings.

Sallow

Unhealthy yellow color; usually said of a complexion or skin

Pallor

Unnatural paleness or absence of color in the skin

The nurse uses the OPQRSTUV method of obtaining the most information about the patient's pain. Which question addresses the P in the OPQRSTUV?

What causes the pain to increase or decrease? P stands for Precipitating-Provocative-Palliative. Rating the pain is a query about Severity. Onset is determined by asking when it started. Spread of symptoms to other body parts is used to determine Radiation and location.

Jaundice

Yellow tinge to the skin