Assessment quiz elsevier

Which documentation would a nurse use when charting an 8-mm depression in the medial malleolus area when checking the severity of edema

4+ (3+ indicates 6mm) (2+ indicates 4mm) (1+ indicates 2mm)

Which data collection would the nurse perform on an older adult in the geropsychiatric unit as part of the functional assessment

Ability to perform activities of daily living

Which nursing consideration would be made when determining the plan of care for the client who has severe back pain?

Ask the client what the clients tolerable level of pain is Administer the pain medications regularly around the clock

Which action would the nurse take upon determining that a clients urine output has progressively diminished and is less than 40ml/he over the past three hours, despite the clients having received 2900 ml intake for two days

Assess breath sounds and obtain vital signs

Which action would the nurse perform when completing a medical history on a client who is not fluent in English?

Assess the clients verbal and nonverbal communication

Which assessment would be the priority action of the new nurse who is caring for a client with a leg in traction

Assessing the skin integrity

Which assessment would the nurse determine is the priority in a client who just returned to the floor after a right total knee replacement

Circulation and sensation in right leg

Which assessment technique would be used to best assess the rehydration status in an 85yr old client with a 3 day history of nausea, vomiting, and diarrhea?

Daily weight

A client is admitted for dehydration and an IV infusion of normal saline at 125 ml per hour has been started. One hour after the IV initiation, the client begins screaming "I can't breathe!" Which nursing action is priority at this time?

Elevate the head of the bed and obtain vital signs

When assessing a clients abdomen, the nurse palpates the area directly above the umbilicus. Which area is this known as?

Epigastric

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. Which direction would the nurse give the client to determine orientation to place?

Identify the name of the clinics town

When would the nurse assess the symptomatic quadrant of a client reporting stomach pain?

Last

Slit lamp test

Magnifies anatomic structures of the eye and can identify conditions such as elevated intraocular pressure

Which priority assessment would be completed while evaluating breathing?

Observe for chest wall trauma Assess breath sounds and respiratory effect

Which finding would the nurse include in the pain assessment of a client with chronic pain in the knee?

Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors

Which action would the nurse take first when caring for a postoperative client who reports incisional pain?

Perform a focused assessment of the client

Which action would the nurse take next when a client on daily weights has a 2 pound weight gain and bilateral lower extremity pitting edema

Perform a head to toe assessment, including vital signs

Which assessment is the priority when a client arrives in the emergency department with multiple crushing wounds of the chest

Quality of respirations and presence of a pulse

Which finding is determined when the nurse pulls up on the clients skin, releases the skin, and watches to see if it returns to its original position

Skin turgor

Which information would a nurse expect to find when reviewing a newly admitted clients MAR

The clients allergies

Which consideration would assist the nurse in prioritizing client assessments?

The most recent assessment of the client The information from the change of shift report The pertinent information from the medical record

Which rationale explains why a primary health care provider prescribes a snellen test for a client

To assess for visual acuity

Which reason explains the use of Glasgow coma scale by the nurse performing an assessment of a traumatized client?

To assess level of consciousness

Which intervention would the nurse implement as directed when finding poor skin tutor and scanty urine output on assessment of a client experiencing a psychotic episode?

Turn at least every two hours Initiate input and output recording watch urine output closely Perform neurologic assessment every 4 hours Encourage oral fluids in small amounts Give IV solution at 125mL per hour as prescribed

Which response would the nurse use to determine the Glasgow coma score in a client with neurological deficits after a MVA

Verbal response to speech Eye opening in response to speech Motor activity in response to verbal command

Which action would the nurse take next when experiencing difficulty palpating the pedal pulse of a client with venous insufficiency?

Verify the pulse using a doppler

Schirmer test

a test that measures lacrimal gland flow by placing special filter paper strips inside the lower eyelid for 5 minutes

Amsler grid test

early detect macular degeneration