Exam 1 3060 part 3
Which assessment notation describes a client's level of consciousness?
"Client was alert and cooperative during the assessment."
A nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements?
"The burning sensation in my feet has gotten worse over the past year."
A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.
- Gloves - Gown - Face shield
The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)
- Heart rate 115 beats/minute. - Blood pressure 180/75.
During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? Select all that apply
-Assess the client's apical pulse for a full minute. -Assess the client's S1 and S2 sounds for regularity.
A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?
Ask the client if they have allergies.
How may a nurse demonstrate cultural competence when responding to clients in pain?
Avoid stereotyping responses to pain by clients.
During the introduction phase of the interview, the client begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?
Courteously interrupt the client to clarify some information.
On which health problem should the nurse focus when assessing this client?
Cushing's syndrome
The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?
Do you have any thoughts of wanting to harm or kill yourself? '
Which of the following is not released during the stress response?
Dopamine
A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?
Faces Pain Scale
A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?
Give the prn morphine
Which of the following is the best example of assessment in everyday life?
Measuring the remaining tread on a car tire to determine whether it is time to replace it
Mr. Garcia comes to the office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, the nurse notes a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this?
Neuropathic
When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely:
Neuropathic
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies:
Pain is a natural part of aging."
The nurse is following a structured head-to-toe approach to identify changes in a client's body systems. Which component of the health assessment is the nurse completing with the client
Physical examination
'The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds
Reduce all environmental noise
A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?
Somatic
Which describes the nurse using the technique of percussion?
The nurse notes resonance over the individual's thorax.
The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?
deep palpation
A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?
depression
The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because
depression often mimics signs and symptoms of dementia.
While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should
maintain eye contact while asking the questions from the form.
A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing
neuropathic
A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?
neuropathic
The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:
orthostatic hypotension.
During a lecture on pain management, the nursing instructor informs the group of nursing students that the primary treatment measure for pain is which of the following?
Analgesics
Student nurses are taking vital signs at a community screening clinic. The nursing instructor should intervene when the student nurse performs which of the following actions?
Applies the cuff to the right arm above the client's shunt location.
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Ashen gray
A nurse assesses a newly admitted 43-year-old client and documents the vital signs as follows: temperature 98° F (36.7° C), pulse 93 beats/min regular rhythm and bounding, blood pressure 145/93 mm Hg, and respiratory rate 16 breaths/min. What is the first action of the nurse?
Ask the client if they are experiencing other symptoms.
A nurse is preparing to evaluate an older client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?
Braden scale
The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?
Burning, tingling
What is one way nurses use critical thinking in regard to the nursing process?
Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions
A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?
Flight of ideas
A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?
Have you been sitting for a long time?"
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
How do you manage your stress?"
A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?
How does the pain influence your overall mood?
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?
Identify in what areas the client needs the most care.
A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data?
Inspection
A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?
Measure the client's vital signs, height, and weight.
A construction worker in his mid-40s suffered a severe laceration on his leg while on the job site. Soon after he arrives at the emergency room, a nurse assesses his pain. The client states that pain, although severe, has lessened since the accident first occurred. The nurse knows that the pain message likely has been inhibited by release of endorphins and other neurotransmitters. Which physiological process does this represent?
Modulation
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?
Neuropathic
An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?
Nursing intervention
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
Nursing process
The client has a murmur. This is what type of data?
Objective
Assessment of the pulse amplitude is accomplished by which of the following?
Palpating the flow of blood through an artery
Applies the cuff to the right arm above the client's shunt location.
Provides a reference point for psychosocial developmental level
Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?
The blood viscosity would be thinner, causing the blood pressure to decrease.
A client admitted with hyperthyroidism develops life-threatening symptoms—high fever (104° F/40° C), tachycardia (150 bpm), and elevated blood pressure (200/105 mm Hg)—prior to receiving radioactive iodine treatment. What type of assessment should the nurse perform on this client?
emergency
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?
emergency
A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?
health maintenance
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
hyperresonance.
The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should
record the vital signs.
A client reports pressure in the chest but describes pain in the jaw and right arm. Based on these findings, the nurse determines that the client may be experiencing which of the following types of pain?
referred
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery
