Health Assessment + Vsim

The nurse is assessing flexion in Mr. Russell's hip. What instructions would the nurse give to Mr. Russell to complete this assessment?

"Bend your knee to your chest, and then pull it against your abdomen." Rationale: To assess flexion of the hip, the nurse would instruct Mr. Russell to bend his knee to his chest and then pull it against his abdomen. Instructing the patient to lie face down and then bend the knee and lift it up assesses extension. Asking the patient to lie flat and then move the lower leg away from the midline assesses abduction. Instructing the patient to lie flat and then bend the knee and move the lower leg toward the midline assesses adduction.

The nurse is implementing a progressive mobility regimen on a patient who has been on prolonged bed rest. List the steps of the procedure in the order they should be performed.

1)Raise the head of the bed to 30° 2)Raise the head of the bed to 45° 3)Position bed at 45°, legs dependent 4)Position bed at 65°, legs dependent 5)Position bed at 65°, feet on floor Rationale: The nurse should first increase the head of the patient's bed to 30°. The nurse would then increase the head of the patient's bed to 45°. In the third step, the nurse would maintain the head of the patient's bed at 45°and position the patient's legs in a dependent position. Next, the nurse should increase the head of the patient's bed to 65° and position the patient's legs in a fully dependent position. Finally, the nurse should maintain the head of the patient's bed at 65° and have him place his feet on the floor.

The nurse is assessing the muscle strength in Mr. Russell's left hand and notes active motion against some resistance. How would the nurse document this finding?

4 Rationale: The nurse would document this finding as 4, slight weakness. Active motion against full resistance is 5, or normal strength. Active motion against gravity would be charted as 3, average weakness. Finally, a finding of 2 is passive range of motion (ROM) or poor ROM.

A patient is demonstrating signs and symptoms associated with appendicitis. Which laboratory result supports the diagnosis of appendicitis?

A white blood cell (WBC) count of 24,000 cells/mcL Rationale: A normal WBC count is from 4,500 to 10,500 cells/mcL (SI, 4.5 to 10.5 — 109/L). An elevation to 24,000 cells/mcL would indicate that an inflammation or infection is present within the body. The other options are all normal values that are not associated with possible appendicitis.

Mr. Russell asks the nurse, "What is the purpose of these passive range-of-motion (ROM) exercises? I can move my own arms and legs." What is the correct response by the nurse?

"Passive range-of-motion exercises will help you to maintain mobility in your joints." Rationale: The nurse would explain to Mr. Russell that the passive range-of-motion exercises will help him to maintain mobility in his joints. The purpose of passive range-of-motion exercises is not to prevent clot formation or skin breakdown. Mr. Russell is not confined to bed and can ambulate with the help of a walker.

Which patients under a nurse's care require a comprehensive pain assessment? (Select all that apply.)

A patient transferred from intensive care unit to a medical unit, A patient being admitted to the unit, A patient medicated with morphine sulfate 20 minutes ago, A patient who is being prepared for postoperative physical therapy Rationale: Comprehensive pain assessments should be performed when: a clinician assumes care of the patient; if the patient's status changes; if the patient demonstrates signs of pain or is subjected to a presumably painful event; if a change in analgesic medication occurs; or within the expected peak time of an administered pain medication. If an intervention is performed, the pain level should be assessed before the intervention and within 1 hour after the intervention to assess the patient's response. Although anxiety is an issue that must be addressed, it is not always associated with pain and thus is not managed with pain medication.

A patient diagnosed with appendicitis is scheduled for surgery. How will the nurse best ensure that the patient's data, obtained through nursing assessment, monitoring, and care interventions are appropriately shared with interdisciplinary care team members?

Add appropriate, inclusive documentation to the patient's medical record Rationale: Effective, inclusive documentation ensures that information about the patient and family is easily accessible to members of the health care team, provides a vehicle for communication, and prevents fragmentation, repetition, and delays in carrying out the plan of care. The other options are appropriate at specific times or for specific documentation activities.

Which nursing interventions will minimize a patient's voluntary guarding during the palpation required of an abdominal assessment? (Select all that apply.)

Apply light pressure to the patient's sternum when palpating, Begin palpation by placing your hand over the patient's hand, Encourage the patient to take deep, slow breaths Rationale: Minimize voluntary guarding by asking the patient to perform self-palpation. Place your hands over the patient's hand. After a while, let your fingers glide slowly onto the abdomen while still resting mainly on the patient's fingers. Work with the patient to promote relaxation and minimize voluntary guarding by placing a pillow under the patient's knees, not lumbar region, and asking the patient to take slow, deep breaths through the mouth. Applying light pressure over the patient's sternum with your left hand while palpating with the right hand encourages the patient to relax, not tighten, the abdominal muscles during breathing against sternal resistance.

The nurse is assessing a patient's gait. Which factors should the nurse observe as the patient ambulates in the room? (Select all that apply.)

Arm swing, Base of support, Stride, Posture Rationale: When assessing a patient's gait, the nurse should observe for base of support, weight-bearing stability, foot position, stride, arm swing, and posture. The nurse would not focus on the patient's breathing when ambulating.

Which activity is at the foundation of a nurse's personal ability to provide culturally competent, unbiased nursing care associated with pain management?

Asking oneself, "How do I react differently from others when I am in pain?" Rationale:It is very important for you as a nurse to recognize your own response to pain and how it may differ from the way others react. A perception that our responses and beliefs are "normal" and those of others are not can lead to miscommunications between nurses and patients. Although the other options relate to culturally competent nursing care related to pain management, they are not focused on the nurse's perception and thus do not address the issue of unbiased, personal perception of pain and its management.

Which nursing action best supports the nurse's attempt to collect the appropriate subjective data during a pain assessment related to abdominal pain?

Asking the patient to rate the degree of abdominal pain on a scale of 0 to 10 Rationale: Subjective data consist of information that the patient or significant others tell the nurse and are nonconfirmable by typical assessment methods. They include sensations, feelings, or interpretations. Objective data are gathered by observation, inspection, palpation, percussion, or auscultation. Having the patient rate pain on a scale provides a means of determining the patient's interpretation of the sensation of pain, data that would not be otherwise assessable, and thus is subjective. Being attentive to the patient's physical needs will assist in the assessment process in general but is not specifically associated with the pain assessment process. Nonverbal signs are observable and thus are objective in their nature. Determining the triggers that may have caused the abdominal pain would be related to the process of gathering objective data.

The nurse is conducting an abdominal assessment on a patient diagnosed with possible acute appendix inflammation. Which nursing action would be appropriate when assessing for referred pain?

Assess the patient for a positive Blumberg's sign Rationale: A positive Blumberg's sign is associated with an acute appendicitis and confirms the presence of rebound tenderness. Pancreatic inflammation can produce referred pain felt in the back. The appendix is located in the right lower quadrant. The pain worsens when assuming a supine position when the patient is experiencing gastroesophageal reflux disease.

The nurse conducting an abdominal assessment has completed the inspection of the abdominal area. Which action by the nurse will then follow?

Auscultate to assess for bowel sounds Rationale: The sequence for assessment of the abdomen differs from the typical order of assessment. Auscultate after inspection so as not to alter the patient's pattern of bowel sounds. After auscultation, perform percussion and then palpate lightly followed by deeply.

The nurse is assessing a patient's joints. What should the nurse include in this assessment? (Select all that apply.)

Color, Symmetry, Size Rationale: In an assessment of a patient's joints, the nurse should assess for size, shape, color, and symmetry. Reflexes and sensation should be included in a neurologic assessment.

The nurse is educating Mr. Russell on the effects of prolonged immobility. What physiologic change(s) would the nurse describe to Mr. Russell? (Select all that apply.)

Decreased muscle mass, Bone demineralization, Increased muscle catabolism, Decreased muscle protein synthesis Rationale: Decreased muscle protein synthesis, increased muscle catabolism, decreased muscle mass, and bone demineralization are physiologic changes that result from prolonged immobility. Increased respiratory effort would not be a physiologic change related to prolonged bed rest.

The nurse is completing a health history on a patient reporting musculoskeletal pain. Which question(s) would be appropriate for the nurse to include in the interview? (Select all that apply.)

Do you exercise regularly?, Have you had any recent weight gain?, Have you experienced any previous injuries to your joints?, What medications are you currently taking?, What type of job do you have? Rationale: The nurse should ask about previous injuries to joints because the patient is reporting musculoskeletal pain. Assessing the patient's exercise level is important because regular exercise promotes flexibility, bone density, muscle tone, and strength. The nurse would ask about occupation because certain job-related activities can increase the risk of musculoskeletal problems. Recent weight gain could put stress on the musculoskeletal system. It is important to ask about medications because some medications can affect musculoskeletal function.

The nurse is completing passive range-of-motion (ROM) exercises and bends the patient's foot so that the toes point upward. Which skeletal muscle movement has the nurse performed?

Dorsiflexion Rationale: The skeletal muscle movement the nurse has performed is dorsiflexion. In plantar flexion, the toes point downward. Abduction is a movement away from the body, and adduction is a movement toward the body.

The nurse is caring for Mr. Russell, who is recovering from a stroke and has mild left-sided hemiplegia. What would the nurse include in the plan of care? (Select all that apply.)

Encourage the patient to set realistic, short-term goals, Perform passive range-of-motion (ROM) exercises Rationale: The nurse includes passive range-of-motion exercises in the plan of care and should encourage the patient to set realistic, short-term goals. The patient should call for assistance when ambulating rather than try to maintain independence. It is important for the patient to use assistive devices as long as necessary. The nurse should cluster care activities to allow the patient to rest rather than spread them throughout the day.

The nurse is completing passive range of motion on Mr. Russell. What movements would the nurse expect to complete at the elbow joint?

Flexion, extension, supination, pronation Rationale: At the elbow joint, the nurse would expect to find flexion, extension, supination, and pronation of the forearm.

The nurse is assessing a patient's range of motion and notes a limitation in the movement of the elbow joint. Which tool would the nurse use to measure the degree of movement in the joint?

Goniometer Rationale: The nurse would assess range of motion using a goniometer, which measures the degree of movement in a joint. The tape measure, metric ruler, and reflex hammer would not be used to measure the degree of movement.

The nurse is educating Mr. Russell on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching?

I should press my call light when I want to get out of bed. Rationale: Mr. Russell has understood the teaching if he states he will use the call light if he wants to get out of bed. Mr. Russell should have non-skid socks on at all time while ambulating and should always use his walker—not just when feeling unsteady. He should keep the walker close to his bed rather than close to the door so that it is easily accessible.

A patient diagnosed with acute appendicitis is experiencing abdominal pain and asks for a heating pad, stating, "Heat always makes me feel better when I have cramps before I menstruate." What is the nurse's response to the patient's request?

I'm sorry but in this situation the heat from the heating pad might cause your appendix to rupture. Rationale: When dealing with appendicitis, diagnosed or suspected, never apply heat to the abdomen, especially the right lower quadrant. Although the heat may provide comfort to some patients, because it can cause the inflamed appendix to rupture, itis not an appropriate intervention. Although elevating the bed and providing pain medication is not inappropriate, doing so does not address the patient's need for education regarding the danger of such a request.

A potentially serious complication of appendicitis is peritonitis. Which changes in assessment data compared with admission values would indicate the development of this complication and thus should be monitored for by the nurse? (Select all that apply.)

Increase in white blood cell (WBC) count to 24,000 cells/mcL, Increase in temperature to 37.8°C (100.0°F) Rationale: Physical and diagnostic findings associated with the development of peritonitis include fever, tachycardia, abdominal rigidity, and leukocytosis. An increase, not decrease, from baseline abdominal rigidity is to be monitored. Ms. Lin's level of agitation would not generally be affected by peritonitis but rather her overall condition.

Which assessment question concerning the character of the pain associated with appendicitis is most appropriate?

Is your pain dull and aching? Rationale:Although the description of pain is subjective, the terms "dull" and "achy" as well as "burning" and "gnawing" are often used to describe pain associated with appendicitis. Colon cancer is likely to produce colicky pain, whereas pressure is associated with prostate cancer and prostatitis. "Ripping" is a term that might be used when describing pain associated with muscle trauma.

The nurse is reviewing Mr. Russell's medications. Which medication(s) would place Mr. Russell at a higher risk for falls? (Select all that apply.)

Losartan, Chlorthalidone, Metformin Rationale: Losartan (antihypertensive), metformin (antidiabetic), and chlorthalidone (diuretic) all place Mr. Russell at a higher risk for falls. Aspirin and the nicotine patch do not contribute to fall risk.

Which statement best demonstrates the nurse's understanding of the primary goal of effective, appropriate documentation of a patient's assessment data?

My documentation of a patient's assessment data will assist in the development of an effective, safe plan of care. Rationale: The primary reason for documentation of assessment data is to promote effective communication in order to facilitate safe and effective patient care. The remaining statements identify individual factors/actions that contribute to the delivery of safe, effective care.

What assessment information will serve as a baseline for the pain management provided by the nursing staff of a medical-surgical unit? (Select all that apply.)

Pain began 18 hours ago., Pain is described as sharp and stabbing., The patient states, "Nothing I do makes it hurt less." Rationale: When conducting a pain assessment ask the patient about the pain's character, quality, onset, location (and whether it radiates), duration, and frequency. Determine what exacerbates the pain and what relieves it. Determine whether the patient has a current pain regimen and, if he does, how it relates to his current level of pain. Findings from these assessments provide information about the patient's current pain level and provide a baseline for future assessments and the management of the pain. The patient's age is not pertinent to a pain assessment, and the patient's perceived ability to tolerate pain is not useful in serving as a baseline measure.

During an abdominal assessment the nurse is assessing for rebound tenderness. Which response by the patient indicates a positive Blumberg's sign?

Patient states, "I felt a very sharp pain as you let up on the pressure to my stomach." Rationale: The patient has rebound tenderness when the patient perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumberg's sign). It suggests peritoneal irritation (as from appendicitis). If the patient feels pain at an area other than where the nurse is assessing for rebound tenderness, consider that area as the source of the pain. Nausea is not associated with a positive Blumberg's sign. A patient will feel intense pain and hold his or her breath in response to pressure applied to the right costal margin (Murphy's sign) when experiencing cholecystitis.

A patient diagnosed with appendicitis and scheduled for surgery has been prescribed 5 mg of intravenous (IV) morphine sulfate to manage the pain. It has been 4 hours since the medication was last administered. Considering the medication's peak effect and duration of effectiveness, which intervention would the nurse implement?

Reassessing the patient's pain level Rationale: IV morphine sulfate has a peak of 20 minutes with a duration of 4 to5 hours. It is appropriate for the nurse to reassess the patient's pain level for the administration of another dose of morphine sulfate if needed. Although assessing and monitoring the patient's blood pressure and level of consciousness are appropriate because of morphine's effect on the central nervous and cardiovascular systems, the greatest effects would be observed at the medication's peak, rather than at the end of its period of duration. Reassessing the abdomen is not related to medication management.

The nurse is using the Morse Fall Scale to determine Mr. Russell's fall risk. What variable(s) will the nurse assess by using this tool? (Select all that apply.)

Secondary diagnosis, Presence of IV, History of falls Rationale: The Morse Fall Scale is widely used in hospital and long-term care settings and is used to assess six variables that put patients at a higher risk for falls. These include the following: history of falls, secondary diagnosis, ambulatory aid, IV or IV access, gait, and mental status. Although advanced age and female gender place a patient at risk for falls, they are not included in the Morse Fall Scale.

Which statement by the nurse during a pain assessment demonstrates the best understanding of the need to avoid stereotypes when working with a member of an Asian cultural group who has a history of rheumatoid arthritis?

What do you usually do to manage your chronic pain? Rationale: Although members of a culture may hold common beliefs and practices associated with pain, it is not appropriate to assume all members will react similarly. The nurse must complete the pain assessment to address the unique needs of each individual. Although the knowledge gained from the other options may add to the effectiveness of the assessment, none is related to the unique needs of the patient.

An adolescent patient has been admitted with a diagnosis of appendicitis, and the family has been told surgery will be scheduled. How will the nurse respond when asked, "What kind of surgery are we talking about?

The two choices are open or laparoscopic surgery, and the decision will be made by the surgeon. Rationale: The nurse will respond by answering the question with the information available. Appendicitis is treated with either open surgery that requires a cut into the abdomen near the appendix (through which the organ is removed) or by laparoscopic surgery, which uses a few much smaller incisions. A laparoscopic camera is passed through these incisions to find and transmit pictures of the internal abdomen to a monitor for analysis by the surgeon, who then directs the removal of the appendix. The decision to use one surgery over the other is made by the surgeon. The other options either fail to answer the question by deferring to the surgeon or avoid a discussion directly addressing the types of surgical options available.

A nurse is assessing the abdomen of a patient reporting pain and constipation. Which interventions would best help minimize barriers to the auscultation of the patient's abdomen? (Select all that apply.)

Use a properly fitted stethoscope, Select an environment that is quiet Rationale: Auscultation is most successful when performed in a quiet environment with a properly fitted stethoscope. Although the remaining options are appropriate, they are not directly associated with auscultation.

The nurse is assessing a patient for fall risk. Which factor(s) would place the patient at a higher risk for falls? (Select all that apply.)

Use of more than four prescription medications, Gait or balance impairment, Depression Rationale: Factors that place a patient at higher risk for falls include depression, gait or balance impairment, and use of four or more prescription medications. Female gender, rather than male, puts the patient at higher risk. Patients age 80 or over are also at higher risk for falls.

Regarding the reassessment of a patient's pain, which statement/question by the nurse demonstrates an understanding of appropriate nursing management?

What would you rate your pain now that your pain medication has had time to take effect? Rationale:Joint Commission standards for the management of pain require that the patient have regular reassessments of their pain with the appropriate follow-up actions. Pain medication should be given in anticipation of pain related to the physical therapy session, not after. Although the other options provide actions and reassuring comments, they are not directly focused on the patient's right to regular reassessment of their pain and its appropriate management. The management of pain is patient driven, meaning the nurse must work in cooperation with the patient to provide appropriate care.