Nurs 38800

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?

Decreased range of motion in right shoulder

To alleviate a client's anxiety during a comprehensive assessment, the nurse should do which of the following?

Explain each procedure being performed and the reason for the procedure.

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

Last surgery date validated by adult daughter

The nurse and a client are developing a transcultural nursing care plan related to hypertension. Which of the following should the nurse include in the plan?

Nutritional information specifically for the client's culture

A nurse is caring for an elderly client who is unable to walk without a support due to knee pain. During his initial assessment, however, the client does not mention pain. Which of the following beliefs common in elderly clients may cause them to underreport their pain?

Pain is a normal part of aging

Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to

Promote harmony between health and spirituality

What are some of the general recommendations when the nurse is taking a spiritual history? (Select all that apply)

Spirituality is an important component of physical well-being and mental health Respect a patient's privacy and do not impose your beliefs on them. Make referrals to chaplains, spiritual directors, or community resources as appropriate.

The nurse is conducting a cultural assessment with a client who recently immigrated to the United States. Which interview question is of most importance when addressing family history as it impacts the client's care?

Who is primarily responsible for making family decisions since arriving in the United States?"

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

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The nurse is obtaining information about a client's past health history. Which client statement would best reflect this aspect?

"I had surgery 5 years ago to repair an inguinal hernia."

The nurse is assessing the diet and nutritional status of a client from a different culture. Which of the following questions would be appropriate for the nurse to ask? (Select all that apply.)

"What foods do you commonly eat?" "Do you have any special routines for eating?" "Are there any foods that you can't eat?" "Do you have certain foods to keep you healthy?"

A nurse admits a client to the hospital who is African American. The nurse recognizes that this client is at increased risk for what conditions due to ethnicity or culture? (Select all that apply.)

-Cardiovascular disease -Peripheral artery disease -Asthma

What actions should the nurse take to become culturally competent? (Select all that apply.)

-Seek cultural encounters -Be aware of cultural differences -Learn about different cultures -Become skilled with different cultures

A patient is having pain and rates it as 4 on a scale of 0 to 10. The patient states that she does not want to take any medication at this time. Using the gate control theory, what nonpharmacological approach could the nurse use to decrease the patient's pain?

Back rub

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

Chief complaint

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross

The nurse is working with a client on how to manage his hypertension. The client states that he is taking herbs recommended from within his community. How should the nurse best respond?

"Let's talk with your physician to see how we can incorporate these into your plan of care."

The nurse prepares to analyze a list of a client's health problems. List the steps in the order the nurse completes critical thinking of these problems.

1.Identify abnormal data and strengths 2.Cluster the data 3.Draw inferences and identify problems 4.Propose possible nursing diagnoses 5.Check for defining characteristics of the diagnoses 6.Confirm or rule out nursing diagnoses

The nurse prepares to assess a 5-month-old client for pain. When using the FLACC Behavioral Scale, what should the nurse observe to determine the presence of pain in this client? (Select all that apply.)

Answers: Cry Face Legs The FLACC Behavioral Scale is a tool used to assess pain level in infants. The areas assessed include the baby's cry, face, and leg movement. Additional areas assessed are activity and consolability.

During the introduction phase of the interview, the patient 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 patient to clarify some information

A nurse has completed her physical examination of a client and is recording her findings. Which of the following should she do while documenting? (Select all that apply.)

Document the findings in a private area, where no other clients can read the nurse's notes Write entries objectively without making premature judgments or diagnoses

A purpose of the genogram is to assist the nurse in which of the following? (Select all that apply.)

Identifying patterns of the family's health problems Identifying family members and the family's structure Visualizing multiple generations of a family's health

A client tells the nurse about her experience with prolonged therapy for her breast cancer. The nurse responds, "That must have been a very trying time for you." What is this an example of?

Validation

A client on the orthopedic unit is being discharged home. The client is elderly and has a broken right humerus; the client is right handed. The client's closest family member lives 50 miles away. What should the nurse consider before discharging the client? (Select all the apply.)

Who will be there to help the client with ADLs? How will the client get home from the hospital? How will the client cook and eat?

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

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