A patient on a medical- surgical floor reports having shortness of breath. The nurse needs to conduct which type of assessment? - Ans-A problem-based/focused assessment For which patient is a shift assessment indicated? - Ans-The person who had abdominal surgery yesterday Which of the following examples represents a secondary prevention level of health promotion? - AnsBlood pressure screenings Which of the following is an example of objective data? - Ans-Vomiting A nurse suspects a patient is a victim of physical abuse. Which response by the nurse will most likely encourage the patient to confide in the nurse? - Ans-"I've seen people who have been hurt by their significant others. Do you feel safe in your home?" A patient answers questions quietly and appears sad. While answering questions about her marriage, she begins to cry. Which response by the nurse is appropriate in this situation? - Ans-"I see that you are upset. Is there something you'd like to discuss?" A nurse is interviewing a patient. Which of the following questions is an open-ended question? - AnsCan you tell me how you have been feeling? When interviewing a patient to obtain a health history, asking if the patient has "dypsnea" can fall into which of the following systems? - Ans-Respiratory and Cardiovascular A nurse asks a patient to rate their pain on a scale of "0-10". This is which part of the mnemonic for symptom analysis of "OLD CARTS"? - Ans-Severity When examining a patient, the nurse remembers to follow which principle of Standard Precautions? - Ans-Wear gloves when in contact with the patient's blood or other body fluids. Which of the following is a correct statement regarding the technique LIGHT palpation? Light palpation is - Ans-Used to assess tenderness The nurse is unable to hear the patient's breath sounds. To determine the cause of this problem the nurse needs to ensure that the - Ans-valve is open to the diaphragm on the head of the stethoscope. A nurse is preparing to take a patient's blood pressure. The blood pressure cuff is too narrow (small). How accurate will this patient's blood pressure be using this blood pressure cuff? - Ans-Higher than the actual value Where does the nurse attach the sensor probe of the pulse oximeter to measure a patient's oxygen saturation? - Ans-Around the patient's index fingernail During a physical assessment of an elderly adult, the nurse has difficulty palpating the patient's dorsalis pedis pulses. Which piece of equipment would be helpful during this assessment? - Ans-Doppler A patient on a cardiac floor is complaining of chest pain. The nurse needs to conduct which type of assessment? - Ans-A problem-based focused assessment An example of Primary prevention of Health Promotion is: - Ans-Immunizations Which of the following is an example of subjective (symptoms) data? - Ans-Headache Which of the following is one of the goals of Healthy People 2020? - Ans-To promote quality of life & healthy behaviors across all life stages During a mental health assessment, a women begins to cry when the nurse asks about her marriage. Which action by the nurse is most therapeutic? - Ans-" I see that you're upset. Can you discuss why you're feeling this way?" While collecting data on a patient, the nurse obtains vital signs. This is done PRIMARILY to - Ans-obtain baseline indicators of the patient's health status. A nurse is about to take a patient's temperature. The patient has just finished a cup of hot coffee. The nurse should : - Ans-wait 10 minutes, then take the temperature. To position an adult's ear correctly for a tympanic membrane temperature, the nurse should - Ans-tug the ear's helix in an upward direction. A nurse assesses an irregular pulse while counting for 15 seconds. What is the most appropriate action for the nurse to take at this time? - Ans-Count the patient's pulse for a full minute. A nurse takes a patient's pulse. The nurse documents "80 beats per minute and regular"- What does the "regular" refer to? - Ans-Rhythm A nurse is taking vital signs of an adult patient whose oxygen saturation is 96%. The patient's temperature is 102 F, blood pressure is 120/77 pulse is 90 beats/min, and respiratory rate is 26 breaths/min. Which factor may be contributing to the elevated respiratory rate? - Ans-Temperature Which actions by the nurse results in the patient's blood pressure measurement being falsely high? 1. Deflating the blood pressure cuff too rapidly 2. Positioning the patient's arm above the level of the heart 3. Using a blood pressure cuff that is too narrow for the upper arm 4. Wrapping the blood pressure cuff too loosely 5. Reinflating the blood pressure cuff before it is completely deflated - Ans-2,3,4 The difference between the systolic pressure and the diastolic pressure is known as the - Ans-Pulse pressure A patient who is obese and has a fractured leg is reporting pain at 8/10. The patient is also craving a cigarette. Vital signs are temperature 38.1 C, respirations 18 breaths/min, pulse 77 beats/min and blood pressure 170/95mm Hg. Which of the following could be contributing to the increase in blood pressure? - Ans-Pain, obesity, smoking A patient's vital signs are temperature 37.1 C, respirations 18-20 breaths/minutes, blood pressure 120/70mm Hg, oxygen saturation 79%. Which vital sign is considered abnormal and in need of further evaluation? - Ans-Oxygen saturation Which set of vital signs should the nurse recognize as within the expected range for that age group? - Ans-NEWBORN BP 84/60: pulse, 128 beats/min; respirations, 42 breaths/min True or False: Nurses are responsible for knowing about the health beliefs, practices and values of ALL cultural and racial groups. - Ans-False An older man who is near death has been admitted to the hospital and family members are at his bedside. During the admission assessment the nurse uses which question or statement to appropriately address spiritual needs? - Ans-"Are there any special needs that you and your family request at this time?" Which of the following would indicate that the nurse needs additional education about pain management?Select all that apply. - Ans-A patient's report of pain is probably inaccurate when the patient looks comfortable. A patient is only in pain if their vital signs reflect it with increase heart rate and inspirations. Trying to determine the "drug seeking" patients. During an admission history a patient reports having lower back pain for about a year. How would the nurse categorize this pain? - Ans-persistent (chronic) Which of the following statements is TRUE about pain tolerance? - Ans-Pain tolerance increases after alcohol consumption Pain tolerance decreases with repeated exposure to boredo