Exam 28: Hospitalized Patient

While conducting a rapid assessment for a client who has diabetes, the student nurse notes that the client is experiencing emotional stress following the recent death of the spouse. When discussing the client with the nurse preceptor, which statement by the student nurse student indicates the need for further education?

The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature. Which statement by the student nurse indicates the need for further education prior to monitoring a rectal temperature?

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which statement by the student nurse indicates that further education is required?

The nurse is preparing to assess the general appearance of the hospitalized client. Which statements by the client are expected if the client is experiencing undernutrition?

The student nurse measures the client's oxygen saturation level by using a pulse oximeter, and confers with the nurse preceptor after completion. Which statement by the student indicates the need for further education?

The nurse is performing a rapid assessment for the assigned clients. Which clients require immediate medical assistance?

The nurse works on a medical-surgical unit. Which clients will require a rapid assessment?

The nurse is assessing a newborn client who was born 5 minutes ago and notes six fingers on the left hand. Which term will the nurse use when documenting this finding in the medical record?

The student nurse is preparing to auscultate the client's lungs during the initial assessment. Which student nurse statement to the nurse preceptor indicates the need for further education prior to conducting the assessment?

The nurse is conducting an initial respiratory assessment on the client recently admitted to the unit. Rank the following steps in the correct sequence. A) The nurse percusses the client's thorax. B) The nurse unties the client's gown to better visualize the client's thorax. C) The nurse warms his stethoscope and listens to the client's lung sounds in each lung field. D) The nurse gently palpates the client's thorax.

The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the client's oxygenation level and the presence of jaundice. Which statements indicate that the nurse is performing these specific assessments?

The nurse assesses the hospitalized client and prepares to document the findings using APIE in the medical record. Rank the following findings in the proper order of documentation. A) The client states upon admission, "I don't know what's wrong with me, but I can't see out of my left eye and I can't stand up by myself." B) The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance. C) The healthcare provider writes an order for the nurse to administer heparin. D) On the morning of the client's discharge from the hospital, the client has been able to ambulate 50 feet with a walker.

The nurse is performing an assessment on an adolescent client. Which finding would be unexpected?

The nurse is performing an assessment of a 7-month-old. Which finding would require further assessment?

The student nurse is preparing to perform an assessment on a 5-year-old Arab American client who is hospitalized for dehydration. The nurse preceptor accompanies the student nurse to the client's room. Which statements by the student nurse indicate that further education is required?

The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the activities of the nursing process in the proper order. A) The nurse educates the client regarding the care of his sternal and leg incisions. B) The client arrives at the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft. C) The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection. D) The nurse develops a plan to help prevent some of the known complications associated with surgery.

The nurse is performing an assessment on an older adult client. Which finding will warrant further investigation?

During the physical assessment, the hospitalized client states, "I've been under an incredible amount of stress since my healthcare provider diagnosed me with colon cancer 2 days ago." Which assessment data collected by the nurse are associated with increased stress?

The nurse is performing a focused interview with an older adult client. Which statements indicate the client has an increased risk of developing depression?

A toddler-age client is brought to the emergency department (ED) with difficulty breathing. The healthcare provider diagnoses the client with epiglottitis. Which assessment data collected by the nurse are consistent with this diagnosis?