NURS 2539 ASSESSMENT

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ASSESSMENT Question 1 Which statement regarding heart sounds is correct? Question 2 See full question 4s When assessing a family suspected of abusing its 4-year-old child, which behavior is the... most important criterion that would suggest abuse? Question 3 See full question 11s A 13-year-old girl is being evaluated for possible Crohn's disease. The nurse expects to prepare her for which diagnostic study? Question 4 See full question 12s A nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? Question 5 See full question 8s What assessment data of a laboring woman would require further intervention by the nurse? Question 6 See full question 10s A nurse assesses a client’s vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge? Question 7 See full question 13s A nursing assistant (unregulated care provider, UCP) has finished taking routine vital signs of the clients assigned to her. While charting later in the shift, a nurse finds that the assistant (UCP) documented a client's blood pressure at 192/126 mm Hg. What is the most appropriate action for the nurse to take? Question 8 See full question 13s A fourth heart sound (S4) indicates a: Question 9 See full question 10s A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding? Question 10 See full question 3s The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? Question 11 See full question 1s The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive? Question 12 See full question 3s Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? Question 13 See full question 2s When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next? Question 14 See full question 2s A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because “voices on television are talking about me.” The nurse should first: Question 15 See full question 2s A young child with sickle cell anemia prefers a side-lying position with the knees sharply flexed. The nurse should assess further for: Question 16 See full question 3s A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 meq KCL/L running at 60 mL/h. Vital signs are a temperature of 100.4° F (38° C), heart rate of 120 bpm, respiratory rate of 28 breaths/min, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: Question 17 See full question 3s Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? Question 18 See full question 2s A nurse assesses a client who was admitted to the emergency department with a thermal burn to the right arm and upper chest. Which assessment requires immediate action? Question 19 See full question 3s A nurse caring for a client with schizophrenia goes into the client’s room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? Question 20 See full question 3s A client is admitted with chest pain and kept overnight for stress testing the next morning. Prior to sending the client to the stress test, the nurse reviews the results of the laboratory reports (see lab report). The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test? Question 1 See full question 13s A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: Question 2 See full question 13s Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by: Question 3 See full question 2s A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask? Question 4 See full question 10s A 30-month-old toddler is being evaluated for a ventricular septal defect (VSD). Identify the area where a VSD occurs. ..........................................CONTINUES......................................... [Show More]

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