Nursing Care Quiz: Patient Assessment & Priorities

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Questions and Answers

What is the most appropriate response for a nurse when a client with delirium expresses anxiety?

  • I'll get you some medicine to help you relax. The more you worry, the worse it will get.
  • I'll sit with you until you calm down a little. (correct)
  • I wish I could do something to make it stop, but unfortunately I can't.
  • As soon as we know what's causing this, we can try to stop it. I'll get you some medicine to help you relax.

Which statement indicates a primigravid client understands exercise recommendations during pregnancy?

  • Even though I'm pregnant, I can learn to ski next month.
  • While we are on vacation next month, I can continue to scuba dive.
  • Sitting in a hot tub after exercise will help me to relax.
  • While pregnant, I should avoid contact sports. (correct)

What is the first priority for a nurse assessing a client who has had a myocardial infarction?

  • Prepare the client for discharge.
  • Determine the patient's level of pain.
  • Identify the cardiac rhythm present. (correct)
  • Monitor vital signs continuously.

What is the most appropriate action for a nurse who is untrained in administering chemotherapy?

<p>Ask a nurse from the oncology floor to come to administer the medication. (C)</p> Signup and view all the answers

Which is a priority goal after the surgical repair of a cleft lip?

<p>Preventing infection. (B)</p> Signup and view all the answers

What should be an appropriate outcome for a client diagnosed with rheumatoid arthritis?

<p>The client will manage joint pain and fatigue to perform activities of daily living. (C)</p> Signup and view all the answers

What is the primary purpose of continuous bladder irrigation after a transurethral resection of the prostate (TURP)?

<p>To keep the catheter free from clot obstruction. (A), To control bleeding in the bladder. (D)</p> Signup and view all the answers

When preparing for a child with meningococcal meningitis's admission, what should the nurse do first?

<p>Institute droplet precautions. (D)</p> Signup and view all the answers

In the context of emergency response, why is it essential to call a crisis nurse after a tour bus accident?

<p>To coordinate calls from relatives about the passengers. (C)</p> Signup and view all the answers

Which assessment finding would most likely indicate a distended bladder during a physical examination?

<p>Dullness. (B)</p> Signup and view all the answers

To help prevent tension on the perineum in a neonate post-surgery for an imperforate anus, which position should the nurse avoid?

<p>Abdomen, with legs pulled up under the body. (D)</p> Signup and view all the answers

Which activity would be the most beneficial for a 14-year-old boy feeling bored due to being in a cast?

<p>Playing a card game with a boy the same age. (B)</p> Signup and view all the answers

What key information should the nurse include when preparing an adolescent for an emergency appendectomy?

<p>The scar will be small. (B), The teen will be back in school in 1 week. (C)</p> Signup and view all the answers

Why is it important to monitor siblings' health at home when admitting a child with meningococcal meningitis?

<p>To assess for symptoms of the illness in siblings. (B), To ensure that siblings are not at risk of contagion. (D)</p> Signup and view all the answers

What is the first action the nurse should take when the client returns to the room after surgery for sequential compression therapy?

<p>Confirm the client's identity using two client identifiers. (B)</p> Signup and view all the answers

In the context of handling a family crisis, which issue should be prioritized regarding the adolescent's behavior following a sibling's suicide?

<p>Potential suicidal thoughts/plans of both family members. (C)</p> Signup and view all the answers

Which characteristic of child molesters is essential for the educational program on safety?

<p>Child molesters pick children or teens over whom they have authority. (D)</p> Signup and view all the answers

During the assessment of a woman in labor, which action should be prioritized for pain management?

<p>Assess the intensity of contractions. (B)</p> Signup and view all the answers

What is a common misconception regarding child molesters that should be clarified in educational programs?

<p>Understanding their motivations can reduce incidents of molestation. (A)</p> Signup and view all the answers

Which factor is NOT a priority when evaluating a parent’s response to a child's behavioral problems post-crisis?

<p>The parent's ability to provide financial support. (B)</p> Signup and view all the answers

What should be included in the follow-up assessment for a previously healthy client admitted with unexplained vomiting?

<p>Assess for signs of dehydration. (B)</p> Signup and view all the answers

Which of the following is an essential nursing duty in managing a laboring woman considering an epidural?

<p>Monitor the frequency of contractions. (B)</p> Signup and view all the answers

Flashcards

Continuous bladder irrigation after TURP

Continuous bladder irrigation is used after a transurethral resection of the prostate (TURP) to control bleeding and prevent clot formation in the bladder.

Bladder percussion sound in distension

A distended bladder percussed will produce a dull sound.

Reason for calling crisis nurse after accident

Passengers could experience emotional distress, needs for coordination for family updates, and/or psychological support after a serious accident.

Post-operative infant positioning

Positioning after surgery to prevent tension on the infant perineum is key. Avoid placing the neonate on the abdomen or with legs pulled up.

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Meningococcal meningitis precaution

Droplet precautions are essential to protect others from this contagious illness.

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Appropriate activity for a bored child in a cast

Engaging, age-appropriate activities such as playing card games with peers will help a child remain occupied while hospitalized and avoid boredom.

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Realistic appendectomy information

Provide honest and realistic information including potential recovery time, scar size, and limitations, avoiding promises that cannot be upheld.

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Expected post-surgery complication

Potential medical complications of a surgical procedure.

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Delirium Anxiety Response

A nurse's best response to a delirious, anxious client is to acknowledge their distress and offer reassurance, along with medication to calm anxiety, while investigating the cause.

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Pregnancy Exercise Advice

A pregnant client should avoid contact sports, scuba diving, and hot tubs after exercise.

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Myocardial Infarction Rhythm

A nurse assessing a client with a myocardial infarction should recognize various heart rhythms to diagnose an irregular heart beat.

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Chemotherapy Administration

If the nurse isn't trained in chemotherapy, immediately ask for help from another nurse or staff in oncology handling the chemotherapy for the client.

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Cleft Lip Surgery Priority

The most important goal following cleft lip repair is managing pain and potential infection.

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Rheumatoid Arthritis Outcome

A suitable outcome for a rheumatoid arthritis client involves managing joint pain and fatigue to maintain daily activities.

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Rehabilitation Duration

Bone healing after an injury typically takes 8 months or longer.

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Post-Surgical Repair

Pain management is a key priority after any surgical procedure, since it impacts healing.

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Priority issue in adolescent substance abuse

The parent's ability to emotionally support the adolescent through the crisis is the priority.

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Sexual predator tactics

Sexual predators gain trust and maintain secrecy using manipulation and threats.

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First nursing action post-op

Confirm the client's identity using two client identifiers is the first action.

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Nursing assessment of labor pain

Assess contraction intensity, pain level, and desire for pain management (e.g., epidural).

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Post-op client need

Client identity verification is critical to ensure proper care.

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Potential complication in pregnancy pain

Abruption (placental separation) is a possible complication of severe pain during labor.

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Client with unexpected symptoms (vomiting/pain)

Focus on client safety, especially if ambulating while sick. Confirm client's identity and assess carefully.

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Labor Pain Management

Administer pain management interventions (e.g. epidural) as needed and appropriate, and coach the woman in breathing exercises for pain relief

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Study Notes

TEST 1: COMPREHENSIVE

  • A client with HIV and AIDS confides in the nurse that he is homosexual and his employer does not know his HIV status. The best response by the nurse is "The information you confide in me is confidential."
  • A mother of a child with bronchial asthma tells the nurse that the child wants a pet. The most appropriate pet for a child with asthma is a fish.
  • An elderly client admitted to same-day surgery for cataract extraction has several diamond rings. The rings should be placed in an envelope, the client should sign the envelope, and the envelope is placed in a safe.
  • When an infant resumes taking oral feedings after surgery, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier provides an outlet for emotional tension.

TEST 1: COMPREHENSIVE questions

  • A client with HIV and acquired immunodeficiency syndrome (AIDS) confides that he is homosexual and his employer does not know his HIV status. Which response by the nurse is best?
    1. "Would you like me to help you tell them?”
    1. “The information you confide in me is confidential."
    1. "I must share this information with your family."
    1. "I must share this information with your employer."
  • The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets is most appropriate?
    1. Cat.
    1. Fish.
    1. Gerbil.
    1. Canary.
  • An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that:
    1. The rings will be taped before the surgery.
    1. The rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe.
    1. The rings will be locked in the narcotics box.
    1. The nursing supervisor will hold onto the rings during the surgery.
  • When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier:
    1. Provides an outlet for emotional tension.
    1. Indicates readiness to take solid foods.
    1. Indicates intestinal motility.
    1. Is an attempt to get attention from the parents.

Other questions

  • Under which circumstance may a nurse communicate medical information without the client's consent?
  • When requested by the client's family.
  • A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which of the following is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?
  • The physician will get a consultation from another physician and proceed with placement of the ICP catheter until the family arrives to sign the consent.
  • A 68-year-old client's daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse's best response is which of the following?
  • "The follow-up for your father will be a chest x-ray every 6 months."
  • Which of the following blood administration set should the nurse use?
  • Micron mesh filter.

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