NURSING 7890 Fundamentals Unit 2 Study Guide

NURSING 7890 Fundamentals Unit 2 Study Guide 1) An older adult patient complains of thirst, headache, and weight loss. The patient appears emaciated. On physical assessment, the nurse finds that the patient’s skin does not return to normal shape after being assessed. This finding is consistent with what? Poor skin turgor 2) The student nurse has been assigned to the pediatric unit for her clinical training this semester. She is assisting with the admission of a 5-month-old infant admitted with pneumonia. The student nurse is responsible for taking the child’s vital signs and weighing and measuring the child. The infant’s mother is very concerned when the student nurse tells her that the baby weighs 14 pounds. The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home. What is the student nurse’s best response to the mother’s concern? Weight measurements can vary between scales 3) A nurse is preparing to perform a physical exam on a patient. She has found that it is best to perform the physical with a head-to-toe approach. Why is this important? Being systematic and well organized helps so you don’t miss important assessments and allows you to anticipate the next step. 4) A registered nurse is preparing to perform a physical examination on a 5-year-old child. To make the child feel safer during the examination the nurse should do what? Start assessment with easier, less invasive areas, such as the hands. This will slowly engage the child and reassure them that you are there to help. 5) A nurse is preparing to perform a physical examination on a patient who has mobility issues. In preparing for the examination, the nurse should do what? Perform thorough hand hygiene before preparing equipment 6) A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment. After using light palpation to examine the patient, the nurse uses deep palpation. With deep palpation, the nurse does what? Assess the organs and detect less obvious masses. 7) While auscultating a patient with pneumonia, a nurse hears low-pitched, rumbling coarse sounds during inspiration and expiration. These sounds can best be described as which of the following? Rhonchi (sonorous wheeze). 8) A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. The patient is still unconscious. What intervention should the admitting nurse do first? Vitals. Getting her warm, such as wrapping her in warm blankets or possibly even the bear hugger. 9) A 26-year-old man was helping a friend replace a roof on his backyard shed after work on a hot July afternoon. His friend brought him to the hospital after the patient complained of severe muscle cramps and became confused. What should the admitting nurse do first when assessing the patient? Take his temperature 10) A 6-year-old was taken to the hospital after having a seizure at home. The patient’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. The patient’s mother believes that the seizure was caused by a fever of 99.5° F, which the patient had during the course of her illness. What is the nurse’s best response?