Exam (elaborations) 245-HESI2

1.During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question? “How do you feel today?” 2.The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: Give him the Four Unrelated Words Test. 3.A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not four unrelated words . Recall; after a 30-minute delay 4.During a mental status assessment, which question by the nurse would best assess a person’s judgment? “Tell me what you plan to do once you are discharged from the hospital.” 5.Which of these individuals would the nurse consider at highest risk for a suicide attempt? Older adult man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun 6.When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk of alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? Decreased liver and kidney functioning 7.During an assessment, the nurse asks a female patient, “How many alcoholic drinks do you have a week?” Which answer by the patient would indicate at-risk drinking? “I have seven or eight drinks a week, but I never get drunk.” 8.The nurse is asking an adolescent about illicit substance abuse. The adolescent answers, “Yes, I’ve used marijuana at parties with my friends.” What is the next question the nurse should ask? “When was the last time you used marijuana?” 9.The nurse has completed an assessment on a patient who came to the clinic for a leg injury. As a result of the assessment, the nurse has determined that the patient has at-risk alcohol use. Which action by the nurse is most appropriate at this time? State, “You are drinking more than is medically safe. I strongly recommend that you quit drinking, and I’m willing to help you.” 10.A patient is brought to the emergency department. He is restless, has dilated pupils, is sweating, has a runny nose and tearing eyes, and complains of muscle and joint pains. His girlfriend thinks he has influenza, but she became concerned when his temperature went up to 39.4° C. She admits that he has been a heavy drug user, but he has been trying to stop on his own. The nurse suspects that the patient is experiencing withdrawal symptoms from which substance? Heroin 11.Patient taking ipratropium reports nausea, blurred vision, has, insomnia after using the inhaler. RN action to implement - withhold med and report symptoms 12.A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?