NURS 251 FINAL TEST 100% VERIFIED SOLUTIONS 2023/2024

NURS 251 FINAL TEST 100% VERIFIED SOLUTIONS 2023/2024 After completing an initial assessment of the patient, the nurse has charted that his respirations are eupneic and his pulse is 58 bpm. What type of assessment data is this? A. Objective B. Reflective C. Subjective D. Introspective - ANSWER A. objective data that the patient says, signs and symptoms reported by the patient during the assessment - ANSWER subjective data data that the nurse observes - ANSWER objective data name, address, phone #, age and birthdate, birthplace, gender, relationship status, race, ethnic status, occupation, primary language - ANSWER biographic data housekeeping , shopping, cooking, laundry, telephone, finances, nutrition, social relationships - ANSWER Instrumental ADLs COLDSPA - ANSWER C- character of symptom or condition (throbbing pain, stabbing, achy pain) O- onset (when did it begin: better? Worse? same?) L-location (where and does it radiate?) D- duration S- severity (on a scale of 1-10?) P-pattern (what makes it better? worse? A- associated factors (other associated symptoms? Effect on leisure or exercise? rigid box that protects brain - ANSWER skull enables head rotation and flexion and divides each side of neck into anterior and posterior triangles - ANSWER sternomastoid muscles move shoulders and extend and turn head - ANSWER trapezius hormones that stimulate rate of cellular metabolism - ANSWER Thyroxine (T4) and triiodothyronine (T3) air filled pockets within cranium - ANSWER paranasal sinuses The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? A. Patient with postoperative pain B. Newly diagnosed patient with diabetes who needs diabetic teaching C. Individual with small laceration on sole of foot D. Individual with shortness of breath and respiratory distress - ANSWER D. Individual with shortness of breath and respiratory distress During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A. Ask the patient about the item and its significance B. Ask the patient to lock the item with other valuable in the hospitals sade C. Tell the patient that a family member should take valuables home D. No action is necessary - ANSWER A. Ask the patient about the item and its significance The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? A. Do you smoke? B. What is your religion? C. Do you have a history of heart disease? D. How many years have you lived in the United States? - ANSWER D. How many years have you lived in the United States? The nurse is asking questions about a patient's health beliefs. Which questions are appropriate? (SATA) A. What is your definition of health? B. Does your family have a history of cancer? C. How do you describe illness? D. What did your mother do to keep you from getting sick? E. Have you ever had any surgeries? F. How do you keep yourself healthy? - ANSWER A. What is your definition of health? C. How do you describe illness? D. What did your mother do to keep you from getting sick? F. How do you keep yourself healthy? The nurse asks, "I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here." Based on this question, the nurse is at which phase of the interview process? A. Summary B. Closing C. Working D. Opening or introduction - ANSWER D. Opening or introduction A pregnant woman states, "I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor." The nurse responds by stating, "Oh, don't worry about labor so much. I have been through it and although it is painful, many good medications are available to decrease the pain". Which statement is true regarding the nurse's response. A. Therapeutic response. By sharing something personal, the nurse gives hope to thesis woman B. Non Therapeutic response - ANSWER B. Non Therapeutic response The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? A. To provide an opportunity for interaction between the patient and nurse B. To provide a form for obtaining the patient's biographic information C. To document the normal and abnormal findings of a physical assessment D. To provide a database of subjective information about the patient's past and current health - ANSWER D. To provide a database of subjective information about the patient's past and current health A patient tells the nurse that he is allergic to penicillin. What is the best response by the nurse? A. "Are you allergic to any other drugs?" B. "How often have you received penicillin?" C. "Describe what happens to you when you take penicillin?" D. "I'll write your allergy on your chart so you won't receive any penicillin?" - ANSWER C. "Describe what happens to you when you take penicillin?" The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? (SATA) A. "Where is the headache pain?" B. "Did you have these headaches as a child?" C. "On a scale of 1-10 how bad is the pain?" D. "How often do headaches occur?" E. "What makes the headaches feel better?" F. "Do you have any family history of headaches? - ANSWER A. "Where is the headache pain?" C. "On a scale of 1-10 how bad is the pain?" D. "How often do headaches occur?" E. "What makes the headaches feel better?" The nurse is assessing a 75 year old man. What should the nurse expect when performing the mental status portion of the assessment? A. Will have no decrease in any of his abilities including response time B. Will have difficulty on test of remote memory because this ability typically decreased with age C. May tackle a little longer to respond but his general knowledge and abilities should not have declined D. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge - ANSWER C. May tackle a little longer to respond but his general knowledge and abilities should not have declined The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview? A. "I sleep like a baby" B. "I have no health problems" C. "I never did good in school" D. "I am not currently taking any medications" - ANSWER C. "I never did good in school" 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 thought he had influenza,, but she became concerned when his temperature went up to 39.4C. 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? A. Alcohol B. Heroin C. Cocaine D. Sedatives - ANSWER B. Heroin When reviewing the use of alcohol by older adults, the nurse notes that older adults have several characteristics that can increase the risk for alcohol use. Which would increase the bioavailability of alcohol in the blood for longer periods in the older adult? (SATA) A. Increased muscle mass B. Decrease blood pressure C. Increased cardiac output D. Decreased liver metabolism E. Decreased kidney functioning - ANSWER D. Decreased liver metabolism E. Decreased kidney functionin