Health Assessment 2 - Final Exam
Review
NURSE IS REVIEWING PX'S PLAN OF CARE, WHICH INCLUDES NRS DX STATEMENT:
IMPAIRED PHYSICAL MOBILITY RELATED TO TIBIAL FRACTURE AEB PX'S INABILITY
TO AMBULATE. WHICH PART OF DX DOES NURSE NEED TO REVISE?
a. ETIOLOGY
b. NRS DX
c. COLLABORATIVE PROBLEM
d. DEFINING CHARACTERISTIC
a. ETIOLOGY
- TIBIAL FRACTURE IS A MEDICAL DX, WHICH SHOULD NOT BE USED IN A NRS DX.
INSTEAD, USE R/T SEVERE PAIN or SWELLING.
NURSE IS REVIEWING A PX'S PLAN OF CARE WHICH INCLUDES NRS DX
STATEMENT: IMPAIRED PHYSICAL MOBILITY RELATED TO TIBIAL FRACTURE AS
EVIDENCE BY PATIENT'S INABILITY TO AMBULATE. WHICH PART OF THE
STATEMENT DOES NURSE NEED TO REVISE?
A. ETIOLOGY
B. NRS DX
C. COLLABORATIVE PROBLEM
D. DEFINING CHARACTERISTICS
A. ETIOLOGY
- THE CAUSE (ETIOLOGY) CANNOT BE A MEDICAL DX. TIBIAL FRACTURE SHOULD
BE CHANGED TO SEVERE PAIN OR ANOTHER NRS DX FROM THE NANDA LIST.
,NURSE IS TEACHING CLASS ON PREVENTING OSTEOPOROSIS TO GROUP OF
PERIMENOPAUSAL WOMEN. WHICH ACTION IS BEST WAY TO PREVENT OR DELAY
BONE LOSS?
A. TAKING CALCIUM AND VITAMIN D SUPPLEMENTS
B. TAKING MEDS TO PREVENT OSTEOPOROSIS
C. PERFORMING PHYSICAL ACTIVITY, SUCH FAST WALKING
D. ASESS BONE DENSITY ANNUALLY
C. PERFORMING PHYSICAL ACTIVITY, SUCH FAST WALKING
- EXERCISE PREVENT BONE LOSS IN PERIMENOPAUSAL WOMEN. THE FASTER THE
PACE THE HIGHER THE PREVENTIVE EFFECT IS ON THE RISK OF HIP FRACTURE.
We have an expert-written solution to this problem!
WHEN ASSESSING MUSCLE STRENGTH IN AN IMMOBILIZED PX, NURSE OBSERVES
COMPLETE RANGE OF MOTION AGAINST GRAVITY WITH FULL RESISTANCE. WHAT
GRADE OF MUSCLE STRENGTH NURSE WHOULD RECORD USING A 0-5 SCALE?
A. 2
B. 3
C. 4
D. 5
D. 5
- COMPLETE ROM AGAINST GRAVITY IS A NORMAL MUSCLE STRENGTH RECORDED
AT GRADE 5.
NURSE DISCOVERS A PX ON FLOOR, PX STATES THAT HE FELL OUT OF BED.
NURSE ASSESS THE PX AND PUT HIM BACK IN BED. WHAT ACTION SHOULD NURSE
TAKE NEXT?
A. NOTHING, NO HARM HAS OCCURRED
B. NOTIFY HCP
C. COMPLETE INCIDENT REPORT
, D. ASSESS PX
B. NOTIFY HCP
- REPORT IMMEDIATELY TO HEALTH CARE PROVIDER IF PX FALL OR HAVE AN
INJURY. NURSE MUST PROVIDE SAFE CARE, SCENARIO INIDICATES THAT NURSE
ALREDY ASSESSED THE PX WHEN PUT IN BACK IN BED. AFTER PX IS STABILIZED,
COMPLETING THE INCIDENT REPORT WOULD BE THE PAST STEP.
NURSE IS CARING FOR PX THAT SUDDENLY BECOME CONFUSED AND TRIES TO
REMOVE IV. WHICH PRIORITY ACTION WILL NURSE TAKE?
A. ASSESS PX
B. RESTRAINT SUPPLY
C. ATERNATIVE TO RESTRAIN
D. CALL HCP FOR RESTRAIN ORDER
A. ASSESS PX
- WHEN PX BECOME SUDDENLY CONFUSED THE PRIORITY IS TO ASSESS THE PX
TO IDENTIFY REASON FOR CHANGE IN BEHAVIOR, TO TRY TO ELIMINATE CAUSE.
PX IS CONFUSED, TRYING TO GET OUT OF BED AND PULLING IV TUBING. WHICH
NURSING DX WILL NURSE ADD TO CARE PLAN?
A. IMPAIRED HOME MAINTENANCE
B. DEFICIENT KNOWLEDGE
C. IMPAIRED TSSUE INTEGRITY
D. RISK FOR INJURY
D. RISK FOR INJURY
-PX'S BEHAVIOR SUPPORT THE NRS DX OF RISK FOR INJURY. PX IS CONFUSED,
PULLING IV AND TRYING TO CLIMB OUT OF BED. INJURY COULD RESULT IF PX
FALLS OUT AND BEGINS TO BLEED FROM PULLING IV LINE.
Review
NURSE IS REVIEWING PX'S PLAN OF CARE, WHICH INCLUDES NRS DX STATEMENT:
IMPAIRED PHYSICAL MOBILITY RELATED TO TIBIAL FRACTURE AEB PX'S INABILITY
TO AMBULATE. WHICH PART OF DX DOES NURSE NEED TO REVISE?
a. ETIOLOGY
b. NRS DX
c. COLLABORATIVE PROBLEM
d. DEFINING CHARACTERISTIC
a. ETIOLOGY
- TIBIAL FRACTURE IS A MEDICAL DX, WHICH SHOULD NOT BE USED IN A NRS DX.
INSTEAD, USE R/T SEVERE PAIN or SWELLING.
NURSE IS REVIEWING A PX'S PLAN OF CARE WHICH INCLUDES NRS DX
STATEMENT: IMPAIRED PHYSICAL MOBILITY RELATED TO TIBIAL FRACTURE AS
EVIDENCE BY PATIENT'S INABILITY TO AMBULATE. WHICH PART OF THE
STATEMENT DOES NURSE NEED TO REVISE?
A. ETIOLOGY
B. NRS DX
C. COLLABORATIVE PROBLEM
D. DEFINING CHARACTERISTICS
A. ETIOLOGY
- THE CAUSE (ETIOLOGY) CANNOT BE A MEDICAL DX. TIBIAL FRACTURE SHOULD
BE CHANGED TO SEVERE PAIN OR ANOTHER NRS DX FROM THE NANDA LIST.
,NURSE IS TEACHING CLASS ON PREVENTING OSTEOPOROSIS TO GROUP OF
PERIMENOPAUSAL WOMEN. WHICH ACTION IS BEST WAY TO PREVENT OR DELAY
BONE LOSS?
A. TAKING CALCIUM AND VITAMIN D SUPPLEMENTS
B. TAKING MEDS TO PREVENT OSTEOPOROSIS
C. PERFORMING PHYSICAL ACTIVITY, SUCH FAST WALKING
D. ASESS BONE DENSITY ANNUALLY
C. PERFORMING PHYSICAL ACTIVITY, SUCH FAST WALKING
- EXERCISE PREVENT BONE LOSS IN PERIMENOPAUSAL WOMEN. THE FASTER THE
PACE THE HIGHER THE PREVENTIVE EFFECT IS ON THE RISK OF HIP FRACTURE.
We have an expert-written solution to this problem!
WHEN ASSESSING MUSCLE STRENGTH IN AN IMMOBILIZED PX, NURSE OBSERVES
COMPLETE RANGE OF MOTION AGAINST GRAVITY WITH FULL RESISTANCE. WHAT
GRADE OF MUSCLE STRENGTH NURSE WHOULD RECORD USING A 0-5 SCALE?
A. 2
B. 3
C. 4
D. 5
D. 5
- COMPLETE ROM AGAINST GRAVITY IS A NORMAL MUSCLE STRENGTH RECORDED
AT GRADE 5.
NURSE DISCOVERS A PX ON FLOOR, PX STATES THAT HE FELL OUT OF BED.
NURSE ASSESS THE PX AND PUT HIM BACK IN BED. WHAT ACTION SHOULD NURSE
TAKE NEXT?
A. NOTHING, NO HARM HAS OCCURRED
B. NOTIFY HCP
C. COMPLETE INCIDENT REPORT
, D. ASSESS PX
B. NOTIFY HCP
- REPORT IMMEDIATELY TO HEALTH CARE PROVIDER IF PX FALL OR HAVE AN
INJURY. NURSE MUST PROVIDE SAFE CARE, SCENARIO INIDICATES THAT NURSE
ALREDY ASSESSED THE PX WHEN PUT IN BACK IN BED. AFTER PX IS STABILIZED,
COMPLETING THE INCIDENT REPORT WOULD BE THE PAST STEP.
NURSE IS CARING FOR PX THAT SUDDENLY BECOME CONFUSED AND TRIES TO
REMOVE IV. WHICH PRIORITY ACTION WILL NURSE TAKE?
A. ASSESS PX
B. RESTRAINT SUPPLY
C. ATERNATIVE TO RESTRAIN
D. CALL HCP FOR RESTRAIN ORDER
A. ASSESS PX
- WHEN PX BECOME SUDDENLY CONFUSED THE PRIORITY IS TO ASSESS THE PX
TO IDENTIFY REASON FOR CHANGE IN BEHAVIOR, TO TRY TO ELIMINATE CAUSE.
PX IS CONFUSED, TRYING TO GET OUT OF BED AND PULLING IV TUBING. WHICH
NURSING DX WILL NURSE ADD TO CARE PLAN?
A. IMPAIRED HOME MAINTENANCE
B. DEFICIENT KNOWLEDGE
C. IMPAIRED TSSUE INTEGRITY
D. RISK FOR INJURY
D. RISK FOR INJURY
-PX'S BEHAVIOR SUPPORT THE NRS DX OF RISK FOR INJURY. PX IS CONFUSED,
PULLING IV AND TRYING TO CLIMB OUT OF BED. INJURY COULD RESULT IF PX
FALLS OUT AND BEGINS TO BLEED FROM PULLING IV LINE.
