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A nurse is caring for a client who asks about measures the nurse takes to protect client
privacy. Which of the following is an appropriate response by the nurse?
a. "I will provide their information to anyone who requests it."
b. "I will make sure my password to log into the system is the same one I use for
everything else."
c. "I will talk to my friends about the client in order to get advice."
d. "I will log off the computer in between seeing clients." - CORRECT ANSWER:
Answer: d
HIPAA establishes national standards for the protection of certain health info. The
privacy rule can be violated if a client's health info is on the computer screen and the
nurse leaves it up while taking care of other clients.
A patient is crying and says, "Please get me something to relieve this pain." What
should the nurse do next?
a. Verify that the patient has an order for pain medications and administer order as
directed
b. Assess the level of pain and ask patient what usually works for his or her pain,
administer pain medication as needed, then reassess pain level
c. Assess the level of pain and give medications according to pain level, and then
reassess pain
d. Reposition the patient, then reassess the pain after intervention - CORRECT
ANSWER: Answer: B
,Answers A, C, and D are incorrect because pain management should be collaborative,
and the patient is not part of the decision making process in these answers.
A patient with a history of a knee injury reports local pain in the knee. Which test would
the nurse perform to further evaluate the knee?
a. Phalen
b. Thomas
c. Bulge Sign
d. McMurray - CORRECT ANSWER: Answer: d
* The McMurray test is performed when a patient has reported a history of trauma
followed by locking, giving way, or local knee pain
* If you hear a "click" = McMurray test is positive for a torn meniscus
A patient with a severe muscle cramp tells the nurse, "The pain is a little better when I
massage the muscle or apply a cold pack." Which criterion of the PQRST method of
pain assessment is addressed in the patient's statement?
a. Severity Scale
b. Quality/Quantity
c. Region/Radiation
d. Provocation/Palliation - CORRECT ANSWER: Answer: d
PQRST is a pain assessment scale; it stands for Provocation/Palliation,
Quality/Quantity, Region/Radiation, Severity Scale, and Timing. Because the patient is
describing methods that provide comfort and relieve the pain, it indicates that the patient
is addressing Provocation/Palliation. If the patient reports about severity of pain on a
scale of 0 to 10, then it indicates that the patient is addressing Severity. When
addressing the Quality/Quantity of the pain, the patient describes the pain felt. If the
patient reports about the site of pain, then the patient is addressing Region/Radiation.
, An older adult patient comes in due to his recent loss of his partner of 52 years. What is
this patient at risk for and how does this loss impact him? - CORRECT ANSWER: He is
at risk for depression, grief, and despair. This loss impacted his by having him question
his purpose and independence due to his loss which also entailed the loss of his role as
a husband.
Borborygmus - CORRECT ANSWER: sound of hyperperistalsis
FICA is an assessment tool used to determine a patient's spiritual history. What does
FICA stand for? - CORRECT ANSWER: F = faith
I = importance/influence
C = community
A = address/action
Genu valgum - CORRECT ANSWER: knock-knees
Genu varum - CORRECT ANSWER: bowlegs
HEENMT - CORRECT ANSWER: - Head is normocephalic, face is symmetrical, neck is
proportionate to head and face, and hair distribution is normal
- Pupils are equal, round, reactive to light (direct and consensual), and accommodated.
Convergence is noted B/L, pupil size, no drainage or jaundice, symmetrical, sclera
white, conjunctive pink
- Ears are symmetrical, intact, skin color is consistent with exposed skin, pinna (pull up)
and tragus (push in) are mobile and nontender
- Nose is midline, nares are symmetrical and patent
- Tongue and buccal mucosa are pink, moist, and w/o lesions, dentition intact
- Trachea is midline