1. Hx/General Survey/VS/Pain

A nurse has just admitted a patient who has a wound infection to the unit. After assessing the patient, what is the next step the nurse should perform?

• Implement a plan of action

• Interpret the findings

• Respond to the findings

• Reflect on the plan of action

A client's significant other is tearful over the clients condition and lack of improvement. He says he feels powerless and unable to help. Which response by the nurse is the best?

• Agree with the person

• Tell him there’s nothing he can do

• State she understands how he must feel

• Ask if he would like to help with some comfort measures

Which factor is an example of subjective data in a nursing assessment?

• Client’s feelings and statements about health problems

• Report of a diagnostic procedure

• Physical assessment data

• Laboratory study results

An 83-year-old client fractured a hip after a fall in his home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells a nurse he doesn't know how he's going to get better. Which response is best?

• “You’re doing fine.”

• “What’s your biggest concern right now?”

• “Give it some time and you’ll be okay.”

• “Why do you believe that you’re not doing well?”

The nurse collects data on a client's chief complaint (a spell of numbness and tingling on the left side). Which of the following questions would be best for eliciting information related to associated/related factors?

• "How bad was the tingling and numbness?"

• "How long did the spell last?"

• "Where did the numbness and tingling occur?"

• "What other symptoms occurred during the spell?"

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

• Personal health history

• Chief complaint

• Review of systems

• History of present illness

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

• Ask the client to identify which medications taken every day.

• Ask the client to bring all the medications and supplements to an interview.

• Ask the caregiver whether the client is taking prescribed medications.

• Ask the client about the use of any over-the-counter medications.

The nurse should respond to a client's request to "keep what I'm about to tell you a secret" with which statement?

• "Confidentiality is a right you have as a client."

• "I have to share the information if it reveals something that could hurt you."

• "Don't share anything with me that you don't want your health provider to know."

• "I'm ethically bound to keep your health information confidential."

A patient is wearing a hospital gown and sitting on the exam table. What area should the nurse include in the general survey?

• Blood Pressure

• Breath sounds

• Facial expressions

• Oral lesions

The nurse is preparing to assess the respirations of an alert adult patient. How should the nurse perform this assessment?

• Explain to the patient that you will be counting respirations

• Observe for equal bilateral chest expansion

• Count for 15 seconds and multiply the number by 4 to obtain the rate

• Ask the patient to lay supine, which makes counting the respirations easier