TB-Chapter 30 Bedside Assessment and Electronic Documentation PDF

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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK

TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

451

Chapter30:BedsideAssessmentandElectronicDocumentation MULTIPLECHOICE 1.Atthebeginningofroundswhenenteringtheroom,whatshouldthenursedofirst? a.

Checktheintravenous(IV)infusionsiteforswellingorredness.

b.

Checktheinfusionpumpsettingsforaccuracy.

c.

Makeeyecontactwiththepatient,andintroducehimorherselfasthepatientsnurse.

d.

Offerthepatientsomethingtodrink.

ANS:C Whenenteringapatientsroom,thenurseshouldmakedirecteyecontact,withoutbeingdistractedbyIV pumpsandotherequipment,andintroducehimorherselfasthepatientsnurse. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 2.Duringanassessment,thenurseisunabletopalpatepulsesintheleftlowerleg.Whatshouldthenursedo next? NURSINGTB.COM

a.

Documentthatthepulsesarenonpalpable.

b.

Reassessthepulsesin1hour.

c.

Askthepatientturntotheside,andthenpalpateforthepulsesagain.

d.

UseaDopplerdevicetoassessthepulses.

ANS:D ThenurseshouldbepreparedtoassesspulsesinthelowerextremitiesbyDopplermeasurementiftheycannot bedetectedbypalpation. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 3.Duringamorningassessment,thenursenoticesthatapatientsurineoutputisbelowtheexpectedamount. Whatshouldthenursedonext? a.

ObtainanorderforaFoleycatheter.

b.

Obtainanorderforastraightcatheter.

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

c.

Performabladderscantest.

d.

Referthepatienttoanurologist.

452

ANS:C Ifurineoutputisbelowtheexpectedvalue,thenthenurseshouldperformabladderscanaccordingto institutionalpolicytocheckforretention. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 4.Whatshouldthenurseassessbeforeenteringthepatientsroomonmorningrounds? a.

Postedconditions,suchasisolationprecautions

b.

Patientsinputandoutputchartfromthepreviousshift

c.

Patientsgeneralappearance

d.

Presenceofanyvisitorsintheroom

ANS:A NURSINGTB.COM

Onthewaytothepatientsroom,thenurseshouldassessthepresenceofconditionssuchasisolation precautions,latexallergies,orfallprecautions. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 5.ThenursehasadministeredapainmedicationtoapatientbyanIVinfusion.Thenurseshouldreassessthe patientsresponsetothepainmedicationwithin_____minutes. a.

5

b.

15

c.

30

d.

60

ANS:B Ifpainmedicationisgiven,thenthenurseshouldreassessthepatientsresponsein15minutesforIV administrationor1hourfororaladministration. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapies

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

453

6.Duringanassessmentofahospitalizedpatient,thenursepinchesafoldofskinundertheclavicleoronthe forearmtotestthe: a.

Mobilityandturgor.

b.

Patientsresponsetopain.

c.

Percentageofthepatientsfat-to-muscleratio.

d.

Presenceofedema.

ANS:A Pinchingafoldofskinundertheclavicleorontheforearmisdonebythenursetodeterminemobilityand turgor. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 7.Whenassessingtheneurologicsystemofahospitalizedpatientduringmorningrounds,thenurseshould includewhichoftheseduringtheassessment? a.

Bloodpressure

b.

Patientsratingofpainonascaleof1to10

c.

Patientsabilitytocommunicate

d.

Patientspersonalhygienelevel

NURSINGTB.COM

ANS:C Assessmentofapatientsabilitytocommunicateispartoftheneurologicassessment.Bloodpressureandpain ratingaremeasurements,andpersonalhygieneisassessedundergeneralappearance. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 8.Whenassessingapatientsgeneralappearance,thenurseshouldincludewhichquestion? a.

Isthepatientsmusclestrengthequalinbotharms?

b.

Isptosisorfacialdrooppresent?

c.

Doesthepatientappropriatelyrespondtoquestions?

d.

Arethepupilsequalinreactionandsize?

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

454

ANS:C Assessingwhetherthepatientappropriatelyrespondstoquestionsisacomponentofanassessmentofthe patientsgeneralappearance.Theotheranswersreflectcomponentsoftheneurologicexamination. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 9.Whenassessingapatientinthehospitalsetting,thenurseknowswhichstatementtobetrue? a.

Thepatientwillneedabriefassessmentatleastevery4hours.

b.

Thepatientwillneedaconsistent,specializedexaminationevery8hoursthatfocusesoncertain parameters.

c.

Thepatientwillneedacompletehead-to-toephysicalexaminationevery24hours.

d.

Mostpatientsrequireaminimalexaminationeachshiftunlesstheyareincriticalcondition.

ANS:B Inahospitalsetting,thepatientdoesnotrequireacompletehead-to-toephysicalexaminationduringevery24hourstay.Thepatientdoes,however,requireaconsistentspecializedexaminationevery8hoursthatfocuses oncertainparameters. NURSINGTB.COM DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 10.Thenurseisgivingreporttothenextshiftandisusingthesituation,background,assessment, recommendation(SBAR)frameworkforcommunication.WhichofthesestatementsreflectstheBackground portionofthereport? a.

Imworriedthathisgastrointestinalbleedingisgettingworse.

b.

Weneedanorderforoxygen.

c.

MynameisMs.Smith,andImgivingthereportonMrs.Xinroom1104.

d.

Heis4dayspostoperative,andhisincisionisopentoair.

ANS:D DuringtheBackgroundportion,thenurseshouldstatedatapertinenttothemomentsproblemsuchasthe conditionofthepatientsincision.DuringtheSituationportion,thenurseprovideshisorhernameandthe patientsname.DuringtheAssessmentportion,thenursestateswhatheorshethinksishappening(e.g., gastrointestinalbleeding).DuringtheRecommendationportion,thenurseshouldofferprobablesolutionsor ordersthatmaybeimplemented. DIF:CognitiveLevel:Analyzing(Analysis)

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

455

MSC:ClientNeeds:SafeandEffectiveCareEnvironment:SafetyandInfectionControl MULTIPLERESPONSE 1.ThenurseisassessingtheIVinfusionatthebeginningoftheshift.Whichfactorsshouldbeincludedinthe assessmentoftheinfusion?Selectallthatapply. a.

ProperIVsolutionisinfusing,accordingtothephysiciansorders.

b.

TheIVsolutionisinfusingattheproperrate,accordingtophysiciansorders.

c.

Theinfusionisproper,accordingtothenursesassessmentofthepatientsneeds.

d.

Capillaryrefillinthefingersischeckedandnoted.

e.

TheIVsitedateisnoted.

f.

Whetherthepatientissufficientlyvoidingisnoted.

ANS:A,B,C,E ThenurseshouldverifythattheproperIVsolutionishangingandisflowingattheproperrateaccordingtothe physiciansordersandthenursesownassessmentofthepatientsneeds.Inaddition,thenurseshouldnotethe dateoftheIVsiteandsurroundingskincondition.Checkingcapillaryrefillispartofthecardiovascular NURSINGTB.COM assessment;checkingthepatientsvoidingispartofthegenitourinaryassessment. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PharmacologicandParenteralTherapies 2.Thenurseiscompletinganassessmentonapatientwhowasjustadmittedfromtheemergencydepartment. Whichassessmentfindingswouldrequireimmediateattention?Selectallthatapply. a.

Temperature:38.6C

b.

Systolicbloodpressure:150mmHg

c.

Respiratoryrate:22breathsperminute

d.

Heartrate:130beatsperminute

e.

Oxygensaturation:95%

f.

Suddenrestlessness

ANS:A,D,F Thefollowingexaminationfindingsrequireimmediateattention:

NURSINGTB.COM

PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

Highorlowtemperature:(36.1Cor37.8C) Highorlowbloodpressure:(systolicpressure90mmHgor160mmHg) Highorlownumberofrespirations:(12or28breathsperminute) Highorlowheartrate:(60or90beatsperminute) Oxygensaturation:92% Suddenrestlessnessoranxiety,alteredlevelofconsciousness,confusion,ordifficultyinarousing DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation

NURSINGTB.COM

NURSINGTB.COM

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