Quiz #13: Assessment Hospitalized Flashcards
The nurse is concerned that an older client is developing delirium. What findings caused the nurse to make this clinical determination? Select all that apply.
a) Sleep disturbances
b) Easily distracted by unimportant things
c) Inability to recall recent events
d) Combative behavior
e) Rambling speech
a) Sleep disturbances
b) Easily distracted by unimportant things
d) Combative behavior
e) Rambling speech
A nurse assesses a client’s blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education?
a) Prevention of falls
b) Vitamin supplementation
c) Daily exercise routine
d) Diet high in iron
a) Prevention of falls
The RN working on a surgical unit should question which of these orders before completing it?
a) Change a central line dressing
b) Administer a narcotic infusion
c) Reapply a staple in an inclusion
d) Check intracranial pressure
c) Reapply a staple in an inclusion
The nurse enters a client’s room to administer scheduled meds through a barcode system. The client is not wearing an armband. What is the nurse’s best action?
a) Confirm the client’s identity with visitors who are present
b) Scan the barcode on the client’s chart, then administer the meds
c) Ask the client for name and birth date, then administer the meds
d) Leave the room to obtain another armband for the client
d) Leave the room to obtain another armband for the client
The nurse has entered a client’s room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse’s priority action?
a) Count respirations
b) Ensure a patent airway
c) Assess blood pressure
d) Check for pupil reaction
b) Ensure a patent airway
The RN may delegate which care component to a nursing assistant?
a) Ambulation assistance
b) Wound care and assessment
c) Evaluating vital signs
d) Check client’s pain level
a) Ambulation assistance
When conducting a focused health assessment, the nurse asks questions specifically targeting what?
a) The client’s gender
b) The client’s culture
c) Issues and symptoms specific to the client
d) The client’s sexual orientation
c) Issues and symptoms specific to the client
When assessing the skin, hair, and nails of the older adults, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply.
a) The number of sweat and sebaceous glands increases
b) The epidermis thickens
c) Nails become thick and brittle with slow growth
d) Wound healing slows
e) Nails become thin and brittle with increased growth
f) The epidermis thins
c) Nails become thick and brittle with slow growth
d) Wound healing slows
f) The epidermis thins
Before interviewing the older adult, the nurse should set up the room and create an environment that facilitates hearing and understanding of communication.
a) True
b) False
a) True
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?
a) Weakness
b) Fever
c) Confusion
d) Falls
b) Fever
Identify the assessment for a Pt at risk of falling:
Morse Fall Scale (MFS)
MFS consists of 6 categories
- History of falling (immediate or within 3 MOS): no = 0, yes = 25
- Secondary diagnosis: no = 0, yes = 15
- Ambulatory aid: None, bed rest, wheel chair, nurse = 0; crutches, cane, walker = 15; furniture = 30
- IV/Heparin lock: no = 0, yes = 20
- Gait/transferring: normal, bed rest, immobile = 0; weak = 10; impaired = 20
- Mental status: oriented to own ability = 0; forgets limitations = 15
What score is considered at high risk for falling?
greater than/equal to 51
What score is considered no risk for falling?
0-24
