Deck 28: Hospitalized Patient

Question 1

During the physical assessment, the hospitalized client states, "I've been under an incredible amount of stress since my healthcare provider diagnosed me with colon cancer 2 days ago." Which assessment data collected by the nurse are associated with increased stress?

A) Apical heart rate is 104 beats per minute.
B) Respiratory rate is 16 breaths per minute.
C) Pupils were equal, dilated, and round.
D) Client is hypoglycemic.
E) Blood pressure is 158/94.

Answer 1

Apical heart rate is 104 beats per minute.
Pupils were equal, dilated, and round.
Blood pressure is 158/94.

Question 2

The nurse is performing a rapid assessment for the assigned clients. Which clients require immediate medical assistance?

A) The client is pale and is breathing in a shallow manner.
B) The client's oxygen saturation level is 74% and is dyspneic.
C) The client is rating his pain at a 3 out of a 10 on a pain scale.
D) The client is unable to follow directions.
E) The nurse determines that the client's level of consciousness is decreasing.

Answer 2

The client is pale and is breathing in a shallow manner.
The client's oxygen saturation level is 74% and is dyspneic.
The client is unable to follow directions.
The nurse determines that the client's level of consciousness is decreasing.

Question 3

While conducting a rapid assessment for a client who has diabetes, the student nurse notes that the client is experiencing emotional stress following the recent death of the spouse. When discussing the client with the nurse preceptor, which statement by the student nurse student indicates the need for further education?

A) "Emotional stress can negatively impact the immune system's ability to function."
B) "The client has probably not been eating well recently."
C) "I should not ask about the use of drugs or alcohol at this time."
D) "The client may be hyperglycemic."

Answer 3

"I should not ask about the use of drugs or alcohol at this time."

Question 4

A toddler-age client is brought to the emergency department (ED) with difficulty breathing. The healthcare provider diagnoses the client with epiglottitis. Which assessment data collected by the nurse are consistent with this diagnosis?

A) Oxygen saturation level is 85% on room air.
B) Respiratory rate is 22 per minute.
C) Stridor is audible without stethoscope.
D) Apical heart rate is 72 beats per minute.
E) Temperature is 103.7°F.

Question 5

The nurse is performing a routine assessment on a dark-skinned client who has been admitted to the hospital. The nurse is assessing the client's oxygenation level and the presence of jaundice. Which statements indicate that the nurse is performing these specific assessments?

A) "I need to look at your eyes."
B) "Please open your mouth for me."
C) "Squeeze my fingers with your hands."
D) "I am going to listen to your belly with my stethoscope."
E) "I need to press on your fingernail."

Question 6

The nurse is performing an assessment of the hospitalized client. After speaking with the client, the nurse believes that the client is demonstrating altered thought processes. Which statements by the client validate the nurse's conclusion?

A) "When I was little I had four cats. Can I wear a dress instead of this hospital gown?"
B) "I wish that my grandmother's daughter would visit me more often."
C) "I have never had so much pain. I just don't feel like speaking with you right now."
D) "My doctor has only been to visit me once during the last three days. I'm starting to feel angry that she hasn't come to see if I'm doing better."
E) "Red squirrels dance on the divine divide."

Question 7

The nurse is performing an assessment of a 7-month-old. Which finding would require further assessment?

A) The anterior fontanelle is closed.
B) The posterior fontanelle is closed.
C) The head is disproportionately large in comparison to the body.
D) There are two "baby teeth" present.

Question 8

The student nurse measures the client's oxygen saturation level by using a pulse oximeter, and confers with the nurse preceptor after completion. Which statement by the student indicates the need for further education?

A) "A normal finding is that the client's oxygen saturation level is above 70%."
B) "The pulse oximeter can measure the oxygen saturation of the hemoglobin."
C) "I placed the sensor on the client's finger."
D) "This test is noninvasive and painless."

Question 9

The nurse assesses the hospitalized client and prepares to document the findings using APIE in the medical record. Rank the following findings in the proper order of documentation.

A) The client states upon admission, "I don't know what's wrong with me, but I can't see out of my left eye and I can't stand up by myself."
B) The client is unable to move from the bed to the chair without the assistance of two nurses. The client is unable to eat without assistance.
C) The healthcare provider writes an order for the nurse to administer heparin.
D) On the morning of the client's discharge from the hospital, the client has been able to ambulate 50 feet with a walker.

Question 10

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which statement by the student nurse indicates that further education is required?

A) "The rapid assessment should last approximately 10 minutes."
B) "I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care."
C) "The rapid assessment will help me establish baseline data about the client."
D) "After I perform the rapid assessments on the clients I've been assigned, I can go back and get more information during my routine assessments."

Question 11

The nurse is assessing a newborn client who was born 5 minutes ago and notes six fingers on the left hand. Which term will the nurse use when documenting this finding in the medical record?

A) Syndactyly.
B) Polydactyly.
C) Brachial plexus injury.
D) Erb palsy.

Question 12

The nurse performs an assessment on four hospitalized pediatric clients. After reviewing each client's admitting diagnosis, which pediatric client may have an enlarged spleen?

A) 14-year-old admitted with acute gastroenteritis.
B) 17-year-old admitted with an acute exacerbation of asthma.
C) 11-year-old admitted with an umbilical hernia.
D) 9-year-old admitted with a sickle cell crisis.

Question 13

The client is comatose and the healthcare provider orders that the client's temperature is to be taken by the rectal route. The student nurse is assisting the more experienced nurse and volunteers to obtain the client's temperature. Which statement by the student nurse indicates the need for further education prior to monitoring a rectal temperature?

A) "I will need to turn the client into the prone position."
B) "The probe for a rectal thermometer is usually red."
C) "I should insert the thermometer 1.5 to 4 centimeters into the client's anus."
D) "This is an appropriate way to monitor a client's temperature if they are unable to close the mouth around the oral thermometer."

Question 14

The nurse works on a medical-surgical unit. Which clients will require a rapid assessment?

A) The client had an open appendectomy 2 days ago and is preparing to be discharged today.
B) The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia.
C) The client has just been received from the Post Anesthesia Care Unit.
D) The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse.
E) The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%.

Question 15

The nurse is performing routine assessments on five hospitalized clients. Which clients does the nurse expect to exhibit poor skin turgor?

A) The client had an open appendectomy 2 days ago.
B) The client was admitted with severe nausea and vomiting.
C) The client has lost 16 pounds during the last 30 days.
D) The client has had a high fever during the last four days and was admitted through the Emergency Department last night.
E) The client was admitted this morning with a severe migraine.

Question 16

The nurse is performing an assessment on an adolescent client. Which finding would be unexpected?

A) Apical heart rate of 110 beats per minute.
B) Respiratory rate of 14 breaths per minute.
C) Blood pressure of 98/58 mmHg.
D) Temperature of 98.8°F.

Question 17

The nurse uses the nursing process to create a plan of care for a hospitalized client. Rank the activities of the nursing process in the proper order.

A) The nurse educates the client regarding the care of his sternal and leg incisions.
B) The client arrives at the hospital with chest pain. The client is admitted with an evolving myocardial infarction and is taken to surgery for a coronary artery bypass graft.
C) The nurse determines that the client has an impaired skin integrity and an increased risk for the development of an infection.
D) The nurse develops a plan to help prevent some of the known complications associated with surgery.

Question 18

The nurse is preparing to assess the general appearance of the hospitalized client. Which statements by the client are expected if the client is experiencing undernutrition?

A) "It seems like I catch every bug that comes along. I can't seem to stay well."
B) "This wound that I've had for the last 3 months on my leg won't heal."
C) "I have gained five pounds over the last week and my ankles and feet are swollen."
D) "My nails are so brittle."
E) "I know my blood pressure has been up because I've been experiencing headaches in the morning, just like last time."

Question 19

The nurse is conducting an initial respiratory assessment on the client recently admitted to the unit. Rank the following steps in the correct sequence.

A) The nurse percusses the client's thorax.
B) The nurse unties the client's gown to better visualize the client's thorax.
C) The nurse warms his stethoscope and listens to the client's lung sounds in each lung field.
D) The nurse gently palpates the client's thorax.

Question 20

The student nurse is preparing to auscultate the client's lungs during the initial assessment. Which student nurse statement to the nurse preceptor indicates the need for further education prior to conducting the assessment?

A) "I should think about how loud the auscultated sound is, the tone of the sound, and how long it lasts."
B) "I should leave the client's television on during the assessment to make the client feel relaxed and comfortable during the assessment."
C) "I have to remember to keep the client warm during this part of the assessment."
D) "I cannot listen through the client's gown."

Question 21

The nurse is performing an assessment on an older adult client. Which finding will warrant further investigation?

A) Slight bulging along the lower eyelids.
B) Reduced perspiration.
C) Reduced sebum production.
D) Large white spots on the upper arms and trunk.

Question 22

The student nurse is preparing to perform an assessment on a 5-year-old Arab American client who is hospitalized for dehydration. The nurse preceptor accompanies the student nurse to the client's room. Which statements by the student nurse indicate that further education is required?

A) "It would be best to have the child sit in his mom's lap if we have to give him a shot."
B) "Before I listen to the child's lungs, I can let him play with my stethoscope."
C) "I will be able to see the tympanic membrane more clearly if I pull the tragus down and back."
D) "It really doesn't matter what his culture is; mommies always make the decisions about children's health care issues."
E) "I'm going to have to be firm but friendly with my approach to the child."

Question 23

The nurse is performing a focused interview with an older adult client. Which statements indicate the client has an increased risk of developing depression?

A) "I've been so lonely since my wife, Maggie, passed away 2 months ago."
B) "My mother had a history of depression."
C) "I was diagnosed with chronic bronchitis 4 years ago."
D) "My son visits at least once a week and takes care of my financial stuff."
E) "I visit my sister every Monday and she makes me dinner."

Question 24

The nurse is preparing to interview the older adult client and perform a head-to-toe assessment. Which actions by the nurse are appropriate?

A) The nurse has requested that the client put on a cotton gown prior to the interview.
B) The nurse seats the client so that the light from the window faces the client with the nurse's back to the window.
C) The nurse addresses the client by her first name.
D) The nurse maintains eye contact; both nurse and client are seated.
E) During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.

Question 25

The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration. Which findings are consistent with this condition?

A) Tenting noted on dorsal aspect of client's hand when skin turgor was assessed.
B) Client has produced 175 milliliters of urine over the last 8 hours.
C) Dentures are loose, small sores noted in oral mucosa.
D) Healthcare provider notes client is exhibiting xerostomia.
E) Client's apical heart rate is 82 beats per minute.