Mr. Holmes has come to the clinic for a well-patient visit. When assessing his vital signs, the nurse palpates an irregular heart rate. The nurse must than auscultate for a full minute at the apical pulse site. Locate the apical pulse on the diagram below
The apical pulse is close to the left nipple.
What are the four characteristics of a pulse?
Rate, rhythm, force (amplitude), elasticity.
An unconscious 20 yr-old woman arrives at the hospital after drinking large quantities of alcohol. Her vital signs are T 98.2F; P 58; R 9; BP 100/64. What conclusion would the nurse make about the patient's respiratory status?
The patient is experiencing bradypnea.
The patient's radial pulse is weak and thready. The nurse would document the finding as:
1+/4+
The nurse is preparing to assess the vital signs of a 62-yr-old woman following hip surgery. When the nurse arrives, the patient is sitting in her chair having just finished breakfast. What is the appropriate nursing action?
Wait 20 to 30 minutes and then take vital signs.
The postoperative vital signs of a 47-yr-old with a ruptured appendix are BP 112/68, pulse 56, R 8, T 37.6 C temporally. The patient is pale and confused, with minimal urine output. The nurse should
notify the clinician
The pulse pressure for a patient with a BP of 144/86 is
58 (144-86)
The nurse is caring for an elderly confused patient. In assessing temperature, the nurse will obtain the reading using
a tympanic thermometer
The nurse notes an irregular radial pulse in a patient. Further assessment includes assessing the
apical pulse
Which action will result in an accurate BP reading?
A. Applying the center of the bladder of the cuff
B. Raising the arm to the level of the heart
C. Using the bell to assess the BP
Caitlyn was 20 in long at birth and weighed 7lb, 8 oz. At her 1-year well child checkup, the nurse determines that Caitlyn is 26 in and weighs 16 lb. The nurse's reaction to these assessment findings is to be
concerned because Caitlyn should have tripled her birth weight by now.
The nurse's response to Emily lenghth, which is 26 in now and was 20 in at birth is to be
concerened, because Emily should have grown 10 to 12 in by now.
Jasmyn, who has just had her second birthday, comes to the well-child clinic for an assessment. The nurse reviews her records and discovers that Jasmyn weighed 7 lb at birth. Today the expects that Jasmyn's weight should be
28 lbs.
Tamika is often in a hurry with her toddler daughter, Samantha, and usually does things for her that Samantha could do herself if given more time, Erikson would say that Tamika's daughter
is at risk of developing a sense of shame and doubt because of her mother's behavior.
Oscar, 6 years old, has come to the well-child clinic for a visit. He is 46 in tall today. Assuming that he grows at the normal pace, how tall would the nurse expect Oscar to be at 10 years?
54 in
Mallory, 16 years old, is having difficulty in school and with her friends. She has not decided what she wants to do with the rest of her life after high school. Erik Erikson would say that Mallory is at risk for
role confusion
At 27 years, Steve is considering purchasing his first house. How might the nurse characterize Steve's cognitive processes now that he has entered into early adulthood?
He will be less optimistic and more practical, considering the complexities of the situation.
Neil, 50 years old, is worried about whether her intelligence will change as she continues to advance through middle age. What can the nurse tell Nell about what might happen to her cognitive skills in middle age?
Nell can expect to be slightly slower as she does cognitive tasks.
Earl is healthy and vigorous at 68 years. Which of the following will NOT be true of his cognitions as he ages?
His long-term memory will definitely be impaired.
Amber and Michael Carr need to be taught that 2-month-old Emily
needs stimuli each day, in short periods when she is awake.
A nurse is working with a new patient. To establish rapport, the nurse would use which of the following statements?
There are questions that I ask all my patients.
The patient's family should not be present during the interview with the patient requiring a translator because
All of the above which include:
A. the patient may feel uncomfortable speaking openly with a relative present, especially if that person is contributing to the patient's stress.
B. the translator may not ask questions related to the family member and coul
do you have any thoughts of wanting to kill or harm yourself?" is a common question to assess for suicidal ideation because it
will cover both suicidal and parasuicidal thoughts.
When charting general appearance and behavior, documentation may include
clothes disheveled
Abnormal movements from medications might be described
uncoordinated
Normal speech is audible is a normal finding describing which quality of speech?
Loudness
A 90 yr-old patient has a drooped body position, appears sad, and says that she has seasonal affective disorder. What tool would the nurse use to assess her?
Geriatric Depression Scale.
Which of the following represents the nurse's documentation of a patient with normal mood?
Pleasant or appropriate to situation
Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of
divergent tactics.
The MMSE is used to assess for severity in orientation, registration, attention and calculations, recall, and language. For which of the following patients would the MMSE be most appropriate?
Adults to asses for cognitive impairment and the severity.
National Standards for Culturally and Linguistically Appropriate Services in Health Care mandate that standards
be upheld in every health care setting
CAM therapies used instead of conventional treatments to restore health are often termed
alternative
The social context influences the patterns of health and illness for individuals, communities, and societies. An example is
assessment of focus groups in multiple locations.
The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to
provide a picture of the individual's culture-based health care needs.
With transcultural assessment, the nurse must
determine which questions to ask
A shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world is defined as
culture
Even when daily prayers or other religious practices are not a part of a patient's life routine, they often take central position during life transitions, such as loss of a loved one, accident, or serious illness. A related nursing diagnosis might be
spiritual distress
It is important to identify similarities and differences among the cultural beliefs of the patient, health care agency, and the nurse to
avoid making assumptions
Seeking understanding of one's culturally based health care practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that
may affect patient's adherence to treatments.
What is the nurse's best response when a Muslim patient has a basin of water on his bedside stand that he does not want emptied?
Support and accommodate his preference.