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NSG 521 Module 12 Assessment of the Hospitalized Client Questions With Complete Solutions
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NSG 521 Module 12 Assessment of the Hospitalized Client Questions With Complete Solutions
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NSG 521 Module 12 Assessment of the Hospitalized ClientQuestions With Complete Solutions
A blood transfusion means only transfusion of whole blood.
Correct Answer False: may include different blood components
A child's head circumference is a measurement that should be
obtained at every well-child visit until the child is 5 years old
because it will provide information on the child's readiness for
kindergarten. Correct Answer False
A condition where medical or nursing interventions trigger a
sequence of adverse events in a frail older adult is called cascade
iatrogenesis. Correct Answer True
A delay in speech development may signal a hearing loss or
mental health concern, such as autism. Correct Answer True
A Do Not Hospitalize order is often used for patients in long-
term care and other residential settings who have elected not to
be hospitalized for further aggressive treatment. Correct
Answer True
A do not resuscitate order and allow natural death order mean
the same thing. Correct Answer True
A mother brings her 6-month-old infant to the clinic for a
routine evaluation. At birth, the term infant weighed 3.5kg
(7lb12oz) and was 51 cm (20in) long. He now weighs 4.6kg
(10lb2oz). The nurse should next measure head and chest
circumference and length, then plot current weight, length, and
,head and chest circumference on standardized growth charts.
Correct Answer True
A newborn (neonate) is an infant 28 days old or younger.
Correct Answer True
A normal fetal heart rate as auscultated with a Doppler
sonometer is Correct Answer 120 beats/min
A nurse is caring for an 80-year-old patient who is living in a
long term care facility. To help this patient adapt to the present
circumstances, the nurse is using reminiscence as therapy.
Which question would encourage reminiscence? Correct
Answer "Tell me about how you celebrated Christmas when
you were young."
A nurse midwife is assisting a patient who is firmly committed
to natural childbirth to deliver a full-term baby. A cesarean
delivery becomes necessary when the fetus displays signs of
distress. Inconsolable, the patient cries and calls herself a failure
as a mother. The nurse notes that the patient is experiencing
what type of loss? Select all that apply. Correct Answer Actual
Perceived
Psychological
A nurse should consider the type of medication being given
when gathering the equipment for an injection because there are
special syringes for certain types of medication, for example,
insulin syringes used only to inject insulin. Correct Answer
True
,A nurse should gather a stethoscope, thermometer, watch with a
second hand, sphygmomanometer or vital signs machine, and
pulse oximeter when preparing to assess a hospitalized patient.
Correct Answer True
A nurse understands that a patient who says they have an allow
natural death order means the same thing as a do not resuscitate
order. Correct Answer True
A nurse who gives subcutaneous and intramuscular injections to
patients in a hospital setting attempts to reduce discomfort for
the patients receiving the injections. Which technique is
recommended? Correct Answer The nurse uses the Z-track
technique for intramuscular injections to prevent leakage of
medication into the needle track.
A nursing instructor teaching classes in gerontology to nursing
students discusses myths related to the aging of adults. Which
statement is a myth about older adults? Correct Answer Old
age means mental deterioration.
A patient comes to the clinic for a scheduled NST when the
nurse notes that the FHR tracing is nonreactive. Which of the
following actions would be appropriate for the nurse to do first?
Correct Answer Change the mother's position
A patient's fundal height measures 28 cm (11in). The nurse
expects the gestational age to be 28 weeks. Correct Answer
true
, A reactive nonstress test is indicative of a healthy fetus. If the
monitoring strip is nonreactive, the nurse may offer the mother a
position change or a drink of cold water or juice to stimulate the
fetus. The fetal response helps to distinguish a true nonreactive
test from a normal fetal sleep cycle. If the position change is not
effective, this is an indicator of fetal distress and should be
reported to the provider immediately. Correct Answer True
A significant drop in blood pressure is an indicator of
hemorrhage caused by a ruptured ectopic pregnancy. Correct
Answer True
A significant drop in blood pressure is an indicator of
hemorrhage caused by a ruptured ectopic pregnancy. Correct
Answer True
Abdominal assessment Correct Answer Inspect for distension,
auscultate bowel sounds, palpate for tenderness.
Acute and urgent situations such as the following warrant
immediate attention and interventions:
A respiratory rate lower than 8 or greater than 28 breaths/min
An acute change in oxygen saturation below 90% despite
oxygen administration
A threatened airway
Acute change in systolic BP to less than 90 mm Hg or a
sustained increase in diastolic BP greater than 110 mm Hg
Acute change in heart rate to fewer than 50 or greater than 120
beats/min
New-onset chest pain or signs of acute myocardial infarction
An acutely cold, cyanotic, or pulseless extremity
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