Which actions by the nurse maintain confidentiality of the documented information?

Assignment

 

1. The nurse documents on the facility’s electronic documentation system located in each client’s room. Which actions by the nurse maintain confidentiality of the documented information? (Select all that apply.)

 

· Refuse to leave the computer screen open so that family can review.

 

· Shut of the computer after documenting and before leaving the room.

 

· Use the nurse’s personal password for access to the client’s record.

 

· Share a password so a colleague can document on the client’s record.

 

· Explain to visitors that information about the client cannot be shared.

 

2. Upon assessment, the nurse notes a client has an enlarged thyroid gland. Which other assessment information does the nurse expect to find from the health history related to this condition? Select all.

 

· Bradycardia

 

· Nervousness

 

· Weight loss

 

· Constipation

 

· Dry coarse skin

 

· Exophthalmos

 

3. The nurse interviews a client diagnosed with substance abuse. The nurse knows which populations are at risk for abusing substances. (Select the correct answer)

 

· Persons who try substances at an early age.

 

· Persons undergoing significant stress.

 

· Persons who are or have been abused.

 

· Persons with a genetic predisposition to addiction.

 

· Persons living in a family with addiction.

 

· Persons diagnosed with clinical depression.

 

4. The nurse teaches the UAP about hand hygiene. Which statements does the nurse make? Select the correct answers.

 

· Wash hands during client care if contaminated with body fluids.

 

· Perform hand hygiene before removing gloves will be worn.

 

· Perform hand hygiene even if gloves will be worn.

 

· Soap and water must be used for all hand hygiene.

 

· Wash the hands before exiting the client’s room.

 

5. The nurse provides care for four clients. Which client does the nurse assess first?

 

· A client diagnosed with sepsis and who has a fever and needs antibiotics started.

 

· A client with lower back pain and who is requesting pain medication.

 

· A client diagnosed with syncope and who reports having “heart palpitations.”

 

· A client diagnosed with asthma and whose oxygen saturation has dropped to 90%.

 

6. The nurse assesses the skin of an older adult client. Which finding is of great concern to the nurse? (Select all that apply.)

 

· Petechiae on upper chest.

 

· Striae on lower abdomen.

 

· Cherry angioma on back.

 

· Red area that does not blanch.

 

· Seborrheic keratosis on arm.

 

7. The nurse assesses a client’s visual fields. Which action does the nurse take first to determine if the peripheral vision is normal?

 

· Brings two fingers from the left side while the client covers the right eye.

 

· Asks the client to follow the nurse’s fingers in a W-shaped pattern.

 

· Asks the client? look up, down, and side-to-side in the nurse’s direction.

 

· Brings a wiggling finger from behind the client’s head forward.

 

8. The nurse obtains the BP reading of 142/78 mm Hg on an older adult client. Which statement best describes the interpretation of this result?

 

· The readings are indicative of the category of an “elevated” BP.

 

· The client’s systolic reading indicates that the client is retaining fluid.

 

· The systolic reading is most likely related to decreased vessel elasticity.

 

· The systolic and diastolic reading both support the presence of stage 2 hypertension.

 

9. The nurse intervenes a new client who states that everything is fine and there is no reason to be in the hospital. Which client behavior indicates a need for the nurse to investigate further before creating the plan of care? Select the correct answer.

 

· The client looks at the floor when discussing the living arrangements.

 

· The client begins to cry when talking about a family member that died of cancer

 

· The client continuously swings the right leg while talking about the disease.

 

· The client laughs and grimaces when the right arm is moved.

 

· The client is dressed in tattered clothing, and there is a strong body odour

 

· The client stares angrily at the nurse when talking about the partner.

 

10. The nurse plans the assessment of a client’s knee. Which actions does the nurse plan? Select all that apply.

 

· Requests the client to swing the leg in a circle when standing.

 

· Asks client to swing the lower leg forward and backward when sitting.

 

· With the client relaxed with leg extended, moves the patella up and down.

 

· Asks the client to return to a standing position after squatting.

 

· Asks the client to squat to the floor from a standing position.

 

· Supports the flexed knee and has the client extend the leg against the nurse’s hand.

 

11. The nurse completes a client assessment using the Romberg test. Which observation indicates normal client response?

 

· Stands and sways for 20 seconds with eyes closed.

 

· Stands without swaying for 60 seconds with eyes open.

 

· Stands and sways for 10 seconds with eyes open.

 

· Stands without swaying for 30 seconds with eyes closed.

 

12. The nurse provides care for an older adult client who has left-sided weakness. Which action does the nurse include in the client’s plan of care to decrease the risk for falls? (Select all that apply.)

 

· Assess if the client has experienced any falls in the recent past.

 

· Assess the client’s level of consciousness and ability to understand verbal commands.

 

· Evaluate the client’s degree of muscle strength and sensation in all extremities.

 

· Note abnormalities in vital signs that may place client at risk for falls.

 

· Monitor the client’s ability to ambulate and determine if assistance is needed.

 

13. The nurse assesses a client’s chest and back. Which assessment is included as part of the nurse’s inspection? (Select all that apply.)

 

· integrity of the integument of the thorax.

 

· Deformities of the anterior thorax.

 

· Shape of the anterior thorax

 

· Retractions of the posterior thorax

 

· Symmetry of the anterior and posterior thorax.

 

14. The nurse assesses a client diagnosed with diabetes mellitus. The client smokes cigarettes. Which question does the nurse ask related to possible peripheral vascular changes? (Select the appropriate answers.

 

· How many cigarettes do you smoke daily?”

 

· ‘Do you keep your blood glucose levels normal?”

 

· “Do your feet feel cold or numb at any times?”

 

· ‘Do your legs hurt when you walk for a while?”

 

· “Do your feet or legs have swelling at any time?”

 

15. A client reports some pain and burning during urination. Which question does the nurse ask for further assessment? (Select the correct answer

 

· Are you having urinary frequency? *

 

· Is there any rash on your perineum?’

 

· “Do vou have frequent intercourse?’

 

· Do you need to urinate urgently?”

 

· ‘is there any blood in your urine?

 

· Are you taking any medications right now?”

 

16. The nurse assesses vital signs of an older adult client. Which vital sign does the nurse expect to be lower than the normal range in the older adult population?

 

· Respirations.

 

· Temperature.

 

· Blood pressure.

 

· Pulse

 

17. When assessing the skin of an older adult client, the nurse notes uneven pigmentation. Which action by the nurse provides the most accurate information?

 

· Inquire if the client or client’s family has a history of skin cancer.

 

· Ask the client about the use of cosmetics or tanning agents.

 

· Ascertain if the client feels the office environment is too cool.

 

· Accept that the finding is normal because of the client’s age.

 

18. The nurse prepares to teach a class about hearing loss prevention. Which information does the nurse include? (Select the correct answers.

 

· Noises of 85 decibels are likely to cause hearing loss.

 

· Hearing loss may be gradual after exposure to noise.

 

· Persons should limit exposure to environmental noise.

 

· Repeated noise at decibels below 85 decibels may cause hearing loss.

 

· Nearly 80% of adults over age 80 have some form of hearing loss.

 

· Use of ear protectors will help eliminate the effects of environmental noise.

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