NURS 2539 ASSESSMENT LATEST UPDATE 2021

NURS 2539 ASSESSMENT LATEST UPDATE 2021 Question 1 See full question 21s Which statement regarding heart sounds is correct? You Selected:  S1 is loudest at the apex, and S2 is loudest at the base. Correct response:  S1 is loudest at the apex, and S2 is loudest at the base. Explanation: Remediation: Add a Note Question 2 See full question 4s When assessing a family suspected of abusing its 4-year-old child, which behavior is the most important criterion that would suggest abuse? You Selected:  Responsibility taken by the child for the act Correct response:  Incompatibility between the history (mechanism) and the injury Explanation: Remediation: Add a Note Question 3 See full question 11s A 13-year-old girl is being evaluated for possible Crohn's disease. The nurse expects to prepare her for which diagnostic study? You Selected:  Colonoscopy with biopsy Exam (elaborations) NURS 2539 (NURS 2539)NURS 2539 ASSESSMENT LATEST UPDATE 2021 Correct response:  Colonoscopy with biopsy Explanation: Remediation: Add a Note Question 4 See full question 12s A nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? You Selected:  It's characterized by an acute onset and lasts hours to a number of days. Correct response:  It's characterized by an acute onset and lasts hours to a number of days. Explanation: Remediation: Add a Note Question 5 See full question 8s What assessment data of a laboring woman would require further intervention by the nurse? You Selected:  Maternal heart rate 125 beats/minute Correct response:  Maternal heart rate 125 beats/minute Explanation: Remediation: Add a Note Question 6 See full question 10s A nurse assesses a client’s vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge? You Selected:  Lochia rubra Correct response:  Lochia rubra Explanation: Remediation: Add a Note Question 7 See full question 13s A nursing assistant (unregulated care provider, UCP) has finished taking routine vital signs of the clients assigned to her. While charting later in the shift, a nurse finds that the assistant (UCP) documented a client's blood pressure at 192/126 mm Hg. What is the most appropriate action for the nurse to take? You Selected:  Take the blood pressure herself. Correct response:  Take the blood pressure herself. Explanation: Remediation: Add a Note Question 8 See full question 13s A fourth heart sound (S4) indicates a: You Selected:  failure of the ventricle to eject all blood during systole. Correct response:  failure of the ventricle to eject all blood during systole. Explanation: Remediation: Add a Note Question 9 See full question 10s A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding? You Selected:  vertigo Correct response:  exhaustion Explanation: Remediation: Add a Note Question 10 See full question 3s The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? You Selected:  Arrange for the placement of the client in a skill-training program. Correct response:  Make an appointment to meet the client at the mental health center, and ask him about the situation. Explanation: Remediation: Add a Note Question 11 See full question 1s The treatment team recommends that a client take an assertiveness training class offered in the hospital. Which behavior indicates that the client is becoming more assertive? You Selected:  The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. Correct response:  The client asks his roommate to put away his dirty clothes after telling the roommate that this bothers him. Explanation: Add a Note Question 12 See full question 3s Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? You Selected:  absence of crying during the examination Correct response:  absence of crying during the examination Explanation: Remediation: Add a Note Question 13 See full question 2s When assessing a 2-month-old infant, the nurse feels a "click" when abducting the infant's left hip. What should the nurse do next? You Selected:  Reschedule the child for a follow-up assessment in 3 weeks. Correct response:  Check the lengths of the femurs to determine if they are equal. Explanation: Remediation: Add a Note Question 14 See full question 2s A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because “voices on television are talking about me.” The nurse should first: You Selected:  obtain information about the client's medication compliance. Correct response:  obtain information about the client's medication compliance. Explanation: Remediation: Add a Note Question 15 See full question 2s A young child with sickle cell anemia prefers a side-lying position with the knees sharply flexed. The nurse should assess further for: You Selected:  emotional regression. Correct response:  abdominal pain. Explanation: Remediation: Add a Note Question 16 See full question 3s A 7-year-old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an IV of D5 NS + 20 meq KCL/L running at 60 mL/h. Vital signs are a temperature of 100.4° F (38° C), heart rate of 120 bpm, respiratory rate of 28 breaths/min, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation for: You Selected:  rectal diazepam. Correct response:  IV lorazepam. Explanation: Remediation: Add a Note Question 17 See full question 3s Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized? You Selected:  The client’s skin is a shiny, dry ulceration with bruising noted. Correct response:  The client’s skin is intact with non-blanchable redness of a localized area over a bony prominence. Explanation: Remediation: Add a Note Question 18 See full question 2s A nurse assesses a client who was admitted to the emergency department with a thermal burn to the right arm and upper chest. Which assessment requires immediate action? You Selected:  Bright red skin with small blisters on the right arm Correct response:  Hoarse voice Explanation: Remediation: Add a Note Question 19 See full question 3s A nurse caring for a client with schizophrenia goes into the client’s room to administer medication. While looking out the window at the trees, the client remarks, "That school across the street has creatures in it that are waiting for me." Which of the following is the most appropriate response by the nurse? You Selected:  “You are delusional.” Correct response:  “How do you feel when you see the creatures?” Explanation: Remediation: Add a Note Question 20 See full question 3s A client is admitted with chest pain and kept overnight for stress testing the next morning. Prior to sending the client to the stress test, the nurse reviews the results of the laboratory reports (see lab report). The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test? You Selected:  troponin Correct response:  troponin Explanation: Remediation: Add a Note Question 1 See full question 13s A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: You Selected:  harsh, nonproductive cough Correct response:  production of thick, sticky mucus Explanation: Remediation: Add a Note Question 2 See full question 13s Family members of a client with bipolar disorder tell a nurse that they