NURS 3315 MODULE 1 QUIZ ANSWERS.

NURS 3315 MODULE 1 QUIZ ANSWERS. 1. Which statement below best documents objective findings? Complains of feeling short of breath. Dizziness and sensation of impending doom. Crackles in lower lobes bilaterally, with high-pitched wheezes throughout lung fields. Reports history of cardiac surgery in 2008. 2. Which action would be the best for the nurse at the beginning of the nurse client encounter for a client visiting a walk in clinic for complaints of a fever? Lymph nodes examination Subjective data collection Head and neck examination Vital signs including temperature 3. The nurse is reviewing a client’s medical record and notes the various forms of information. The nurse understands that which of the following is subjective data? Results of radiographic studies Family medical history Laboratory analysis reports Physical examination results 4. Verifying that data is correct is a method of validating findings to be certain of accuracy. Which methods of validation are best? Select all the apply. Compare your subective and objective data to see if they agree. Re-phrase questions if you didn't understand the patient's meaning. Verify the data by asking another nurse to confirm a specific objective finding. 5. The nurse is documenting an assessment of a 50-year-old female client who has sought care for recurrent migraines that have not responded to treatment. Following the review of systems, how should the nurse best document unremarkable results of the subjective portion of the gastrointestinal assessment? “Client's gastrointestinal health is within reference ranges for age.” “Gastrointestinal problems are absent.” “Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain.” “Client denies GI signs and symptoms.” 6. In thinking critically, nurses need to have a sense of urgency, yet put all facts in the context of the evolving situation. The daughter of a geriatric patient rushes to the nursing station and shouts, “I need someone to come now! I think mother has stopped breathing!” The charge nurse hurries to the room and sees the patient lying calmly in bed with respiratory rate of 28. Which response by the nurse shows evidence of critical thinking? The nurse does a quick subjective assessment to determine if the patient agreed that she had stopped breathing at any point recently. The nurse documents that the patient’s daughter seems paranoid about the mother’s condition. The nurse states, “Looks like the problem has resolved!” and plans to monitor the situation closely over the next few hours. The nurse thanks the daughter and asks what it was that made her feel that there was a problem with her mother’s breathing. Next 7. Which route will yield the highest temperature reading? Select one answer. Axillary Tympanic membrane Oral (sublingual) Temporal artery 8. A client is two weeks postoperative appendectomy and is still experiencing pain. The nurse realizes this client is most likely experiencing: cutaneous pain Referred pain Visceral pain Deep somatic pain 9. Which measurement index will be most helpful in determining subcutaneous fat stores? (This can show if nutritional status is over-nourished or under- nourished.) Body type evaluation with blood albumin levels. Skin-fold measurement from triceps or supra-iliac region. BMI Weight comparison for the last 3 - 6 months 10. Analyzing the already-collected subjective and objective data occurs in which phase of the nursing process? Assessment Diagnosis Planning Implementation