HEALTH ASSESSMENT FINAL EXAM 2022
The nurse is caring for patients on the surgical floor and has just received report from the previous shift. Which of the following patients should the nurse see FIRST?
- A 35-year-old admitted three hours ago with a gunshot would; 1.5 cm area of dark
drainage noted on the dressing
- A 43-year-old who had a masectomy tow days ago; 23 cc of serosanguinous fluid
noted in the Jackson-Pratt drain
- A 59-year-old with a collapsed lung due to an accident; no drainage noted in the
previous eight hours
- A 62-year-old who had an abdominal-perineal resection three days ago; patient
complains of chills - correct answerD The nurse is caring for patients in the outpatient clinic. Which of the following phone calls should the nurse return first?
- A client with hepatitis A who states "My arms and legs are itching."
- A client with a cast on the right leg who states, " I have a funny feeling in my right
leg."
- A client with osteomylitis of the spine who states, " I am so nauseous that I can't
eat."
- A client with rheumatoid arthritis who states, " I am having trouble sleeping." -
correct answerB high priority - correct answerAirway Breathing Circulaltion Vital Signs Second priority - correct answermental status change untreated medical problem acute pain acute urinary elimination problem abnormal lab value risk of infection 1 / 2
cultural consideration hispanic - correct answerCuranderos use herbs, aromas, and rituals to treat the ills of the body, mind and spirit.have a higher rate of diabetes cultural consideration chinese - correct answereldest son holds responsibility for family Control of emotions, restraint, obedience to authority, conforming and "face" are highly valued and important balance between hot foods and cold foods lung (worry), gallbladder/liver (anger), heart (happy), kidney (fear), spleen (desire) considerations japanese - correct answerdiabetes, cancer, dementia muslim consideration - correct answerfemale/female or male/male for nursing care as they place high value on modesty left hand=dirty what distance should you be from patient when you are conducting interview - correct answer4-5 feet ten traps of interviewing - correct answerfalse assurances giving unwanted advice using authority using avoidance language engaging in distancing using professional jargon using leading or biased questions talking too much interrupting using why questions this age uses telegraphic speech so it is best to keep explainations simple - correct answerpreschooler this age can tolerate and understand others viewpoints, more objective and realistic, able to reason very curious - correct answerschool age value peers, crave acceptance, think that no adult can understand them - correct answeradolescent broca's aphsia - correct answercan understand language but cannot express it himself nonfluent, dysarthic, effortful speech wernickes aphasia - correct answercan hear sounds but cannot relate them to previous experiences speech is fluent, effortless and well articulated but has many paraphasias and made up words
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