NUR 304 Test 6 - will need to prioritize the patients according ...

NUR 304 Test 6

• The nurse is working triage in the ED when three (3) patients arrive to be seen.The nurse

will need to prioritize the patients according to their situations with the highest priority or first- level priority problems receiving immediate attention. Match the following patient situations with their correct priority level.

Answer A patient newly diagnosed with type 2 diabetes mellitus that does not know how to check his own blood glucose levels with a glucometer.

A teenager who was stung by a bee during a soccer match is having trouble breathing.An older adult with a urinary tract infection is also showing signs of confusion and agitation.

• When planning a cultural assessment, the nurse should include which component?

Answer Health-related beliefs

• The nurse is asking an adolescent about illicit substance abuse. The ado- lescent answers,

"Yes, I've used marijuana at parties with my friends." What is the next question the nurse should ask?

Answer "When was the last time you used marijuana?"

• The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be

most concerned about possible abuse?

Answer A 4-month-old with bruises on the arms

• During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded

and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How should the nurse interpret this type of sound?

Answer Air-filled areas. 1 / 3

• What is the most important step that the nurse can take to prevent the transmission of

microorganisms in the hospital setting?

Answer Wash hands before and after contact with each patient.

• A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best

way for the nurse to begin the assessment?

Answer Allow the child to keep a security object such as a toy or blanket during the examination.

• The nurse is unable to palpate the right radial pulse on a patient. What should the nurse do

next?

Answer Use a Doppler device to check for pulsations over the area.

• In a patient with acromegaly, which assessment finding will the nurse expect to find?

Answer Overgrowth of bone in the face, head, hands, and feet

• A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of

32 cm. Based on the interpretation of these findings, what action should the nurse take?

Answer Consider these findings normal for a 1-month-old infant.

• A patient is seen in the clinic for complaints of "fainting episodes that started last week."

How should the nurse proceed with the examination?

Answer His blood pressure is recorded in the lying, sitting, and standing positions.

• A patient is complaining of severe knee pain after twisting it during a basketball game and

is requesting pain medication. Which action by the nurse is appropriate? 2 / 3

Answer

Administering pain medication and then proceeding with the assessment

• When performing a genitourinary assessment, the nurse notices that the urethral meatus is

ventrally positioned.What does this indicate?

Answer Hypospadias

• When performing a genital assessment on a middle-aged man, the nurse notices multiple

soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. What does this finding suggest?

Answer Genital warts

• While performing an assessment of the perianal area of a patient, the nurse notices that the

pigmentation of the anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What does this assessment and history most likely indicate?

Answer Thrombosed hemorrhoid

• During the interview, a patient reveals that she has some vaginal discharge. She is worried

that it may be a sexually transmitted infection. What would be the most appropriate response by the nurse?

Answer "I'd like more information about the discharge. What color is it?"

• When standing with their eyes closed, feet together, and arms at their sides, a patient

sways and starts to fall. How should the nurse document this finding?

Answer Positive Romberg sign

• The nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the

nurse ask the patient to do?

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