NUR214 Quiz 2 Review

Front

True or False: A nurse is inspecting the tympanic membranes of a teenager. The pinna should be moved down and back to achieve the best visualization?

Back

FALSE--gently pull the pinna back and up on adults

Front

What is the normal heart rate range for an infant?

a. 60 - 100bpm

b. 70- 100bpm

c. 65- 110bpm

d. 80- 150bpm

Back

d. 80- 150bpm

Front

Which statement by the client would indicate learning has occurred in the affective domain?

a. "it is important to wash my hands because it prevents the spread of germs."

b. "washing my hands kills germs and removes dirt."

c. "I should wash my hands for at least 20 seconds."

d. "I should only wash my hands after visiting the restroom."

Back

A. Affective--how they FEEL and what the action leads to in the FUTURE

Front

Which of the following is true regarding skin turgor?

a. skin turgor should have a slow reflex

b. skin turgor may be decreased in older adults due to their decreased elasticity

c. a brisk reflex is indicative of dehydration

d. skin tenting is not an abnormal finding

Back

B. skin turgor may be decreased in older adults due to their decreased elasticity

Best place to check skin turgor? Clavicle and Sternum

Front

A client says, "I asked to go to the hospital because I am seeing double and everything is very blurry." Which kind of data is the client describing?

a. objective

b. secondary

c. subjective

d. tertiary

Back

c. subjective data

Front

Which client would benefit most from care coordination?

a. a non-English speaking mother who presents to the clinic

b. a 32 year old female client recently diagnosed with HIV

c. a 41 year old type 1 diabetic being prepped for an appendectomy

d. an otherwise healthy 65 year old diagnosed with hypertension

Back

B: a 32 year old female client recently diagnosed with HIV

Rationale: disease process that is progressively/long term and has a difficult or unpleasant regimen

Front

A nurse is caring for a client who presents with diarrhea, abdominal cramps, diaphoresis, shortness of breath, and severe anxiety. Which thermometer should the nurse use to obtain the client's temperature?

a. Rectal

b. Tympanic

c. Paperstrip

d. Electric Oral

Back

B. Tympanic

Front

When assessing changes in the functional or health status of an older client, which piece of information is important to know?

a. most recent baseline

b. birth history

c. recent illness or injury

d. recent medication changes

Back

a. most recent baselines

when assessing changes in the functional or health status of an older client, it is imperative to know the recent baselines

Front

Verbal communication tools that aid in hand-off report include which of the following? (select all that apply)

a. SBAR

b. ISNP

c. I-PASS

d. ANTICipate

Back

A, C, D

SBAR: Situation, Background, Assessment, Recommendation (most common)

I-PASS: Illness seveity, patient summary, action list, situational awareness and contingency planning, synthesis by receiver

ANTICipate: Administrative date, new clinical data, tasks, illness severity, contingency plans

Front

Which of the following clients should the nurse see first?

a. a client with diabetes who needs assistance with insulin injections

b. a client with a potassium level of 6.2 mEq/L

c. a client who is reporting pain 8/10

d. a client who needs discharge teaching

Back

B. potassium level of 6.2