NUR 101EXAM3 (LATEST UPDATE) HEALTH ASSESSMENT |
GUIDE WITH QUESTIONS AND VERIFIED ANSWERS
1. What nursing intervention should be implemented to minimize the risk of
injury to a PT who has lost sensation to the integumentary system over the
lower portion of body ANS Inspect skin frequently, especially bony
prominences
2. What assessment question should the nurse ask as part of the auditory
observation of a PT ANS "It is alright to listen to your heart?"
3. A nurse is required to document an adult PT's BP. What nursing intervention
will help ensure that systolic reading is not artificially elevated ANS Inflate the
cuff to a pressure of 30 mm Hg above the point where the pulse disappears
4. How would the nurse classify the source of a sunburn ANS Radiation
5. What step of the nursing process should the nurse complete before notify-
https://www.stuvia.com/user/Mboffin 1/8
, ing a physician of a client emergency admission ANS Nursing assessment
6. A PT presents with skin that is moist and pinkish with blister and some
blanching what degree of burns would the nurse document ANS Second
degree ANS superficial. partial thickness
7. What is the extent of tissue damage seen in third-degree burns ANS
Entire epidermis, dermis, and into the subcutaneous fat
8. What action indicates proper use of the nursing diagnosis processes ANS
Direct nursing interventions to meet the client high priority needs
9. A PT who has sustained injuries as a result of a car accident is having trou-
ble sleeping and constantly relives the incident. what diagnostic statement
should the nurse make? ANS post trauma response related to the automobile
accident AEB nightmares, insomnia
10. What precaution should the nurse take when assessing the body temp of
a PT orally ANS Postpone the assessment if the PT has recently drank a cold or
hot liquid
11. The nurse is administering medication to a PT. In what stage of the nursing
process is the nurse engaging ANS Implementation
12. What types of diet would be prescribed for a PT with 3rd degrees full
thickness burn on 30% of the body ANS High calorie, high protein
13. What is the correct sequence for the planning of nursing care ANS
Setting priorities
Establishing expected outcomes
selecting nursing interventions
writing a nursing care plan
14. What is the correct sequence when composing a diagnostic statement AN
-
https://www.stuvia.com/user/Mboffin 2/8
GUIDE WITH QUESTIONS AND VERIFIED ANSWERS
1. What nursing intervention should be implemented to minimize the risk of
injury to a PT who has lost sensation to the integumentary system over the
lower portion of body ANS Inspect skin frequently, especially bony
prominences
2. What assessment question should the nurse ask as part of the auditory
observation of a PT ANS "It is alright to listen to your heart?"
3. A nurse is required to document an adult PT's BP. What nursing intervention
will help ensure that systolic reading is not artificially elevated ANS Inflate the
cuff to a pressure of 30 mm Hg above the point where the pulse disappears
4. How would the nurse classify the source of a sunburn ANS Radiation
5. What step of the nursing process should the nurse complete before notify-
https://www.stuvia.com/user/Mboffin 1/8
, ing a physician of a client emergency admission ANS Nursing assessment
6. A PT presents with skin that is moist and pinkish with blister and some
blanching what degree of burns would the nurse document ANS Second
degree ANS superficial. partial thickness
7. What is the extent of tissue damage seen in third-degree burns ANS
Entire epidermis, dermis, and into the subcutaneous fat
8. What action indicates proper use of the nursing diagnosis processes ANS
Direct nursing interventions to meet the client high priority needs
9. A PT who has sustained injuries as a result of a car accident is having trou-
ble sleeping and constantly relives the incident. what diagnostic statement
should the nurse make? ANS post trauma response related to the automobile
accident AEB nightmares, insomnia
10. What precaution should the nurse take when assessing the body temp of
a PT orally ANS Postpone the assessment if the PT has recently drank a cold or
hot liquid
11. The nurse is administering medication to a PT. In what stage of the nursing
process is the nurse engaging ANS Implementation
12. What types of diet would be prescribed for a PT with 3rd degrees full
thickness burn on 30% of the body ANS High calorie, high protein
13. What is the correct sequence for the planning of nursing care ANS
Setting priorities
Establishing expected outcomes
selecting nursing interventions
writing a nursing care plan
14. What is the correct sequence when composing a diagnostic statement AN
-
https://www.stuvia.com/user/Mboffin 2/8
