Update) Health Assessment | Guide with Questions
and Verified Answers | 100% Correct | Grade A –
Fortis
5 Functions of Skeletal System - ANSWER-1. *Provides shape and support*
2. *Enables to move*
3. *Protects organs*
4. *Produces blood cells (hematopoiesis)*
5. *Stores minerals and other materials*
A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are
the expected errors in the obtained readings? - ANSWER-False High
Rationale: If the client's arm is unsupported, or if the arm is below the heart level, the resulting outcome
is a false high reading. Application of the stethoscope too firmly against antecubital fossa will result in a
false low diastolic reading. Repeated assessments of blood pressure too often result in a false high
systolic reading. Deflating the cuff too slowly results in a false high diastolic reading.
Acceptable HR for Adults - ANSWER-60-100
Acceptable HR for Infants - ANSWER-120-160
Acceptable HR for School-Age - ANSWER-75-100
Active Range of Motion (AROM) - ANSWER-range of motion for joints that a patient is able to perform
without assistance from someone else
After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the
toes. What should the nurse do first? - ANSWER-Stay in bed
Exam 3: NUR101 / NUR 101 (Latest
Update) Health Assessment | Guide with Questions
and Verified Answers | 100% Correct | Grade A –
Fortis
, Exam 3: NUR101 / NUR 101 (Latest
Update) Health Assessment | Guide with Questions
and Verified Answers | 100% Correct | Grade A –
Fortis
Rationale: Localized sensory changes may indicate nerve damage, impaired circulation, or
thrombophlebitis. Activity should be limited. Bed rest is indicated to prevent the possibility of further
damage. Symptoms indicate a possible problem with thrombus formation. While fluids may be helpful
to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in
case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral
intake. Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if
present.
Airborne Precautions - ANSWER-Reduces risk of spreading infectious agents that can be carried in air by
droplets (small particles 5 microns or less) or on dust particles, and inhaled by susceptible pts. EX.)
Measles, Varicella, TB.
Isolation-Private room w/negative air pressure-door kept closed
Wear- gown, gloves, PAPR mask/respiratory protection
antigravity muscles - ANSWER-stabilize joints
Arm Above Heart Level - ANSWER-False Low
Arm Below Heart Level - ANSWER-False High
Arm Not Supported - ANSWER-False High
Axila Temp Site Advantages & Limitations - ANSWER-Advantages: Safe/inexpensive, recommended only
for screening, reliable in stable/preterm infants
Exam 3: NUR101 / NUR 101 (Latest
Update) Health Assessment | Guide with Questions
and Verified Answers | 100% Correct | Grade A –
Fortis