During the interview, the nurse notes that the client is confused as to day and time.
This would be an indicator of
Client's orientation
Client's affect and mood
Client's willingness to cooperate
Client's level of anxiety
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Client's orientation
Rationale: Client's ability to state the name, location, and date and time
assesses for the orientation to person, place, and time.
A nursing assistant will be obtaining vital signs on a client who had a left-sided
mastectomy two days prior. What specific instructions would the nurse provide to the
, nursing assistant in delegating this task?
No special instructions are necessary
Take blood pressure on the left arm
Take blood pressure on both arms for a baseline
Take blood pressure on the right arm
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Take blood pressure on the right arm
Rationale: The blood pressure should not be taken on the same side as the
mastectomy. It should also not be taken on the same arm as a shunt,
trauma, or disease. In these situations, the opposite arm should be used. If
this is not possible, then a thigh pressure should be obtained.
Gathering the history and completing the physical exam is mostly the responsibility of
the physician. The nurse should gather the assessment tools and wait for the physician
to complete the health assessment.
T or F
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FALSE
Health assessment is within the role of the nurse!
When assessing for sound using percussion, the nurse will use
Direct percussion
Indirect percussion
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This would be an indicator of
Client's orientation
Client's affect and mood
Client's willingness to cooperate
Client's level of anxiety
Give this one a try later!
Client's orientation
Rationale: Client's ability to state the name, location, and date and time
assesses for the orientation to person, place, and time.
A nursing assistant will be obtaining vital signs on a client who had a left-sided
mastectomy two days prior. What specific instructions would the nurse provide to the
, nursing assistant in delegating this task?
No special instructions are necessary
Take blood pressure on the left arm
Take blood pressure on both arms for a baseline
Take blood pressure on the right arm
Give this one a try later!
Take blood pressure on the right arm
Rationale: The blood pressure should not be taken on the same side as the
mastectomy. It should also not be taken on the same arm as a shunt,
trauma, or disease. In these situations, the opposite arm should be used. If
this is not possible, then a thigh pressure should be obtained.
Gathering the history and completing the physical exam is mostly the responsibility of
the physician. The nurse should gather the assessment tools and wait for the physician
to complete the health assessment.
T or F
Give this one a try later!
FALSE
Health assessment is within the role of the nurse!
When assessing for sound using percussion, the nurse will use
Direct percussion
Indirect percussion
Give this one a try later!
