EAQ's -Health Assessment fully
solved & updated (graded A+)
A client is in a state of uncompensated acidosis. What approximate arterial
blood pH does the nurse expect the client to have?
7.20
7.35
7.45
7.48 - answer 7.20
The pH of blood is maintained within the narrow range of 7.35 to 7.45. When
there is an increase in hydrogen ions, the respiratory, buffer, and renal
systems attempt to compensate to maintain the pH. If compensation is not
successful, acidosis results and is reflected in a lower pH.
Which action of the nurse would be most important to convey interest in
starting a conversation with a client who has hearing loss?
Smiling while seeing the client
Nodding head in front of the client
Making eye contact with the client
,Leaning forward towards the client - answer The nurse should make eye
contact with the client to show interest in starting a conversation with a
client with hearing loss. Smiling while seeing the client would help to build a
positive relationship. Nodding in front of the client helps to regulate the
conversation. Leaning forward towards the client shows attention and
awareness.
Question 3
During a peer review, the chief operational officer of a healthcare unit
understands that the newly appointed nurse excels in reminiscence theory.
What statement of the nurse confirms this understanding?
The nurse restores the client's sense of reality.
The nurse builds self-esteem by asking about a client's previous
achievements.
The nurse agrees to a confused client's incorrect statement. - answer
Reminiscence theory involves helping the client to recall past experiences to
help resolve current conflicts. A nurse who builds a client's self-esteem by
asking about his or her previous achievements is using the theory. Reality
orientation is associated with the restoration about the sense of reality.
Validation therapy is associated with agreeing with a confused older client's
incorrect statement. The nurse may use therapeutic communication to
address the expressed and unexpressed needs of the client.
While caring for a client dealing with pain, the nurse assesses the health
status and prioritizes his or her needs. Which phase of the helping
relationship is observed?
,Working phase
Orientation phase
Termination phase
Preinteraction phase - answer During the orientation phase, the nurse
assesses the health status of the client and prioritizes his or her needs.
During the working phase, the nurse encourages and helps the client to set
treatment goals. In the termination phase, the nurse evaluates the
achievement of treatment goals with the client. In the preinteraction phase,
the nurse reviews the client's medical and nursing history and talks to the
caregivers.
At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline
solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30
am the healthcare provider changes the IV solution to lactated Ringer
solution, which is to infuse at 100 mL/hr. What total amount of intravenous
solution should the client have received by the end of the 8-hour shift?
Record your answer using a whole number. - answer 863 mL
The client will have absorbed 313 mL of solution before the healthcare
provider changes the prescription (2.5 hours × 125 mL/hour = 312.5,
rounded up to 313); for the remaining 5.5 hours of the shift, the client will
have received 550 mL (5.5 hours × 100 mL/hour), for a total of 863 mL.
A client has been diagnosed as brain dead. The nurse understands that this
means that the client has what?
No spontaneous reflexes
, Shallow and slow breathing
No cortical functioning with some reflex breathing
Deep tendon reflexes only and no independent breathing - answer client who
is declared as being brain dead has no function of the cerebral cortex and a
flat electroencephalogram (EEG). The client may have some spontaneous
breathing and a heartbeat. The guidelines established by the American
Association of Neurology include coma or unresponsiveness, absence of
brainstem reflexes, and apnea. There are specific assessments to validate
the findings. No spontaneous reflexes, shallow and slow breathing, and deep
tendon reflexes only and no independent breathing do not fit the definition of
brain dead.
A mother of a seven-month-old infant reports that her baby still cannot sit
without support. Upon asking further questions, the nurse realizes that the
child's gross-motor skills are not properly developed. Which question did the
nurse most likely ask the mother?
Can your child hold on to furniture?
Can your child show hand preference?
Does your child move on his or her hands and knees?
Can your child place objects in containers? - answer Can your child hold on to
furniture?
solved & updated (graded A+)
A client is in a state of uncompensated acidosis. What approximate arterial
blood pH does the nurse expect the client to have?
7.20
7.35
7.45
7.48 - answer 7.20
The pH of blood is maintained within the narrow range of 7.35 to 7.45. When
there is an increase in hydrogen ions, the respiratory, buffer, and renal
systems attempt to compensate to maintain the pH. If compensation is not
successful, acidosis results and is reflected in a lower pH.
Which action of the nurse would be most important to convey interest in
starting a conversation with a client who has hearing loss?
Smiling while seeing the client
Nodding head in front of the client
Making eye contact with the client
,Leaning forward towards the client - answer The nurse should make eye
contact with the client to show interest in starting a conversation with a
client with hearing loss. Smiling while seeing the client would help to build a
positive relationship. Nodding in front of the client helps to regulate the
conversation. Leaning forward towards the client shows attention and
awareness.
Question 3
During a peer review, the chief operational officer of a healthcare unit
understands that the newly appointed nurse excels in reminiscence theory.
What statement of the nurse confirms this understanding?
The nurse restores the client's sense of reality.
The nurse builds self-esteem by asking about a client's previous
achievements.
The nurse agrees to a confused client's incorrect statement. - answer
Reminiscence theory involves helping the client to recall past experiences to
help resolve current conflicts. A nurse who builds a client's self-esteem by
asking about his or her previous achievements is using the theory. Reality
orientation is associated with the restoration about the sense of reality.
Validation therapy is associated with agreeing with a confused older client's
incorrect statement. The nurse may use therapeutic communication to
address the expressed and unexpressed needs of the client.
While caring for a client dealing with pain, the nurse assesses the health
status and prioritizes his or her needs. Which phase of the helping
relationship is observed?
,Working phase
Orientation phase
Termination phase
Preinteraction phase - answer During the orientation phase, the nurse
assesses the health status of the client and prioritizes his or her needs.
During the working phase, the nurse encourages and helps the client to set
treatment goals. In the termination phase, the nurse evaluates the
achievement of treatment goals with the client. In the preinteraction phase,
the nurse reviews the client's medical and nursing history and talks to the
caregivers.
At the beginning of the shift at 7:00 am, a client has 650 mL of normal saline
solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30
am the healthcare provider changes the IV solution to lactated Ringer
solution, which is to infuse at 100 mL/hr. What total amount of intravenous
solution should the client have received by the end of the 8-hour shift?
Record your answer using a whole number. - answer 863 mL
The client will have absorbed 313 mL of solution before the healthcare
provider changes the prescription (2.5 hours × 125 mL/hour = 312.5,
rounded up to 313); for the remaining 5.5 hours of the shift, the client will
have received 550 mL (5.5 hours × 100 mL/hour), for a total of 863 mL.
A client has been diagnosed as brain dead. The nurse understands that this
means that the client has what?
No spontaneous reflexes
, Shallow and slow breathing
No cortical functioning with some reflex breathing
Deep tendon reflexes only and no independent breathing - answer client who
is declared as being brain dead has no function of the cerebral cortex and a
flat electroencephalogram (EEG). The client may have some spontaneous
breathing and a heartbeat. The guidelines established by the American
Association of Neurology include coma or unresponsiveness, absence of
brainstem reflexes, and apnea. There are specific assessments to validate
the findings. No spontaneous reflexes, shallow and slow breathing, and deep
tendon reflexes only and no independent breathing do not fit the definition of
brain dead.
A mother of a seven-month-old infant reports that her baby still cannot sit
without support. Upon asking further questions, the nurse realizes that the
child's gross-motor skills are not properly developed. Which question did the
nurse most likely ask the mother?
Can your child hold on to furniture?
Can your child show hand preference?
Does your child move on his or her hands and knees?
Can your child place objects in containers? - answer Can your child hold on to
furniture?
