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– Chamberlain
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Exam 2: NR 304 / NR304 Health Assessment II
Term
Older adults experience a neurological functioning with changes
in vision and muscle movement. This change in neurologic functioning
makes them more prone to
Gradual improvement, better balance
, Rapid increase, improved
Stable condition, enhanced reflexes
coordination
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Term
In hospitals and residential care facilities, nurses and their nursing
colleagues spend the most time with the client, and therefore, during
their time spent together, the key points to avoid failure to rescue are:
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b. Person's eyes open spontaneously during the assessment.
c. Person wiggles the fingers when asked to do so.
e. Person is oriented to self, place, and time.
-Apply continuous pulse oximetry monitoring with an alarm
-Coordinate 30-minute rounds with the unlicensed assistive personnel (UAP)
Recently diagnosed with decreased bone density
1.5 inches shorter than 1 year ago
Reduced range of motion of the joints
Clicking and crepitus when bending knees
early recognition of declining health status
understanding the significance
, communicating the urgency of the need to the appropriate interprofessional
healthcare team
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Definition
Delaying notifying a healthcare provider (HCP) that a post-operative
client's pain medication is no longer working.
Returning to assess the client 1 hour after administering a high dose of
narcotic pain medication via intramuscular (IM) injection. Narcotic pain
medication is likely to suppress the client's breathing and has a
relatively short therapeutic onset. The nurse should reassess the client
about 30 minutes after administration.
Administering STAT medication 2 hours after it was ordered.Although
facility policy may vary, STAT orders for medication are to be carried
out within 1 hour. Delaying administration can put the client at risk of
deteriorating health.
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Which nursing action is an example of anchoring bias after a BP of 88/42 is obtained
on a client admitted with chest pain?
Leaving the room to get a blood pressure cuff that works
Calling another colleague for immediate assistance
Asking the client if they are experiencing chest pain
Completing a focused cardiovascular assessment
, 3. During the health history, a 64-year-old man tells you he "never has sex anymore."
Check the following appropriate follow-up questions you could use that are
associated with withdrawal from sex. Select all that apply.
a. "Have you been told about any side effects of your medications?"
b. "Let's ask your provider for a blood test to detect decreased sperm production."
c. "Would you say you have had feelings of depression in the last few months?"
d. "How many alcohol drinks do you have each day?"
e. "This is an expected outcome in aging men."
f. "Have you experienced the loss of your spouse or your partner?"
Which nursing actions demonstrate a potential cause of failure to rescue?
Select all that apply.
Administer STAT medication 2 hours after it was ordered.
Failure to record the percentage of food intake at dinner time.
Review the client's current laboratory results before administering medication.
Delay notifying a healthcare provider (HCP) that a post-operative client's pain
medication is no longer working.
Ask a colleague to check on a critically ill client during a meal break.
Return to assess the client 1 hour after administering a high dose of narcotic
pain medication via intramuscular (IM) injection.
Which outcome would be appropriate for a client with mild scoliosis?
The client will attend physical therapy sessions.
The client will follow up with their healthcare provider to monitor the severity.
The client will attend support groups for those with spinal fusions.
The client can state three ways to reduce muscle spasms.
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Term
A 67-year-old female (pronouns: she/her/hers) is in for her annual visit
and the nurse is completing the assessment. The client states she
cannot take walks outside with the frequency she had in the past