COMPREHENSIVE ASSESSMENT
EXAM 2025 LATEST NEWEST
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nurse is caring for a pt who is experiencing a situational crisis. which finding should the
nurse expect
, -the pt recently lost a grandparent in a motor vehicle accident
situational crisis is when an unexpected event occurs
an adventitious crisis is an external disaster such as town hit by tornado
nurse is admitting pt with alcohol disorder. which statement by pt indicates pt is using denial
as a defense mechanism
"i am able to go to wrk every day, so i dont have a problem"
nurse assessing a client who recently used cocaine. which finding should nurse expect
Hypertension
cocain is stimulant that increases BP, HR, Temp, energy levels, and metabolism
nurse in providers office is collecting health history from the guardian of a school age child
who has been taking atomoxetine. which adverse effect reported by guardian is the priority
for the nurse to report to provider
dark urine
greatest risk if liver damage from atomoxetine
nurse is caring for a pt who has a recent diagnosis of mild alzheimers disease. the pts partner
asks the nurse about expected manifestations. the nurse should teach the partner to expect
which of the following manifestations to occur first
frequently misplaces objects
nurse is caring for pt whose child has a terminal illness. the client requests info about how to
deal w the upcoming loss. which statemen should nurse make
"it is not uncommon to feel angry toward yourself or others"
, blame and anger towards oneself or others is expected when experiencing a loss
nurse is performing a cognitive assessment to distinguish delirium from dementia in a pt
whose family reports episodes on confusion. which assessment finding supports the nurses
suspicion of delirium
easily distracted
extreme distractability is a hallmark manifestation of delirium
nurse is caring for an older adult client who is experiencing delirium. which following
intervention should nurse include in plan of care
permit the client to perform daily rituals to decrease anxiety
this provides helps decrease agitation and anxiety
a nurse is talking with a group of parents who have recently experienced the death of a child.
which action should the nurse take
suggest forming a weekly support group for parents who have experienced the death of a
child
nurse is assessing a client who is experiencing opioid withdrawal. which manifestations
should the nurse expect
rhinorrhea
-flu like symptoms; yawning, sneezing, abdominal pain
-insomnia
-tachycardia
-hyperthermia
nurse in a community health center is working w a group of clients who have PTSD. which
intervention should nurse include to reduce anxiety among the group members
guided imagery
assists pt to imagine a restful and safe place
, nurse at providers office is interviewing an older adult client. client reports a history of
anxiety, diagnosed with alzheimers 2 months ago, partner died 6 months ago. reports
decreased apetitie, low energy levels, insomnia for several wks and some memory loss. which
action should the nurse plan to take
use a screening tool to evaluate the client for depression
nurse is assisting a pt who has a terminal illness adjust to progressive loss of independence.
which statement by client indicates acceptance of her illness
"i am going to order a wheelchair for when im unable to walk"
a nurse is discussing the home care for a pt who has advanced alzheimers disease with the pts
partner who is planning on going out of town for several days. which resource should the
nurse recommend to the caregiver
respite care
-this allows the pt to stay in a nursing facility for a set number of days, allowing caregivers to
go on vacation or have time to themselves
a nurse is caring for an older adult pt who has dementia and has wandered into the day room
looking for their deceased partner. which action should nurse take?
talk with the pt about activities they enjoyed with their partner
talking about positive experiences can help distract the pt from their disorientation
nurse is assessing a school aged child who has conduct disorder. which characteristic should
nurse expect the child to demonstrate
agression towards people and animals
nurse is planning care for pt who has a new prescription for Olanzapine. which intervention
should the nurse identify as the priority?
-instruct the pt to avoid driving during initial therapy
greatest risk for pt is injury resulting from drowsiness or dizziness