A nurse is working in the operating room with a client just prior to the procedure. While setting up for the procedure, the nurse notices that the client has become unresponsive and respirations have become shallow
What type of assessment would be necessary in this situation?
1. Initial assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed assessment
Correct Answer: 3
Rationale: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems. Initial assessment is performed within a specific time after admission to a health care agency. Problem-focused assessment is an ongoing process integrated with nursing care. Time-lapsed assessment occurs several months after the initial assessment to compare the client's current status to baseline data previously obtained.
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Your schizophrenic patient suddenly is observed with her head turned in an awkward position that she is unable to move. What would be your first action?
A. Obtain a blood specimen per standing order. B. Ignore the patient, as this is most likely part of her psychotic behavior. C. Call the charge nurse and physician immediately. D. Administer an additional dose of prn antipsychotic medication.
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
A) Attach the condom prior to erection. B) A condom may be reused with the same partner if ejaculation has not occurred. C) Use skin lotion as a lubricant if alternatives are unavailable. D) Hold the condom by the cuff upon withdrawal.
A 45-year-old client continues to request intravenous pain medications 4 days after being placed in skeletal traction due to a complex fracture of the hip
While giving report to the next shift, the nurse who cared for the client during the day states, "I just do not know why he still needs medication 4 days after surgery. The client we had last month with the same type situation did not need any medication after 2 days." Which of the following responses by a nursing peer is the best example of being a client advocate? 1. "I just think this client needs more because of his age." 2. "Have you tried getting the doctor to order oral pain medications to see if they work?" 3. "Wouldn't you want all of the pain medication you could have if you were in traction?" 4. "Everyone does not have the same pain perception or response to a similar injury."
An older patient lives at home alone. Which assessment data would indicate modifiable risk factors for a hip fracture?
Select all that apply. 1. complaints of lower extremity weakness 2. problems with balance 3. medications: atenolol 50 mg daily, lisinopril 10 mg daily, Xanax 0.25 mg daily, Seroquel 50 mg daily 4. report of sleeping with two pillows 5. complaints of nonproductive dry cough