Which of the following questions would the nurse use to assess a client's judgment?
1. "Why did you run away?"
2. "When did you first start hearing voices?"
3. "What would you do if you smelled smoke in your home?"
4. "Do you believe you hear voices, or do you think it is in your mind?"
ANS: 3
Judgment is the ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions. Judgment may be assessed by ask-ing a question that has a common-sense answer. Option 3 is an example of such a question. Op-tion 1 asks about motivation. Option 2 elicits historical information about the illness. Option 4 seeks information about insight.
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The nurse is assessing an adult client. Which observations should the nurse include when documenting the general survey of this client?
Select all that apply. 1. Blood pressure 112/68, pulse 68, 98.6 °F, respiratory rate 16. 2. Thin, well-nourished male client, appears younger than stated age. 3. Client moves about exam room without difficulty. 4. Abdomen flat, nondistended, bowel sounds present, nontender on palpation. 5. Pain rating of 3 on a 0 to 10 scale.
The nurse assessing a patient with multiple myeloma should keep in mind that patients with multiple myeloma are at risk for:
A) Chronic liver failure B) Acute heart failure C) Pathologic bone fractures D) Hypoxemia
A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patient's urine output hourly and notifies the physician when the hourly output is less than what?
A) 30 mL B) 50 mL C) 100 mL D) 125 mL
During auscultation, you can limit your perceptual field best by:
a. asking patients to describe their symp-toms. b. closing your eyes. c. performing auscultation before percussion. d. using an aneroid manometer.