NR 305

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. A.Set the room temperature at a comfortable level. B.Remove distracting objects from the interviewing area. C.Place a chair for the client across from the nurse's desk. D.Ensure comfortable seating at eye level for the client and nurse. E.Provide seating for the so that the faces a s...

1. For which of the following patients would a comprehensive health history be appropriate? A) A new patient with the chief complaint of "I sprained my ankle" B) An established patient with the chief complaint of "I have an upper respiratory infection" C) A new patient with the chief complaint of "I am here to establish care" D) A new patient with the chief complaint of "I cut my hand" c) a new patient with the CC of "I am here to establish care" the patient is new to the pro...

A nurse conducting a physical assessment is observing the client's balance and performing tests to determine the client's sense of equilibrium. Which cranial nerve is the nurse assessing? 1. Cranial nerve II 2. Cranial nerve IX 3. Cranial nerve VII 4. Cranial nerve VIII 4. Cranial nerve VIII Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client's balance when ...

5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C) Request a sign language interpreter before meeting with him to help facilitate the communication. D) Speak loudly and with exaggerated facial movement when talking with him because this helps with ...

While measuring a patient's blood pressure, which set of Korotkoff sounds should be recorded as systolic and diastolic pressure? 1 Phase III/phase V 2 Phase I/phase V 3 Phase II/phase III 4 Phase I/phase IV 2 What should the nurse document as a normal finding when auscultating a toddler's chest for breath sounds? 1 Bronchovesicular breath sounds in the peripheral lung fields 2 Persistent peristaltic sounds with diminished breath sounds 3 Persistent fine crackles that are ...

1. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break...

B. Denial The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation. The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes patt...

A 59 year old patients tells the nurse practitioner that he thinks he must have ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse practitioner best document THE FACTS for his reason for seeking care? A) JM is a 59 year old male here for having "black stools" for the past 24 hours. B) JM came into the clinic complaining of black stools for the past 24 hours. C) JM is a 59 year old male here for "ulcerative colitis." D) JM, a 59 year old mal...

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. The nurse makes this determination based on which observation? An involuntary rhythmic, rapid, twitching of the eyeballs A dorsiflexion of the great toe with fanning of the other toes A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed A lack of normal sense of position when the client is unable to return extended fingers to a point of re...

The nurse hears bilateral louder, longer, and lower tones when percussing over the lungs of a 4-year old child. What should the nurse do next? a) Palpate over the area for increased pain and tenderness. b) Ask the child to take shallow breaths and percuss over the area again. c) Refer the child immediately because of an increased amount of air in the lungs. d) Consider this a normal finding for a child this age and proceed with the examination. d) Consider this a normal finding for a child ...