Question

1. An older adult comes in for a well visit. Upon your assessment, you observed your client to be confused. Which of the following is not a sign of confusion? a) Short term memory loss b) Diminished vision or hearing c) Labile emotions d) Diminished attention span 2.A nurse is preparing to assess a client who is experiencing shortness of breath. How should the nurse proceed with the assessment? a) Have the client lie down to obtain an accurate cardiac, and respiratory assessment b) Obtain a through history and physical assessment information from the client's family c) Perform a complete history and physical assessment to obtain a baseline d) Examine the system appropriate to the problem prior to performing a complete assessment 3.A nurse is assessing a client with a heart rate of 55 bpm. Which of the following clients would be most likely to have a pulse rate of 55 bpm? a) An older adult who is dehydrated b) A young athlete who just had surgery two days ago c) An older adult who presents with acute asthma exacerbation d) An adult with a temperature of 101F rectally 4. A nurse is about to take the blood pressure of a client. Which of the following actions the nurse may interfere with valid blood pressure? a) The nurse sits comfortably seated at eye-level with the client b) The nurse allows a 5-minute rest period before taking the blood pressure c) The nurse secures eye contact with the client for the entire measurement d) The nurse uses a proper fitting blood pressure cuff the measurement

Answer 1

1. b)Diminished vision or hearing

Rationale: Confusion can lead to memory problems, shortened attention span, difficulty concentrating, changes in emotions and altered perception.

2. d)Examine the system appropriate to the problem prior to performing a complete assessment.

Rationale: It will be appropriate to do an emergency assesment to know the causes of shortness of breath. A client with shortness of breath should be given Fowler's position instead of supine position.

3. b) A young athlete who just had surgery two days ago.

Rationale: Athletes are usually found to have a lower resting heart rate. Conditions like dehydration, high temperature and asthma exacerbations leads to tachycardia.

4. c) The nurse secures eye contact with the client for entire measurement.

Rationale: A valid blood pressure measurement needs proper cuff measurements, the equipment to be at heart level and resting period before the measurement.

Answer 2

Which of the following is a true statement regarding cultural aspects of pain?