DATA COLLECTION
Patient presents to the clinic with a chief complaint of a headache. Patient states that "it feels like someone is stabbing me with a knife". The nurse records this information as ___?
Characteristics
A new nurse is taking vital signs for a patient that has come to the clinic. The nurse knows that the normal HR, RR, temperature, and BP readings/ranges are?
HR 60-100, RR 12-20, temperature 98.6F, BP 120/80
The nurse is formulating a plan of care for the patient. She knows that the components of the nursing process are?
Assessment, diagnosis, planning, implementation, evaluation
A nurse is caring for a talkative patient. The nurse knows that when interviewing this type what should be done in the first few minutes?
Patient should be given free reign for first 5-10 minutes
A 45 year old female presents to the emergency room with dizziness, mental confusion, and vomiting. The patient is admitted to the observation floor. The Observation nurse sits down to complete the comprehensive health assessment. The nurse notes that patient smells like alcohol. What is a tool that the nurse will use to assess alcohol use for this patient?
CAGE: cut down, annoyed, guilty, eye-opener
Patient has called the clinic to report pain in her right lower abdomen. The triage nurse is working on developing a care plan for the patient and recognizes that she needs some more information. The patient tells the nurse that she has a “consistent throbbing in the right lower abdomen for the last 4 days.” What type of data is this information considered?
Subjective data
A patient presents to the ER in excruciating pain in her left foot. She states that she dropped a concrete block on her left foot while trying to move it. She states that the pain occurred right after she dropped the block on her foot. The nurse knows that this is which type of pain?
ACUTE PAIN
A charge nurse is reviewing the steps of the nursing process with a group of nurses. A new nurse states that “I just checked on my second day postoperative patient and they have achieved satisfactory pain relief.” The charge nurse knows this is which of the following steps of the nursing process?
Evaluation
A Medical-Surgical nurse is caring for a patient with a language barrier in the acute care setting. What is one of the most important tools to use when interviewing this type of special patient?
Use an interpreter
The Medical-surgical nurse is completing a physical assessment. The nurse knows that when assessing patients what techniques should be used?
inspection, palpation, percussion, auscultation
Patient has called the clinic to report pain in her right lower abdomen. The triage nurse is working on developing a care plan for the patient and recognizes that she needs some more information. The patient tells the nurse that she has a “consistent throbbing in the right lower abdomen for the last 4 days.” The patient has just told the nurse which of the components of OLD CART?
Duration, onset, characteristics, location
A patient presents to the ER for pain in his lower back. He states that 6 months ago he slipped on some ice while walking into work and landed right on his back. The nurse notes that this type of pain is?
Chronic pain
A nurse is discussing the nursing process with a newly incensed nurse. The newly licensed nurse states “I will determine the most important client problems that we should address.” The nurse realizes that the new nurse is verbalizing understanding of which step of the nursing process?
Planning
A nurse in the Dermatology clinic is explaining the wound care instructions to a patient with a language barrier. The nurse knows that when using the INTERPRET tool, the E stands for?
Ethics-use an interpreter not family member
The CCU nurse is obtaining a health history for a newly admitted patient. What key elements will the nurse assess when completing this section of the health assessment?
Allergies, medications, childhood illnesses, adult illnesses, and health maintenance (ex: immunications, screening, safety measures, risk factors-alcohol, tobacco, environment or occupational hazards, substance use)
Patient presents to the ER with chest pain. As the nurse is collecting data, the patient states that the pain is "crushing and it feels like there is an elephant sitting on her chest." The nurse reviews the patient’s vital signs as follows: BP 160/85 in the right arm sitting, RR 25, HR 120 irregular, temperature 98.6 degrees F tympanic. The nurse knows that which of the received data is considered objective?
Vital signs
A new nurse is recording vital signs for a female patient before her gynecological exam. The nurse gets a blood pressure reading of 90/50. The patient states “that is very low compared to my normal. I normally run 140/85.” The nurse knows that what can cause a false low reading?
Cuff too large, arm above heart level, repeating assessments too quickly, inaccurate level of inflation, pressing stethoscope too tightly against pulse
A nurse is discussing the nursing process with a newly incensed nurse. The newly licensed nurse states “I will carry out the new prescriptions from the provider.” The nurse realizes that the new nurse is verbalizing understanding of which step of the nursing process?
Implementation
A cardiology nurse is caring for an interview with a talkative patient. The nurse knows that what steps should be taken to ensure a smooth interview process?
Give free reign first 5-10 minutes, focus on what is important to patient, do not interrupt, to not get impatient, set limits where needed, explain need for another session if needed
A day shift nurse is giving report to the night shift nurse. The day shift nurse states that the patient was just admitted to the floor 10 minutes ago. Based on this information, the night shift nurse knows that she will need to complete what type of assessment?
Comprehensive health assessment
Patient presents to the hospital with pain. The nurse is recording subjective data from the patient. The nurse knows that the components of old cart is ___?
Onset, location, duration, characteristics, aggravating factors/associated manifestations, relieving factors, treatment
A new nurse is recording vital signs for a female patient before her gynecological exam. The nurse gets a blood pressure reading of 185/85. The patient states “that is very high. I normally run 110/70.” The nurse knows that what can cause a false high reading?
Cuff too small, cuff too loose, arm below heart level, arm not supported, inflating/deflating cuff too slowly, deflating cuff too quickly
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was 6 hrs ago. The prescription reads every 4 hours as needed (PRN) for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
Assessment
The nurse is caring for a patient with a language barrier. The nurse knows that in order to effectively interview/treat this patient what steps should be taken?
Use of an interpreter, use clear, concise, short questions; do not use a family member to interpret; speak directly to the patient
A Medical-Surgical nurse is completing a comprehensive health assessment. She has just gotten to the review of systems section. The nurse knows that the review of systems section contains what? What areas of the body will be addressed?
A series of questions about symptoms from head to toe. Includes: general, skin, HEENT, neck, breasts, respiratory, cardiovascular, GI, peripheral vascular, urinary, reproductive, musculoskeletal, psychiatric, neurologic, hematologic, endocrine