DOCUMENTATION
How should a nurse respond if a client tells them a secret?
I have to share the information if it reveals something that could hurt you or someone else.
When assessing a client, the client is yelling that you are not his daughter and you need to leave his garage. Which part of the assessment should the nurse now focus on?
Mental
What is the purpose of gathering data about the client's family history?
Uncover client's risk for certain illnesses.
What does the "O" in OLDCARTS stand for?
Onset
Which components of the health assessment is a nurse completing with a client when the nurse is following a structured head-to-toe approach to identify changes in the body system?
Physical Examination.
Which part of the general survey is when a nurse determines if a client is awake, alert, and oriented?
Level of consciousness
What will a nurse do to acknowledge the sensitivity of the information of a client that begins to talk about being abused by a spouse?
Stop documenting in order to maintain eye contact with the client.
A nurse should record data under which section of the health history if a client states that he can never seem to get warm lately and decided to come to the clinic?
Chief complaint.
Using OLDCARTS, how would you measure pain in a client?
Pain 0-10
A nurse suspects a client is a victim of physical abuse. How can the nurse encourage the client to confide in the nurse?
I've seen people being physically abused. Does anyone hit you?
How will a nurse document a client's complaint of right hip pain for a comprehensive health history?
I have pain in my right hip when I walk.
What would a nurse record concerning a client's respirations after completing a general physical examination?
The rate, rhythm, and depth of respirations taken for one full minute.
A client comes into ambulatory surgery and states that she is allergic to Latex. What is the appropriate response of the nurse at this time?
Removing all latex products from the client's room.
Which part of the hand would a nurse use to obtain the most accurate information to assess the temperature of the feet of an older client with diabetes?
Dorsal hand surface
Which client is most in need of an emergency assessment?
A young girl crying that she might be pregnant
A baby coughing with a fever
An older man with chest pain and diaphoresis for an hour
An older man with chest pain and diaphoresis for an hour
Who would be responsible for collecting the subjective data on a client during an initial comprehensive assessment?
Nurse
Prior to assessing a client's blood pressure for a routine physical examination, what will a nurse do to prepare the client?
Ask the client to sit in a chair quietly for 5 minutes.
How should a nurse best react when a client tells their story during an interview?
Avoid interrupting the client
A client is grimacing during an assessment. How should the nurse respond?
Are you currently experiencing any pain?
What is the overall purpose in describing a comprehensive nursing health assessment?
Make a clinical judgement concerning a client.
A female client tells a nurse that it has been 5 years since her last pap smear exam. Where will the nurse document this information?
Health Maintenance
What is an example of subjective information?
A client has BP is 165/92, he is under a lot of stress, respiratory rate is 27 and he has an irregular heart rhythm.
He is under a lot of stress
A man is being assessed for a sexual transmitted disease. How should a nurse respond when a client tells them that he has had sexual intercourse with both men and women?
Can you tell me more about your sexual health practices?
After completing an examination, a nurse realizes that part of the examination was omitted by mistake and not in the proper sequence. How should the nurse proceed?
Complete the forgotten part of the exam out of sequence.
A young adult has signs and symptoms of an eating disorder. What kind of question should a nurse ask the client concerning their body image?
What would you change about your body, if you could?