Hospitalized Client Latest Update -

NSG 521 Module 12 Assessment of the Hospitalized Client Latest Update - Actual Exam 190 Questions and 100% Verified Correct Answers Guaranteed A+ Approved by the Professor

A blood transfusion means only transfusion of whole blood. - CORRECT ANSWER:

False: may include different blood components

A child's head circumference is a measurement that should be obtained at every well- child visit until the child is 5 years old because it will provide information on the child's

readiness for kindergarten. - CORRECT ANSWER: False

A condition where medical or nursing interventions trigger a sequence of adverse events in a frail older adult is called cascade iatrogenesis. - CORRECT ANSWER: True

A delay in speech development may signal a hearing loss or mental health concern,

such as autism. - CORRECT ANSWER: True

A Do Not Hospitalize order is often used for patients in long-term care and other residential settings who have elected not to be hospitalized for further aggressive

treatment. - CORRECT ANSWER: True

A do not resuscitate order and allow natural death order mean the same thing. -

CORRECT ANSWER: True

A mother brings her 6-month-old infant to the clinic for a routine evaluation. At birth, the term infant weighed 3.5kg (7lb12oz) and was 51 cm (20in) long. He now weighs 4.6kg (10lb2oz). The nurse should next measure head and chest circumference and length, then plot current weight, length, and head and chest circumference on standardized

growth charts. - CORRECT ANSWER: True

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A newborn (neonate) is an infant 28 days old or younger. - CORRECT ANSWER: True

A normal fetal heart rate as auscultated with a Doppler sonometer is - CORRECT

ANSWER: 120 beats/min

A nurse is caring for an 80-year-old patient who is living in a long term care facility. To help this patient adapt to the present circumstances, the nurse is using reminiscence as therapy. Which question would encourage reminiscence? - CORRECT ANSWER: "Tell me about how you celebrated Christmas when you were young."

A nurse midwife is assisting a patient who is firmly committed to natural childbirth to deliver a full-term baby. A cesarean delivery becomes necessary when the fetus displays signs of distress. Inconsolable, the patient cries and calls herself a failure as a mother. The nurse notes that the patient is experiencing what type of loss? Select all

that apply. - CORRECT ANSWER: Actual

Perceived Psychological

A nurse should consider the type of medication being given when gathering the equipment for an injection because there are special syringes for certain types of medication, for example, insulin syringes used only to inject insulin. - CORRECT

ANSWER: True

A nurse should gather a stethoscope, thermometer, watch with a second hand, sphygmomanometer or vital signs machine, and pulse oximeter when preparing to

assess a hospitalized patient. - CORRECT ANSWER: True

A nurse understands that a patient who says they have an allow natural death order

means the same thing as a do not resuscitate order. - CORRECT ANSWER: True

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended? - CORRECT ANSWER: The nurse uses the Z-track 2 / 4

technique for intramuscular injections to prevent leakage of medication into the needle track.

A nursing instructor teaching classes in gerontology to nursing students discusses myths related to the aging of adults. Which statement is a myth about older adults? -

CORRECT ANSWER: Old age means mental deterioration.

A patient comes to the clinic for a scheduled NST when the nurse notes that the FHR tracing is nonreactive. Which of the following actions would be appropriate for the nurse

to do first? - CORRECT ANSWER: Change the mother's position

A patient's fundal height measures 28 cm (11in). The nurse expects the gestational age

to be 28 weeks. - CORRECT ANSWER: true

A reactive nonstress test is indicative of a healthy fetus. If the monitoring strip is nonreactive, the nurse may offer the mother a position change or a drink of cold water or juice to stimulate the fetus. The fetal response helps to distinguish a true nonreactive test from a normal fetal sleep cycle. If the position change is not effective, this is an indicator of fetal distress and should be reported to the provider immediately. -

CORRECT ANSWER: True

A significant drop in blood pressure is an indicator of hemorrhage caused by a ruptured

ectopic pregnancy. - CORRECT ANSWER: True

A significant drop in blood pressure is an indicator of hemorrhage caused by a ruptured

ectopic pregnancy. - CORRECT ANSWER: True

Abdominal assessment - CORRECT ANSWER: Inspect for distension, auscultate bowel

sounds, palpate for tenderness.

Acute and urgent situations such as the following warrant immediate attention and

interventions:

A respiratory rate lower than 8 or greater than 28 breaths/min 3 / 4

An acute change in oxygen saturation below 90% despite oxygen administration A threatened airway Acute change in systolic BP to less than 90 mm Hg or a sustained increase in diastolic BP greater than 110 mm Hg Acute change in heart rate to fewer than 50 or greater than 120 beats/min New-onset chest pain or signs of acute myocardial infarction An acutely cold, cyanotic, or pulseless extremity Confusion, agitation, or delirium Unexplained lethargy or acute altered mental status Difficulty speaking or signs of acute stroke Acute change in pupillary response New seizure Temperature greater than 39.0°C (102.2°F) Uncontrolled pain Acute change in urine output less than 50 ml (about 1¾ oz) over 4 hours Acute bleeding

Suspected severe sepsis (AHRQ, 2013a) - CORRECT ANSWER: True

Additional diagnostic tests within the nursing scope of practice for hospitalized patients include electrocardiogram (for ischemic cardiac changes), oxygen and arterial blood

gases, and chest x-ray (during rapid response emergencies). - CORRECT ANSWER:

True

Administer blood components using an in-line filter or an add-on filter that is appropriate for the prescribed component, following the manufacturer's directions for use (INS, 2016b). It is generally recommended to start the infusion slowly and carefully monitor for complications after getting baseline vital signs. Facility policies vary on the frequency of vital signs and assessment during the infusion, but in general the most intense monitoring is required in the first 15 minutes of the infusion. - CORRECT ANSWER: fact

Administering Intravenous (IV) Fluid Therapy

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