Medical-Surgical B
1. 1.ID: 310947654
Which method elicits the most accurate information during a physical assessment of an older client?
o Ask the
... [Show More] client to recount one's health history.
o Obtain the client's information from a caregiver.
o Review the past medical record for medications.
o Use reliable assessment tools for older adults. Correct
Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. (A and B) are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although (C) is a good resource to identify polypharmacy, a written record may not be available or currently accurate.
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 310972705
A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection?
o Inform the client how to protect sexual and needle-sharing partners.
o Teach the client about the medications that are available for treatment.
o Identify the need to test others who have had risky contact with the client.
o Discuss retesting to verify the results, which will ensure continuing contact. Correct
Encouraging retesting (D) supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about (A, B, and C), retesting encourages the client to maintain medical follow-up and management.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 310955083
The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded?
o Inspiratory wheezes in both lungs. Incorrect
o Crackles in the right and left lower lobes. Correct
o Abnormal lung sounds in the bases of both lungs.
o Pleural friction rub in the right and left lower lobes.
Fine crackles (B) are short, high-pitched sounds heard just before the end of inspiration that are the result of rapid equalization of pressure when collapsed alveoli or terminal bronchioles suddenly snap open. Wheezing (A) is a continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls that are first evident on expiration and may be audible. Although (C) describes an adventitious lung sound, this documentation is vague. (D) is a creaking or grating sound from roughened, inflamed surfaces of the pleura rubbing together heard during inspiration, expiration, and with no change during coughing.
Awarded 0.0 points out of 1.0 possible points. [Show Less]