Health assessment final exam Questions and answers. 2022/2023. Rated A+

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The nurse is caring for patients on the surgical floor and has just received report from the previous shift. Which of the following patients should the nurse see FIRST? A. A 35-year-old admitted ... three hours ago with a gunshot would; 1.5 cm area of dark drainage noted on the dressing B. A 43-year-old who had a masectomy tow days ago; 23 cc of serosanguinous fluid noted in the Jackson-Pratt drain C. A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous eight hours D. A 62-year-old who had an abdominal-perineal resection three days ago; patient complains of chills - ✔✔D The nurse is caring for patients in the outpatient clinic. Which of the following phone calls should the nurse return first? A. A client with hepatitis A who states "My arms and legs are itching." B. A client with a cast on the right leg who states, " I have a funny feeling in my right leg." C. A client with osteomylitis of the spine who states, " I am so nauseous that I can't eat." D. A client with rheumatoid arthritis who states, " I am having trouble sleeping." - ✔✔B high priority - ✔✔Airway Breathing Circulaltion Vital Signs Second priority - ✔✔mental status change untreated medical problem acute pain acute urinary elimination problem abnormal lab value risk of infection cultural consideration hispanic - ✔✔Curanderos use herbs, aromas, and rituals to treat the ills of the body, mind and spirit. have a higher rate of diabetes cultural consideration chinese - ✔✔eldest son holds responsibility for family Control of emotions, restraint, obedience to authority, conforming and "face" are highly valued and important balance between hot foods and cold foods lung (worry), gallbladder/liver (anger), heart (happy), kidney (fear), spleen (desire) considerations japanese - ✔✔diabetes, cancer, dementia muslim consideration - ✔✔female/female or male/male for nursing care as they place high value on modesty left hand=dirty what distance should you be from patient when you are conducting interview - ✔✔4-5 feet ten traps of interviewing - ✔✔false assurances giving unwanted advice using authority using avoidance language engaging in distancing using professional jargon using leading or biased questions talking too much interrupting using why questions this age uses telegraphic speech so it is best to keep explainations simple - ✔✔preschooler this age can tolerate and understand others viewpoints, more objective and realistic, able to reason very curious - ✔✔school age value peers, crave acceptance, think that no adult can understand them - ✔✔adolescent broca's aphsia - ✔✔can understand language but cannot express it himself nonfluent, dysarthic, effortful speech wernickes aphasia - ✔✔can hear sounds but cannot relate them to previous experiences speech is fluent, effortless and well articulated but has many paraphasias and made up words subjective data - ✔✔"Lately I just don't feel like myself" objective data - ✔✔HR=80 BP=125/80 T=38 RR=18 skin feels cool, & clammy etc interpreter - ✔✔dont use family member must use trained medical interpreter nonverbal cross cultural - ✔✔vocal cues action cues object cues use of personal and territorial space touch nonverbal - ✔✔physical appearance posture gesture facial expression eye contact voice touch standard based precautions - ✔✔designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources, and they apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, whether or not they contain visible blood; (3) nonintact skin; and (4) mucous membranes transmission based precaution - ✔✔i`ntended for use with patients with documented or suspected transmissible infections. They are designed in addition to Standard Precautions to interrupt transmission in hospitals. There are three types of transmission-based precautions: airborne, droplet, and contact infant examination considerations - ✔✔nonverbal communication is key firm gentle handling quiet calm voice keep parent in view aging adult considerations - ✔✔p.40 biggest fear is losing independence avoid elder speak allow more time for interview collect most important data first, allow for multiple meetings adjust pace; allow time to answer questions fully head/chest circumference infant - ✔✔Newborn's chest grows at a faster rate than the cranium; @ some point btw 6mths & 2 yrs, both measurements are about the same, & after 2 yrs of age the chest circumference is greater than the head circumference. Enlarged head circumference occurs w/ increased ICP [Show More]

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