nursing

NUR101 Health AssessmentExam C Short Answer, Students shall uphold the highest standards of academic integrity, present only their own work, never assist others with cheating or any other form of academic dishonesty and refuse to tolerate academic dishonesty in others. Name__________________

Instructions: Read each question carefully. Answer each question in essay format and answer with a minimum of one paragraph. Make sure you answer the entire question as partial credit will not be given.

Question 1

The nurse is caring for a 26-year old female that was brought in by her mother for inappropriate dress being “difficult to handle.” The nurse notes that the client is wearing a pink skirt, with black boots that come up over her knees and green hair. The client appears restless and has darting watchful eyes.

(5 points each)

What type of mental health examination should the nurse perform and why?

How would the nurse assess the client’s judgment?

Discuss the components of the mental status examination.

The nurse notes that the client is restless and has darting watchful eyes. How does the nurse interpret these findings?

During the eye assessment the nurse notes that the client’s eyes are constricted. How does the nurse interpret this finding?

Question 2

The nurse is caring for a 58-year-old male client with a history of heart failure. The client reports difficulty sleeping while lying flat.

(5 points each)

Discuss the cardiac assessment for this client and include the location and valve correspondence of each landmark.

Discuss the assessment findings the nurse will expect to find.

What additional questions should the nurse ask the client about sleeping? Explain the rationale.

The nurse auscultates the carotid artery. Describe the technique and the rationale for auscultating the carotid artery.

The client reports a weight of 285 lbs. How many kilograms does the client weigh?

NUR101 Health AssessmentExam

C Short Answer

Question 3

A client presents to the emergency department after a motor vehicle accident. The client denies hitting their head; however, they do report pain in the left upper quadrant of their abdomen.

(10 points)

How should the nurse proceed with assessment of the client’s abdomen? Describe the steps the nurse would take.

The nurse palpates a mass in the upper left quadrant. How should the nurse proceed with the assessment?

The nurse documents normal bowel sounds. What sounds did the nurse hear?

The client reports that he has no difficulty with bowel movements but has the occasional black stool. What additional questions should the nurse ask the client and why?

The doctor orders for the client to get 1L of normal saline via intravenous infusion. How many mL will the client receive?