Chapter 02 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 02 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)The client has an elevated temperature. The nurse would document that the clientis:A)Fever.B)Febrile.C)Hyperpyrexia.D)Hyperthermia.Answer:BExplanation:A)The clientisfebrile. The clienthasa fever, hyperpyrexia, and hyperthermia.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: ImplementationB)The clientisfebrile. The clienthasa fever, hyperpyrexia, and hyperthermia.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: ImplementationC)The clientisfebrile. The clienthasa fever, hyperpyrexia, and hyperthermia.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: ImplementationD)The clientisfebrile. The clienthasa fever, hyperpyrexia, and hyperthermia.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: ImplementationObjective:Learning Outcome 2-1: Define the key terms used in the skills of measuring vital signs.2)The nurse assesses the client in respiratory distress and notes that the client has see-saw respirations with thechest and abdomen alternately rising, blue discoloration of the fingertips, and noisy difficult respirations. Howwould the nurse describe the client’s condition when calling the physician?A)Client is tachypneic with costal breathing and cyanosis.B)Client is bradycardic with diaphragmatic breathing and cyanosis.C)Client is demonstrating diaphragmatic breathing, and is dyspneic and cyanotic.D)Client is demonstrating diaphragmatic breathing with audible Korotkoff’s sounds.Answer:CExplanation:A)The use of the abdominal muscles for respiration indicates diaphragmatic breathing. Thedifficult respirations would be described as dyspnea, and the blue discoloration of the fingertipsis cyanosis. The client’s respiratory rate is unknown, so she cannot be described as tachypneic.Bradycardia is a slow heart rate, and the client’s pulse is unknown.Cognitive Level: ApplicationClient Need: Physiological IntegrityNursing Process: AssessmentB)The use of the abdominal muscles for respiration indicates diaphragmatic breathing. Thedifficult respirations would be described as dyspnea, and the blue discoloration of the fingertipsis cyanosis. The client’s respiratory rate is unknown, so she cannot be described as tachypneic.Bradycardia is a slow heart rate, and the client’s pulse is unknown.Cognitive Level: ApplicationClient Need: Physiological IntegrityNursing Process: Assessment1
C)The use of the abdominal muscles for respiration indicates diaphragmatic breathing. Thedifficult respirations would be described as dyspnea, and the blue discoloration of the fingertipsis cyanosis. The client’s respiratory rate is unknown, so she cannot be described as tachypneic.Bradycardia is a slow heart rate, and the client’s pulse is unknown.Cognitive Level: ApplicationClient Need: Physiological IntegrityNursing Process: AssessmentD)The use of the abdominal muscles for respiration indicates diaphragmatic breathing. Thedifficult respirations would be described as dyspnea, and the blue discoloration of the fingertipsis cyanosis. The client’s respiratory rate is unknown, so she cannot be described as tachypneic.Bradycardia is a slow heart rate, and the client’s pulse is unknown.Cognitive Level: ApplicationClient Need: Physiological IntegrityNursing Process: AssessmentObjective:Learning Outcome 2-1: Define the key terms used in the skills of measuring vital signs.3)The nurse is informed during shift report that the assigned client has a wide a pulse pressure, is hypertensive,and has a pulse deficit. When the nurse enters the client’s room, what assessments would the nurse perform inorder to confirm this report?A)Blood pressure and apical pulse assessmentsB)Blood pressure and radial pulse assessmentC)Blood pressure and respiratory rate assessmentD)Blood pressure and radial-apical pulse assessmentAnswer:DExplanation:A)In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulserate, the nurse must perform an apical-radial pulse assessment. Wide pulse pressure andhypertension would be assessed by measuring blood pressure.Cognitive Level: AnalysisClient Need: Physiological IntegrityNursing Process: AssessmentB)In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulserate, the nurse must perform an apical-radial pulse assessment. Wide pulse pressure andhypertension would be assessed by measuring blood pressure.Cognitive Level: AnalysisClient Need: Physiological IntegrityNursing Process: AssessmentC)In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulserate, the nurse must perform an apical-radial pulse assessment. Wide pulse pressure andhypertension would be assessed by measuring blood pressure.Cognitive Level: AnalysisClient Need: Physiological IntegrityNursing Process: AssessmentD)In order to assess a pulse deficit, defined as a discrepancy between the apical and radial pulserate, the nurse must perform an apical-radial pulse assessment. Wide pulse pressure andhypertension would be assessed by measuring blood pressure.Cognitive Level: AnalysisClient Need: Physiological IntegrityNursing Process: AssessmentObjective:Learning Outcome 2-1: Define the key terms used in the skills of measuring vital signs.2
4)The nurse should assess vital signs at all of the following times except:A)When a client has a change in health status.B)On admission to the facility.C)Before and after ambulating the client.D)When a terminal client’s condition changes.Answer:DExplanation:A)When caring for a terminal client who has a do not resuscitate order, the nurse might not needto assess vital signs when his condition changes if it will not impact the plan of care, and deathis imminent. In all of the other situations, vital signs should be measured.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: PlanningB)When caring for a terminal client who has a do not resuscitate order, the nurse might not needto assess vital signs when his condition changes if it will not impact the plan of care, and deathis imminent. In all of the other situations, vital signs should be measured.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: PlanningC)When caring for a terminal client who has a do not resuscitate order, the nurse might not needto assess vital signs when his condition changes if it will not impact the plan of care, and deathis imminent. In all of the other situations, vital signs should be measured.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: PlanningD)When caring for a terminal client who has a do not resuscitate order, the nurse might not needto assess vital signs when his condition changes if it will not impact the plan of care, and deathis imminent. In all of the other situations, vital signs should be measured.Cognitive Level: KnowledgeClient Need: Physiological IntegrityNursing Process: PlanningObjective:Learning Outcome 2-2: Identify the indications for measuring and assessing:A.Temperature.B.Pulse.C.Respirations.D.Blood pressure.E.Oxygen saturation.3
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.5)The nurse is caring for several clients. Rank the order in which the nurse would assess vital signs on thefollowing clients:1.Client who is returning from the operating room after abdominal surgery.2.Client who will walk the hallway for the first time.3.Client who was febrile and required an antipyretic medication one hour ago.4.Client who is to be discharged this morning.Answer:1, 3, 2, 4Explanation:The client returning from the operating room is the nurse’s first priority because of the risk forrespiratory problems secondary to sedation. The client who was febrile must be assessed todetermine if the antipyretic was effective, and would be the next priority. The client who is waitingto ambulate would be next, while the client who is to be discharged later this morning would be thelast priority.Cognitive Level: ApplicationClient Need: Safe, Effective Care EnvironmentNursing Process: PlanningObjective:Learning Outcome 2-2: Identify the indications for measuring and assessing:A.Temperature.B.Pulse.C.Respirations.D.Blood pressure.E.Oxygen saturation.