Author Question: While preparing a client for a procedure, the nurse notes that the client has become unresponsive ... (Read 66 times)

nramada · **on:** Jul 23, 2018

While preparing a client for a procedure, the nurse notes that the client has become unresponsive and respirations have become shallow. What type of assessment should the nurse complete at this time?

1. Initial assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed assessment

Question 2

Unlicensed assistive personnel measure a newly admitted client's vital signs to be: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. What should the nurse do to validate this data?

1. Retake the vital signs.
2. Call the physician.
3. Continue with the physical assessment as soon as possible.
4. Report the findings to the charge nurse.

matt95 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: Initial assessment is performed within a specific time after admission to a health care agency.
Rationale 2: Problem-focused assessment is an ongoing process integrated with nursing care.
Rationale 3: An emergency assessment is performed during any physiologic or psychologic crisis of the client to identify life-threatening problems.
Rationale 4: Time-lapsed assessment occurs several months after the initial assessment to compare the client's current status to baseline data previously obtained.

Answer to Question 2

Rationale 1: Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate.
Rationale 2: Calling the physician would be premature.
Rationale 3: The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated.
Rationale 4: Reporting the findings to the charge nurse before they have been validated would be premature.