24 a client has illuminated his call light and tells

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nurses to perform handoff as quickly as possible. 24. A client has illuminated his call light and tells the nurse that he is having ìten out of tenî pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? A) Ask the client to repeat his rating of his pain. B) Observe the client for several seconds to see if his demeanor or his behavior changes. C) Consult the client's medication administration record (MAR) to check for recent analgesic use. D) Perform further assessments addressing various aspects of the client's pain.
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Page 6 25. A hospital nurse is admitting a client with a documented history of acute pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding would most clearly warrant validation? A) The client's blood pressure is 148/88 mm Hg. B) The client is oriented to person and place but not to time. C) The client states that she only drinks alcohol on a social basis. D) The client states, ìMy skin's kind of yellow because of my liver.î 26. A small, rural hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met? A) Expand the use of the Nursing Minimum Data Set. B) Eliminate the use of verbal handoffs between nurses. C) Increase interdisciplinary collaboration in the hospital . D) Increase the use of electronic health records (EHRs) in the hospital. 27. The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data? A) The man has male pattern baldness. B) The man has a diffuse rash on his torso. C) The man's heart rate is 63 beats per minute. D) The man had an inguinal hernia repair in 2008. 28. There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many caregivers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite? A) Increased influence for the nursing profession B) Elimination of documentation C) Improved continuity of care D) Reduced nursing workload 29. While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? A) ìPossible pressure ulcer observed over client's coccyx region.î B) ìReddened area noted on skin surface superficial to client's coccyx.î C) ìArea of nonblanching erythema noted over client's coccyx, 2 cm ◊ 2 cm.î D) ìImpaired Skin Integrity related to decreased mobility.î Page 7
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