2/22/2021 vSim for Nursing | Health Assessment
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vSim for Nursing > Health Assessment Case 3: Sara Lin >
Post-Simulation Quiz
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1 Suggested Reading
2 Pre-Simulation Quiz
3 vSim
4 Post-Simulation Quiz
5 Documentation Assignments
6 Guided Reflection Questions
Post-Simulation Quiz
Quiz Stats
N W d B k Q i l di 28 42 i
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2/22/2021 vSim for Nursing | Health Assessment
Name: Wendy Bartok Quiz completed in: 28.42 mins
Date: 2021-2-22 Time: 12:39:02 Questions answered: 10
Number correct: 4 (40%)
Answer Key
QUESTION 1: A patient diagnosed with appendicitis and scheduled for
surgery has been prescribed 5 mg of intravenous (IV) morphine
sulfate to manage the pain. It has been 4 hours since the
medication was last administered. Considering the
medication's peak effect and duration of effectiveness, which
intervention would the nurse implement?
Your Response: b) Assessing the patient's level of consciousness (LOC)
Correct Response: Reassessing the patient's pain level
Explanation: IV morphine sulfate has a peak of 20 minutes with a duration
of 4 to5 hours. It is appropriate for the nurse to reassess the
patient's pain level for the administration of another dose of
morphine sulfate if needed. Although assessing and monitoring
the patient's blood pressure and level of consciousness are
appropriate because of morphine's effect on the central
nervous and cardiovascular systems, the greatest effects
would be observed at the medication's peak, rather than at
the end of its period of duration. Reassessing the abdomen is
not related to medication management.
Lippincott Advisor, Drugs: Morphine hydrochloride
QUESTION 2: A patient diagnosed with acute appendicitis is experiencing
abdominal pain and asks for a heating pad, stating, "Heat
always makes me feel better when I have cramps before I
menstruate.” What is the nurse's response to the patient's
request?
Your Response: Correct!
Correct Response: I'm sorry but in this situation the heat from the heating pad
might cause your appendix to rupture.
Explanation: When dealing with appendicitis, diagnosed or suspected, never
apply heat to the abdomen, especially the right lower
quadrant. Although the heat may provide comfort to some
patients, because it can cause the inflamed appendix to
rupture, itis not an appropriate intervention. Although
elevating the bed and providing pain medication is not
inappropriate, doing so does not address the patient's need for
education regarding the danger of such a request.
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2/22/2021 vSim for Nursing | Health Assessment
Lippincott Advisor, Diseases and Conditions: Appendicitis
QUESTION 3: A patient is demonstrating signs and symptoms associated with
appendicitis. Which laboratory result supports the diagnosis of
appendicitis?
Your Response: Correct!
Correct Response: A white blood cell (WBC) count of 24,000 cells/mcL
Explanation: A normal WBC count is from 4,500 to 10,500 cells/mcL (SI, 4.5
to 10.5 × 109/L). An elevation to 24,000 cells/mcL would
indicate that an inflammation or infection is present within
the body. The other options are all normal values that are not
associated with possible appendicitis.
Lippincott Advisor, Diseases and Conditions: Appendicitis
QUESTION 4: A patient diagnosed with appendicitis is scheduled for surgery.
How will the nurse best ensure that the patient's data,
obtained through nursing assessment, monitoring, and care
interventions are appropriately shared with interdisciplinary
care team members?
Your Response: a) Use facility-approved forms to document assessment data
Correct Response: Add appropriate, inclusive documentation to the patient's
medical record
Explanation: Effective, inclusive documentation ensures that information
about the patient and family is easily accessible to members
of the health care team, provides a vehicle for
communication, and prevents fragmentation, repetition, and
delays in carrying out the plan of care. The other options are
appropriate at specific times or for specific documentation
activities.
Weber and Kelly, Health Assessment in Nursing, 6th
Edition, p. 45
QUESTION 5: A nurse is assessing the abdomen of a patient reporting pain
and constipation. Which interventions would best help
minimize barriers to the auscultation of the patient's
abdomen? (Select all that apply.)
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2/22/2021 vSim for Nursing | Health Assessment
Your Response: a) Use a properly fitted stethoscope
b) Select an environment that is quiet
d) Warm your hands before touching the patient
e) Drape the patient appropriately so that the abdomen is
easily assessable
Correct Response: Use a properly fitted stethoscope
Select an environment that is quiet
Explanation: Auscultation is most successful when performed in a quiet
environment with a properly fitted stethoscope. Although the
remaining options are appropriate, they are not directly
associated with auscultation.
Lippincott Procedures: Assessment techniques
QUESTION 6: Which patients under a nurse's care require a comprehensive
pain assessment? (Select all that apply.)
Your Response: Correct!
Correct Response: A patient who is being prepared for postoperative physical
therapy
A patient medicated with morphine sulfate 20 minutes ago
A patient transferred from intensive care unit to a medical
unit
A patient being admitted to the unit
Explanation: Comprehensive pain assessments should be performed when: a
clinician assumes care of the patient; if the patient's status
changes; if the patient demonstrates signs of pain or is
subjected to a presumably painful event; if a change in
analgesic medication occurs; or within the expected peak time
of an administered pain medication. If an intervention is
performed, the pain level should be assessed before the
intervention and within 1 hour after the intervention to assess
the patient's response. Although anxiety is an issue that must
be addressed, it is not always associated with pain and thus is
not managed with pain medication.
Lippincott Procedures: Pain assessment
QUESTION 7: What assessment information will serve as a baseline for the
pain management provided by the nursing staff of a medical-
surgical unit? (Select all that apply.)
Your Response: Correct!
Correct Response: The patient states "Nothing I do makes it hurt less "
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2/22/2021 vSim for Nursing | Health Assessment
Correct Response: The patient states, Nothing I do makes it hurt less.
Pain is described as sharp and stabbing.
Pain began 18 hours ago.
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