3306 quizzes for exam 1

The nursing instructor is teaching about health assessment and explains to students how to assess the roles and relationships of the client. The students know that this type of information is assessed in what type of assessment?

functional assessment

When caring for clients in any health care environment, what is the most important technique for preventing infection?

hand hygiene

What does HOH stand for?

hard of hearing

The three major frameworks to organize assessment findings include the functional assessment based on Gordon's functional patterns, the systematic ___________ assessment, and body systems assessment.

head to toe

Which formula will the nurse use to calculate cardiac output?

heart rate x stroke volume

A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

inspect the area

A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being worst pain. What characteristic of pain is the nurse assessing?

intensity

Active _________ is the ability to focus on a patient and his or her perspectives.

listening

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

melanome

A 62 year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

myocardial infaction

What does PERRLA stand for?

pupils equal, round, reactive to light and accommodation

An oxygen ______________ level less than 85% indicates inadequate oxygenation to the tissues

saturation

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump?

size

What tool does the nurse use to auscultate the client's abdomen?

stethoscope

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse noted considerable skin tenting. Why does this finding require further assessment?

tenting indicates dehydration

The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of

the loss of accommodation

To make a legal entry into the medical record, the nurse must document what

time of assessment

A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea.

true

All nursing practice revolves around the nurse-patient relationship.

true

Critical thinking is used to determine what assessment data to report to whom and how quickly and by what method.

true

Maintaining fluid balance is one function of the lymphatic system.

true

One extremity cooler than the other indicates arterial insufficiency.

true

The general survey includes overall appearance, hygiene and dress, skin color, body structure and development, behavior, facial expression, level of consciousness, speech, mobility, posture, range of motion, and gait.

true

The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways.

true

When using an otoscope to assess the inner ear the nurse should hold the patient's ear at the helix, lifting up and back for best visualization.

true

During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that The client describes pain at the ulcer site as achy. The nurse suspects the client may have what?

venous insufficiency

What techniques can be performed when palpating the breasts? Select all that apply.

vertical, wedge, circular

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this?

3+ pitting edema

A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?

A recently retracted nipple that was previously everted

Which principle should guide the nurse's approach when conducting a general survey on an older adult client?

Allow the client time to answer questions

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?

Chronic obstructive pulmonary disease

HIPAA gives clients greater control over their medical records. What else does HIPAA provide?

Client recourse if privacy protections are violated

A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?

Deep vein thrombosis (DVT)

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data?

Ineffective Tissue Perfusion

A client comes to the clinic reporting pain in her legs while walking. the client states the pain is goes away when resting. The nurse suspects the client is experiencing what?

Intermittent claudication

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen to the lungs starting in the apices.

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Orthopnea

what are the six Ps of arterial occlusion

Pallor Pain Paresthesia Paralysis Pulselessness Poikilothermia

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique?

Palpating carotid pulses simultaneously.

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound?

Pericardial friction rub

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

Right carotid bruit auscultated

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

S1

Effective verbal communication among the health care team may be organized using the ___________ framework.

SBAR

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic pressure 180 mm Hg.

he sternal angle at the right 2nd rib space is also known as what?

The aortic area

he nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes

The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?

The ulcer is necrotic

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

To establish a database against which subsequent assessments can be measured

The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?

Use the flat pads of three fingers

Acute pain can be differentiated from chronic pain because

acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months whereas chronic pain persists longer than 6 months

A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use?

braden scale

When assessing the lower extremities, it is critical that the examiner

compares side to side.

A nurse performs a comprehensive assessment on a client. Which is included only in a comprehensive assessment?

complete health history

Peripheral vision is evaluated by the nurse using the

confrontation test

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis