chapter 30 jensen

The nurse completes the assessment of a client's reflexes. Which position should the nurse place the client to assess the Romberg sign? prone supine sitting standing

standing

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care? Decreased activity level Altered nutrition Fatigue Depression

Fatigue

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? "I try not to let the pain affect my life." "I haven't had a checkup in over 5 years." "I had my appendix removed when I was 14 years old" "I have an aunt who had breast cancer."

"I haven't had a checkup in over 5 years."

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test? "Tell me which number I am tracing on your back with my finger." "Quickly flip your hands back and forth on your knees as I demonstrate." "Touch the tip of your nose, then the tip of my finger as I move my finger." "With your eyes closed, identify the object I place in your hand."

"With your eyes closed, identify the object I place in your hand."

A nurse knows that a normal capillary bed refills in how many seconds? Less than 1 1 to 2 3 to 4 5 to 6

1 to 2

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding? Ask for the client's permission to perform the assessment Decide whether to alter the process of starting at the head and proceeding to the feet Uncover only the part being examined, covering everything else Ask if the client wants an observer for the assessment

Ask for the client's permission to perform the assessment

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority? Troubleshooting the infusion pump Talking with family members Assessing nutrition Assessing for pain

Assessing for pain

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Call bell within reach Bed at mid-level, locked position Correct intravenous lines and fluids Wearing client identification bracelet Correct tubes and drains intact

Call bell within reach Correct intravenous lines and fluids Wearing client identification bracelet Correct tubes and drains intact

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client? Collaborate with the physician to treat anemia Evaluate adequacy of exercise Evaluate urinary patterns Have the client explain an energy-conservation plan to offset the effects of fatigue

Collaborate with the physician to treat anemia

The nurse is assessing an adult client with a family history of stroke. The nurse should contact the healthcare provider immediately due to which assessment finding? Redness and swelling over the sinuses Immobile lymph nodes Diminished carotid pulses Conductive hearing loss

Diminished carotid pulses

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client? Administer a nebulizer treatment Order a chest x-ray Begin antibiotic therapy through intravenous route Encourage turning, coughing, and deep breathing

Encourage turning, coughing, and deep breathing

The nurse has a hand-held Snellen. When in the sequence of assessment should the nurse assess visual acuity? General assessment Eye assessment Beginning of exam End of exam

Eye assessment

When discussing health assessment, the nursing instructor would tell the students that potential or actual problems are identified in order to focus on areas requiring what? Psychological testing Interdisciplinary collaboration Nutritional supplementation Health teaching

Health teaching

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms? Hypokalemia Hyperkalemia Hyponatremia Hypernatremia

Hyponatremia

An adult client is brought via ambulance to the emergency department. Vital signs are blood pressure 84/62, pulse 122 beats/min, respirations 36 breaths/min, temperature 37.4°C (99.3°F), and oxygen saturation 78% on nonrebreather mask at 10 L of oxygen. The client is anxious and sitting in the tripod position. Which problem does the nurse need to address immediately? Oxygen saturation of 78% Pulse of 122 Respirations of 36 BP of 84/62

Oxygen saturation of 78%

The nurse would auscultate for voice sounds during which part of the comprehensive examination? Posterior chest Abdomen Head and face Neck

Posterior chest

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed? Fibrinous Serous Sanguineous Purulent

Sanguineous

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland? Standing in front of the client, place the fingers just below and under the mandible Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage Standing in front of the client, hook the fingers into the clavicle and press firmly and deeply Standing behind the client, place fingers at the base of the ears and palpate along the sternomastoid muscle on either side

Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? Ophthalmoscope Tuning fork Tongue depressor Stethoscope

Tuning fork

The nurse is performing a head-to-toe assessment of a client. What would be an example of information obtained during the review of the client's body systems? Wears dentures; denies problems with eating, chewing, and swallowing. States her father died of a heart attack at age 70. Uses over-the-counter antacid for occasional heartburn. Vaginal delivery of two children without complications.

Wears dentures; denies problems with eating, chewing, and swallowing.

How should a nurse assess graphesthesia as a part of the physical assessment of arms, hands, and fingers? Write a number in the palm of the client's hand Place a quarter or key in the client's hand Ask the client to touch finger to nose with eyes closed Evaluate sensitivity of position of fingers

Write a number in the palm of the client's hand

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? Write a number in the palm of the client's hand Place a quarter or key in the client's hand Ask the client to touch finger to nose with eyes closed Evaluate sensitivity of position of fingers

Write a number in the palm of the client's hand

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? hand grasps bowel sounds cranial nerves carotid arteries

carotid arteries

A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client? urgent focused complete evaluative

complete

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side? validate findings identify problems determine symmetry compare with the medical record

determine symmetry

When obtaining subjective data from a new patient, you focus primarily on evaluating risk factors assessing family cohesion assessing the patient's use of alcohol assessing the patient's coping ability

evaluating risk factors

Two body systems that may be logically integrated and assessed at the same time are the eye and ear exams. eye exam and cranial nerves II, III, IV, and VI. ear exam and cranial nerves IV, VI, and VIII. ear and nose exams.

eye exam and cranial nerves II, III, IV, and VI.

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose? otoscope pen light cotton swab ophthalmoscope

otoscope

The nurse is preparing to assess a client's anterior thorax. In which position should the client be placed to assess the heart? sitting supine standing right lateral

sitting

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason? to assess pedal pulses to auscultate the lungs to assess jugular venous pressure to check the radial pulse

to auscultate the lungs

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame? 2 hours 1 hour ½ hour ¼ hour

½ hour

The nurse will palpate a client's axillae during a head-to-toe assessment. The nurse should combine this with examination of which area? Neck Anterior chest Heart Breasts

Breasts

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage? Hearing loss Puffy "moon" face Tongue deviation Asymmetrical smile

Asymmetrical smile

A client has a nursing diagnosis of ineffective coping related to repeat episodes of diarrhea and financial stressors. Which of the following is an appropriate intervention for this nursing diagnosis? Gradually increase activity as tolerated Accurately assess stressors and effectiveness of coping methods Monitor effectiveness of medication used to treat diarrhea Monitor intake and output

Accurately assess stressors and effectiveness of coping methods

A new nurse is learning how to perform a head-to-toe assessment. Her preceptor correctly tells the new nurse that it's best to do the musculoskeletal examination with range of motion before assessing the cardiac and respiratory status. True False

False

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? Mental status examination Head and face Ears Mouth and throat

Head and face

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed? Hospital policy Supervising physician State's nurse practice act Federal law

State's nurse practice act

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which principle? The client has the right to refuse the assessment. Obtaining permission enhances therapeutic rapport. The client will be more willing to disclose after giving permission. The client's level of comfort will be increased by granting explicit consent.

The client has the right to refuse the assessment.

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? The client has the right to refuse. Permission maintains the client's confidentiality. It ensures that the client will answer personal questions. The client's level of comfort will be increased

The client has the right to refuse.

The nurse is preparing to gather equipment prior to a client's head-to-toe assessment. The nurse's selection of equipment should be based primarily on what variable? The nurse's time allowance The nurse's level of expertise The client's health needs The client's level of participation

The client's health needs

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound? Bronchial Vesicular Tracheal Bronchovesicular

Vesicular

Before beginning a physical assessment it is important for the nurse to explain to the client in detail how each body system will be assessed. explain to the client the purpose of every physical assessment technique you will be using. acquire your client's verbal permission to perform the physical examination. acquire your client's written permission to perform the physical examination.

acquire your client's verbal permission to perform the physical examination.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? after assessing the abdomen after assessing cranial nerve function after assessing the anterior and posterior thorax after assessing the motor function of the lower extremities

after assessing the motor function of the lower extremities

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique? assess abdominal reflex determine the liver border find the lower pole of the left kidney change the character of bowel sounds

assess abdominal reflex

When integrating the total physical examination the nurse should perform the Mental Status Exam after examining all other body systems. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. assess peripheral vascular status when examining the lower extremities. integrate the rectal examination with the abdominal examination.

assess peripheral vascular status when examining the lower extremities.