Focused Assessment 1 Prep U
A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the abdomen. Which of the following would the nurse perform next? a. Auscultation b.Percussion c.Palpation d.Perirectal examination
A
According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment? A. Location, onset, alleviating factors, and aggravating factors B. Quality, location, intensity, and family history C.Nutritional deficiencies, onset, duration, and effects of pain D.Intensity, variations, range of motion, and the client's goal for pain control
A
Assessment of a patient's bowel sounds is best obtained by performing which assessment technique? a.Auscultation b.Inspection c.Palpation d.Percussion
A
To assess subjective data related to a client's elimination pattern, the nurse a.Reviews the latest laboratory report of the urine b.Asks the client about changes in elimination patterns c.Notes the frequency, amount, and time the client voids d.Palpates the abdomen for pain or distention
A
Which of the following describes awakening at night to urinate? a. Nocturia b. Polyuria c. Oliguria d. Dysuria
A
The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (Select all that apply.) a.Encourage deep breathing. b.Play the client's favorite music. c.Promote a restful environment. d.Encourage increased protein. e.Encourage the use of a sitter.
A,B,C
When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order? a.Palpation, percussion, inspection, auscultation b.Percussion, auscultation, inspection, palpation c.Inspection, auscultation, percussion, palpation d.Inspection, percussion, auscultation, palpation
C
Which of the following is the first portion of the small intestine? a. Pylorus b. Peritoneum c. Omentum d. Duodenum
D
The nurse collects a urine sample from a client for urinalysis. Which of the following would the nurse document as a normal characteristic? a. Light yellow color b. Cloudy appearance c. Presence of mucus shreds d. Ammonia odor
a
The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. a."How long have you experienced this pain?" b."Please point to where you are experiencing pain." c."You've never had this pain before, have you?" d. "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." e."What aggravates your chest pain?"
a, b, d, e,
A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: a. initiate a stream of urine. b. breathe deeply. c. turn to the side. d. hold the labia or shaft of the penis.
b. breathe deeply
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? a.Loss of small amount of urine when intraabdominal pressure rises b.Need to void perceived frequently, with short-lived ability to sustain control of flow c.Loss of urine control because of inaccessibility of a toilet d.Loss of urine without any identifiable pattern or warning
d
A nurse is using inspection as an assessment technique. What does the nurse use during inspection? a.equipment such as a stethoscope b.both hands to produce sounds c.light palpation to detect surfaces d. senses of vision, hearing, smell
d
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? a. "Are you having pain?" b. "Is the pain constant?" c. "How does the pain medication make you feel?" d. What does the pain feel like?"
d. What does the pain feel like?
Definition of Auscultation?
listening to organ sounds with a stethoscope
