HA preps

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

-A child is persistent in trying to please a parent. -A caregiver of a cognitively intact older adult dominates the interview. -A preschooler rubs her perineum and complains of it hurting.

Which clients are most at risk for depressive symptoms? (Select all that apply.)

-Chronically ill clients -Females -Divorced clients

What included in personal protective equipment? Select all that apply

-Gloves -Gown -Mouth, nose, eye protection

The nurse has completed a comprehensive assessment and physical examination on a 52-year-old client at a community clinic. The nurse has collected supportive and abnormal cues. Which statement best identifies how the nurse will use supportive and abnormal cues? Select all that apply

-Identify areas where the client's health can be improved -Identify a risk for client concerns -Decrease client concerns

Which of the following techniques are used in a physical assessment? Select all that apply

-Inspection -Palpation -Auscultation

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which client would the nurse most likely expect to facilitate a referral?

A 50-year-old client newly diagnosed with diabetes

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?

After assessing for cigarette use

What term is used to describe the degree of vascular resistance to ventricular contraction?

Afterload

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?

Analyze the data

The nurse is reviewing the medical record of a newly admitted client to the rehabilitation center. Which subjective question should the nurse confirm with the client?

Are you aware of any allergies that you may have?

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment?

Asking the appropriate questions

The nurse is attempting to cluster the data collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next?

Assess the client further for evidence of reduced mobility and decreased range of motion

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds?

Auscultate to determine the heart rate and if the rhythm is normal

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?

Blood

A nurse is creating a genogram of a client's family health history. The nurse should use which of the following symbols to denote the client's female relatives?

Circle

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross

The nurse plans time to sit with a client to help address the client's spiritual needs. Why is this important?

Clients are holistic beings consisting of body, mind, and spirit

A client comes to the emergency department wanting to be examined for the symptom of chest pain. While listening to the client describe his symptom in more detail, the nurse says "Go on," then later "Mm-hmmm." This is an example of which of the following skilled interviewing techniques?

Continuers

While gathering data for the family history portion of the health history, what would you ask about?

Coronary artery disease

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?

Do you perform any sustained or continually repetitive motions with that arm?

A client from Italy who became ill while visiting America is admitted to the medical floor. When admitting this client, the nurse should include which of the following questions?

Do you use any special remedies or treatments back home?

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

Establish a baseline for the comparison of future health changes.

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

When does the nurse screen for alcohol and drug use?

Every client/every client history

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?

Eye-openers

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the client's pain, what is the most appropriate pain assessment tool for the nurse to use?

FACES Pain Scale

A genogram is developed to visually show what?

Family health patterns

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

Grade 5

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

Hand hygiene

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock

During the health history inquiry about alcohol intake, which of the following is a CAGE question?

Have you ever felt annoyed by criticism about drinking?

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of

Healthy People 2020

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

The nurse would use the tuning fork to assess for what?

Hearing loss

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

Inspection, palpation, percussion, auscultation

The nurse wants to support a client's spirituality. To do so, what must the nurse do first?

Keep an objective perspective and meet the client at his or her level

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

Nursing intervention -used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence

A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?

Observe for a decrease in jugular venous pressure

The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?

Past history

The nursing student demonstrates a need for further teaching when she states which of the following?

Patients do not need to understand their problems

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview?

Remain in control and allow the client to vent feelings

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

The nurse is assessing a client's ability to employ coping mechanisms when given a diagnosis of cancer. What type of assessment would be beneficial for the nurse to use?

Spiritual assessment

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen

What must occur before a client will be willing to teach the nurse about her culture?

The nurse needs to establish rapport and trust

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

To clarify

A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is

analyze the data

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's

apex of the heart.

A nurse is conducting a health assessment. How will the information collected from the client be used?

as a basis for the nursing process

Which statement would demonstrate the correct method for writing an evaluation of client progress after implementing the nursing process?

client ambulated 3/3 times during a planned 8-hour period

The nurse is drawing inferences from collected data. What action did the nurse complete immediately before beginning this step of the process?

clustering cues

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive

When planning a community program related to Healthy People 2020, the critical first step involves

defining the community

The nurse uses the Mini-Mental State Examination to assess a client. For which reason is this assessment tool most likely used?

dementia

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?

depression

When the nurse collects objective data, which finding requires immediate follow-up?

enlarged lymph node in the neck

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental

The nurse is observing an older adult client dress and groom as part of a mental health assessment. Which finding indicates that the client may need further follow-up related to a cerebral vascular accident (CVA)?

extreme unilateral neglect

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

focused

A 38-year-old client has been admitted to the emergency department (ED) with reports of abdominal pain and vomiting for the past 6 hours. Which type of assessment will the nurse complete on this client?

focused assessment

The nurse notes that an intervention provided to a client for a specific health problem was not effective. The nurse continues to monitor and care for the client. Which type of assessment is the nurse performing?

ongoing or partial assessment

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention

The nurse is preparing to complete a comprehensive assessment of a newly admitted client. Why is the nurse completing this type of assessment?

provides a baseline for future assessments

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

reflex hammer

The nurse is completing an assessment on a new client at the community health clinic and would like to screen the client's cognitive ability. There are many resources that provide screening tools for nurses. Which agency would be most helpful in directing the nurse to a screening tool to assess the client's cognitive ability?

the Alzheimer's Association (AA)

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply

-Speak clearly -Avoid jargon -Show respect -Use simple terms

The nurse is gathering objective information from the medical record of a newly admitted client to the medical-surgical unit of an acute care facility. Which of the following data would the nurse consider as a priority in assessing the client? Select all that apply.

-clients medical diagnosis -recent abnormal findings -recent changes in BP

The obstetric nurse is performing an initial assessment of a pregnant woman. Which subjective data will the nurse include in the assessment? Select all that apply.

-health care practices -personal medical history -number of pregnancies

The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply.

-spiritual -physiologic -sociocultural -psychological -developmental

A nursing instructor asks students to list culturally based characteristics. The students should include which of the following? (Select all that apply

-touch -eye contact -time -diet

During the mental status assessment of a new client, the nurse has asked the client to describe some of the similarities and differences between a tennis ball and a soccer ball. Despite adequate time and cuing, the client is unable to state any similarities or differences. The nurse should document what assessment finding?

A deficit in abstract reasoning

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning

A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

Blood pressure

Which of the following statements is true about biologic variation?

Both genetics and environment produce biologic variation

The nurse assesses a client's neck as shown. What is the nurse assessing?

Carotid artery

A nurse is participating in an educational exercise in which she is conducting a self-examination of her own biases. This activity addresses what construct of cultural competence?

Cultural awareness

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Ensure that contact with the skin is maintained

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds?

Erb point

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?

Focused assessment

A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?

Have you thought of hurting yourself?

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

Head-to-toe

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

How do you manage your stress?

During the interview, the client states, "Is today the 12th? My wife died 2 months ago today." Which of the following responses would be most appropriate?

How does that make you feel right now?

A nurse assesses the spirituality of a client who is terminally ill with pancreatic cancer. Which of the following is the best rationale for this action, from the nurse's perspective?

Identifying possible coping mechanisms

In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason?

Identifying the primary problems or patterns of concern

The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?

L

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile

A nurse is performing a spiritual assessment on a client that is diagnosed with aggressive form of lymphoma. What is the best intervention by the nurse to address the client's spiritual end of life issues if she is unable to?

Make a referral to the appropriate professional

A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. How would the students identify this layer?

Myocardium

Your client has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Data"?

None currently

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurses collaborate with clients to identify areas in which clients are willing to make changes

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the firstaction of the nurse?

Open the client's airway

During the interview process, the nurse obtains what type of data from the client?

Primary

As a nursing student you learn that mastering all the components of the comprehensive history provides what?

Proficiency

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information

The nurse utilizes the Depression Questionnaire on a client who has recently moved to a long-term care facility. The total score is 22. What would the nurse to do next?

Refer for further evaluation

What would be the expected tone elicited by percussion of a normal lung?

Resonance

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

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?

Sinus arrhythmia

A nurse is auscultating a client's heart sounds. What action should the nurse perform during this assessment?

Systematically listen to the entire precordium

A clinic nurse is conducting a comprehensive assessment of a client. The nurse observes that the client rarely makes eye contact and holds his head low during the assessment. Using knowledge of cultural practices how should the nurse best interpret this practice?

The client may be showing the nurse respect

Which is an example of subjective data from a primary source?

The client states, "My chest hurts and my left arm feels numb."

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

The exam can provide clues about the validity of the client's responses now and throughout

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

Uses evidence-based techniques

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation

A nurse is caring for a client in the mental health unit. The client states, "They are poisoning my food by telepathy." This is an example of which types of delusion?

paranoid

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status

The anterior chest area that overlies the heart and great vessels is called th

precordium

The nurse is taking a health history on a newly admitted client. When the nurse asks, "How would you describe yourself?" the nurse is assessing which of the following?

self-perception/self-concept

A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?

time

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?

working

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

Heart sounds

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

Which of the following would be most important for a nurse when developing critical thinking skills?

Maintenance of an open mind

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words

The nurse is setting an outcome with the client experiencing spiritual distress. Which goal would be appropriate?

The client will express meaning and purpose in life

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment?

The diaphragm should be held firmly against the body part

The nurse prepares to complete a holistic assessment of a client with a chronic health problem. Which areas will the nurse include in this assessment? Select all that apply

-Spiritual -Physiologic -Sociocultural -Psychological Developmental

A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which direct result?

Nursing diagnoses

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain

The client states, "I cannot believe I have breast cancer. I am a good person; I don't know why God is punishing me." The nurse suspects the client is experiencing

Spiritual distress

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

Flat neck veins

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time?

Sexual history

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?

Summation gallop

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

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information?

neurologic

Which of the following is the most important skill a nurse needs when conducting a mental status assessment?

Effective listening skills

A nurse has completed data analysis. Which of the following would the nurse identify first as the result?

Nursing diagnosis

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

Nursing diagnosis

While preparing a client for surgery, a nurse discovers that the client's view about spirituality is entirely different from hers. What is the most appropriate action by the nurse?

Respect the privacy of his spiritual beliefs and rituals

The client states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the client is at risk for

Suicide

The nurse is clustering abnormal and supportive cues after the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and reported "a bit of soreness" in the joint. The nurse identifies a client concern. What should the nurse do next?

Validate the client concern with the client and family

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

When assisting a client with health promotion, what must the nurse also nurture?

A healthy environment

The nurse should assess for which pain complaints from a client diagnosed with Type II Diabetes Mellitus?

Burning, tingling

Based on a colleague's feedback, a nurse learns that she is aware of cultural differences in a general way but does not know what the specific differences are or how to communicate with a person of a specific culture. This nurse exhibits which of the following?

Conscious incompetence

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client?

Low-fat, low-cholesterol meals

A client arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The client begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?

Emergency

After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when they state which of the following?

Nursing has only recently begun to incorporate spirituality into client care

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders.

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis.

After assessing a type 1 diabetic client who states they are unable to pay for their prescribed insulin, the nurse includes this information in the cluster of cues collected during the assessment. In which phase of the nursing process will this take place?

Step 2

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

What diseases did you have as a child?

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

What other symptoms occurred during the spell?

Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate?

You're certainly justified in being upset, but I am ready to begin your exam now

The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to

allow the client to verbalize his or her feelings

A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to:

lie on the back with the legs together on the examining table

A nursing instructor is discussing mental health assessments with students. In what situations would the instructor tell the students an acute mental health assessment is necessary?

A situation that involves danger of harm to self or others

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

What do you do if you have pain?

If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts

is important and will not stimulate the thought of suicide

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.

-To help identify those diseases for which the client may be at risk -To provide counseling and health teaching in high-risk areas -To identify genetic family trends for which the client is at risk

A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?

Characteristic

The nurse is attempting to understand how the concept of critical thinking relates to how critical thinking is demonstrated in the nursing practice. Which statement indicates a basic understanding of how critical thinking is displayed in the nurse's interaction with clients and colleagues? Select all that apply

-explores and considers alternatives prior to making a clinical judgment -asks the client for more information when additional understanding is required -validates data and clinical judgments with other experts in the field -uses past knowledge and experience when analyzing data

Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle?

Carotid artery

A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do?

Check for pulse inequality between right and left carotid arteries

During a spiritual assessment the nurse realizes that personal beliefs differ significantly from those of the client. What should the nurse do?

Continue with the assessment

After completing an admission assessment the client asks if the room door can be closed so that the client can have silence when reading the Bible. What does this indicate to the nurse about the client's spirituality?

Reading the Bible provides comfort to the client

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

Review the client's medical record

When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?

Show genuine interest in the client's culture and personal life experiences

The client states "What does it matter? I have no purpose in this life." This client is questioning what?

Spirituality

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should

avoid premature judgments about the client

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)

focused or problem-oriented assessment.

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis