Health assessment exam 1
An unconscious 22-year-old man arrives at the hospital after experimenting with hallucinogenic substances. His vital signs are temperature 37.2°C, orally; pulse 142 beats/min; respirations 20 breaths/min; BP 100/64 mm Hg. The patient is experiencing A.tachycardia. B.eupnea. C.auscultatory gap. D.asystole.
A.tachycardia.
Which of the following interventions is most important to prevent nosocomial infections? A.Proper glove use B.Hand hygiene C.Appropriate draping D.Quiet environment
B.Hand hygiene
The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the A.preinteraction phase. B.beginning phase. C.working phase. D.closing phase.
C.working phase.
The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is A."Don't cry. It will be OK." B."My mother has the same thing." C."I think that you should have surgery." D."I'll stay with you" (gets a tissue).
D."I'll stay with you" (gets a tissue).
The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is A."You must be extremely worried." B."I'd be in worse shape than you are if it were my baby." C."Is there anyone here that you can talk to?" D."You seem worried, but I need to ask a few questions."
D."You seem worried, but I need to ask a few questions."
Which of the following is an example of inspection? A.Heart rate and rhythm regular B.Lungs clear C.Abdomen tympanic D.Skin pink
D.Skin pink
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing a. deep palpation. b. very deep palpation. c. moderate palpation. d. light palpation.
a. deep palpation
The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing? a. peripheral vascular b. gastrointestinal c. respiratory d. genitourinary
a. peripheral vascular
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in? a. Standing b. Lithotomy c. Supine d. Prone
b. Lithotomy
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? a. consider using it when planning care b. include in the past medical history c. create a genogram d. document it in a narrative note
c. create a genogram
What physical assessment technique should a nurse use to obtain a pulse on a client? a. Bimanual palpation b. Moderate palpation c. Deep palpation d. Light palpation
d. Light palpation
The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus? a. activity-exercise b. sleep-rest c. self-perception/self-concept d. coping-stress-tolerance
d. coping-stress-tolerance
What would be the expected tone elicited by percussion of a normal lung? a. Resonance b. Dullness c. Tympany d. Hyper-resonance
d.resonance
The nurse is auscultating a client's blood pressure and identifies the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds. This is known as which of the following? a. Diastolic value b. Auscultatory gap c. Korotkoff sounds d. Phase V
b. Auscultatory gap
The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds. a. True b. False
b. False
After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following? a. Phase V reflects the systolic pressure. b. Phase II sounds appear muffled and swishing. c. Phase IV sounds are clear and repetitive. d. Phase I reflects the diastolic pressure.
b. Phase II sounds appear muffled and swishing
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a. developmental history. b. physiologic status. c. level of functioning. d. holistic wellness status.
b. physiologic status.
A patient has just been diagnosed with diabetes. What would be the most appropriate nursing diagnosis for this patient? a. Ineffective coping b. Nutrition: less than body requirements c. Knowledge deficit d. Acute pain
c. Knowledge deficit
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) a. ongoing or partial assessment. b. initial comprehensive assessment. c. focused or problem-oriented assessment. d. emergency assessment.
c. focused or problem-oriented assessment.
How should the nurse place the ear of an adult when using the otoscope? a. Down and back b. Up and forward c. Down and forward d. Up and back
d. Up and back
To assess self-perception, the nurse asks A. "How would you describe yourself?" B."Are you having difficulty handling any family problems?" C."What gives you hope when times are troubled?" D."How do you usually deal with stress? Is it effective?"
A. "How would you describe yourself?"
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning steps of the nursing process A. I will determine the most important client problems that we should address B. I will review past medical history on the client's record to get more information C. I will go carry out the new prescriptions from the provider D. I will ask the client if the nausea has resolved
A. I will determine the most important client problems that we should address
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the clients MAR and noted the last dose of pain med was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse admin the med and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. assessment B. Planning C. intervention D. evaluation
A. assessment
A nurse is caring for a client who states, "I have to check with my partner and see if they think I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating
B. Reflecting
A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? select all that apply A. address the client with the appropriate title and their last name B. Use a mix of open and closed ended questions C. reduce environmental noise D. have the client complete a printed history form E. perform the general survey before the examination
B. Use a mix of open and closed ended questions C. reduce environmental noise E. perform the general survey before the examination
Which of the following strategies should a nurse use to establish a helping relationship with a client? A. make sure the communication is equally reciprocal between the nurse and client B. encourage client to communicate his thoughts and feelings C. give nurse-client communication no time limits D. allow communication to occur spontaneously throughout nurse-client relationship
B. encourage client to communicate his thoughts and feelings
A nurse is caring for a school-age child who is sitting in a chair. to facilitate effective communication, which of the following actions should the nurse take? A. touch childs arm B. sit at eye level with the child C. stand facing child D. stand with relaxed posture
B. sit at eye level with the child
An auscultatory gap is defined as A.a drop in the SBP of 15 mm Hg or more with position change. B.a period of silence heard between Korotkoff sounds. C.the difference between the apical and radial pulse. D.SBP minus the DBP.
B.a period of silence heard between Korotkoff sounds.
A nurse is caring for a client who is concerned about being discharged to home with a new colostomy bag because of being an avid swimmer. Which of the following statements should the nurse make? select all that apply A. "You will do great! You just have to get used to it" B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."
C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer risk
C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning client every 2hr to reduce pressure ulcer risk
Tympany is a percussion sound commonly located in the A.thorax. B.upper arm. C.abdomen. D.lower leg.
C.abdomen.
The nurse assessing an older adult focuses the health history on A.previous pregnancies, obstetrical history, and psychosocial factors. B.birth history, immunizations, and growth and development. C.sensory deficits, illness history, and lifestyle factors. D.religion, spirituality, culture, and values.
C.sensory deficits, illness history, and lifestyle factors.
Which of the following are components of a comprehensive health assessment? A.Nursing diagnoses B.Goals and outcomes C.Collaborative problems D.Examination of body system
D.Examination of body system
Which of the following processes is the most important when providing nursing care to an ill patient? A.Writing outcomes B.Performing a focused assessment C.Collecting objective data D.Using critical thinking
D.Using critical thinking
Latex allergies A.always result in anaphylactic reactions and shock. B.can be reduced by moisturizing the hands after washing. C.cannot be caused by equipment such as a stethoscope. D.are more common in nurses and in frequently hospitalized patients
D.are more common in nurses and in frequently hospitalized patients
Adult patients may have variations in pulse rates with A.respirations. B.food intake. C.heat. D.exercise.
D.exercise.
The nurse documents the following information in a patient's chart: "Cough and deep breathe every hour while awake." This is an example of A.evidence-based nursing. B.priority setting. C.comprehensive assessment. D.nursing interventions.
D.nursing interventions.
A client's blood pressure while lying supine is recorded as 124/76 mmHg. The nurse records the client's pulse pressure as which of the following? a.. 48 mmHg b. 76 mmHg c. 200 mmHg d. 32 mmHg
a.. 48 mmHg
When performing a physical assessment on an older adult client, what should the nurse consider offering this client? a. A pillow b. An extra blanket c. Elevation of the head of the examination table d. A family member in the room
b. An extra blanket
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? a. C b. L c. O d. D
b. L
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following? a. Pulse pressure b. Palpitation c. Dyspnea d. Apical beats
b. Palpitation
The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? a. Flatness b. Resonance c. Tympany d. Dullness
b. Resonance
A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam? a. Providing a comfortable, warm room temperature b. Explaining why standard precautions are being used c. Ensuring client's privacy by providing an examination gown d. Arranging exam equipment on a bedside tray table
c. Ensuring client's privacy by providing an examination gown
A nurse has assessed the blood pressure of a recently admitted patient and obtained a reading of 128/78 mm Hg. What is this patient's pulse pressure? a. 128 mm Hg b. 78 mm Hg c. 103 mm Hg d. 50 mm Hg
d. 50 mm Hg
When assisting a patient with health promotion, what must the nurse also nurture? a. Knowledge of the Healthy People 2020 indicators b. Family communication c. School/work attendance d. A healthy environment
d. A healthy environment
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? a. Otoscope b. Penlight c. Tuning fork d. Ophthalmoscope
d. Ophthalmoscope
A patient says that she is having throbbing pain that she rates as 6 on a 10-point scale. This is referred to as A.subjective primary data. B.subjective secondary data. C.objective primary data. D.objective secondary data.
A.subjective primary data.
A nurse measured the blood pressure of a client who has had a fractured femur. The blood pressure reading is 140/94 mmhg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an anti hypertensive med B. Ask the client if they are having pain C. Request a prescription for an anti anxiety med D. Return in 30min to recheck the clients BP
B. Ask the client if they are having pain
Nurses advocate for underserved populations to reduce health disparities. This promotes A.autonomy. B.altruism. C.respect. D.human dignity
C.respect.
Which of the following is an appropriate use of gloves? A.Gloves are worn during anticipated contact with intact skin. B.Gloves are removed when going from clean to contaminated areas. C.Gloves are worn during anticipated contact with body secretions. D.Gloves are removed when assessing the back of an incontinent patient.
C.Gloves are worn during anticipated contact with body secretions
Nurses advocate for underserved populations to reduce health disparities. This promotes A.autonomy. B.altruism. C.respect. D.human dignity.
C.respect.
What are the components of the SBAR? Select all that apply. a. Assessment b. Situation c. Recommendation d. Biophysical test results e. Referral
a. Assessment b. Situation c. Recommendation
Which of the following questions would be most important for the nurse to ask first when obtaining the health history? a. "Do you have adequate health insurance coverage?" b. "What is your major health concern at this time?" c. "Did you bring all your medications with you?" d. "Are you generally fairly healthy?"
b. "What is your major health concern at this time?"
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? a. Deep palpation b. Moderate palpation c. Light palpation d. Bimanual palpation
c. Light palpation
The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? a. gained 15 lbs. over the last 6 months b. experiences panic attacks several times a week c. misses seeing friends who used to go for walks together d. unable to go to the gym since having back surgery
d. unable to go to the gym since having back surgery
Which of the following is an example of a recent trend in nursing roles? a. Using auscultation to examine heart sounds b. Using palpation to assess the abdomen of a pregnant woman c.Performing visual inspection of a client's eyes to detect illness d.Gathering forensic evidence for a legal proceeding
d.Gathering forensic evidence for a legal proceeding
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A. Reassess the client to determine the reasons for unsatisfactory pain relief. B. See whether the pain lessens during the next 24 hr. C. Change the plan to ensure that the client achieves adequate pain relief. D. Teach the client about the plan of care for managing his pain.
A. Reassess the client to determine the reasons for unsatisfactory pain relief.
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data (select all that apply) A. Respiratory rate is 22/min with even unlabored respirations B. The client's partner states "He said he hurts after 10 min of walking C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limp
A. Respiratory rate is 22/min with even unlabored respirations D. Skin is pink, warm, and dry E. The assistive personnel report the client walked with a limp
which of the following actions should the nurse take when demonstrating an empathic presence to a client? select all that apply A. Use an open posture B. Write down what the client says to avoid forgetting details C. Establish and maintain eye contact D. Nod in agreement with the client throughout the conversation E. Sit facing the client
A. Use an open posture C. Establish and maintain eye contact E. Sit facing the client
A nurse in a provider's office is documenting his findings following an assessment he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. posture B. skin lesions C. speech D. allergies e. immunization status
A. posture B. skin lesions C. speech
When assessing a child, the nurse makes the following adaptation to the usual techniques: A.A pediatric stethoscope is used for better contact. B.The child is seated away from the parent. C.The room is full of toys for play. D.The child is undressed, including the diaper.
A.A pediatric stethoscope is used for better contact
the patient is complaining of abdominal pain. What technique is used to form an overall impression? A.Auscultation B.Light palpation C.Direct percussion D.Deep palpation
A.Auscultation
Which of the following findings during the general survey may indicate a change in mental status? Select all that apply. A.Disheveled appearance B.Rapid speech C.Lethargy D.Asymmetrical movements
A.Disheveled appearance B.Rapid speech C.Lethargy
The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse assesses that the patient is concerned because his father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient? A.Health belief model B.Diagnostic reasoning model C.Cultural competence model D.Body systems model
A.Health belief model
Which organs or body areas does the nurse auscultate as part of the admitting assessment? A.Heart, lungs, and abdomen B.Kidneys, bladder, and ureters C.Abdomen, flank, and groin D.Neck, jaw, and clavicle
A.Heart, lungs, and abdomen
Which actions will result in an inaccurate BP reading? Select all that apply. A.Obtaining a BP immediately after the patient has entered the room B.Using a BP cuff with a bladder length which is 80% of the arm circumference C.Asking the patient to hold out his or her arm above heart level D. Pumping the cuff 10mm Hg above the palpated systolic BP
A.Obtaining a BP immediately after the patient has entered the room B.Using a BP cuff with a bladder length which is 80% of the arm circumference D. Pumping the cuff 10mm Hg above the palpated systolic BP
Standard precautions A.are used on every patient because it is not always known whether a patient is infected. B.state that hand gel is used for infection with Clostridium difficile. C.include the use of gowns, gloves, and masks with all patients. D.recognize that transmission-based precautions are common.
A.are used on every patient because it is not always known whether a patient is infected
The nurse notes an irregular radial pulse in a patient. Further evaluation includes assessing A.for a pulse deficit. B.the carotid pulse. C.for diminished peripheral circulation. D.the brachial pulse.
A.for a pulse deficit.
The nurse conducts the health history based on the patient's responses to the medical diagnosis. This type of framework is based on the A.functional framework. B.objective framework. C.coordinator framework. D.collaborative framework.
A.functional framework
The purpose of health assessment is to A.obtain subjective and objective data. B.intervene to correct difficulties. C.outline appropriate care. D.determine whether interventions are effective.
A.obtain subjective and objective data.
Nurses belong to the ANA as part of their A.ongoing professional responsibility. B.role as manager of care. C.wellness promotion for patients. D.cultural education activities.
A.ongoing professional responsibility.
The nurse performs patient teaching after assessing that the nutritional history reveals that the patient generally consumes a high-fat, high-calorie diet. This critical thinking A.uses subjective data to analyze findings and intervene. B.documents and communicates data using appropriate medical terminologies. C.individualizes health assessment considering the age, gender, and culture of the patient. D.uses assessment findings to identify medical and nursing diagnoses.
A.uses subjective data to analyze findings and intervene
A nurse is preparing to perform a comprehensive physical examination on an older adult client. Which of the following interventions should the nurse use in consideration of the clients age? select all that apply A. expect the session to be shorter that for a younger client B. plan to allow plenty of time for position changes C. make sure the client has any essential sensory aids in place D. tell the client to take their time answering questions E. invite the client to use the bathroom before beginning the examination
B. plan to allow plenty of time for position changes C. make sure the client has any essential sensory aids in place D. tell the client to take their time answering questions E. invite the client to use the bathroom before beginning the examination
The nurse assesses the following vital signs in a 78-year-old man: temperature 36.6°C, temporal; pulse 72 beats/min, regular, 2+; respirations 18 breaths/min, regular, no use of accessory muscles; BP 142/92 mm Hg. Which of the findings is abnormal? A.Pulse B.BP C.Respirations D.Temperature
B.BP
The best way to assess a client's respiration rate is by: A.Place a hand over the client's chest and count for 30 seconds B.Observe and count respirations for 30 seconds and multiply by two without mentioning that you are observing the respirations. C.Ask the client to breath normally for one minute. D.If respirations are irregular have the client rest for 10 minutes and then recount.
B.Observe and count respirations for 30 seconds and multiply by two without mentioning that you are observing the respirations.
A patient is having adverse effects resulting from a medication. The nurse calls the primary care provider to request a change in the medication order. The nurse is functioning as a/an A.educator. B.advocate. C.organizer. D.counselor.
B.advocate.
A nurse in a provider's office is performing a physical examination on an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface E. Base of the fingers
C. Dorsal surface
The nurse who asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking is assessing A.whether the patient is a reliable historian. B.functional health patterns. C.ADLs. D.review of systems.
C.ADLs.
A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform on admission? A.Emergency B.Focused C.Comprehensive D.Illness
C.Comprehensive
What technique facilitates accurate auscultation? A.Earpieces of the stethoscope are positioned to point toward the back. B.The tubing of the stethoscope is long and dark in color. C.The chestpiece of the stethoscope is sealed against the skin. D.The diaphragm of the stethoscope is used for low-frequency sounds.
C.The chestpiece of the stethoscope is sealed against the skin.
The patient's radial pulse is weak and thready. The next action of the nurse is to A.transfer the patient to a critical care unit. B.notify the primary care provider. C.compare findings with previous findings and opposite extremity. D.assess vital signs every 15 minutes.
C.compare findings with previous findings and opposite extremity.
When gathering the family history, the nurse draws a genogram A.using circles for males and squares for females. B.putting the patient on the left to show birth order. C.inserting lines between parents to show marriage. D.listing health problems above the symbol for the patient.
C.inserting lines between parents to show marriage.
Which of the following patients should not have a temperature measured orally? A.An 84-year-old woman with diarrhea B.A 30-year-old patient with an earache C.A 45-year-old man with chest pain D.A 62-year-old woman who has had oral surgery
D.A 62-year-old woman who has had oral surgery
The nurse asks, "What are the most important things to you in life?" to assess the functional pattern related to A.role. B.self-perception. C.coping. D.values.
D.values.
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. "Do not measure the client's temperature rectally" b. "Count the client's radial pulse for 30 seconds and multiply it by 2." c. "Do not let the client know you are counting her respirations." d. "Let the client rest for 5 minutes before you measure her blood pressure."
a. "Do not measure the client's temperature rectally"
The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply a. Auscultation b. Palpation c. Percussion d.The medical record e. Inspection
a. Auscultation b. Palpation c. Percussion e. Inspection
The nurse is conducting an assessment of an older adult client who has a diagnosis of chronic heart failure. How can the nurse best assess the effects of the client's stroke volume? a. Calculate the difference between the diastolic and systolic pressures. b. Measure the strength of the radial pulse. c. Take the blood pressure while the client is standing. d. Add the radial pulse and the systolic blood pressure.
a. Calculate the difference between the diastolic and systolic pressures.
The information gathered during a general survey provides the nurse primarily with which of the following? a. Clues about the overall health of the client b. A direct link to the client's illness c. An indication of the level of anxiety experienced by the client d.Indications about normal variations in the status of body systems
a. Clues about the overall health of the client
When obtaining an oral temperature on a client, the nurse inserts the thermometer: a. Deep in the posterior sublingual pocket b. At the gum line between the check and tongue c. Just past the teeth below the tongue d. On either side of the frenulum at gingival level
a. Deep in the posterior sublingual pocket
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? a. Disinfect the stethoscope before touching the client b. Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface c. Put on a personal protection gown d. Disinfect the stethoscope after touching the client
a. Disinfect the stethoscope before touching the client
The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain? a. Facial grimacing, leaning forward b. Sitting upright, hands on lap c. Alert, talkative demeanor d. Regular, unlabored breathing
a. Facial grimacing, leaning forward
How would the nursing instructor explain the goal of guided questioning to his or her students? a. Facilitating the patient's fullest communication b. Providing the most plausible answer to the patient c. Developing a basis for accurate health promotion activities d. Creating an opportunity for the early generation of a plan
a. Facilitating the patient's fullest communication
In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? a. Inspection, palpation, percussion, auscultation b. Percussion, palpation, inspection, auscultation c. Inspection, auscultation, percussion, palpation d. Auscultation, percussion, palpation, inspection
a. Inspection, palpation, percussion, auscultation
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? a. Primary b. Tertiary c. Holistic d. Secondary
a. Primary
When recording the patient's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer: a. Quote the patient's words b. Paraphrase the patient's words c. Describe the patient's concerns and health goals d. Summarize the patient's words
a. Quote the patient's words
For which of the following assessments would the nurse plan to use light palpation? a. Skin temperature b. Size of liver c. Skin rash d. Shape of abdominal mass e. Skin texture
a. Skin temperature c. Skin rash e. Skin texture
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. a. Speak clearly b. Use simple terms c. Show respect d. Avoid jargon e. Use slang
a. Speak clearly b. Use simple terms c. Show respect d. Avoid jargon
The nurse is preparing to assess a client's vital signs. Which vital sign should the nurse assess first? a. Temperature b. Respiration c. Blood pressure d. Pulse
a. Temperature
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? a. Using a moderate amount of eye contact b. Minimizing facial expressions c.Standing while the client is seated d. Sitting across the room from the client
a. Using a moderate amount of eye contact
During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using? a. active listening b. summarizing c. empowering d. empathy
a. active listening
A client's blood pressure is affected by a. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity. b. cardiac intake, elasticity of the veins, blood flow, blood cells, and blood thickness. c. cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity. d. cardiac intake, elasticity of the arteries, blood flow, blood cells, and blood thickness.
a. cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (select all that apply) a. obtain culture specimens before initiating antimicrobials b. restrict the client's oral fluid intake c. encourage the client to rest and limit activity d. allow the client to shiver to dispel excess heat e. assist the client with oral hygiene frequently
a. obtain culture specimens before initiating antimicrobials c. encourage the client to rest and limit activity e. assist the client with oral hygiene frequently
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply). a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate d. count the rate for 30 sec if it is irregular e. count and report any sighs the client demonstrates
a. place the client in Semi-fowler's position b. have the client rest an arm across the abdomen c. observe one full respiratory cycle before counting the rate
The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's a. vital signs. b. ability to swallow. c. height and weight. d. gait.
a. vital signs
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension? a. 130/65 mm Hg b. 120/55 mm Hg c. 160/85 mm Hg d. 140/55 mm Hg
b. 120/55 mm Hg
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? a. Using the bell to detect high-pitched sounds b. Ensuring that contact with the skin is maintained c. Application of firm pressure when using the bell d. Using the diaphragm to listen to low-pitched sounds
b. Ensuring that contact with the skin is maintained
Learning about the effects of the illness does what for the nurse and the patient? a. Gives them each a better understanding of the other b. Gives them the opportunity to create a complete and congruent picture of the problem c. Gives them the basis to establish a trusting relationship d. Gives them the ability to communicate better
b. Gives them the opportunity to create a complete and congruent picture of the problem
Which of the following statements best conveys the rationale for health promotion in a school setting? a. Children younger than 13 years are some of the most common consumers of acute health care services. b. Healthy child development is a critical health determinant because of its implications for lifelong health. c. Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. d. Children contract numerous communicable diseases in the school environment.
b. Healthy child development is a critical health determinant because of its implications for lifelong health.
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 first action of the nurse? a. Ensure that the client is safe b. Open the client's airway c. Begin CPR d. If the client is injured protect the cervical spine
b. Open the client's airway
A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills? a. Reread a nursing textbook on assessment and study the illustrations. b. Practice performing a physical examination on a classmate, friend, or relative. c. Watch videos on the Internet of nurses performing physical examinations. d. Talk with a counselor about fears and learn strategies for managing anxiety.
b. Practice performing a physical examination on a classmate, friend, or relative.
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? a. The client's learning style b. The client's motivation for change c. The client's prognosis for recovery d. The client's medical comorbidities
b. The client's motivation for change
What is the primary function of the health care team? a. To work together to obtain maximum coverage b. To decide the best overall care c. To develop an individual focus for each member d. To guide the patient's care throughout times of crisis
b. To decide the best overall care
An adolescent client presents to the health clinic for a routine physical examination. Which observation by the nurse needs validation by collection of objective data? a. Clean and well groomed appearance b. Wearing long sleeve clothing in July c. Body odor from the axilla area d. Skin warm and flushed in appearance
b. Wearing long sleeve clothing in July
A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? a. olfaction b. auscultation c. palpation d. percussion
b. auscultation
While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process? a. social b. emotional c. mental d. spiritual
b. emotional
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information? a. adult daughter controlling the interview b. last surgery date validated by adult daughter c. confused regarding dates of surgical procedures d. unable to recall exact date of last surgery
b. last surgery date validated by adult daughter
Assessment of the pulse amplitude is accomplished by which of the following? a. Palpating the area of the left ventricle b. palpating the flow of blood through an artery c. Auscultating the flow of blood through an artery d. Auscultating the area of the left ventricle
b. palpating the flow of blood through an artery
When the nurse is assessing the value-belief health patterns of a client with a poor prognosis for a diagnosis of pancreatic cancer, which question would be most appropriate to ask? a. "How well do you think you can manage your care?" b. "How have your regular routines changed?" c. "Where do you find your strength and hope?" d. "Do you feel rested after a night of sleep?'
c. "Where do you find your strength and hope?"
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? a. Triangle b. Square c. Circle d. Rectangle
c. Circle
Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview? a. Establish the agenda, negotiate a plan, establish rapport, and invite the client's story. b. Invite the client's story, negotiate a plan, establish the agenda, and establish rapport. c. Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan. d. Negotiate a plan, establish an agenda, invite the client's story, and establish rapport.
c. Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan.
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? a. Evaluation b. Planning c. Nursing diagnosis d. Implementation
c. Nursing diagnosis
The nurse is conducting a patient interview and responds to the patient in a way that encourages the patient to more completely describe his or her problems. What is this called? a. Focusing b. Clarification c. Promoting elaboration d. Restatement
c. Promoting elaboration
Why is it important for a new nurse, working on a step-down unit, to know the standards of care for the facility in which the nurse is working? a. Standards of care tell the nurse how to get a good evaluation b.Standards of care dictate how to handle clients who have experienced trauma c. Standards of care often set the time frame for assessing the clients on the unit d. Standards of care instruct the nurse how to assess for a cardiac event
c. Standards of care often set the time frame for assessing the clients on the unit
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. a. To elicit negative family history b. To help the client feel at ease and not worry about being sick c. To help identify those diseases for which the client may be at risk d. To identify genetic family trends for which the client is at risk e. To provide counseling and health teaching in high-risk areas
c. To help identify those diseases for which the client may be at risk d. To identify genetic family trends for which the client is at risk e. To provide counseling and health teaching in high-risk areas
The nursing instructor is discussing unprofessional actions. What would the instructor cite as the clearest example of unprofessional conduct? a. Creating an economic relationship b. Establishing a social relationship c. Violating a sexual boundary d. Allowing a personal relationship
c. Violating a sexual boundary
A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? a. review of systems b. health maintenance c. past medical history d.health patterns
c. past medical history
A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse document this information in the comprehensive assessment? a. past history b. health maintenance c. review of systems d.history of present illness
c. review of systems
The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment? a. stethoscope diaphragm b. sphygmomanometer c. stethoscope bell d. Doppler
c. stethoscope bell
What are the primary frameworks used in conducting a health assessment? Select all that apply. a. Analytical b. Gordon's c.Functional systems d. Head to toe e. Body systems
c.Functional systems d. Head to toe e. Body systems
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? a. The client's age b. The nurse's potential for liability c.The client's acuity d. The unit's protocols
c.The client's acuity
A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam? a. Establish the client's reliability as historian. b. Explain the purpose of the interview to the client. c. Construct the client's family genogram. d. Collect necessary equipment essential to the exam.
d. Collect necessary equipment essential to the exam.
Before beginning a health assessment with a patient, the nurse reviews Healthy People 2020 because: a. It lists specific interventions to address most patient health problems. b. It helps determine the patient's plan of care. c. It serves as a guide for the health assessment. d. It identifies risk factors, health issues, and diseases.
d. It identifies risk factors, health issues, and diseases.
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain? a. Nociceptive b. Idiopathic c. Somatic d. Neuropathic
d. Neuropathic
A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding? a. Facilitate a referral to the hospital's rheumatology department b. Obtained a detailed family health history from the client c.Document the assessment finding and inform the anesthesiologist d. Perform a focused assessment of the client's musculoskeletal system
d. Perform a focused assessment of the client's musculoskeletal system
A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination? a. Standing b. Supine c. Dorsal recumbent d. Prone
d. Prone
A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used? a. Axillary b. Oral c. Forehead d. Rectal
d. Rectal
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? a. Obtain basic biographic data. b. Validate information with the client. c. Consult clinical resources explaining the client's diagnosis. d. Review the client's medical record.
d. Review the client's medical record.
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? a. Asks unlicensed staff to measure vital signs b. Focuses on the system that caused the hospitalization c. Follows the ABC approach d. Uses evidence-based techniques
d. Uses evidence-based techniques
The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should a. administer Tylenol. b. instruct the patient to drink more fluids. c. refer the client to a primary care provider. d. record the vital signs.
d. record the vital signs.
