Health Assessment- Final PrepU Questions

Which general survey question focuses on the common "fifth vital sign"?

"Are you experiencing any pain right now?"

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?"

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

A patient is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers?

A-delta fibers

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking

A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database?

As many genetic relatives as the client can recall

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first?

Ask the patient to sip and swallow water.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure?

Client sitting with arm slightly flexed and even with the heart

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings?

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

Impaired comfort related to possible neck injury

The nursing assistant obtains vital signs and reports a blood pressure of 180/95 to the nurse. What is the nurse's best action?

Instruct the nursing assistant to obtain a manual blood pressure.

During general inspection, the examiner:

Integrates visual, auditory, and olfactory data

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the patient record simultaneously.

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

The nurse palpates a client's auricles and notes an elarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding.

A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

Palmar surface

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery

A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?

Perforated eardrum

A nurse in a dermatology clinic cares for an adolescent patient with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this patient?

Pustular acne

A nurse is conducting an admission assessment on an older adult client with an intractable oral infection. The client tells the nurse that he cannot smell things as well as he once could. What should the nurse do initially?

Recognize that the sense of smell decreases with age

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?

Redness and bulging of the eardrum

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?

Small bowel obstruction

A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?

Small pits in the surfaces of the nails

The ulnar edge of the hand is highly receptive to which of the following sensations?

Temperature and vibrations

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

During a general survey, the nurse asks if the patient is feeling cold. What did the nurse most likely observe in the patient?

The patient is wearing clothing that is inconsistent with warm weather.

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear`

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis

A patient diagnosed with arthritis has been taking aspirin and now reports experiencing adverse effects. What adverse effect indicates that a decrease in dose may be necessary?

Tinnitus

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

Use phrases instead of sentences to record data.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Verify the data by having another nurse come in to perform the percussion.

A client shows the school nurse a rash that has developed on the back of her left hand. The school nurse assesses the rash as a depigmented macular area. What might the nurse suspect?

Vitiligo

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

Which of the dimensions of pain listed is being assessed by the question "How does the pain treatment you are getting affect your overall mood?"

affective

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes.

While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is

blue

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?

both sides

The nurse is preparing an educational program on effective hygiene methods for a group of high school teens. When discussing the need for antiperspirants and effective bathing, the nurse will focus on which layer of the skin?

dermis

If the nurse makes an error while documenting findings on a client's record, the nurse should

draw a line through the error, writing "error" and initialing.

Primary headaches are more worrisome than secondary headaches.

false

When interviewing, the nurse should logically move from specific to open-ended questions.

false

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information?

health maintenance

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing?

inspecting

Osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in

kyphosis

The nurse is preparing to assess the respirations of an alert adult client. The nurse should

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in).

An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's

oral mucosa.

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the

pain relief measures.

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an

parotid gland enlargement.

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information?

past medical history

During the interview of an adult client, the nurse should

provide the client with information as questions arise.

During a health history a client recalls the date when being first diagnosed with hypertension. Which term should the nurse use to categorize the quality of the client's data?

reliable

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?

skin cancer prevention

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?

somatic

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

somatic pain

What clinical manifestation of the nails should the nurse anticipate assessing in a client with iron deficiency anemia?

spooning

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

stiff neck

Connecting the skin to underlying structures is/are the

subcutaneous tissue

A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data?

subjective

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

vertigo

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?"

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

Assessment data in the medical record

The nurse is performing a shift assessment on a client who just received a central line. Which finding should the nurse report as a complication of central line placement?

Decreased breath sounds unilaterally

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan's syndrome. What assessment finding would the nurse expect to find?

Elongated fingers

During the integument health history, the nurse asks the patient about both current and previous prescription medications, immunizations, and diagnosed illnesses. What is the primary benefit derived from the data provided by this questioning?

Existence of systemic diseases that have skin manifestations

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition?

Impetigo

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism?

Laboratory tests

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

Sometimes it is necessary to use a tuning fork when performing a physical assessment. What would be one instance where a tuning fork would be used?

To determine vibration sense in the neuromuscular system

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

To have up-to-date information on which to base clinical decisions

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency

You are performing a physical examination on a new patient. What would you be assessing if you were testing the patient's sense of smell?

cranial nerves

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram

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

deep palpation

The nurse is completing a comprehensive assessment with a newly admitted client. In which area should the nurse document the client's list of immunizations?

health maintenance

A patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain?

intractable

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

malignancy

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

tension

A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?

working

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working

A nurse assesses a young adult client who lost consciousness after a head-to-head collision while playing football. Which question should the nurse ask in order to determine characteristic symptoms of the head trauma?

"Do you have a history of seizures?"

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 nurse obtains an objective assessment on a child who presents to the clinic with reports of right ear pain. The nurse observes the following: painful movement of the pinna and tragus; ear canal is red and swollen with presence of purulent discharge from the external canal; temperature 101.8°F. The mother states that the family was on vacation at the beach last week. The nurse recognizes these findings as an indication of what acute ear condition?

Otitis externa

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?

the client