Health Assessment Midterm

A nurse is conducting a review of systems with a client during a health history interview. Which of the following responses by the client requires additional investigation?

"I have a cough"

A nurse is conducting a health history interview with a client. Which of the following is accurate about a directive interview technique?

This technique consists mostly of close-ended questions

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider?

Velvety skin -Associated with thyroid disorders

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical exam? (Select all that apply.) a. Penlight b. Tape measure c. Tongue depressor d. Needle and syringe e. ECG monitor

a, b, c

A nurse is gathering information during a health history interview from a client who reports they have type 1 DM. Which of the following actions should the nurse take?

Ask the client for additional information regarding the management of their diabetes

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?

Assessment

A nurse is preparing to perform a physical exam on a client. Which of the following interventions should the nurse perform to ensure client privacy?

Do not expose any more of the client's body than required at a time

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

Engage in active listening with the client and allow the client to express concerns early in the assessment process

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement?

Fasciculation

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?

Implementation

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment?

Inferior to the collar bone

A nurse has collected biographic data from a client. Which of the following findings in the client's community is considered a social determinant of health that can negatively impact the client's health?

Limited access to a pharmacy -Patterns of obesity, substance use, and exercise habits within a community are considered behavioral determinants of health

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

Maintain a fair distance between self and client

A nurse is caring for a client who is crying and appears upset after receiving news that they'll need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?

Put themselves in the client's situation to understand the client's anxiety

A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take?

Record the client's most recent assessment results

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture, and abnormalities

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider?

Spongy nail base

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting?

Subjective

A nurse is conducting a health history interview and asks the client to describe the pain that they're experiencing. This is an example of what type of question?

Open-ended question

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula -Nurse should record temperature in degrees Celsius -Nurse should record the measured pulse rate and indicate rate, rhythm, and force of the pulse

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?

Palpate the tender areas of the abdomen last

A nurse is collecting a health history from a client who is accompanied by an interpreter. Which of the following actions should the nurse take?

Speak directly to the client throughout the interview

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection?

Vesicles -Vesicles are associated with chickenpox and shingles infections -Wheals are superficial, raised, reddened areas of the skin that have a slightly irregular shape; they're associated with allergic rxns and insect bites -Papules are small, solid, raised areas caused by thickening of the epidermis; they're associated with warts and moles -Bulla (blister) is associated with friction damage, burns, and contact dermatitis

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider?

Yellow discoloration of the palms -Sign of jaundice -Absent tenting of skin is expected; presence of tenting is associated with dehydration and extreme weight loss

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (Select all that apply.) a. Prescription medications taken for recreational purposes b. Determination of when the client last had an alcoholic drink c. Frequency of consumption of OTC medications d. Adverse reactions to medications and environmental substances e. Highest level of schooling completed

a, b

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? (Select all that apply.) a. Location of the pressure injury b. Size of the injury in centimeters c. Depth of the injury in centimeters d. Color and odor of drainage from the wound e. Integrity of the skin surrounding the wound

a, b, and e -Depth of injury is not necessary because a stage 1 pressure injury present with intact, reddened skin; there is no loss of skin or drainage

A nurse is collecting information about a client's spirituality using the FICA Spiritual History Tool. Based on this tool, which of the following information should the nurse gather? (Select all that apply.) a. Does the client identify spiritual or religious beliefs that are of importance to them? b. What impact does the client's spiritual or religious beliefs have on their health care decision making? c. Are there any spiritual or religious practices that should be included when planning the client's care? d. What is the address of the client's identified religious or spiritual gathering place? e. Is there a spiritual or religious group that the client identifies as having an importance in their life?

a, b, c, and e

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply.) a. Time of day b. Obesity c. Diuretic medication d. Height e. Smoking

a, b, c, and e

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of PPE should the nurse wear while performing the task? (Select all that apply.) a. Goggles b. N95 mask c. Gown d. Gloves e. Surgical cap

a, c, d

A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (Select all that apply.) a. Gather supplies to take notes b. Review the client's medical record at the conclusion of the interview c. Conduct the interview in an open area such as the reception area or hallway d. Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview e. Ensure face-to-face contact is at eye level

a, d, e

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? (Select all that apply.) a. Patches of increased pigmentation on the client's cheeks b. Pinpoint areas of purplish-red coloration across the abdomen c. Pale-colored nailbeds d. Darkly pigmented area across the client's sacral area e. Light-colored jagged lines

b, c -Areas of increased pigmentation on the face commonly occurs in pregnancy or in clients taking oral contraceptives -Areas of purplish-red discoloration smaller than 3 mm are petechia; this can be an indication of a bleeding disorder

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (Select all that apply.) a. The reason that the client is seeking health care b. If the client is experiencing abuse or human trafficking c. The environment in which the client resides d. The client's use of substances e. Client's ability to perform activities associated with daily living

b, c, d, and e -A functional assessment determine's the client's ability to care for themselves, their lifestyle choices, and the environment in which they live

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? a. Current medication list b. Past medical history c. Use of assistive devices d. Height and weight e. Behavior and mood

c, d, e

A nurse is planning on obtaining orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps? a. Assist the client to stand and obtain their blood pressure b. Keep the cuff in place and assist the client to a seated position c. Take the client's blood pressure in the supine position d. Place the client in a supine position and allow them to rest e. Take the client's blood pressure in a seated position

d --> c --> b --> e --> a