Health Assessment Prep u chapters 3-9

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor?

"A way of processing information using to formulate conclusions or diagnoses."

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline."

Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment?

"How do you plan to meet your responsibilities at work?"

A nurse begins to assess pain in a client admitted to the hospital for new onset of severe nausea and vomiting. What question should the nurse ask the client to assess the pattern of pain?

"How often do you experience the pain?"

The nursing instructor is teaching a class about how to assess pain in older adults. The teachers tells the students that problems can arise in certain circumstances. The instructor realizes the need for more teaching about pain in the elderly when one of the students replies:

"Pain is a natural part of aging."

A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a patient's record?

"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."

Which question asked by the nurse assesses judgment of the patient?

"What will you do if you feel the need to use cocaine again?"

A 90-year-old patient is crying and states to the nurse, "I've had such a wasted life." The most appropriate response from the nurse will be

"You are feeling like you have had a wasted life...?"

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply.

-Asking the same question over and over again -Losing one's ability to pay bills -Getting lost in familiar surroundings -Neglecting to bathe

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

-Be nonjudgmental and keep an open mind. -Use rationale to support opinions or decisions. -Acquire an adequate knowledge base that continues to build.

What are the primary frameworks used in conducting a health assessment? Select all that apply.

-Functional systems -Body systems -Head to toe

The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

-Heart rate 115 beats/minute. -Blood pressure 180/75.

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

-Increased heart rate -Increased blood pressure -Increased cardiac output

A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply.

-Perspiration -Increased heart rate -Sleeplessness

Which of the following are cues that a person may have dementia? Select all that apply.

-Repeatedly failing to follow instructions -Looking to a family member to answer questions directed to the client -Disorientation

Which is an example of inspection? Select all that apply.

-The nurse notes a fine rash covering the individual's thorax. -The nurse notes symmetry of the individual's thorax. -The nurse detects foul odor of the urine.

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply.

-The presence of a lump in the client's breast discovered on palpation -The client's weight -A description of a large bruise on the client's thigh

When should the nurse perform hand washing? Select all that apply.

-When hands are visibly soiled -After removing gloves -After providing mouth care

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

-complete -accurate -timely -organized -concise

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25

A nurse is taking a rectal temperature on an unconscious patient. What reading would reflect temperature within the normal range?

99°F

As a nurse is adjusting a client's hospital bed, the nurse accidently pinches a finger between the bed and the wall. Which of the following components is involved in the transduction of the pain the nurse feels?

A-delta fiber

A patient is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to decribe 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

A young adult has close personal relationships and desires a permanent love relationship. What should this indicate to the nurse about the client's development?

Achieved intimacy

A client admitted to a health care facility for injuries received in a motor vehicle accident is given the nursing diagnosis of impaired nutrition: less than body requirement. Which type of nursing diagnosis is this?

Actual

A pathophysiology instructor is discussing pain and its treatment across cultures. The instructor points out that patients from racial and ethnic minorities often receive less pain medication compared to Caucasians for what specific conditions?

Acute pain in the ED

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 formulating a nursing diagnosis for a patient that has developed a Stage III decubitus ulcer on the sacrum. What would be an appropriate nursing diagnosis for this patient?

Alteration in skin integrity

A patient has arrived to the clinic for a routine physical examination. Prior to assessing the patient's blood pressure, what should the nurse do?

Ask the patient to sit quietly in a chair for 5 minutes.

The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:

Blood pressure

Chapter 5

Chapter 5

Chapter 6

Chapter 6

Chapter 7

Chapter 7

Chapter 8

Chapter 8

Chapter 9

Chapter 9

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use?

Checklists

The nurse observes an 8-year-old child complete math homework after school. Which stage of Piaget's development is this child demonstrating?

Concrete operational

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task?

Constructional ability

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

Contour and temperature

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?

Cued or checklist forms

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose?

Details are often missing

How does the nurse use critical thinking when accurately assessing vital signs?

Developing nursing diagnoses

Body temperature is not impacted by which of the following factors?

Diet

A middle-aged client is overheard telling another person about the desire to "not get caught" performing an inappropriate action while at work. What does this indicate about the client's moral development?

Difficulty achieving the post-conventional level of development

Which of the following is not released during the stress response?

Dopamine

The nurse is conducting a physical examination of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

In what stage of Erik Erikson's model of development does the older adult come to terms with his or her life choices?

Ego integrity vs. despair

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?

Facility level

When reviewing a client's medication administration record, the nurse should plan to administer a medication containing which substance that blocks pain sensations?

Gamma-aminobutyric acid

What is the most commonly accepted theory of pain?

Gate control theory

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Gather equipment

What term refers to the drive to establish and guide the next generation?

Generativity

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

A nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?

Have the client read a few sentences out loud

The nurse is assessing a female client diagnosed with fibromyalgia. The nurse should assess for which physiological indicators of pain? (Select all that apply.)

Heart rate 115 beats/minute.

The student nurse is caring for a patient with emphysema. What sound would the student nurse expect to hear when percussing the patient's lungs?

Hyperresonant

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.

How does the client's medical record affect financial reimbursement? (select all that apply.)

Insurance companies audit client records to ensure that billing is accurate

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

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.

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light

As the density of tissue decreases, the percussion note becomes:

Lower pitched

Which of the following best describes neuropathic pain?

May be labelled as central pain

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

Modulation

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

Narrative charting

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?

None

A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action?

Notify the healthcare provider.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

Which of the following cultural expressions of pain would be likely to be found in a person of Hispanic culture?

Pain must be endured to perform gender role duties, but response to it is very expressive.

The charge nurse on a geriatric unit should further educate a new staff nurse who makes which statement?

Pain sensation is diminished in older adults.

For which assessment would the nurse plan to use light palpation?

Papular rash

A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Parkinson's disease

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Progress notes

The patient 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 patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain

Select the following nursing diagnosis that is correctly stated.

Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

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

An elderly farmer has sustained severe injuries after a serious accident involving a combine harvester. At the hospital, he tells the nurse that he thinks the pain he is feeling now is "payback" for living a "mean, selfish life." The nurse recognizes that this response by the man indicates which dimension of pain?

Spiritual dimension

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

When assessing a client, the nurse notes that he is delusional. The nurse would know that delusional thinking can lead to what?

Suicide

Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

Systolic pressure

Which of the following events during the assessment process most indicates a need for validation?

The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment.

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 SUBMIT ANSWER

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity

A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart?

Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm

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

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is theinstructor describing?

Tympanic

The nurse recognizes that assessment of core body temperature is quick, noninvasive, and safe using which method?

Tympanic

Which assessment finding on a hospitalized adult client requires urgent intervention?

Urine output of 100 mL in 8 hours

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.

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

A 75-year-old homemaker brings her 76-year-old husband to the clinic. She states that 4 months ago he had a stroke; ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong, he was taken to the hospital by ambulance. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time "he doesn't make any sense." She gives an example that when she reminded him the car needed to be serviced he told her "I will change the Kool-Aid out of the sink myself with the ludrip." She says that these sayings are becoming frustrating. She wants the nurse to tell her what is wrong and what can be done about it. What type of aphasia does the client have?

Wernicke's aphasia

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.

Chapter 4

chapter 4

The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following?

cues that are clustered yet unrelated

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?

identifying abnormal or positive findings

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis?

impaired skin integrity

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 SUBMIT ANSWER

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

kyphosis

Lawrence Kohlberg based his theory of moral development on the premise that

moral development is determined, in part, by decisions that challenge the person.

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?

neuropathic

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process.

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).

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.

*Sigmund Freud postulated that

puberty allows sexual impulses to reappear.

The nursing student demonstrates understanding of the different types of patient problems when he identifies which of the following to be a collaborative problem?

risk for complication: pneumothorax

Each of Erik Erikson's central developmental tasks is composed of opposing viewpoints. Erikson thus theorized that

the person must accomplish a healthy balance between these opposing viewpoints in order to progress to the next psychosocial stage.

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape

A nurse understands that the identified strengths found during the assessment of a patient are used for which of the following nursing diagnoses?

wellness diagnosis

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?

Repeat the command louder and in a lower tone of voice

The nurse manager should provide further teaching to a new staff nurse on the pediatric unit when the staff nurse makes which statement?

"Physical growth in children takes place in an expected, steady pace."

A nurse is assessing a 40-year-old client in terms of his psychosexual, psychosocial, cognitive, and moral development using both subjective and objective data. Which of the following are examples of objective data collected by the nurse? Select all that apply.

-Is capable of repressing anxious thoughts -Demonstrates generativity -Is capable of readjusting and modifying goals as necessary -Appears to rely on internalized principles of self when making moral decisions

What included in personal protective equipment? Select all that apply.

-Mouth, nose, eye protection -Gown -Gloves

According to Piaget, which child activities are indicative of the preoperational stage of development? (Select all that apply.)

-Recalls visiting the zoo several days after the visit. -Participates in pretend play. -Scribbles pictures of pets, clouds, and cars

A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply.

-Use rationale to support opinions and decisions. -Reflect on thoughts before reaching a conclusion. -Use past clinical experience to build knowledge.

The nurse has clustered assessment data on a patient with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this patient?

Actual nursing diagnosis.

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety

The school nurse is assessing height and weights for the 4th grade students. She is unsure if one of the students meets the standard for growth. What should the nurse do to validate the information she obtained?

Assess the growth and development chart that provides the standards.

The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor?

Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis."

A 12-year-old child is working on algebra problems in order to solve the calculation for "x." Which stage of Piaget's development is this child demonstrating?

Formal operational

The person who is able to correctly calculate algebraic equations has most likely attained which Piagetian stage of cognitive development?

Formal operational.

The nurse is conducting a health history with an older adult who recently lost a spouse. The patient reports difficulty sleeping, a lack of appetite, and having one glass of wine each week. The patient states, "I don't know how I can go on. Why did God have to take him? I feel so lost without my husband." Which tool should the use to further assess the patient?

Geriatric Depression Scale

All the following are stages in Erik Erikson's model of development except which one?

Identity vs. isolation

The nurse is deciding if an older client's moral behavior is normal or abnormal. What should the nurse consider before making this decision?

If the client is harming self or others

Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 lb in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the overweight will begin to affect the client's health. The nurse makes a note to discuss it with the client at the next visit. Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: more than body requirements

Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

Beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain?

Infants can feel pain and may respond with crying or agitation.

A student nurse learns that especially in the very young and very old pain can be inadequately treated. What else would the student learn about inadequate pain treatment in the very young?

It can lead to neurodevelopmental problems

During an assessment the nurse asks the client "how do you learn the best?" What is the reason for the nurse to ask this question?

It is because each person learns differently

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs. SUBMIT ANSWER

The nurse learns that a client has a family member with a mental health disorder. Why is this information helpful when planning this client's care?

It may be genetic and influence the client's mental health

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

Meaningful use of electronic health records

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is

NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics.

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

A parent tells the nurse she is concerned that her 5 year old has an imaginary friend. The nurse understands that the child is in what stage of Piaget's cognitive development.

Preoperational

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

Progress notes

You are educating your patient on taking blood pressure at home. What would be important to include in your patient education?

Routine recalibration of the device

A nurse is assessing an 82-year-old client in terms of his psychosocial development, following Piaget's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client?

The need for assistance in correctly taking daily medication

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

A nurse is caring for a client whose injured cells are releasing chemicals such as substance P, prostaglandins, bradykinin, histamine, and glutamate. Which phase of pain is the client experiencing?

Transduction

It is recommended that a left-handed examiner adopt a right-sided position.

True

The nurse is assessing a client with a history of drug addiction. What will be helpful in determining interventions that will be most beneficial for providing adequate pain relief to this client?

Using in-depth questions to collect significant data about the client's pain

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?

Vision and hearing