Health Assessment Review Chp-1-13

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence?

"I will assess a client for abuse and violence with every client encounter."

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

Be respectful, open, and willing to discuss spiritual issues as appropriate

An older client tells the nurse "My kids still ask me to help them with their home projects." This is an example of what stage of Erikson's development?

Ego integrity

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action?

Enter the room and auscultate the client's lung sounds.

A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what?

Ethnocentrism

Learning about the effects of the illness does what for the nurse and the patient?

Gives them the opportunity to create a complete and congruent picture of the problem

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

Health maintenance

During screening of a child for abuse, the nurse determines that the child has been abused. Which of the following should the nurse say to the child?

I'm sorry this is happening to you. This is not your fault. I will help you in any way I can.

When doing an overall assessment of a patient, the nurse is able to utilize findings and do what?

Identify in what areas the patient needs the most care

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?

Kicking

Which of the following is the most important assessment to be conducted on the survivor of abuse?

Lethality (danger) assessment

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?

Mediterranean and Africa.

The mother of an adolescent is concerned because the client's personality "seems to be changing daily." If Erikson's theory is followed, what should the nurse include when responding to this mother?

Personality evolves throughout the life span

A client asks how long the hospitalization will be since family and friends will not be able to visit because of the distance to travel. Which nursing diagnosis should be identified for this client's concern?

Risk for social isolation

What is the most common measurement used to determine abdominal visceral fat?

Waist circumference

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed

focused

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

focused

A middle-aged adult nurse is having difficulty using the computerized documentation system. What does this indicate about the nurse's developmental level?

has difficulty meeting life expectations

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

intuition

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

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

ongoing

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

reassess blood pressure

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

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