Module 1: Introduction to Health Assessment and Quiz

What do you not want to do while performing Therapeutic Communication?

- Using inappropriate plural pronouns (we). - Assuming the client knows about a health interview or physical. - Asking personal questions that are not relevant to the situation. - Giving personal opinions. - Using automatic responses and false reassurances. - Relaying disapproval of client statements and health practices.

What is Beneficence?

Act to promote the good of the client.

What is Infection Control?

Using standard precautions during a physical assessment and should be implemented with all clients.

What is Credible Sources?

Involves using intuition standards, state standards, and multiple scholarly sources to determine best practices.

What is Auscultation?

Listening to the sounds of the heart, lungs, stomach, intestines, and arteries.

What is Inspection?

Looking carefully and thoroughly at a client.

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

Palpate the tender areas of the abdomen last. The client reported abdominal tenderness. So the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client.

The nurse is preparing to assess a newly admitted client. Which pieces of equipment does the nurse need to begin the inspection part of the physical examination?

Penlight. Tape measure. Tongue depressor.

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

Put themselves in the client's situation to understand the client's anxiety. When the nurse expresses empathy, the nurse reflects an understanding of the client's feelings and feels the importance of the client's communication. This is a therapeutic communication technique.

What is Confidentiality?

Respecting the rights of the client to maintain privacy.

A nurse is preparing to perform a physical examination on a client. Which intervention should the nurse perform to ensure client privacy?

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

What is Nonverbal Therapeutic Communication?

Face the client when speaking and maintain an awareness of personal space (arms length is good).

What is Mandated Reporting?

If a nurse suspects abuse they are required by law to report it.

What is Personal Protective Equipment (PPE)?

Includes goggles, gowns, masks, gloves, face shields, and N95 masks.

What is ISBARR?

Is a tool to have clear communication for effective client care. - Identify. - Situation. - Background. - Assessment. - Recommendations. - Read back orders.

What is Personal Privacy?

Maintaining confidentiality and ensuring the client has been identified properly.

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

Record the client's most recent assessment results. The nurse should include factual, accurate, and objective information.

What is Autonomy?

The client's right to make decisions, the client can refuse treatment if they so desire.

What is Exploring Alternatives?

The use of holistic approaches for treating the whole person.

What is Nonmaleficence?

To do no harm. It is the first and foremost in healthcare.

What is Justice?

Treat everyone fairly regardless of ability to pay, social status, or cultural or religious background.

What is Verbal Therapeutic Communication?

- Ask what the client prefers to be called (otherwise surname). - Ask open ended questions. - Redirect the client as needed. - Engage in active listening. - Use everyday language. - Give positive reinforcement.

A nurse in the emergency department has received a 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. The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing a client, and observing a client.

What safety actions did Nurse Tiffany take?

Sanitize hands, door closed, checking name, age, and DOB.

What are Personal Factors?

Self-Awareness: by evaluating your own thoughts and feelings regarding the client, health care issues, or other aspects of nursing care, you will be able to maintain a neutral attitude. Cultural Awareness: being wholly aware of the various cultures and providing accommodations.

What are the Nurses Responsibilities in Mandated Reporting?

Assess and document verbatim of what the client says and what the nurse observes.

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which ethical principal is the client using?

Autonomy. Autonomy involves the client's right to make decisions about their care, including the right to refuse treatment if they choose. This ethical principle refers to a client's freedom.

A nurse is preparing to irrigate the client's leg wound. Which pieces id personal protection equipment should the nurse wear while performing this task?

Goggles. Gloves. Gown.

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

Implementation. During the implementation step, the nurse carries out the interventions developed in the plan of care, which will assist the nurse and other members of the health care team to monitor the client's progress. Implementation is when the nurse puts the plan of care into action.

A nurse has just received report on a newly admitted clement who reports abdominal tenderness in the lower right quadrant. What is the first step the nurse should perform during the abdominal assessment?

Inspection. Using the nursing process, the nurse should first inspect the client's abdomen and observe for symmetry between the right and left side of the body. The nurse should note the presence of contours and any abnormalities with the skin, rashes, deformities, or masses.

What Physical Privacy?

Is needed to make the client feel secure. Example: Exam area should be quiet enough to facilitate the ability to auscultate heart, breath, and bowel sounds.

What is Palpation?

Is the act of using the dorsal surface (or back) of the hands and fingertips to feel around body for various findings, temp, moisture, or abnormalities that may have been noticed during inspection.

A nurse is performing a pre-admission assessment in 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. The nurse should maintain a personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.

What is Ethical Principals?

Nursing care is based on ethical principles, which help nurses make ethical choices affecting individuals every day.

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with the effectiveness with the client during the initial assessment process?

Request assistance from an interpreter during the assessment. The nurse may enlist a professional interpreter if the client speaks a different language than the nurse.

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

Skin temperature, moisture, and abnormalities.

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this pet of the assessment?

Stethoscope. The nurse will need a stethoscope to be able to listen to the sounds of the client's body.

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

Subjective data.

What is Percussion?

Tapping of the clients skin with a short, quick motion to determine vibrations and sounds depending on the underlying structure or organ.

What is Reflecting and Deciding?

The nurse should do some self-reflection, then reflect on the clients goals and decide on the interventions with client input.

What is Hand Hygiene?

The nurse should wash their hands as the first line of defense in preventing the spread of any illness.