NADN 2110 Student Review- Assessment

Answer: c "Identifying activities that exacerbate symptoms" is an example of data collection or assessment. Defining patient goals is an example of Outcome Identification. Appraisal of current regimen is a form of Evaluation. Applying oxygen is an example of Implementation.

A nurse is admitting a patient with congestive heart failure. Which of the following describe appropriate aspects of assessment? a. Define patient goals for increasing ability for self-care b. Appraise current therapeutic regimen at home c. Identify activities that exacerbate symptoms d. Apply oxygen therapy via nasal cannula

Correct Answer C. Rationale: Objective data is that which is measured by a professional nurse. It is used to validate subjective data. Secondary data is from secondary, not primary, sources. Constant data is that which will not change, such as age and race.

After conducting the health interview, the nurse begins to measure the client's vital signs. The nurse is collecting: A. Subjective data B. Constant data C. Objective data D. Secondary data

Answer: D. Client has a rash on the chest and arms Rationale: Subjective data, collected during the health history, consists of information that the client says about him or herself. Objective data are obtained through the physical examination and vital sign measurements, what the nurse observes, and laboratory study and diagnostic test results. Answers A, B, and C identify subjective data.

2. A nurse is reviewing the findings on a physical examination that are documented in a client's record. The nurse notes which of the following as a piece of documented objective data? A. Client experiences migraine headaches B. Client has difficulty urinating C. Client takes atenolol (Tenormin) for blood pressure D. Client has a rash on the chest and arms

Correct answer A. Rationale: The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as barrel chest. The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

A nurse is assessing a patient with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprets that the client has which of the following forms of chronic airflow limitation. a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis

Correct Answer D. Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration

Answer: C. Follow-up measurements of BP Rationale: A single reading of a mildly elevated BP is not significant, but measurement should be taken again over time to determine if hypertension is a problem. The nurse would recommend a return visit to the clinic for a recheck.

A patient has a BP reading of 130/90 mmHg when visiting a clinic. What would a nurse recommend to the patient? A. Immediate treatment by a physician B. A change in dietary intake C. Follow-up measurements of BP D. Nothing because the nurse thinks this reading is due to anxiety

Correct Answer C Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset.

A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken

Answer: A. Decrease in heart rate Rationale: Insertion of a rectal thermometer may stimulate the vagus nerve, which in turn, would decrease heart rate. This may potentially be harmful for patients with cardiac problems.

When assessing a temperature rectally, the nurse would use extreme care when inserting the thermometer to prevent which of the following? A. Decrease in heart rate B. Increase in respirations C. Increase in heart rate D. Decrease in BP

Answer: a, b, d Clubbing of the nail bed indicates chronic hypoxia, crackles in the lungs indicates air passing through fluid, and pitting in dependent extremities such as the ankles indicates fluid accumulation in the tissues. Vesicular breath sounds are normal respiratory findings heard over all areas of the lungs except major airways.

Which of the following would be abnormal assessment findings for a patient with congestive heart failure? Select all that apply: a. Clubbing of the nail bed b. Crackles in the bases of the lungs c. Vesicular breath sounds d. Pitting of the ankles

Correct answer A Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure.

A nurse is taking the history of a client with silicosis. The nurse assesses whether the client wears which of the following items during periods of exposure to silica particles? a Mask b Gown c Gloves d Eye protection

Answer: b The apical pulse provides the most accurate assessment of the pulse rate and is the preferred site when the peripheral pulses are difficult to assess or the pulse rhythm is irregular. Correct technique includes placing the diaphragm of the stethoscope at the fifth (not third) intercostal space at the midclavicular line and counting for a full 60 seconds. The first pulsation should be counted as "zero," and S1 and S2 should be counted as one beat.

A nurse is checking an apical pulse of a patient who has just returned from surgery. Which of the following are important elements of this procedure? a. Place the diaphragm of the stethoscope at the third intercostal space at the midclavicular line b. Count the pulse for 60 seconds c. Count the first audible pulsation as "one" d. Count S1 and S1 sounds separately

Answer: c The best nursing action is to wait to assess the respirations until the child is not crying. Noting the pattern and rate when crying does not indicate normal function, although thorough documentation is beneficial to provide context. Calling the physician with the current respiratory pattern and rate is not advised because this does not reflect the normal condition or current trend. Measuring the respiratory rate before the temperature is advised before the child is upset. In this scenario, the child is already upset, so this advice would not be pertinent.

A nurse is checking the respiratory rate of a toddler, previously admitted with asthma. The child is crying and upset by the hospital the process of taking his vital signs. What should the nurse do? a. Note the respiratory pattern and rate, including a comment that the child is crying b. Call the physician since the respiratory rate is 60 and extremely labored c. Wait to assess respirations until the child is not crying d. Measure the respiratory rate before the temperature

Answer: B because palpation and percussion can alter the frequency and intensity of bowels sounds, the nurse should auscultate the abdomen next-and before using those two techniques.

A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

Answer: A, B, and C. A because having he client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements. B because with the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements. C because observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count. Students should count for 1

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-Fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate D. Count the rate for 1 min if it is regular E. Count and report any sighs the client demonstrates

Answer: B, C, D, and E. B because many older adults have the mobility challenges, the nurse should plan the session to allow extra time for position changes. C because the nurse should make sure older adults who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury. D because some older clients need more time to collect their thoughts and answer questions, but more are reliable historians. Feeling rushed can hinder communication. E because this is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who might have a diminished bladder capacity. A is not because the nurse should perform the various parts of the assessment in several shorter segments to avoid overtiring the client.

A nurse is performing a comprehensive physical examination for an older adult. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Perform the assessments in one continuous session B. Plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. Tell the client to take her time answering questions E. Invite the client to use the bathroom before beginning the examination

Answer: A Set the room temperature at a comfortable level, E. Remove distracting objects from the interviewing area, and F. Ensure comfortable seating at eye level for the client and nurse. Rationale: When preparing the physical environment for an interview, the nurse would set the room temperature at a comfortable level. The nurse would provide sufficient lighting for the client and nurse to see each other. The nurse would avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment should be removed from the interview area. The nurse should arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a des

A nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply. A. Set the room temperature at a comfortable level B. Provide seating for the client so that the client faces a strong light C. Ensure that the distance between the client and nurse is at least 6 feet D. Place a chair for the client across from the nurse's desk E. Remove distracting objects from the interviewing area F. Ensure comfortable seating at eye level for the client and nurse

Correct answer C Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

A nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Chest x-ray b. Bronchoscopy c. Sputum culture d. Tuberculin skin test

Correct Answer B. Rationale: Charting by exception is a system in which documentation is limited to exceptions from pre-established norms or significant findings. Flow sheets with appropriate information and parameters are completed. This type of documentation eliminates much of the repetition involved in narrative and other forms of documentation.

After completing a health assessment, the nurse documents the findings on a flow sheet with check marks and short notations. The type of documentation this nurse is using is most likely: A. SOAP B. Charting by exception C. APIE D. Narrative

Correct Answer C. Rationale: The focused interview is used to clarify points, obtain missing information, and to follow up on verbal and nonverbal clues identified in the health history. A prepared set of questions is not used.

After completing the health history of a health assessment, the nurse begins to ask more questions about specific information. This portion of the health assessment is A. Interpretation of findings B. Documentation follow up C. Focused interview D. Physical assessment

Answer: A. because vital signs are something that can be measured and is not stated by patient.

After conducting the health interview, the nurse begins to measure the client's vital signs. The nurse is collecting: A. Objective data B. Secondary data C. Constant data D. Subjective data

Answer: C. Left knee has been swollen and hot for the past 3 days Rationale: Subjective data is what the patient says about him or herself during history taking. Objective data is what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Range of motion is assessed by inspection. Crepitation is assessed by palpating, and Arthritis is a medical diagnosis.

An example of subjective data is: A. Decreased range of motion B. Crepitation in the left knee joint C. Left knee has been swollen and hot for the past 3 days D. Arthritis

Correct Answer C. Rationale:

During a health interview, the client states that she becomes increasingly short of breath when sitting in city traffic. The nurse views this information as... A. A cultural factor B. An emotional factor C. An external emotional factor D. An internal emotional factor

Answer: a, b, c These three statements assess the functional health patterns of Nutrition-Metabolism, Coping-Stress Tolerance, and Sleep-Rest. Statement D focuses on past symptoms in relation to the current admission adhering to a medical model or review of body systems. Vital signs are objective data collected in adherence to a head-to-toe model to first gauge the current state of health.

The nurse has admitted a single mother with nausea and vomiting for the last 3 days and upper left quadrant abdominal pain. Which of the statements below indicate that the nurse is using the functional health patters model of assessment? Select all that apply: a. "Please describe your pain over the last week." b. "What kind of help have you had from your family since this started?" c. "Have you been able to sleep or rest lately as usual?" d. "Have you had symptoms like this in the past?" e. "Your blood pressure is 94/48, heart rate is 112."

Correct Answer A. Rationale: In the health promotion model, health is the actualization of inherent and acquired human potential through goal-directed behavior. This client is requesting help to change behaviors, which exemplifies goal-directed behavior change.

The nurse is assessing a client's smoking behavior. During the interview, the nurse learns the client wants to stop smoking but needs help with this behavior change. Which nursing theory would best support the care this client needs? A. Health promotion model B. Eudemonistic model C. Clinical model D. Ecologic model

Answer: A. because the information is being told by the patient and cannot be measured.

The nurse is documenting the findings from a health assessment. Which of the following demonstrates the documentation of subjective information? A. "It hurts when I put weight on it." B. Abdomen soft and nontender to palpation C. Pulses present in lower extremities D. Blood pressure 110/68