PrepU Chp. 1-5 HA

What test would the nurse perform to test for strabismus? A-Corneal light reflex B-Cover C-Allen D-Static

A-Corneal light reflex

A female client tells the nurse it has been 5 years since her last pap smear examination. Where should the nurse document this information? A-physical examination B-health maintenance C-personal and social history D-review of systems

B-health maintenance

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?

Diagnosis

What are the types of nursing assessments? (Select all that apply.) Physical Focused Mental Emergency Comprehensive

Focused Emergency Comprehensive

After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client? A - Healthy People 2020 B - The client's family history C - Organization standards of care D - The client's past medical history

A - Healthy People 2020

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern? A-"Do you have family who visit you regularly?" B-"What amount of cleaning have you been doing in the past?" C-"Have you tried to schedule a cleaning service?" D"Are you friendly with your neighbors?"

A-"Do you have family who visit you regularly?"

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

How does a nurse best facilitate the nursing health assessment? A-Maintaining privacy B-Asking the appropriate questions C-Formulating a nursing diagnosis D-Creating a nursing care plan

B-Asking the appropriate questions

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what? A-How much time the nurse has B-The client's acuity C-The client's cooperation D-Onset of current symptoms

B-The client's acuity

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions? A-Follows the ABC approach B-Uses evidence-based techniques C-Asks unlicensed staff to measure vital signs D-Focuses on the system that caused the hospitalization

B-Uses evidence-based techniques

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question? A-self-concept B-mental health C-family violence D-role-relationship

C-family violence

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have A-advanced preparation in this area. B-experience in dealing with these types of clients. C-knowledge of his or her own thoughts and feelings about these issues. D-personal experiences with death, dying, and sexuality.

C-knowledge of his or her own thoughts and feelings about these issues.

What are nurses able to detect through the health assessment? A-Areas that need continuous care B-Areas that need in-hospital care C-Areas that need referral to a specialist D-Areas in need of health adjustments

D - Areas in need of health adjustments

A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use? A-Rationale B-American Nurses Association recommendations C-Physical assessment skills D-Diagnostic reasoning

Diagnostic reasoning

A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply. Identification of collaborative problems Assessment of the outcome of the care plan Identification of the need for referrals Formulation of nursing diagnosis(es) Development of a nursing care plan

Identification of collaborative problems Identification of the need for referrals Formulation of nursing diagnosis(es)

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing? Planning Evaluation Implementation Nursing diagnosis

Nursing diagnosis

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? A-Emergency B-Ongoing C-Focused D-Comprehensive

B-Ongoing

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's A-nodules. B-bullae. C-vesicles. D-wheals.

C-vesicles

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point? A-Transition B-Summarization C-Reassurance D-Termination

B-Summarization

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next A-cluster the data collected. B-draw inferences and identify problems. C-document conclusions. D-check for the presence of defining characteristics.

D-check for the presence of defining characteristics.

When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what? A-Assessment B-Diagnosis C-Planning D-Evaluation

B-Diagnosis

A 58-year-old gardener comes to the office for evaluation of a new lesion on her upper chest. The lesion appears to be "stuck on" and is oval, brown, and slightly elevated with a flat surface. It has a rough, wart-like texture on palpation. Based on this description, what diagnosis is most likely? A-Actinic keratosis B-Seborrheic keratosis C-Basal cell carcinoma D-Squamous cell carcinoma

B-Seborrheic keratosis

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing? A-Planning B-Evaluation C-Implementation D-Nursing diagnosis

D-Nursing diagnosis

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be A-"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." B-"the doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." C-"each assessment is important and the nurse and doctor will get together to determine what orders need to be written." D-"I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home."

A-"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? A-Fluid-filled lesions greater than 1 cm in diameter B-Purulent, fluid-filled, raised lesions of any size C-Raised, reddened, edematous papules or plaques, varying in size and shape D-Fluid-filled lesions less than 1 cm in diameter

D-Fluid-filled lesions less than 1 cm in diameter

Learning about the effects of the illness does what for the nurse and the patient? A-Gives them the basis to establish a trusting relationship B-Gives them each a better understanding of the other C-Gives them the ability to communicate better D-Gives them the opportunity to create a complete and congruent picture of the problem

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

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information? A-create a genogram B-document it in a narrative note C-include in the past medical history D-consider using it when planning care

A-create a genogram

A client presents to the health care clinic with reports of new onset of generalized hair loss for the past 2 months. The client denies the use of any new shampoos or other hair care products and claims not to be taking any new medications. The nurse should ask the client questions related to the onset of which disease process? A-Diabetes mellitus B-Hypothyroidism C-Crohns disease D-Cushing disease

B-Hypothyroidism

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is A-"Do you feel stress at work?" B-"How often do you feel stressed?" C-"Is stress a problem in your life?" D-"How do you manage your stress?"

D-"How do you manage your stress?"

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? A-Bell's palsy B-Tension headache C-Temporal arteritis D-Migraine headache

D-Migraine headache

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? A-History of present illness B-Review of systems C-Chief complaint D-Personal health history

D-Personal health history

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data? A-Speak to the client using local slang. B-Maintain a professional distance during assessment. C-Avoid any eye contact with the client. D-Ask one of the client's children to interpret.

B-Maintain a professional distance during assessment.

How does a nurse decide what health-promotion activities are necessary for a particular client? A-Nurses address areas associated with healthy behaviors only B-Nurses collaborate with clients to identify areas in which clients are willing to make changes C-Nurses assess areas in which clients are willing to make changes only D-Nurses construct their own theories to identify perceptions, barriers, and positive outcomes

B-Nurses collaborate with clients to identify areas in which clients are willing to make changes

A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about his presenting symptoms? A-"When did the sleeplessness first start?" B-"Are you taking any new medications?" C-"Have you lost any weight this week?" D-"Do you think your wife is getting better?"

D-"Do you think your wife is getting better?"

Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility? A-collecting information regarding the client's health status B-stabilizing the client's physical condition C-developing an effective, respectful nurse-client relationship D-creating an environment that encourages client autonomy

A-collecting information regarding the client's health status

Which of the following statements best conveys the rationale for health promotion in a school setting? A-Health promotion in a school setting can yield improved health outcomes for the student's siblings and parents. B-Children younger than 13 years are some of the most common consumers of acute health care services. C-Children contract numerous communicable diseases in the school environment. D-Healthy child development is a critical health determinant because of its implications for lifelong health.

D-Healthy child development is a critical health determinant because of its implications for lifelong health.

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a A-migraine headache. B-cluster headache. C-tension headache. D-tumor-related headache.

A-migraine headache.