Week 3 Health Assessment Revie

Persons with chronic conditions, such as sickle-cell anemia, are seen by their primary care provider for ______________ assessment.​ focused complete follow-up interim

follow-up

The _____________ assessment is often collected in a primary care setting, such as a women's health clinic.​ Complete Focused Initial Closing

Complete

Not included in General Survey

History of asthma​ Client states pain 3/10 Denies cough​ "I feel happy."​

Which heart sounds are best heard with the bell of the stethoscope?

Murmurs

Which are components of a health history? Select all that apply. Vital signs​ Reason for seeking care​ Medication reconciliation​ Skin inspection​ Biographic data ​ Review of systems​

A health history may include biographic data, the reason for seeking care, present health or history of present illness, past history, medication reconciliation, family history, review of systems, functional assessment, developmental assessment, and cultural assessment. Skin inspection and vital sign assessment are completed as part of the physical assessment, not the health history.

A man runs into an urgent care center and tells the receptionist that his partner stopped breathing a couple of minutes ago.

Emergency assessment

Child whose parent shares that they have recently begun refusing to go to school because of a stomachache

Focused Assessment​

Individual who fell down a flight of stairs and lost consciousness

Focused Assessment​

Middle-adult woman being seen for middle back and upper arm pain that has been present off and on for 2 days

Focused Assessment​

Detailed health history

Follow-Up Assessment & Complete​ Assessment

The client states they had their appendix removed 10 years ago. The examiner would document this under which portion of the health history?​ Past history ​ Functional assessment​ Review of systems​ Family history​

Surgical history would be asked and documented under the past history portion of the health history. Information about the health of close relatives is obtained during the family history.​ The review of systems is an inventory of each body system through a set of questions that gather data related to the present illness and health promotion practices.​ A functional assessment measures the person's ability to complete tasks and activities associated with daily living.

The client is refusing any treatments ordered by the healthcare provider. The nurse advised the client of the risks and benefits of treatment. The client continued to refuse. What should the nurse do? Document it. It is the client's right to refuse. Set up another appointment to discuss treatment again. Tell the client it is not optional. Call the provider to convince the client to take the treatment.

The client has the right to refuse treatment. The nurse should advise the client of risks and benefits then document the client's decision.

Which of the following is included in the general survey?​ Select all that apply. Vital signs​ Physical appearance ​ Mobility​ Behavior Palpation​ Family history​ Body structure ​

The four areas in a general survey are physical appearance, body structure, mobility, and behavior. Vital signs are taken after the general survey. Palpation is an assessment technique, and family history is part of the health history.​

The client states, "My last physical exam was last year." This would be documented under (functional assessment; review of systems.)

The review of systems includes the date of the client's last physical exam and other health promotion practices. The functional assessment measures the client's ability to complete tasks and activities associated with daily living.

Deep Palpation

Use one hand on top of the other Depress the skin 1½ to 2 inches Assess internal organs and masses

When a client is experiencing a short-term problem, such as a rash, the care provider conducts a(n) __________________ assessment.​ problem-centered complete follow-up exit

problem-centered

In which situations is verifying a person's identity required when they are in the hospital? Select all that apply. -Before completing an assessment -Before transporting an individual to a test -When meeting the person for the first time -Prior to administering blood pressure medication -When delivering a meal tray -When answering their call for assistance

-Before completing an assessment -Before transporting an individual to a test -When meeting the person for the first time -Prior to administering blood pressure medication -When delivering a meal tray

The novice nurse completing a focused assessment prior to administering a cardiovascular medication notices a rubbing sound when assessing the apical pulse. The client denies pain and the vital signs are normal. The abnormal sound has not been previously documented on the client's health record. The highest priority action for the nurse to take at this time is -Request a more experienced colleague assess the heart sounds. -Administer the medications. -Notify the prescribing healthcare provider of the changed assessment. -Wait 10 minutes and reassess the apical pulse.

-Request a more experienced colleague assess the heart sounds.

The nurse is performing an initial assessment on a new client in the clinic. Which elements would be included as part of the general survey? Select all that apply. Takes a calcium supplement Cooperative behavior Clean appearance History of breast cancer Blood pressure 118/82

Appearance and behavior are part of the general survey. History and the supplement belong to the health history. The blood pressure is part of the vitals.

Indicate which aspects of the complete health assessment can or cannot be delegated by the nurse to an unlicensed assistive person (UAP) to complete. Vital signs Physical assessment of lungs Known allergies Current medications Height and weight Family history

Can be Delegated: Vital Signs; Height and weight. Cannot be Delegated: Physical assessment of the lungs; known allergies; current medications; family history

A woman seeing a midwife for the first time after discovering she is pregnant.

Complete assessment

Targeted physical assessment

Complete​ Assessment, Focused​ Assessment, Follow-Up Assessment, & Emergency​ Assessment

The healthcare provider assesses the abdomen of a postoperative client who has not passed gas since surgery, 24 hours ago.

Focused​ assessment

An adult with asthma that is stable

Follow-Up Assessment​

An expectant woman at home with severe morning sickness

Follow-Up Assessment​

A toddler is having the stitches removed from their arm at the doctor's office.

Follow-up assessment

Which of the following should always be followed by the examiner when practicing assessment techniques at home or in the learning laboratory? Select all that apply. Right to refuse Privacy Respect Confidentiality Comfort Safety

Right to refuse Privacy Respect Confidentiality Comfort Safety

A (symptom; sign) is a(n) (subjective; objective) abnormal assessment finding detected on physical examination or through diagnostic testing. A (symptom; sign) is a(n) (subjective; objective) feeling a client has that is associated with a disorder.​

Sign, objective symptom, subjective

A nurse has completed a general survey on four clients.​ Which of the clients should the nurse ask the healthcare provider to see first? A 72-year-old whose clothes are disheveled A 49-year-old who appears anxious A 22-year-old who appears in distress A 42-year-old with even skin tone

The nurse should ask the healthcare provider to see the 22-year-old who appears in distress first. ​ The appearance of distress could be life-threatening or unsafe. The client with anxiety and the one who is disheveled have an abnormal general survey, but do not appear unsafe based on the description. The client with the even skin tone does not appear to have an abnormal general survey.

What determines the frequency of assessment needed for each individual?

The person's health and wellness needs; Data obtained from each assessment determines not only treatment for current alterations in health, but the frequency and type of follow-up assessments. While the CDC and health insurance companies often provide evidence-based recommendations for care, it is the clinical judgment of the care team that makes the final determination.​ While age is included in the assessment data for each individual, it is not the only evidence used to determine assessment frequency.

A client is struggling to complete the health history questionnaire because English is not their primary language. Which action should the examiner implement? Request an interpreter to assist the client.​ Read the questionnaire to the client.​ Do not have the client complete the questionnaire.​ Have the client call a family member. ​

Communicating through an interpreter aids in effective, accurate communication and provides a better experience for the client. Reading the questionnaire to the client will not increase the understanding of the questions. The health history is an essential part of the assessment process, so it cannot be omitted. Asking the client to call a family member may not be an option and there is an assumption that the client wants to share medical information with the family. ​

A client with anorexia nervosa states, "I will never be beautiful because I am fat."​ Which of the following nursing diagnoses would be most appropriate when planning interventions for this client? Activity intolerance related to fatigue Weight loss related to altered nutrition Disturbed body image related to negative evaluation of self Altered nutrition: Less than body requirements related to low self-esteem

Disturbed body image is the correct choice. The client's comments suggest a negative evaluation of self, which is the common motivating factor in anorexia nervosa. Neither weight loss nor activity intolerance addresses the client's comment. Altered nutrition mentions the physiologic issue but does not address the client's main issue with body disturbance

Client with acute chest pain being treated in the emergency department.

Health Problem​: Client with acute chest pain being treated in the emergency department. Frequency of Follow-Up​: Continuous Rationale: A person having acute chest pain will receive continuous monitoring, interventions, and follow-up assessment during treatment.

Individual with stable heart failure.

Health Problem​: Individual with stable heart failure. Frequency of Follow-Up​: 2-3 months Rationale​: A person with a stable, chronic condition can be seen in the provider's office periodically.

Included in General Survey

Speech clear​ Upright posture​ Appears stated age​ Body symmetric​ Dressed appropriately for season​

The examiner observes the client staggering into the room. The examiner notes this activity to obtain data related to which of the following? ​ Level of consciousness​ Mood​ Gait Range of motion​

Staggering describes the client's gait. Range of motion, level of consciousness, and mood cannot be determined with this data. ​

The nurse is assisting a school-aged gymnast who fell from a balance beam during practice. The gymnast is crying and holding their deformed lower leg. ______________ ____________is the proper sequence in which the initial assessment of the lower extremities should be performed. (Deep palpation, light palpation, inspection) (Inspection, light palpation, auscultation) (Inspection, light palpation) (Auscultation, deep palpation, light palpation)

(Inspection, light palpation)

Full physical assessment

Complete​ Assessment & Follow-Up Assessment

The general survey begins after the (physical assessment; after vital signs; with the first moment of the encounter) with the client and continues with each interaction that follows. Begin the data collection as soon as you begin the (interview; enter the room; stop the assessment) and continue until you leave.

The general survey begins with the first moment of the encounter (not after the physical assessment or after vital signs) with the client and continues with each interaction that follows.​ Begin the data collection as soon as you enter the room (not begin the interview or stop the assessment) and continue until you leave.

When performing deep palpation during a physical assessment, which part of the hand should the nurse use? Dorsum Finger pads Ball of the hand Palmar surface

Finger pads

Hospitalized client experiencing an allergic reaction to a new medication

Focused Assessment​

While Mr. Chaudhury (pronouns: he/him/his) is recovering from surgery, the healthcare provider prescribes his influenza vaccination (flu shot). The nurse verified that Mr. Chaudhury had not gotten one this year and left a form for him to review and complete. ​ While handing back the complete form, Mr. Chaudhury asked why the same questions are asked every year. Review Mr. Chaudhury's responses before answering the question. ​ What is the best response by the nurse? "It is for insurance purposes." "It provides information on your current state of health." "So long as you give answers, I am not sure it matters." "Your answers help determine if it is safe for you to receive the vaccine today."

"Your answers help determine if it is safe for you to receive the vaccine today."

Which assessment data are abnormal in a general survey? Select all that apply. Calm Say things that don't make sense Even skin tone Appears older than stated age Face symmetric Pallor Oriented to person and place only Gait steady Quiet and withdrawn

Abnormal findings include appearing older than the stated age, saying things that don't make sense, appearing quiet and withdrawn, oriented to person and place only (x2 not x4), and pallor.​ Normal findings are calm, face symmetric, gait steady, and even skin tone.

Which conditions contribute to chronic undernutrition? Bronchitis and rhinitis Anorexia and cancer Pneumonia and asthma Constipation and appendicitis

Anorexia and cancer both can cause chronic undernutrition. The rest of the conditions may cause brief periods of undernutrition, but do not need extended treatment.

Light Palpation

Assess surface abnormalities Depress with the finger pads Use the lightest touch possible

The examiner is assessing a 90-year-old female client. Which assessment findings would be considered normal?​ Additional deposits of fat on the thighs and lower legs​ Increase in body weight ​ Presence of scoliosis and flexion in the knees and hips​ More prominent bony landmarks ​

Changes that occur in the aging person include more prominent bony landmarks. Body weight decreases, fat deposits increase on the abdomen and hips, kyphosis may be present, and there is slight flexion in the knees and hips. ​

A _______ ______ __________ to establish a database is performed the first time a person sees a new care provider. The individual who stops breathing is in grave danger of dying and requires an ________ ___________ with immediate intervention. Before removing stitches, the provider will complete a ________ ___________ related to the assessment data collected when the injury was treated. To understand why the gastrointestinal system of a postoperative client is not functioning after surgery, a ________ ___________ of that system is performed.

Complete Health Assessment Emergency Assessment Follow-up Assessment Focused Assessment

Having misplaced their stethoscope, a nurse borrows one from a colleague. After entering the client's room, washing their hands, making introductions, and stating the purpose of the assessment, the nurse performs proper identification of the client before correctly auscultating the lungs. Which critical health assessment steps were omitted? Select all that apply. -Ensuring privacy and confidentiality by closing the door. -Running warm water over the stethoscope for client comfort. -Cleaning the stethoscope with alcohol. -Using alcohol-based hand disinfectant. -Asking the individual to change into a hospital gown.

Ensuring privacy and confidentiality by closing the door. Cleaning the stethoscope with alcohol.

A young adult who walks into the emergency department saying they cut their hand on a broken glass

Focused Assessment​

Adolescent with asthma meeting with the school nurse to see how they are doing

Follow-Up Assessment

A client walks into the room and states, "I am so dizzy, I feel like I'm going to fall." Prioritize the following actions from first to last. Perform a focused neurologic assessment. Ask about current medications. Get the individual a chair. Call for assistance. Obtain vital signs.

Get the individual a chair. Call for assistance. Ask about current medications. Obtain vital signs. Perform a focused neurologic assessment.

Client with a fever on the second day after surgery.

Health Problem​: Client with a fever on the second day after surgery. Frequency of Follow-Up​: 2-4 hours Rationale​: Fever after surgery is a cue that an infection may be occurring, which requires further assessment of the operative site (redness, swelling, and drainage may indicate infection), respiratory system (medications that depress the respiratory center can allow secretions to accumulate in the lungs causing atelectasis, which can become pneumonia), and the immune system (specifically the serum white blood cells that would begin increasing in response to an infection).

A client appears anxious in the general survey. How should the nurse respond? "You seem nervous, tell me about how you are feeling." "Everyone is anxious coming to the clinic." "I will ask your provider to prescribe you an antianxiety medication." "You are fine, there is no need to be anxious."

It is important and therapeutic to have the client share feelings. It is non-therapeutic to be dismissive of a client's feelings. Medication is not needed.

Which information should be included in a medication reconciliation? Select all that apply. -St. John's Wort 300 mg for depression​ -Atenolol 50 mg for high blood pressure​ -Acetaminophen 500 mg as needed for pain​ -Tobacco 6 cigarettes per day​ -Multivitamin 1 tablet​

Medications include prescriptions, over-the-counter drugs, and herbal supplements. Alcohol, tobacco, and recreational drugs are not included. ​

Body image dissatisfaction

Modifiable risk factors

___________________ will provide the best information regarding impaired arterial blood flow to the legs. (Palpation of pulses; Inspection of the skin; Palpation of the calf muscle; Auscultation of the femoral arteries)

Palpation of pulses

Which information is included in past history? Select all that apply. Date of birth​ Hospitalizations​ Childhood illnesses​ Immunizations​ Pain scale​

Past history includes immunizations, hospitalizations, and childhood illnesses. The pain scale is part of the present health or history of present illness. Date of birth is included in biographical data.

The examiner would like to assess the quality of the client's pain. Which question should the examiner ask?​ "How is the pain impacting your life?"​ "What does the pain feel like?"​ "What makes the pain better?" "On a scale of 0-10, how would you rate your pain?"​

Quality refers to the description of the pain in the client's own words and the examiner could ask, "What does the pain feel like?" Asking about what makes the pain feel better is a palliative question. Severity is measured by rating the pain. Understanding the impact of pain on lifestyle is also important but does not measure quality. ​

During an admission assessment on a 19-year-old client with anorexia, the nurse learns the client has a minor sister with the same health condition. What should the nurse do with this information? Ask if the client can bring their sister in. Contact the client's parents. Contact the primary care provider. Nothing, this is typical for clients in this age range.

Since anorexia can run in families, it is important for the primary care provider to be aware of this. Family counseling may be needed. The client is not a minor, so their parents cannot be contacted without permission, and the client cannot bring their sister in without parental knowledge.

During a clinic appointment, the examiner notes that a client with cancer looks fatigued and is wearing dirty clothes. The client has lost 20 pounds since their last visit. Which statements by the examiner therapeutically assess the client's functional ability? Select all that apply.​ "How is your lack of energy impacting what you want to do?"​ "Tell me more about your support system."​ "Can you tell me how you are doing at home managing your daily activities?"​ "I am going to contact the social worker since it seems you need assistance at home."​ "I think you need a home care nurse to come in at least once a week."​

The examiner should ask about the client's support system, how they are managing daily activities, and how their lack of energy is impacting them as part of the assessment of functional ability. Questions should be asked in a therapeutic manner with the focus on functional ability. "I think you need a home care nurse to come in at least once a week" and "I am going to contact the social worker since it seems you need assistance at home" are based on the examiner's opinion and not client data. ​

Prioritize the following aspects of the general survey in the correct order: -When you touch them, is the client's skin dry or moist? -Ask the client to state their name. Does the client respond immediately and accurately? -Note your first impression. Are there any outstanding features? -As the client is describing reason for visit, observe the client's conversation with you. Can they participate in conversation?

The first impression would be when you first enter the room. The next step is to verify the client and assess level of consciousness. Observing the conversation will give you information about speech. The last step should be touch.

When measuring a client's height, the examiner is aware of which guideline?​ Have the client lie on a platform scale​ Instruct client to put chin to chest​ Use only a wall-mounted device​ The client should not be wearing shoes​

When measuring height, the client should not be wearing shoes. A wall-mounted device may be used, but it is not required. Platform scales are used with infants. The client should stand upright looking forward. ​

Which of the following are abnormal general survey findings? Select all that apply. Posture is upright while sitting Speech is clear Hair appears thin Alert and oriented x 4 Client appears older than stated age

Abnormal findings include the hair appearing thin and the client appearing older than the stated age.​ Clear speech and upright posture are normal. The level of orientation is normal.

The examiner is completing a health history on a client who presents with abdominal pain. Which is an example of biographic information that may be obtained during a health history?​​ Past surgeries​ Current occupation​ Personal values and beliefs​ History of immunizations​

Current occupation is part of biographic data. Past surgeries and immunizations are in past history. Personal values and beliefs can be under functional assessment or cultural assessment. ​

During which portion of the physical assessment should gloves be used? Integumentary Ophthalmic Neurologic Oropharyngeal

For the safety of the nurse, gloves should be worn when the chance of exposure to the client's mucous membranes or body fluids is likely. Of the options listed, contact with body fluids is most likely during the oropharyngeal examination.

A client in the emergency department (ED) is complaining of right lower quadrant abdominal pain. Which techniques in what order would be performed during a comprehensive abdominal examination to evaluate this client?

Inspection, auscultation, palpation. The proper order of an abdominal assessment is inspection, auscultation, percussion, and palpation. Because the generalist nurse does not usually perform percussion, the correct answer, in this case, is inspection, auscultation, and palpation.

A client who speaks Spanish arrives at the triage desk in the emergency department (ED) and requests an interpreter. What is the best action for the nurse to take?​ -Page an interpreter from the hospital's interpreter services. -Have the Spanish-speaking triage receptionist interpret. -Obtain a Spanish-English dictionary and attempt to triage the client. -Have one of the client's family members interpret.

Page an interpreter from the hospital's interpreter services. Using a dictionary slows the triage process and should be used as a last resort. Family members may not appropriately understand what is asked of them and may paraphrase what the client is saying. Also, client confidentiality as well as accuracy of information may be compromised when a family member or non-healthcare provider acts as an interpreter.

An examiner is performing a health history on a client who is being admitted to the hospital. Which questions should be used to gather subjective data? Select all that apply.​ "Can I listen to your lungs?"​ "How does the shortness of breath impact your life?"​ "Do you have a history of heart disease?"​ "How often do you forget to take a dose of your medication?"​ "Where are you working right now?"​

Subjective data is provided by the client and cannot be directly verified by the nurse. Asking the client if they are working, have a history of heart disease, how often they miss a dose of their medication, and how shortness of breath impacts their life is one way to obtain subjective data. "Can I listen to your lungs?" is not a health history question and is used in the physical assessment.​

The health professional responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the health professional examine first? -The individual lying on the floor screaming that their leg is broken. -The colleague with a torn uniform, walking with a limp, directing people out of the lobby -The car driver who is slumped over the steering wheel, not moving -The older adult bleeding from the head, sitting quietly on the floor talking to a crying child

The car driver who is slumped over the steering wheel, not moving As a student, it probably will not happen often that you need to prioritize the order in which you assess clients in a mass casualty situation. Yet as a novice health examiner, you should realize that the person requiring an emergency assessment requires immediate assistance and that using the ABCs is the way to rapidly prioritize care needs. The older adult bleeding from the head, the limping colleague, and the individual crying out that their leg is broken are all talking and alert at this time, so their ABCs are good. The driver of the car, however, is not moving and requires a rapid assessment of their status to determine their health needs.

A 2-month-old infant has a head measurement of 38 cm and a chest circumference of 36 cm. Based on these measurements, what would the examiner do?​ Expect the chest circumference to be greater than the head circumference. ​ Ask the parent to return in a month to re-evaluate the head and chest circumferences.​ Refer the infant to a physician for further evaluation.​ Consider these findings normal for a 2-month-old infant.​

The newborn's head measures approximately 32 to 38 cm and is approximately 2 cm larger than the chest circumference. Between 6 months and 2 years, both measurements are approximately the same, and after age 2, the chest circumference is greater than the head circumference. Therefore, these findings are normal for a 2-month-old infant.

At a 6-month follow-up appointment, the nurse notices a difference in the general survey data. At a previous appointment, the client was clean and appeared healthy. Now the client appears to have hygiene problems and weight loss. What is the nurse's best response? Document the findings only Point out the differences to the client Stop the assessment and notify the provider Encourage the client to share experiences of the past 6 months

The nurse should encourage the client to share experiences of the past 6 months to gain more insight and data. Pointing out the differences may be embarrassing for the client. The nurse will need to document the findings but they need more information. It is not an emergency, so the assessment can continue.​

Which of the following findings during the general survey indicate a change in mobility? ​ Client is 5'2" and 160 pounds​ Client's body is symmetric​ Client is seated in a tripod position​ Client had a stroke 2 years ago and has a walker.​

The stroke and walker are evidence of a mobility impairment. Position, symmetry, and body measurements do not indicate a change in mobility.​

Structures with relatively more (fluid; air; density) typically produce a louder, deeper, and longer sound because it (vibrates freely; is muffled by surrounding fluids; fails to penetrate tissues) . A solid structure, like the (thigh muscle; liver; large intestine) gives a softer, higher, (longer; shorter; deeper) sound because it does not vibrate as easily.

air vibrates freely liver shorter

Which of the following best describes the purpose of a general survey? ​​ To collect subjective information​ To collect information about chronic conditions​ To determine the focus and depth of the physical assessment​ To provide vital signs​

Data collected from the general survey is used to determine the focus and depth of assessment of each system.​ The general survey does not include the collection of subjective information or information about chronic conditions. It is also not to provide vital signs.​

Ensuring the lighting in the examination room is bright is key to an accurate inspection for which reasons? Select all that apply. -Detecting odors from wounds. -Observing changes or differences in skin color. -Noticing pulsations. -Seeing differences in skin texture. -Visualizing deeper masses.

The correct answers are: -Observing changes or differences in skin color. -Seeing differences in skin texture.​ -Noticing pulsations. Bright lighting allows the nurse to observe the color of skin, notice alterations in skin color or texture, detect visible pulsations, and note areas of deformity. Deeper masses, especially in the abdomen, may not be visible and will be detected during palpation. Odors are detected using the sense of smell. Neither palpation or smell require bright lighting to improve the accuracy of assessment data.

The examiner is documenting the reason for seeking care. Which statement is documented correctly?​ Client has pain in the right ankle.​ Client presents with a sprained ankle.​ Client states, "I have pain in my right ankle."​ Assessment of right ankle is needed due to "pain."​

The reason for seeking care is a brief statement documented in quotes indicating that these are the client's own words, such as the client stating, "I have pain in my right ankle." It is not a diagnostic statement by the examiner.​

Which statements about holistic health are correct? Select all that apply. -Societal influences, including family, have little influence on individual health practices. -Disease results from factors within and outside of the body. -Lifestyle choices have no impact on overall health. -Views the mind, body, and spirit as vital to overall wellness.​ -Each person is an active part of their own health and wellness.

-Disease results from factors within and outside of the body. -Views the mind, body, and spirit as vital to overall wellness.​ -Each person is an active part of their own health and wellness.

The client appears to be thin with pronounced bony prominences. The nurse would document this under (behavior; body structure; hygiene.)

Based on these findings, the nurse would document this under body structure (not hygiene or behavior).

(Posture, Body mass index, Head circumference) is a marker of health and an indicator of nutritional status.

Body Mass Index (BMI) is a marker of health and an indicator of nutritional status. It is calculated as weight (kg)/height (m2).​ Head circumference is often measured in newborns and infants to monitor growth and development and screen for hydrocephalus.​ Posture reflects musculoskeletal health, not nutritional status.

The examiner notes that an elderly client is confused regarding the time and date. The examiner would document this finding in which section of the general survey?​ Affect Orientation​ Alertness Mood

Confusion about person, place, time, or situation is orientation. Affect is a visible reaction while mood is an underlying reaction. Alertness refers to being awake. ​

The examiner is entering the room to assess a newly admitted client. Which of the following best describes the purpose of a general survey? ​ ​ To provide information to guide the physical assessment​ To measure vital signs​ To collect the information necessary for diagnostic testing​ To give an opportunity for the client to voice complaints​

Data collected from the general survey is used to determine the focus and depth of assessment of each system.​ Measuring vital signs is part of the physical assessment. Information needed for diagnostic testing is administration. The client voicing their complaints occurs during the interview.

Which question would be asked as part of a developmental assessment?​ "Does your child have a cough?​" "When was your child born?​" "Are the child's grandparents still living?​" "When did your child get their first tooth?​"

Developmental milestones, such as the first tooth, are included in the developmental assessment. Asking about symptoms is part of the history of present illness.​ Date of birth is collected with other biographical information.​ Information about grandparents' health is obtained during the family history.

The examiner is observing behavior which includes (facial features, dress, eye color) , (sexual development, consciousness, mood) , (grooming, race, body type) , and (personal hygiene, age, blood type.)

Dress, grooming, personal hygiene, and mood are aspects of behavior that are observed by the examiner. While dressing, grooming, and personal hygiene are part of the physical appearance, they are controlled by the actions the person takes to care for themselves, while mood is more directly reflected in the person's behavior.​ Age, sexual development, level of consciousness, skin color, and facial features are part of physical appearance that are not impacted by a person's behavior

Child treated at an urgent care center for a rash.

Health Problem​: Child treated at an urgent care center for a rash. Frequency of Follow-Up​: As needed, if rash does not go away Rational​e: Anyone treated for a rash should follow up with their healthcare provider if the rash lingers or worsens after treatment is provided, as needed.

The health examiner preparing to perform a physical assessment of the abdomen is aware that the order each technique is performed is important in obtaining the best assessment.​ Drag each assessment technique into the order it should be completed in an abdominal assessment, from first to last. Percussion Auscultation Inspection Palpation

Inspection Auscultation Percussion Palpation

Close relative with an eating disorder

Non-modifiable developmental risk factors

The nurse is performing an assessment of a client's abdomen. Palpation of the right upper quadrant elicits significant pain. Based on knowledge of normal anatomy and pathophysiology, which organs are likely causing the pain? Select all that apply. Pancreas Liver Spleen Appendix Gallbladder

Liver & Gallbladder The liver and gallbladder are in the right upper quadrant. Pain associated with palpation in the right upper quadrant could suggest an abnormality of the liver or the gallbladder.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse anticipates hearing a low-pitched (click; rub; murmur; squeak) using the (bell; diaphragm) portion of the (otoscope; stethoscope; ophthalmoscope.​)

Murmur Bell Stethoscope

Socially defined "ideal body"

Non-modifiable cultural risk factors

Place the actions taken when conducting a complete health assessment in order from first to last. -Obtain a detailed health history. -Assure the client is comfortable. -Perform hand hygiene. -Verify the client's identity. -Document assessment findings and plan of care. -Discuss findings and next steps. -Introduce self. -Assess the client's current state of health. -Perform hand hygiene again. -Complete a full physical assessment.

Perform hand hygiene. Introduce self. Verify the client's identity. Assess the client's current state of health. Obtain a detailed health history. Complete a full physical assessment. Discuss findings and next steps. Assure the client is comfortable. Perform hand hygiene again. Document assessment findings and plan of care.

Which question would be asked as part of the review of systems?​ "Do you use any drugs or alcohol?​" "Do you have any allergies to any medications?​" "Do you have any difficulty with vision?​" "Do you have any family history of cancer?​"

The purpose of the review of systems is to evaluate each body system to uncover dysfunction or disease. Asking about a client's vision provides information about their eye health, which is part of the sensory system. The other questions provide information about other aspects of the health history.

While dining with friends, the health professional notices a woman at the next table holding her hands to her neck and goes to help. The health professional begins 1. (a complete; a focused; an emergency; a follow-up) assessment of her 2. (airway; breathing; circulation; health) status by asking her, "Are you 3. (dying; choking; allergic) to any medications ?"​

1. an emergency 2. airway 3. chocking

A nurse cares for a 13-year-old female diagnosed with anorexia whose physical and sexual development are delayed because of her stated age. The client's mother asks, "What does this mean?" How should the nurse correctly respond? "She must have a genetic condition that is causing her to have delayed physical development." "Her physical development is delayed compared to other girls her age." "It really doesn't mean anything, she is fine and will continue to grow." "This is a chronic condition, and it will impact on her health."

A client whose physical development and sexual development are not consistent with normal findings for the stated age means that her physical development is delayed compared to other girls her age. It could be genetic or related to a chronic condition. Further testing may be necessary. Delays in development should be monitored.

Which aspects of the client are observed by the examiner during a physical appearance survey? Select all that apply. Dress Personal hygiene Age Level of consciousness Skin color Facial features Sexual development

Physical appearance includes age, sexual development, level of consciousness, skin color, and facial features. Dress, grooming, personal hygiene, and mood are part of behavior.​

The examiner has collected the following subjective data from a 55-year-old client:​ Reason for seeking care: Low back pain​ History of present illness: Started two days ago after lifting furniture. Stabbing pain in the lower back rated 7/10. Lying flat makes pain decrease. Ice makes it better temporarily.​ Past history: Left knee replacement 5 years ago​ Medication reconciliation: Acetaminophen 500 mg every 6 hours for pain as needed​ Family history: History of high blood pressure on father's side; diabetes on mother's side​ Review of systems: Non-remarkable​ Functional assessment: Cannot work due to pain What would the examiner assess first?​ Assess range of motion of the arms. Complete a focused assessment of the left knee​. Complete a focused assessment of the back​. Discuss financial options.

The information collected indicates the current problem is low back pain. This would be the examiner's main focus of the physical examination. The left knee replacement is in the past and financial options are a secondary priority and more the work of a social worker. Range of motion of the arms does not address potential issues with the lower back.

For a client with cardiac arrest, a(n) __________________ assessment may be obtained from relatives.​ comprehensive emergency focused rapid

emergency