Health assessment

A nurse is teaching a groups of newly licensed nurses about routine mammography screenings for female clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

A 55 year old client should receive mammogram screenings at least every 2 years

A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up?

A client has a radial pulse of +4 bilateral.

A nurse is teaching a group of assistive personnel (AP) about techniques used to obtain BP. For which of the following clients should the nurse instruct the AP to obtain an electronic BP measurement?

A client who has stabilized BP measurements

A charge nurse is evaluating a newly licensed nurses documentation of vital signs for several clients. Which of the following documentation should the charge nurse identify as being incomplete?

BP 124/82 mm Hg, lying in bed * it is incomplete because it does not include site in which the blood pressure was obtained

Which of the following factors are included in health literacy?

Basic reading skills Competency using numbers Ability to follow verbal instructions

Vesicular breath sounds

soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue

Which aspect of life is assessed using the FICA approach?

spirituality

Which of the following are tools used with auscultation?

stethoscope and doppler

Pulse sites

temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis

A nurse is observing an assistive personnel (AP) obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse?

The AP informs the client when they are counting the respirations.

A nurse is planning care for a group of clients and is reviewing the recent vital signs obtained by an assistive personnel. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider?

8-year-old male: respiratory rate 34/min, SaO2 97%

A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a viral sign outside the expected reference range and requires intervention?

A 3 year old preschooler who has an apical pulse rate of 144/min. * the nurse should identify the rate is above the expected range for a preschooler of 75 to 129/min.

A nurse is reviewing the recent vital signs of a group of clients: which of the following clients should the nurse see first?

A 52-year-old client who has an SaO2 of 92%

Hypoglossal (CN XII)

Have patient stick our tongue and check it's midline, see if patient can correctly articulate "light, tight, dynamite"

A charge nurse is receiving the expected reference range of blood pressure in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include?

Hypertension is diagnosed with two elevated measurements on two separate occasions

A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entities in the chart requires follow up by the nurse?

Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in hall

A nurse is performing a breast examination on a client and notices that the clients right arm is edematous. Which of the following should the nurse identify as a potential cause of this condition?

Recent surgery on the right side

A charge nurse is teaching a group of assistive personnel (AP) about the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching?

Recording vital signs provides critical information regarding a client's condition.

A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct?

SaO2 97% right index finger, room air

A nurse is evaluating the effectiveness of interventions used to address clients vital signs that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective?

A young adult who is experiencing an asthma attack and has a blood pressure of 116/72 after using an inhaler

A nurse is reviewing beast self examination techniques with a client. Which of the following client statements indicates an understanding of the techniques?

I will use circular motions to feel the texture of my breast tissue.

Oculomotor nerve (CN III)

If pupils dilate with far gaze and constrict with near gaze. Pupils equal, round and reactive to light and accommodation (PERRLA= normal)

A nurse is caring for a client who has in increase in cardiac output. Which of the following findings should the nurse expect?

Increase in blood pressure

Auditory cranial nerve (V III)

Ability to hear whispered words and repeat them

Which of the following is a closed ended question?

" what time do you usually get up in the morning?"

A charge nurse is reviewing orthostatic hypertension with a group of newly licensed nurses. Which of the following statements should the charge nurse make?

"A decrease of 20 millimeters of mercury in the systolic pressure with a position change indicates orthostatic hypotension"

A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include?

"Cardiac output is the amount of blood flow through the heart in 1 minute."

A charge nurse is discussing a client's respiratory data with a newly licensed nurse. Which of the following statements should the nurse include?

"Count the respiratory rate for 1 'minute for clients who have a respiratory infection."

A nurse is obtaining a past health history for a client prior to a breast examination. Which of the following questions should the nurse ask while obtaining the clients past health history?

"Have you ever had breast disease?" "Have you experienced breast trauma?" "Have you had breast surgery?" "Do you perform breast self-examinations?"

A charge nurse is discussing mechanisms of loss of body heat with newly licensed nurse. Which of the following statements should the nurse include?

"Radiation is the loss of body heat when a client is in close proximity to a cooler surface."

A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?

"The body lowers body temperature through sweating."

Bradypnea causes

( usually also paired with dizziness, fatigue, weakness, confusion, impaired coordination) Elevated intracranial pressure Hypothyroidism Shock Alcohol/opioid/sedative toxicity Morbid obesity

Tachypnea causes

(Usually also paired with dizziness, tingling in hands) Physical activity Pain Anxiety Pneumonia

A nurse is preparing to review health promotion recommendations for breast health with a client. Which of the following actions should the nurse plan to take when reviewing health promotion recommendations for breast health?

- ask the client to describe the process for breast self-examination at the end of the teaching. -document instructions provided in the client's medical record. - Review recommendations for mammography based on risk with the client.

Which of the following actions by the nurse are examples of infection control?

-hand washing with soap and water for 15 seconds -using an alcohol-based rub when hands are not visibly soiled -using an alcohol pad to wipe the diaphragm of the stethoscope between clients

Types of pain scales

1. FLACC- face, legs, activity, cry, consolability 2. Wong-baker faces scale 3. 0-10 number scale 4. CRIES- crying, reg. 02, ^vitals, expression, sleeplessness 5. Visual analog scale

A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include?

A pulse strength of +1 indicates that the pulse is weak or diminished upon palpation.

A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention?

A school age child who has a respiratory rate of 14/min * the nurse should identify that a RR of 14/min is below the expected reference range of 18-30 for school aged children. This child is exhibiting bradypnea

Trigeminal (CN V)

Ability to bite and chew. Check sensation of skin on the face

A nurse is preparing to obtain a young adult clients apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the clients pulse?

Apex of the heart * 5th intercostal space to the left of the clients sternum

A nurse is collecting data during a review of systems and asks the client how many pillows are required to sleep comfortable at night. This question involves assessment of which of the following systems?

Cardiovascular

Glossipharyngeal (IX) and vagus cranial nerves (X)

Check the uvula is midline and rises when they say "ah" check ability to swallow.

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. (Acidosis, ketoacidosis, severe kidney disease)

A nurse is discussing breast cancer with a group of male clients. The nurse should include that which of the following findings is a potential indication of breast cancer?

Dilation of the hair follicles Nipple retraction A small bulging nodule lateral to one breast

A nurse is performing a breast inspection on a client. Which of the following finds the nurse report to the provider?

Dimpling

A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?

Encourage the client to change positions slowly

A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to include?

Encourage the client to practice relaxation techniques each day.

A nurse is caring for a client who has a heart rate of 118/min. Which of the following actions should the nurse take to improve the clients heart rate?

Encourage the client to reduce intake of caffeinated soft drinks.

Malpractice

Failure by a health professional to meet accepted standards

A nurse is preparing an in-service about factors affecting respiratory rate for a group of assistive personnel. Which of the following information should the nurse include?

Fever can increase a client's respiratory rate.

What is radiation?

Indirect in close proximity to a cooler surface

A nurse is caring for a client who reports palpable lymph nodes under one axilla. The nurse dan see small nodules under the skin in the area the client describes. Which of the following should the nurse identify as a potential cause of the clients lymph node enlargement?

Infection

A nurse is evaluating the effect I was of interventions provided to a client who was admitted for decreased circulation. Which of the following findings requires further intervention by the nurse?

Left radial pulse is nonpalpable

A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include?

Oxygen saturation reflects the amount of oxygen being delivered to body tissues

cyanosis signs and symptoms

Pallor Dark skinned individuals may have a grayish skin color

A nurse is caring for a recently admitted client and as part of the plan of care, two nurses obtain simultaneous pulse rates. The clients auscultation apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following.

Pulse deficit of 13/min *deficit could be caused by Afib, aortic rupture or CAD. Document and notify provider

For which of the following disease should you obtain family history?

Sickle cell anemia

A nurse is performing a physical assessment of a client. In which of the following positions should the nurse place the client prior to inspecting the clients breasts?

Sitting straight up with arms relaxed and close to the body

A nurse is inspecting a clients axillae. Which of the following should the nurse identify as an expected finding?

Skin has a uniform consistency

Retractions (Breathing)

Skin pulling around the ribs or above the clavicles during inspiration (abdominal breathing)

What is FICA?

Spiritual Assessment Tool - Faith, Importance/Influence, Community/Address Action

social determinants of health

The conditions in which people are born, grow, live, work, and age, shaped by the distribution of money, power, and resources at global, national, and local levels

What is the history of present illness?

The story of symptoms and events that led to the clinic visit Belongs at the beginning of the chart immediately following the CC Summarizes the reason for the visit Basis for the rest of the chart

Why are vitals taken at the beginning?

They are needed for baseline and to see trends/patterns

Which of the following is a purpose of obtaining a health history?

To establish a baseline of the client's health status

Which of the following are research validating reasons to conduct a health history using an interpreter?

To increase the accuracy of the communication To increase the client's satisfaction with care h

A nurse is reviewing the vital signs obtained by an assistive personnel at 1200. For which of the following clients should the nurse plan to intervene?

Toddler who has a respiratory rate of 44/min * respiratory rate in toddlers is 25 to 30/min

What is convection?

Transfer of heat by movement of fluid, including air and water.

Delegation in Nursing

Transferring the authority to perform a selected nursing task in a selected situation to a competent individual

Optic cranial nerve (II)

Use snellen chart to check far vision

A nurse is discussing the use of a clients thigh for blood pressure measurements with an assistive personnel (AP). Which of the following information should the nurse include?

Use the thigh to obtain blood pressure when a client has severe edema in their arms

What is health equity?

Value all patients the same (treating them all the same)

A nurse is teaching a newly licensed nurse about nipple inspection. Which of the following should the nurse include as an example of an expected variation of the nipple?

a client's nipple has remained inverted since childhood

Atelectasis

collapsed lung, absence from breath sounds

A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires follow up by the nurse?

dyspnea

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

implementation * during the implementation step, the nurse Carrie's 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 clients progress. Implementation is when the nurse puts the plan of care into action

A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect?

increase blood pressure * a client with increase in afterload increases risk for hypertension. Afterload is the resistance of the ventricle to pump the heart muscle and eject blood into the clients bloodstream during systole.

Which of the following is the first action during the physical assessment of the client?

inspecting the client

What is PQRST?

mnemonic used for assessing pain. precipitating or palliative, quality or quantity, region or radiation, severity scale, timing

Hypoxia

not enough oxygen in tissues

What is the Review of Systems?

sequential, comprehensive method of eliciting patient symptoms on an organ-by-organ basis

A nurse is reviewing blood flow through the heart with a group of assistive personnel. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle?

pulmonary artery *as the right ventricle contracts; blood is forced into pulmonary artery; where it enters the lungs to become oxygenated. Once oxygenated the blood is returned to the heart via pulmonic vein, where it enters left atrium. Then passed through mitral valve into left ventricle. As the ventricle contracts, the blood is forced into the aorta and systemic circulation.

Olfactory (CN 1)

sense of smell, ability to recognize a familiar scent

What is equality?

the state of being equal, especially in status, rights, and opportunities. (Providing equally)

What is conduction?

transfer of heat through direct contact (another surface)

Which of the following techniques is used with palpation?

use the palmar side of the hands or the pads of the fingers

Facial cranial nerve (CN VII)

Symmetry of facial expressions. Test anterior 2/3s of the tongue for ability to taste.

Techniques of Physical Assessment

1. Inspection (look, listen, smell) 2. Palpation (touch) 3. Percussion (tapping) 4. Auscultation (listen) *unless it's abdominal than it's- inspection, auscultation, percussion, palpation

How many generations should you collect medical history about?

3 generations parents, grandparents, aunts, uncles, siblings

Assessing vital signs

Review Evaluate Document Notify Implement Ensure client safety

______ % of the US suffers from chronic pain

11.2

A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan?

- provide the client with low-sodium meals and snacks - encourage the client to participate in physical activity each day - instruct the use of relaxation techniques - inform the client of the importance of abstaining from using nicotine products

A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients vital signs indicate that interventions were effective?

-A preschooler who was exhibiting tachypnea 2 hr postoperative and now has a RR of 26/ min - an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min - a young adult who had hypotension after revising an opioid analgesic and now has a blood pressure of 98/68

Therapeutic communication involves which of the following

-touch -open-ended questions

A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following information should the nurse include?

A client who has a blood pressure of 162/102 mm Hg has stage II hypertension. *in stage II hypertension the systolic BP must be greater than 140 and diastolic BP greater than 90

a nurse working on a medical surgical unit is caring for a group of clients. Which of the following clients vital signs should the nurse identify is outside the expected reference range and notify the provider?

A client who has an apical pulse rate of 120/min

A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an assistive personnel (AP) to obtain a rectal temperature?

A client who is diaphoretic and frequently chewing ice to relieve dry mouth

A nurse is planning care for a group of clients and is delegating to the assistive personnel to take the clients vital signs. For which of the following clients should the nurse obtain the vital signs rather than the AP?

A client who was recently admitted and reports chest pain

A nurse is preparing an in-service for a group of newly hired assistive personnel (AP) about Boyd temperature. Which of the following information should the nurse include?

A temporal probe thermometer uses infrared scanning to determine a client's temperature

A nurse is reviewing the vital signs for a group of clients obtained by an additive personnel. The nurse should identify that which of the following clients requires a follow up assessment due to bradycardia?

A young adult who has a radial pulse rate of 56/min

A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia?

A young adult who has an apical pulse rate of 104/min

A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention?

An 11-year-old child who has a respiratory rate of 34/min * normal RR in school aged children is 18-30/min

A nurse is reviewing the vital signs for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective?

An adult client who received medication for pain 30 min ago now has a respiratory rate of 18/min

Select the action the PN participated in with the nursing process

Assist the RN with collecting data from the client side

A nurse is discussing the physiology of blood pressure with a group of assistive personnel. Which of the following information should the nurse include?

Blood pressure is measured and documented in millimeters of mercury

A nurses health assessment is the ______ ______ for the patients care plan.

Blue print

A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching?

Body temperature is typically lower in older adults.

A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering?

Bronchodilator

A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness: which of the following is the nurses priority action?

Inform the client to ask for assistance with getting out of bed.

A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take?

Instruct the client to bear down like they are having a bowel movement. * valsalva maneuver

ISBARR

Introduction Situation Background Assessment Recommendation Read back

Documentation should be done ASAP because

It is very important to get done prior to another nurse or the provider sees them so all of the information is easy to access

What is evaporation?

Loss of heat via gases

Bronchial heath sounds

Loud, high pitched, hollow sound. (Anteriorly over trachea)

A nurse is caring for a male client who was recently diagnosed with gynecomastia. Which of the following should the nurse identify as a potential cause of this condition?

Medication adverse effects

A nurse is teaching a group of female clients about breast self awareness. Which of the following instructions should the nurse include?

Menstruating females should examine their breasts about 5 days after their menstrual cycle begins.

Pain starts in the

Nociceptor

Place the steps in the correct order to record information when using the GTPAL format

Number of pregnancies Number of term deliveries Number of preterm deliveries Number of voluntary or involuntary abortions Current number of living children

A nurse obtains a client's electronic blood pressure reading of 188/96 mm Hg. Which of the following actions should the nurse take next?

Obtain a manual blood pressure reading from the client.

A nurse is preparing an in-service about vital signs for a group of newly hired personnel. Which of the following information should the nurse include about measuring body temperature?

Oral temperature is easily accessible despite a clients position

biopsychosocial model of pain

Psychological Biological Social

A nurse is observing an assistive personnel who is obtaining a blood pressure reading from a client. Which of the following actions by the AP requires follow up by the nurse?

The AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 Mm Hg per second. * releasing it this way is too fast, 2mm Hg is recommended

Spinal Accessory (XI)

While providing resistance have patient turnbhead side to side and shrug shoulders upward

Negligence

careless neglect, often resulting in injury

Cheyne-Stokes respiration

an irregular pattern of breathing characterized by alternating rapid or shallow respiration followed by slower respiration or apnea. (Stroke, ICP, brain tumor, heart failure, death)

A nurse is caring for a client who has hypotension, which of the following factors should the nurse identify as a contributing factor to the clients condition?

decrease contractility

A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart?

sinoatrial (SA) node

A nurse is caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response?

smoking

Non-pharmaceutical interventions

-positioning - cutaneous stimulation (heat/cold therapy, massage, acupuncture/acupressure, TENS) - cognitive behavioral therapy - therapeutic touch

A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include.

1) select the site for obtaining the measurement 2) apply the sensor probe on the chosen site 3) confirm the pulse rate displayed o the oximeter by palpating the radial pulse 4) wait 15 seconds and observer the SaO2 percentage displayed on the pulse oximeter

A nurse is teaching a client about performing a breast self exam at home.

1. Look at breasts in front of a mirror with hands placed on hips 2. Inspect for changes in shape, color, or contour 3. Inspect nipples for a rash or drainage 4. Lie down and prepare to palpate breasts with the pads of the second, thirds and fourth fingers 5. Palpate each breast from the outer edge; moving from top to bottom accords the breast

Pharmacological Interventions

1. Mannitol 2. Steroids 3. Antibiotics: if needed 4. Thiamine 5. Narcan 6. Colace 7. Zofran for nausea 8. Anticonvulsant med 9. Tylenol for pain 10. Proton pump inhibitor to reduce risk for ulcers 11. Propofol (Diprivan) 12. Fluid 13. All of our nursing care is about preventing ICP. (M SAT NC ZAT PPFA)

A nurse is reviewing the vital signs of four clients. The nurse should identify that which of the following clients has a vital sign outside of the expected reference range?

A 23-year-old client who runs marathons and has a blood pressure of 82/54 mm Hg

Place the steps in the correct order to conduct a review of systems

Head Eyes Ears Nose Mouth Neck

What does HIPAA refer to?

Health Insurance Portability and Accountability Act

Bronchovesicular breath sounds

Heard over the main stem bronchi, medium pitched (quieter)

A nurse is assessing a 3 month old infant during a well child visit. Which of the following actions should the nurse take when assessing the apical pulse?

Place the stethoscope over the 4th intercostal space to the left of the sternum. * apical pulse is found in 4th intercostal space to the left of the sternum in infant and children less than 7

A nurse is performing a breast inspection during a clients routing physical examination. Which of the following findings should the nurse report to the provider?

Scaley skin at the border of one areola