Health Assessment 1 - Exam 2

Which response by the nurse during a client interview is an example of back channeling? "All right, go on..." "What else is bothering you?" "Tell me what brought you here." "How would you rate your pain on a scale of 0 to 10?"

"All right, go on..." Rationale Back channeling involves the use of active listening prompts such as "Go on...", "all right", and "uh-huh." Such prompts encourage the client to complete the full story.

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition? 1+ 2+ 3+ 4+

4+ Rationale Edema of 8 mm is documented as 4+. If the edema has a depth of 2 mm, then it is documented as 1+. If the edema has a depth of 4 mm, it is documented as 2+. If the edema has a depth of 6 mm, then it is documented as 3+.

How does the World Health Organization (WHO) define "health"? A condition when people are free of disease A condition of life rather than pathological state An actualization of inherent and acquired human potential A state of complete physical, mental, and social well-being

A state of complete physical, mental, and social well-being. Rationale The WHO defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity."

Which physical assessment technique involves listening to the sounds of the body? Palpation Inspection Percussion Auscultation

Auscultation Rationale Auscultation involves listening to the sounds of the body.

The nurse is assessing a client's pulse strength and records it as a 3+. Which description best describes this client's pulse strength? Bounding Absent Expected Diminished

Bounding Rationale A pulse strength of 3+ is considered full or bounding. A pulse strength is considered normal, expected, and easily palpable when it is 2+.

The nurse noticed the breathing rate as regular and slow while assessing a client for respiration. What could be the condition of the client? Apnea Bradypnea Tachypnea Hyperpnea

Bradypnea Rationale In bradypnea the breathing rate is regular, but it is abnormally slow.

The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. What is the purpose of the nurse's action? Data collection Data validation Data clustering Data interpretation

Data collection Rationale The nurse is gathering objective data to support the subjective data. The client's report of difficulty breathing is subjective data that needs to be supported by data from physical examination.

While performing a physical assessment, the nurse notices a minute, nonpalpable change in the skin color of a client. What might be the type of skin lesion involved? Wheal Papule Vesicle Macule

Macule Rationale A macule is a flat, nonpalpable change in skin color, which is smaller than 1 cm.

Which client assessment finding should the nurse document as subjective data? Blood pressure 120/82 beats/min Pain rating of 5 Potassium 4.0 mEq Pulse oximetry reading of 96%

Pain rating of 5 Rationale Subjective data are obtained directly from a client. Subjective data are often recorded as direct quotations that reflect the client's feelings about a situation.

The nurse finds that the client's fever spikes and falls without a return to a normal level. Which pattern of fever is this a characteristic of? Relapsing Sustained Remittent Intermittent

Remittent Rationale In a remittent pattern, fever spikes and falls without returning to normal temperature levels.

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data? The client weighs 151 lbs (68.5 Kg). The client's pain is 7 on a scale of 1 to 10. The client's fasting blood sugar is 95 mg/dL. The client's blood pressure is 140/90 mm/Hg.

The client's pain is 7 on a scale of 1 to 10. Rationale Subjective data is information conveyed to the nurse by the client, such as the client's feelings, perceptions, and self-reporting of symptoms. The client rates pain as a 7 on a scale of 1 to 10, therefore it is subjective data.

Which statement is true for collaborative problems in a client receiving healthcare? They are the identification of a disease condition. They include problems treated primarily by nurses. They are identified by the primary healthcare provider. They are identified by the nurse during the nursing diagnosis stage.

They are the identification of a disease condition. Rationale The nurse assesses the client to gather information to reach diagnostic conclusions. Collaborative problems are identified by the nurse during this process. If the client's health problem requires treatment by other disciplines such as medical or physical therapy, the client has a collaborative problem.

Which assessment finding of the skin refers to elasticity? Turgor Edema Texture Vascularity

Turgor Rationale Turgor refers to the elasticity of the skin.

While examining a client, a nurse finds a circumscribed elevation of the skin filled with serous fluid on the cheek. The lesion is 0.6 cm in diameter. What does the nurse suspect the finding to be? Papule Vesicle Nodule Pustule

Vesicle Rationale A circumscribed elevation of the skin that is filled with serous fluid and a lesion size of less than 1 cm describes a vesicle.

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience? Visceral pain Somatic pain Referred pain Intractable pain

Visceral pain Rationale Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity.

Which feature is characteristic of a risk nursing diagnosis? a.) The diagnosis does not have related factors. b.) The diagnosis can be used in any health state. c.) The defining characteristics support the diagnostic judgment. d.) The defining characteristics are supported by a client's readiness.

a.) The diagnosis does not have related factors. A risk nursing diagnosis describes human responses to health conditions that may develop in a vulnerable individual, family, or community. Risk diagnoses do not have related factors or defining characteristics because they have not occurred yet. A risk diagnosis has risk factors that help the nurse plan preventive measures.

While assessing a client for the dorsalis pedis pulse, a nurse documents the reading as 1+. What can be inferred from this finding? a.) There is absence of a pulse. b.) The pulse strength is normal. c.) The pulse strength is bounding. d.) The pulse strength is barely palpable.

d.) The pulse strength is barely palpable.