Health Assessment Exam One
The nurse is examining a newborn infants respirations. What technique is correct? a) Watching the chest rise and fall for 30 seconds b) Observing the movement of the abdomen for a full minute c) Placing a hand across the infants chest and counting for 15 seconds d) Using a stethoscope to listen to the breath sounds for two full minutes.
b) Observing the movement of the abdomen for a full minute
The nurse calculates a pts BMI to be 29.8. Which category does this fall under? a) Normal Weight b) Overweight c) Obese d) Extreme Obesity
b) Overweight
Which situation is most appropriate for the nurse to gather a complete database? a) Patient presents to endocrinologist after being on a new diabetes medication for two weeks. b) Patient is admitted to a long-term care facility c) Patient suddenly loses consciousness d) Patient in an outpatient clinic has cold and influenza- like symptoms
b) Patient is admitted to a long-term care facility
The nurse understands which statement to be true regarding pulse pressure? a) Pulse pressure is an indicator of tissue perfusion b) Pulse pressure is reflective of stroke volume c) Normal pulse pressure is 10-30 mmHg d) Pulse pressure is often narrower in the aging adult
b) Pulse pressure is reflective of stroke volume
When assessing the pulse of a young adult, the nurse notifies that his heart rate speeds up with inspiration and slows to normal with expiration. The rate is within normal limits, what action should the nurse take next? a) Notify the physician about the abnormality b) Record the findings as normal "sinus arrhythmia" c) Check the child's blood pressure and note any variation with respiration d) Document that this child has bradycardia and continue with the assessment
b) Record the findings as normal "sinus arrhythmia"
After assessing a patient who came into the clinic for a hand injury, the nurse determines that the patient has at-risk alcohol use. Which action by the nurse is the most appropriate at this time? a) Consult psychiatry fir a STAT evaluation b) State " You are drinking more than is medically safe. I strongly recommend that you quit drinking, and im willing to help you." c) Provide the patient with a telephone number of a local anonymous chapter d) Notify the clients family members about his risky drinking
b) State " You are drinking more than is medically safe. I strongly recommend that you quit drinking, and im willing to help you."
The nurse documents a pt's radial pulse as a 1+ force which can also be recorded as: a) absent b) Weak c) Easily felt d) Bounding
b) Weak
During the new grad orientation, the nurse teaches about the normal changes that can be expected in older adults. What should the nurse include in the teaching? a) Increase in resting pulse rate b) Widened pulse pressure c) Increase in body temperature d) Slower respiratory rate
b) Widened pulse pressure
The nurse is assessing an elderly client presenting for an annual check-up. What question would be BEST for the nurse to use to assess cognitive function in this client a) "Are you in any pain?" b) "Do you ever feel like people are watching you?" c) "What are your health goals?" d) "What have you eaten in the last 24 hours?"
d) " What have you eaten in the last 24 hours?"
A patient presents to the clinic with "abdominal pain". The nurse asks all of the following question during a full pain assessment EXCEPT; a) "When did the pain begin?" b) "Point to where it hurts the most?" c) "What does your pain feel like?" d) "How is your pain tolerance?"
d) "How is your pain tolerance?"
During an assessment, the nurse asks a female patient, "how many alcoholic drinks do you have a week?" Which answer by the patients would indicate a need for further assessment of her drinking habits? a) "I don't drink because alcoholism runs in my family" b)" I usually have three or four drinks over the span of a weekend." c) "I sometimes have a small glass of wine with dinner" d) "I drink most days, but i never get drunk"
d) "I drink most days, but i never get drunk"
During a mental status examination, the nurse wants to assess a patient's mood. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"
A) "How do you feel today?"
A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? a) at the end b) at the beginning c) before examining the head and neck d)Before auscultating the chest and abdomen
a) at the end
The nurse is preparing to obtain a rectal temperature on a comatose adult. What technique should the nurse use? a) Use a lubricated blunt tip thermometer. b) Insert the thermometer 2 to 3 inches into the rectum. c) Subtract 3 degrees before documenting a rectal temperature. d) Insert the thermometer with the client in the Fowler's position.
a) Use a lubricated blunt tip thermometer.
The nurse is caring for several patients on a pediatric unit. Which patient should the nurse be most concerned about possible abuse? a) a 4-month old with bruises on the arms. b) A 2-year old with bruises on the knees c) An 8-year old with a broken right arm d) A 15-year old football player with a broken leg
a) a 4-month old with bruises on the arms.
An adult client is brought to the emergency department by his sister who says he is an 'addict'. He is disoriented and hallucinating, and vital signs are elevated. The nurse suspects that the patient is experiencing withdraw from which substance? a) Alcohol b) Opioids c) Cocaine d) Cannabis
a) Alcohol
An adult is at the clinic for a complete physical examination. He states that he is "very anxious" about the exam. What steps can the nurse take to make him more comfortable? a) Appear unhurried and confident when examining him. b) Let him leave his clothes on during the examination c) Obtain another nurse to examine the patient d) Defer measuring vital signs until the end of the examination, which allows him time to become comfortable.
a) Appear unhurried and confident when examining him.
Which statement accurately describes the concept of a culturally competent caregiver? a) Attends to the total context of a patient's situation. b) Able to assume a client's needs based on their appearance. c) Able to understand and speak the patients language. d) Denies all stereotypes and biases.
a) Attends to the total context of a patients situation.
The nurse obtains which piece of data during the general survey a) Client is alert and calm b) Clients body mass index is 30 c) Clients heart rate is 80 bpm d) Clients lung sounds are "clear" to auscultation.
a) Client is alert and calm
While percussing over the liver of a patient, the nurse notes a sound that is similar to muffled thud. What should the nurse do? a) Consider this a normal finding b) Deeply palpate to identify skin texture and temperature c) Ask another nurse to percuss the area to validate the findings. d) Consider the finding as abnormal and notify the provider.
a) Consider this a normal finding
A concussed patient is admitted to the unit after a motorcycle accident. The nurse begins the mental status examination and finds that the patient is confused with dysarthria speech and arouses only to painful stimuli. How should the nurse proceed? a) Defer the rest of the mental status examination. b) Skip to the language portion of the examination and proceed onto assessing mood and affect. c) Conduct a full mental status exam. d) Assess for suicidal thoughts
a) Defer the rest of the mental status examination.
A woman presenting to the clinic with "severe anxiety" and admits to using cocaine shortly before arriving. Which of these assessment findings would the nurse expect to find when examining this woman? a) Dilated pupils, pacing and restlessness. b) Pupillary constriction, unsteady gait and aggression. c) Lethargy, pallor, and apathy. d) Delusions, bradypnea, and decreased temperature.
a) Dilated pupils, pacing and restlessness.
A client would like to eat his dinner. The nurse would most likely assist the patient in to what position? a) Fowlers b) Supine c) Prone d) Sim's
a) Fowlers
While assessing for substance abuse, the nurse: a) Refers to drugs using their "street" names so the client understands b) Only assesses for substance abuse in at-risk clients c) Educates the client about the benefits of marijuana d) Asks about each drug, one at a time
a) Refers to drugs using their "street" names so the client understands
The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a) The nurse must consider developmental milestones when assessing a child mental status b) The mental status of children should be assessed in the same way as an adult c)The mini-mental state exam (MMSE) is a useful tool to assess a preschoolers mental status d) Children do not need mental status assessments until they reach school age
a) The nurse must consider developmental milestones when assessing a child mental status
The nurse is caring for a patient with chronic lower back pain. The nurse knows that the most reliable indicator of pain in this client is: a) The patient is reporting "6/10" pain b) The patient is refusing to eat breakfast c) The patients heart rate is 90 bpm d) Client wishes to stay in bed rather than ambulate as ordered
a) The patient is reporting "6/10" pain
A patient tells the nurse that he is allergic to penicillin. What should the nurse ask next? a) "when is the last time you received penicillin?" b) "Describe what happens to you when you take penicillin?" c) "Are any of your family members allergic to it as well?" d) "Any other allergies?"
b) "Describe what happens to you when you take penicillin?"
An adult client presents to the emergency department with "shoulder pain". When assessing the severity of the pain, which question by the nurse is appropriate? a) "What does your pain feel like?" b) "How would you rate your pain on a scale of 0 to 10?" c) "How does pain limit your activities?" d) "What makes your pain better or worse?"
b) "How would you rate your pain on a scale of 0 to 10?"
The nurse understands whom to be at highest risk of suicide? a) 14-year-old overweight female who says "I am being bullied at school." b) 26-year old male with anxiety who says "I am going to take a whole bottle of sleeping pills tomorrow." c) 45-year old female with anorexia who reports a history of 3 suicide attempts. d) 32-year-old male who just lost his husband and children in a house fire.
b) 26-year old male with anxiety who says "I am going to take a whole bottle of sleeping pills tomorrow."
The nurse is taking a family history. Which specific disease pr problem is MOST important to include in the assessment? a) fractured bones. b) Cardiovascular disease. c) Head trauma d) Smoking habits
b) Cardiovascular disease
An adult client is brought to the emergency department after being found on the floor at home. The client's pulse rate is 112 beats per minute and the force is 1+. This is most consistent with: a) Panic attack b) Dehydration c) A healthy heart d) Fluid volume excess
b) Dehydration
The nurse is obtaining the blood pressure on an adult client. As the cuff is deflated the nurse heard the last sound at the point indicated in the figure below. Silence follows. What should the nurse document in the clients chart? a) Systolic blood pressure is 102 b) Diastolic blood pressure is 100 c) Systolic blood pressure is 25-30 mmHg above the indicated point. d) Diastolic blood pressure is 105.
b) Diastolic blood pressure is 100
The nurse is preforming a head to toe assessment on a client presenting for an annual check-up. What part of the hand and technique should be used to best assess the patients temperature? a) Fingertips b) Dorsal surface of the hand c) Ulnar position of the hand d) Palmar surface of the hand
b) Dorsal surface of the hand
The nurse is assessing a client who recently suffered a stroke. Speech is a severely impaired, although comprehension is intact. This finding reflects what type of aphasia? a) Global b) Expressive c) Receptive d) Wernicke's
b) Expressive
The nurse is caring for a 4- month old infant. Which tool is most appropriate for the nurse to use when assessing pain in this client? a) Numeric pain scale b) FLACCC. c) Wong Baker FACES Scale d) Descriptor Scale
b) FLACCC.
Which factor is most likely to contribute to a decreased blood pressure? a) Atherosclerosis b) Hemorrhage c) Pain d) Decreased elasticity of arterial walls.
b) Hemorrhage
While performing a physical assessment, what technique should the nurse always perform first? a) Palpation b) Inspection c) Percussion d) Auscultation
b) Inspection
The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use? a) Slope of the earpieces should point posteriorly. b) It blocks out extraneous room noise but does not magnify sound. c) The tubing length should be 24 inches to dampen the distortion of sound. d) The bell of the stethoscope should be used for breath and bowel sounds.
b) It blocks out extraneous room noise but does not magnify sound.
While assessing a client's level of consciousness, the nurse notes that the client opens his eyes when the nurse calls his name in a normal voice, but he quickly falls back asleep. The nurse documents the client as: a) Alert b) Lethargic c) Obtunded d) Semi-Comatose
b) Lethargic
In a client undergoing withdrawal from opiates, the nurse expects which assessment findings? Select All That Apply. a) Bradycardia b) Nausea and vomiting c) Fever d) Muscle Aches e) Dry skin f) Pupillary constriction g) Anxiety
b) Nausea and vomiting c) Fever d) Muscle Aches g) Anxiety
During percussion of a patients abdomen, the nurse notes a musical, drum-like quality of the sounds across the quadrants. How should the nurse interoperate this type of sound? a) Underlying muscle or bone b) air-filled organs c) Presence of a fluid or solid mass d) Presence of dense organs
b) air-filled organs
When analyzing data, the nurse should remember which aspect about vital signs in an older adult? a) Axillary temperatures are preferred in older adults to promote comfort. b) The body temperature of the older adult is lower than that of a younger adult. c) Older adults get fevers far more often than younger adults. d) In the older adult, the body temperature varies widely because of less effective heat control mechanisms.
b)The body temperature of the older adult is lower than that of a younger adult.
A student nurse asks why they need to utilize the two-step method when obtaining a blood pressure. How should the nurse preceptor respond? a) "The method takes more time which allow more nurse-patient interaction" b) "The two step method ensures you are hearing the Kortokoff sounds more clearly." c) "That method identifies an auscultatory gap and avoids falsely misinterpreting the systolic blood pressure." d) " That method is only used in clients who have documented hypertension."
c) "That method identifies an auscultatory gap and avoids falsely misinterpreting the systolic blood pressure."
During the examination, offering some brief teaching about the examiner's findings is often appropriate. Which one of these statements by the nurse is most appropriate? a) "I am positive you don't have any arrhythmia but let's check anyways" b) "Looking at your legs you have arterial insufficiency and diabetes" c) "Your blood pressure is 116/72, which is within the normal range" d) "I am hearing a murmur. Have you ever had a myocardial infarction?"
c) "Your blood pressure is 116/72, which is within the normal range"
An adult patient tells the nurse that he has an enlarged prostate and he has been having "pain with urination" for the last few days. How would the nurse best document his reason for seeking care? a) "suspected urinary traction infection" b) Flare-up of benign prostate hypertrophy c) "pain with urination for the past two days" d)"urinary problems"
c) "pain with urination for the past two days"
An adult client is in the intensive care unit (ICU) with septic shock. The nurse is careful to monitor the client's vital signs including mean arterial pressure (MAP). Which statement about MAP is true? a) A MAP of 40-60 mmHg indicates that the stroke volume is adequate. b) MAP can only be obtained by using a noninvasive blood pressure (NIBP) monitor. c) A MAP >60 is needed to maintain adequate tissue perfusion. d) MAP is the average of the systolic and diastolic pressures.
c) A MAP >60 is needed to maintain adequate tissue perfusion.
A 10 month-old infant has been brought to the well-child clinic for a checkup. She us currently sleeping, what should the nurse do first in the examination? a) wake the infant before beginning the examination b) Examine the infant's ears and nose with the otoscope before the infant wakes up. c) Ascultate the lungs, abdomen and heart while the infant is still sleeping. d) Begin the examination of the childs motor function and continue with the remainder of the examination in a head-to-toe approach.
c) Ascultate the lungs, abdomen and heart while the infant is still sleeping.
The nurse is examining a toddler who was brought to the emergency department after a fall. Which bruise, if found, would be of most concern? a) Bruises on the knee b) Bruises on the elbow c) Bruises on the abdomen d) Bruises on both of the shins
c) Bruises on the abdomen
A patient repeatedly seems to have difficulty coming up with a word. He says, " I always have trouble finding that metal thing you open the door with." How should the nurse record this on his chart? a) Word Salad b) Neologism c) Circumlocution d) Confabulation
c) Circumlocution
The nurse is administering a mini-cog test to a 75 year old woman. The patient draws a clock with an incorrect time and is also unable to recall any of the three words. This result indicates which finding? a) Mania b) Anxiety disorder c) Cognitive impairment d) Attention deficit disorder
c) Cognitive impairment
When considering a priority setting of problems, the nurse keeps in mind that second- level priority problems include which of these aspects? a) Low self-esteem b) Severely abnormal vital signs c) Complaints of pain d) Lack of knowledge
c) Complaints of pain
A client with hypertension presents to a family practice clinic for an initial visit. How should the nurse take his blood pressure (BP)? a) Cuff should be placed on the patients arm and inflated 30mmHg above the patients pulse rate. b) Cuff should be inflated to 200mmHg in attempt to obtain the most accurate systolic reading c) Cuff should be inflated 25-30 mmHg above the palpated systolic blood pressure d) After confirming that the patients previous blood pressure readings, the cuff should be inflated 30 mmHg above the highest systolic reading recorded.
c) Cuff should be inflated 25-30 mmHg above the palpated systolic blood pressure
Which of the following is an example of neuropathic pain? a) Kidney stones b) Burn injury c) Diabetes neuropathy d) Bone fracture
c) Diabetes neuropathy
An adult client presents to the emergency department with "chest pain". Which of these assessment findings alerts the nurse to recent opioid use? a) Auditory hallucinations. b) Fever. c) Drowsiness d) Pupillary dilation.
c) Drowsiness
You are caring for a 31 year old patient 1 day post cearean section. The pt is complaining of right shoulder pain. What should the nurse do first? a) Notify the provider b) Explain to the pt that this is most likely the cause of positioning in the OR c) Further assess the quality and severity of the pain d) Administer 2mg morphine
c) Further assess the quality and severity of the pain
The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this? a) Ask him to follow a set of directions b) Ask him to describe his first job c) Give him the four unrelated words test d) Ask him to describe what television show he was watching before coming to the clinic
c) Give him the four unrelated words test
The nurse is preparing to complete a respiratory exam. The first step should be to: a) Palpate the thorax for crepitus or pain b) Auscultate all lung fields c) Inspect the thorax for shape, symmetry, lesions d) Percuss to identify areas of consolidation
c) Inspect the thorax for shape, symmetry, lesions
The nurse is performing the Denver II screening test on a toddler during a routine well-child visit. What should the nurse tell the parents about this screening tool? a) Tests three areas of development: cognitive, physical, psychological b) Will indicate whether the child has a speech disorder so that treatment can begin c) Is a screening instrument designed to detect children who are slow in development d) Is a test to determine intellectual ability and may indicate whether problems will develop later in school
c) Is a screening instrument designed to detect children who are slow in development
The nurse is assessing an 80 year old man. What should the nurse expect when performing the mental status portion of the assessment? a) Will have no decrease in any of his abilities, including response time b) Will have difficulty on tests of remote memory because this ability typically decreases with age c) May take a little longer to respond, but his general knowledge and abilities should not have declined d) Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge
c) May take a little longer to respond, but his general knowledge and abilities should not have declined
The nurse is preparing to measure the length, weight, chest, and head circumference of a 4 month old infant. Which measurement technique is correct? a) Measuring the infant's length by standing him against a wall. b) Weighing the infant by placing him or her on an electronic standing scale. c) Measuring the chest circumference at the nipple line with a tape measure d) Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
c) Measuring the chest circumference at the nipple line with a tape measure
A pt with a body mass index (BMI) of 34 falls under which category? a) overweight b) Extreme Obesity c) Obese d) Healthy weight for height
c) Obese
While reviewing a patients past medical history, the nurse notes that the patient has been diagnosed with orthostatic hypotension. What does the nurse understand to be true? a) Orthostatic hypotension is a normal occurrence in people with cardiovascular disease b) Patients with orthostatic hypotension experience a drop in heart rate of at least 20 bpm with position changes c) Patients with documented orthostatic hypotension should be taught to get up slowly d) Clients with orthostatic hypotension experience a rise in systolic blood pressure of at least 10mmHg after standing.
c) Patients with documented orthostatic hypotension should be taught to get up slowly
A 64-year-old woman presents the clinic. Her husband reports she fell last week and seems to be having memory problems. The nurse should: a) Assure the patient and husband these are normal findings associated with aging. b) Perform a brief mental status exam by incorporating it into the interview. c) Perform a full mental status exam. d) Refer the patient for neurological testing.
c) Perform a full mental status exam.
The nurse is assessing a 96 year old client. Which assessment findings would be considered normal? a) Increase in body weight from his younger years b) Additional deposits of fat in the cheeks and forearms c) Presence of kyphosis and flexion in bilateral knees and hips d) Change in overall body proportion, including longer trunk and shorter extremities
c) Presence of kyphosis and flexion in bilateral knees and hips
The nurse is documenting their assessment findings. What piece of data is considered subjective? a) Speech is clear and articulate b) Skin is warm and dry c) Reports of dizziness upon standing d) Swelling noted in left hand
c) Reports of dizziness upon standing
When assessing the elderly, what is one of the first things the nurse should assess before making judgments about the aging persons mental status? a) Presence of social phobias b) Personal habits such as alcohol use and smoking c) Sensory- perspective abilities such as vision and hearing d) Ability to interoperate metaphors.
c) Sensory- perspective abilities such as vision and hearing
During a clinical rotation, a student nurse asks their preceptor: "What is that number in parenthesis on the blood pressure monitor?" The nurse explains; a) That is the MAP- median arterial pressure. It tells us how strong the heart is. b) That is the MAP- mean average pressure, MAP reflects the stroke volume of the heart c) That is the MAP- mean arterial pressure. It reflects the pressure forcing blood into the tissues, averaged over the cardiac cycle. d) That is the MAP and its none of your business.
c) That is the MAP- mean arterial pressure. It reflects the pressure forcing blood into the tissues, averaged over the cardiac cycle.
The nurse is conducting an interview with an adult who denies anxious feelings, but is exhibiting anxious behaviors such as fidgeting, tensing of muscles, and darting eyes. Considering the concept of communication, which statement does the nurse know to be most accurate when describing this client? a) These anxious behaviors are a sign of a different mental disorder b) The client has Generalized Anxiety Disorder but its afraid to admit it c) The client is exhibiting verbal and nonverbal behaviors that do not match d) The client is only anxious today due to the healthcare visit
c) The client is exhibiting verbal and nonverbal behaviors that do not match
Which statement is true regarding head and chest circumference in infants and children? a) Chest circumference should be greater than head circumference at birth b) The head and chest circumference will even out at 3 months c) The newborn head circumference is usually about 2 cm larger than the chest circumference. d) The nurse only needs to check a head circumference in a premature infant.
c) The newborn head circumference is usually about 2 cm larger than the chest circumference.
The nurse is preforming a head-to-toe exam on a client who sustained a burn injury to the right upper arm. The nurse is unable to palpate the right radial purse. What should the nurse do next? a) Apply a hot pack to stimulate blood flow. b) Urgently notify the provider of the finding. c) Use a Doppler device to check for pulsations over the area. d) Check for the presence of pulsations with a stethoscope.
c) Use a Doppler device to check for pulsations over the area.
The nurse is caring for a 10 year old child presenting with "flu-like symptoms". The child has several bruises of varying colors on the arms and buttocks. What action should the nurse take? a)Notify the child's caregivers of the findings. b) Document that the bruises appear to be caused by normal disciplinary actions. c) When the child is alone, ask "how did you get these sore spots?" d) Inform the child "you can tell me who did this to you and we will not allow them to see or hurt you again."
c) When the child is alone, ask "how did you get these sore spots"
The nurse has collected the following information on a patient: Palpated blood pressure-190mm Hg; Auscultated blood pressure - 180/100 mm Hg; Apical pulse - 70 beats per minute. What is the patient's pulse pressure? a) 127 b) The pulse pressure cannot be obtained with these measurements c) 80 d) 90
c)80
The nurse is assessing a patient who admits to being physically abused by her spouse. The patient says, "I wish I would have agreed with my husband, because then I wouldn't have been hit." What is the nurse's best response? a) "Changing your reaction to your spouse will likely change his actions against you." b) "Try not to blame yourself. You will know better for next time." c) "Your husband has to want to change. Let's focus on you for now." d) "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again."
d) "It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again."
A woman who has just discovered that she is pregnant is in the clinic for her first obstetric visit. She asks the nurse if she can continue to drink during her pregnancy. What is the best response by the nurse? a) "Do whatever you think is best for the both you and the baby" b) "It's okay to have up to one glass of wine a day" c) "As long as you avoid getting drunk, you should be safe." d) "No amount of alcohol has been determined to be safe during pregnancy."
d) "No amount of alcohol has been determined to be safe during pregnancy."
During an interview, a woman reports that she feels scared when she fights with her partner and that sometimes he slaps or hits her during arguments. What should the nurse say next? a) "Were you also abused as a child" b) "Do you know what caused this abuse?" c) "I need to report this abuse to the authorities." d) "Tell me more about the abuse in your relationship."
d) "Tell me more about the abuse in your relationship."
The nurse is assessing a woman presenting with "headache" and identifies suspicious injuries upon skin examination. Which question or statement should the nurse use to further assess the situation? a) "I can see you are a victim of domestic violence. Please tell me about this?" b) "Why would somebody want to hurt you?" c) "I am a mandatory reporter so I need to report this abuse to the authorities" d) "These types of injuries can sometimes be caused by other people. Is anyone hurting you or frightening you?"
d) "These types of injuries can sometimes be caused by other people. Is anyone hurting you or frightening you?"
The school nurse is conducting a pain assessment on an adolescent presenting with "back pain". What should the nurse ask first? a) "Is this something new for you?" b) " Is it affecting your daily life?" c) "How have you treated it?" d) "When did this pain begin?"
d) "When did this pain begin?"
The nurse is preparing to complete a physical examination on an older adult. When techniques should be used? a) Ascultate before inspecting or palpating b) Preform the physical examination before obtaining a health history. c) Speak loudly and slowly because most aging adults have hearing deficits d) Arrange the sequence of the examination to allow as few position changes as possible.
d) Arrange the sequence of the examination to allow as few position changes as possible.
The nurse is obtaining a complete health history on a 24-year-old female. What should the nurse do to make the client feel more comfortable during the exam? a) Ask the client to change into a gown for the interview so as to save time. b) Used biased questions to assist the client in answering questions related to sexual activity. c)Avoid direct eye contact so as not to make them feel pressured. d) Assure the client that the information that she shares will remain confidential.
d) Assure the client that the information that she shares will remain confidential.
The nurse is preparing to examine a client's abdomen by palpation. How should the nurse proceed? a) Avoid palpation of reportedly "tender" areas because palpation in these areas may cause pain. b) Palpate a tender area at the beginning to allow the patient time to recover from the pain. c) Start the assessment with deep palpation, while encouraging the patient to relax and take deep breaths. d) Begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched.
d) Begin the assessment with light palpation to detect surface characteristics and to accustom the patient to being touched.
A woman is discussing the problems she is having with her child. She says, "He has fits when we are out in public... it's embarrassing." At this point the nurse's best verbal response would be: a) Interpretation-- "so your child is throwing temper tantrums?" b) Confrontation-- "let's discuss how we can make him act properly in public" c) Empathy-- "I totally understand this- I have a rambunctious child myself!" d) Clarification-- "tell me what you mean by 'fits'"
d) Clarification- "tell me what you mean by 'fits'"
An elderly client with pneumonia is being treated in the intensive care unit (ICU). He is acutely agitated, restless, and disoriented. The nurse documents his level of consciousness as; a) Manic b) Drowsy c) Demented d) Delirious
d) Delirious
The nurse is examining a patient undergoing withdrawal from opiates. The temperature 102 degrees Fahrenheit. What other vital sign change does the nurse expect to find in relation to the fever? a) Bradypnea b) Low oxygen saturation c) Hypotension d) Elevated heart rate
d) Elevated heart rate
Which of the following actions should the nurse take to ensure an accurate blood pressure (BP) reading? a)Ensure the width of the BP cuff is equal to 80% of the arm circumference. b) Take two BP readings 20 seconds apart. c) Ensure that the patient's arm is supported and above heart level. d) Ensure the client's back is supported and feet are flat on the ground.
d) Ensure the client's back is supported and feet are flat on the ground.
A 5 year-old boy is brought to the emergency department for "abdominal pain." Which pain assessment tool should the nurse utilize for this client? a) Descriptor scale b) Numeric rating scale c) Brief pain inventory d) Faces pain scale
d) Faces pain scale
A patient with a body mass index of 24 falls under which category? a) Overweight b) Extreme obesity c) Obese d) Healthy weight for height.
d) Healthy weight for height.
An adolescent male has been brought into the emergency department after a motorized scooter accident. When conducting the mental status examination for the patient, what should the nurse assess FIRST? a) Affect and mood b) Remote memory c) Judgement and abstraction d) Level of consciousness
d) Level of consciousness
A 60 year old man is being admitted for observation after a syncopal episode. He is alert and oriented. Medication reconciliation reveals that he was recently placed on a new medication for his hypertension. What should the nurse include in the plan of care? a) Document the medication as a new patient allergy b) Utilize a doppler device to obtain the clients pulse and blood pressure c) Restrain the client so he doesn't get out of bed d) Obtain a blood pressure in the lying, sitting, and standing position
d) Obtain a blood pressure in the lying, sitting, and standing position
What action by the nurse is appropriate when examining a 16-year-old male teenager? a) Discuss health teaching with the patient because the teen is unlikely to be interested in promoting wellness. b) Ask his parent to stay in the room during the history and physical examination to answer any questions and alleviate his anxiety. c) Talk to him in the same manner as one would talk to a younger child because a teens level of understanding may not match his or her speech d) Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rage of growth and development.
d) Provide feedback that his body is developing normally, and discuss the wide variation among teenagers on the rage of growth and development.
When assessing a 70-year-old patient with heart failure, the nurse notes he is consistently leaning forward with arms on the bedside table. What does the nurse understand to be true? a) Assume that the patient is eager and interested in participating in the interview. b) This is suspicious for pain; a focused abdominal exam should be prioritized. c) Assume that the patient is having difficulty breathing and assist him to a supine position. d) Recognize that a tripod position is often used when a patient is having respiratory difficulties.
d) Recognize that a tripod position is often used when a patient is having respiratory difficulties.
As a mandatory reporter of older adult abuse, which must be present before a nurse should notify the authorities? a) Statements from victims and witnesses b) Intimate Partner Violence c) Proof of any abuse and/or neglect d) Suspicion of child or elder abuse and/or neglect.
d) Suspicion of child or elder abuse and/or neglect.
A patient is in the post-anesthesia care unit (PACU) after knee surgery and complaining of pain. Which of these assessment findings indicates a response to poorly controlled acute pain? a) Confusion b) Pupillary constriction c) Apathy d) Tachycardia
d) Tachycardia
A Hispanic patient is being seen at the clinic for an examination. Why is it important for the nurse to consider the basics of the patient's culture during the assessment? a) So that assumptions can be made regarding health beliefs and practices b) To identify the cause of his illness. c) To make accurate disease diagnosis d) To provide culturally relevant health care
d) To provide culturally relevant health care
A Hispanic patient is being seen at the clinic for an examination. Why is it important for the nurse to consider the basics of the patients culture during the assessment? a) To make accurate disease diagnoses b) So that assumptions can be made regarding health beliefs and practices c) To identify the cause of his illness d) To provide culturally relevant health care.
d) To provide culturally relevant health care.
The nurse is caring for a client who recently had a stroke. When asked how the client is feeling he says, "I buy change get for him and her and take my train until we get to the fair." What is the best description of this patient's problem? a) Dysarthric speech. b) Global aphasia c) Broca's aphasia d) Wernicke's aphasia
d) Wernicke's aphasia
A client presents to the clinic with "abdominal pain". When assessing the quality of the pain the nurse should ask which question? a) When did the pain start? b) Is the pain a stabbing pain? c) Is it a sharp pain or dull pain? d) What does your pain feel like?
d) What does your pain feel like?
The nurse is helping a new graduate obtain a blood pressure on a patients thigh. Which statement is CORRECT regarding thigh pressure? a) The blood pressure in the arm should be 10-40mmHg higher than the thigh. b) The best position to measure thigh pressure is in the supine position with the knee slightly bent. c) Thigh pressure should be obtained in all clients to rule out cardiac abnormalities d) in healthy people, the blood pressure in the thigh should be higher than the arm.
d) in healthy people, the blood pressure in the thigh should be higher than the arm.
A nurse is performing a head-to-toe assessment on a client with pancreatitis. Which assessment data is the most reliable indicator of pain? a) blood pressure 164/86B. b) Client is confused to time and date c) pt refuses to get out bed d) pt reports abdominal pain of 5/10
d) pt reports abdominal pain of 5/10
The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a) Diabetic teaching. b) Bruising on the foot. c) Postoperative pain. d)Respiratory distress.
d) respiratory distress.
