Health Assessment Final
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is Continuous. completed on admission. Linear. performed only by nurses.
A
As the nurse assesses vital signs, he notices the client is shaking. The nurse notes a change in the client's tone and in a loud voice the hospitalized client insists, "You're not my wife. How did you get into my house?" Based upon the client's behavior, which assessment will the nurse now focus upon? Mental Physical Spiritual Interpersonal
A
What is the primary function of the health care team? To work together to obtain maximum coverage To decide the best overall care To guide the client's care throughout times of crisis To develop an individual focus for each member
A
When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to a healthy lifestyle the absence of disease stress reduction changes in the environment
A
A new client is admitted to a long term care facility. The nurse assesses the client with an unsteady gait and incontinence. Which problem should the nurse address when planning care for this client? Falls Osteoporosi Low back pain Neck pain
a
A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? Turning the palm of the hand upward Turning the palm of the hand downward Moving the tips of the fingers toward the forear Moving the tips of the fingers away from the forearm
a
An adolescent male client is diagnosed with testicular torsion. The nurse should prepare the client for which treatment? Emergency surgery Antibiotic therapy Schedule routine follow-up appointment Prostate specific antigen lab work
a
An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize? Smoking cessation Annual MRI screening Nutritional supplementation Improved coping skills
a
An adult client has sought care at the clinic, stating that she believes she has "a raging yeast infection." The nurse would expect to assess what type of vaginal discharge? a. Thick, white vaginal discharge b. Copious clear, foul-smelling discharge c. Yellowish discharge with a metallic odor d. Blood-tinged vaginal discharge
a
An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse? Open the client's airway If the client is injured, protect the cervical spine Begin CPR Ensure that the client is safe
a
Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? Inspect for dependent edema. Ensure that the client lies flat for the examination. Palpate the carotid pulse. Assess for thrills.
a
During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find? Decreased sensation in the feet Severe pain in legs Open sores on legs Bluish discoloration
a
During the health history, a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve? CN I CN II CN VII CN IX
a
Loss of bone density that occurs with greatest frequency in postmenopausal women is called? Osteoporosis Scoliosis Kyphosis Lordosis
a
Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? Angina Musculoskeletal Gastrointestinal Crushing
a
The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process? Tenderness Cool temperature Ecchymosis Nodules
a
The nurse is assessing male genitalia and finds clusters of pimple-like clear vesicles. The nurse recognizes this as what? Herpes Syphilis Gonorrhea Chlamydia
a
The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first? "Do you have any pain or discomfort in your chest?" "Is the pain worse on exertion?" "Do you have cramping pain?' "Is the pain worse when you are lying down?"
a
The nurse is preparing to meet Mr. James Smith, a 70-year-old client. How should the nurse greet this client? "Hello Mr. Smith." "Hi dear! Have a seat!" "So nice to meet you Jim!" "How are you doing today Mr. Jim?"
a
The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning? identifying abnormal or positive findings making a hypothesis about the nature of the client's problem interpreting the findings clustering the findings
a
The nurse performing an admission assessment on an older adult. What would be an expected finding? Decreased vision Numbness and tingling Delirium Dizziness
a
The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this client? Confused Alert
a
When assessing the elbow, a nurse asks a client to hold the arm out and turn the palm down. The nurse is testing which of the following? Pronation Flexion Rotation Supination
a
When determining a client's strength, it is necessary to implement what assessment? Comparing one side to the other Assessing the extremities at the same time Comparing upper and lower extremities Assessing upper and lower extremities at the same time
a
A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. Walk briskly 30 minutes per day Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes. Consume two to three glasses of red wine daily. Increase consumption of dairy products.
abc
The nurse is planning the care of a 77-year-old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply. Risk for injury related to osteoporosis Risk for infection related to osteoporosis Activity intolerance related to osteoporosis Impaired physical mobility related to osteoporosis Disturbed sensory perception related to osteoporosis
acd
A nurse is preparing a health education session for a local community group. When addressing the relationship between coronary artery disease (CAD) and culture, what information would the nurse include? Caucasians usually possess greater lifestyle risks for CAD than African Americans Hypertension is more prevalent in African Americans than among Caucasians. Hypertension is seen more in white women than in African-American women. Hispanic Americans have a higher rate of CAD than white Americans.
b
A nurse recognizes that the second heart sound, S2, is produced by which cardiac action? Isometric contraction Closure of the atrioventricular (AV) valves Closure of the semilunar valves Ventricular contraction
b
The nurse is assessing a client with a cardiac condition who complains of fatigue and nocturia. The nurse should recognize the implication of this statement? The client may have developed a cardiac conduction problem. The client may be experiencing symptoms of heart failure. The client's cardiac problem is being adequately compensated for. The client may be at increased risk for myocardial infarction.
b
The nurse notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating? atrial fibrillation sinus arrhythmia premature atrial contractions premature ventricular contractions
b
What ethnic group has a significantly higher incidence rate of prostate cancer? Native American African American Caucasian Asian
b
When interviewing a client with a language barrier, it is best to use a family member to help interpret so the client has a level of comfort with the process. True False
b
Which question is appropriate for a nurse to ask a client to assess the client's recent memory? "When is your birthday?" "What did you eat for breakfast today?" "How are an orange and an apple different?" "Why are you at the health care clinic today?"
b
The nurse is taking a sexual history on a new client. What action is considered appropriate at this time? (Select all that apply.) Explain to the client what is considered to be normal sexual behavior Affirm that your conversation is confidential Note that you realize this information is highly personal Explain why you are taking the sexual history Relate that you gather this history on only high-risk client
bcd
A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply. Avoid eating dark chocolate Eat foods low in sodium. Walk for at least 30 minutes/day. Limit alcohol intake to 3 drinks per day. Use relaxation techniques to manage stress.
bce
A client has been diagnosed with stomach cancer and has a comorbidity of depression. For what would it be important to assess this client? Dementia Violence Suicide Noncompliance
c
A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action? Encourage early weight bearing and ambulation. Apply an ice pack to the affected extremity. Check for a pulse, color, temperature, and capillary refill. Splint and immobilize the affected extremity.
c
A client with a zosteriform rash (shingles) has a rash that has lesions distributed over a large body area appears with a single lesion in close proximity to a larger lesion, as if "orbiting" the larger lesion is distributed along a dermatome is distributed equally on both sides of the body
c
A male client tells the nurse that his occupation requires heavy lifting and a great deal of strenuous activity. The nurse should assess the client for signs and symptoms of prostate enlargement erectile dysfunction. inguinal hernia. urinary tract infection.
c
A nurse is preparing a program on osteoporosis for a local women's group. What would the nurse cite as a risk factor? Obesity Multiparity (multiple pregnancies) History of smoking African-American ethnicity
c
A nurse is preparing a program on osteoporosis for a local women's group. Which of the following would the nurse include as a modifiable risk factor? Small-boned, thin frame Personal history of fracture Low estrogen levels Age
c
The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse? Osteoarthritis Diabetic neuropathy Carpal tunnel syndrome Gouty arthritis
c
The nurse is collecting data from a client. Which of the following best reflects objective data? Religion Occupation Appearance Age
c
What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor? Extension Abduction Flexion Rotation
c
When examining a newborn male infant, the nurse notes that neither testicle is descended. The nurse documents this finding as which of the following? Epididymitis Orchitis Cryptorchidism Varicocele
c
Which joint movement is a nurse testing when asking a client to move an extremity towards the body? Flexion Extension Adduction Abduction
c
A 70-year-old woman has come to the clinic to follow up her bone density testing. The results suggest that she has osteoporosis. What is a medication that might be ordered for this client? Testosterone Thyroid hormone Vitamin C supplements Calcitonin
d
A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process? Rheumatoid arthritis Verruca vulgaris (warts) Degenerative joint disease Gouty arthritis
d
Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When the nurse speaks with Adam alone, the client states it "would be better if he were not here." What should the nurse do next? Tell Adam that he has a very promising career in anything he chooses and soon will feel better. Tell Adam that he needs an antidepressant and it will take about 4 weeks to work. Speak with Adam's mother about getting him together more with his friends. Assess Adam's suicide risk.
d
During assessment of an elderly male client, the client tells the nurse that he has had difficulty urinating for the past few weeks. The nurse should refer the client to the physician for possible inguinal hernia. sexually transmitted disease. Impotence. prostate enlargement.
d
The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment? The client takes medications to treat hypertension. The client suffered a fractured humerus 1 year earlier. The client has a diagnosis of type 1 diabetes. The client had a total hip replacement 2 years ago.
d
The nurse is performing an assessment of an ambulatory client's musculoskeletal system. What would the nurse examine first? The client's leg length The client's lateral bending ability The client's cervical ROM The client's gait
d
The nurse is preparing an instructional session for male clients about preventing penile cancer. Which non-modifiable risk factor should the nurse include in the teaching? Poor personal hygiene History of human papillomavirus Sexual promiscuity Age 60 years or older
d
The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location? Second intercostal space, left sternal border Third intercostal space, left axillary line Fourth intercostal space, left sternal border Fifth intercostal space, left midclavicular line
d
The nurse is preparing to perform a musculoskeletal examination on an adult client. The nurse has explained the examination procedure to the client. The nurse determines that the client needs further instructions when the client says "You will be asking me to change positions often." "You'll be comparing bilateral joints." "You'll be assessing the size and strength of my joints." "You'll continue with range of motion even if I have discomfort."
d
The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem? Torn rotator cuff Dislocated shoulder Broken clavicle Scoliosis
d
When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition? Dry skin Easy bruising Fungal infections Sun exposure
d
When the female client reports a frothy yellow-green or brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by which of the following? a. Candida albicans b. Gardnerella vaginalis c. Chlamydia d. Trichomonas vaginalis
d
Which of the following is a sign or symptom of benign prostatic hypertrophy (BPH)? Weight loss Bone pain Fever Nocturia
d
One of the goals of Healthy People is to reduce the proportion of adolescents and young adults with sexually transmitted infections (STIs). What subjects would be most appropriate to teach this population to reduce the incidence of STIs? (Select all that apply.) Use of diaphragm Side effects of medications used to treat infections Modes of transmission Correct use of condoms Use of spermicides
...
To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first discuss the client's symptoms with other team members. plan for potential laboratory procedures. review the client's health care record. determine potential health care resources.
C
A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding? Identify a nursing diagnosis of Ineffective Health Maintenance. Identify a collaborative problem that should involve the occupational therapist. Make a referral to the unit's social work department. Reassess the client's blood glucose level.
a
A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate phrase for the nurse to use to clarify the expression's meaning from the client? "Tell me what you mean by ________?" "I think that expression means ____________." "That expression is unclear to me." "Where did you hear that expression?"
a
A 35-year-old client has a Pap test with a normal test result. The client has had two previous tests with normal results. Which information is correct for the nurse to tell this client with regard to future screening for cervical cancer? a. Continue exams every 3 years b. Option to stop screening can be considered c. Lengthen time to every 7 years because of her test results d. Because of the client's age, exams should be done every year
a
A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client? Smoking increases the heart's workload and contributes to atherosclerosis. Smoking decreases the contractility of the myocardium and contributes to valvular disorders. Smoking damages the cardiac conduction system, resulting in dysrhythmias that are entirely preventable. Smoking is a central component of metabolic syndrome.
a
A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? Orthopnea Tachypnea breathing fast Pneumonia Sleep apnea
a
A client with a diagnosis of type 1 diabetes is admitted to the hospital with acute symptomatic seizures. Given the client's underlying condition, what would be the most likely cause of this type of seizure? Hyperglycemia ventricular tachycardia Syncope headache
a
A client's spouse answers the interview questions and will not leave the examination room. What should the nurse suspect may be occurring with the client? intimate partner violence low self-esteem cognitive disorder mental health disorder
a
A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. How would the students identify this layer? Myocardium Epicardium Endocardium Pericardium
a
A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum? a. Prolapse b. Rectal polyps c. Shelf d. Cancer
a
A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what? Closure of the mitral and tricuspid valves Closure of the aortic and pulmonic valves Relaxation of the ventricles Contraction of the ventricles
a
A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling? A thrill A thrust A heave A normal finding
a
A young homosexual client who is currently HIV negative tells the nurse that he is worried about contracting AIDS someday. What teaching would be appropriate for this client? Safe-sex practices and proper use of condoms Conversion therapy to heterosexuality Antiviral drugs used to fight AIDS New AIDS treatments in case the client contracts HIV
a
After completing an assessment of a female with poorly controlled non-insulin dependent diabetes, the nurse is generating the client's problem list. Which problem would have the highest priority for the client? Muscle weakness Insomnia Anxiety Knowledge deficit
a
An adolescent is brought to the clinic by her mother because of abnormal uterine bleeding. What should the nurse explain about this bleeding? It is common in adolescents and woman approaching menopause. It is rare and needs to be medically treated. It only occurs at either end of the reproductive age span It is a sign of cancer and needs to be investigated.
a
An adult client who had a baby 2 weeks ago is brought to the ED because her boyfriend has noticed she has not been herself since they brought the baby home. The client's appearance is unkempt, her hair is a mess, and she appears not to have bathed for several days. What could these findings reflect? Depression Mania Poor nutrition Need for more time to recover from childbirth
a
An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: symptoms of stress. recent radiation therapy. pigmentation irregularities. allergies to certain foods.
a
The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further? temporomandibular joint sternoclavicular joint glenohumeral joint acromioclavicular joint
a
The nurse is asking the client about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason? To identify diseases for which the client may be at risk To get to know the client better To establish personal rapport with the client To assess the client's quality of life
a
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous(redness) in a client who complains of an "itching rash." Which question would be most important for the nurse to ask? Are you allergic to foods, medications, or other substances? "Does anyone else in your family have a rash like this?" "Have you ever had a rash like this before?" "What have you been doing to control the itching?"
a
When the nurse is performing a physical examination on admission of a client to the medical unit, the client says the doctor already did an exam. The best response by the nurse would be "The doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease." "The doctor's and nurse's assessments are totally unrelated and are necessary so all forms are completed appropriately." "Each assessment is important and the nurse and doctor will get together to determine what orders need to be written." "I know it seems repetitive but the doctor is trying to treat the reason you were admitted and I will focus more on getting everything ready for you to go home."
a
Which is an example of subjective data from a primary source? The client states, "My chest hurts and my left arm feels numb." A baby's mother states, "He pulls at his ear when he has pain." The client's chart indicates the client felt nauseous. The client asks, "Does my incision look like it is healing?"
a
Lifestyle can play a big part in developing risk factors for stroke. Which of the following can greatly reduce a client's risk for stroke? Select all that apply. Quitting smoking Regularly exercising Maintaining a healthy weight Eating a high-sodium diet Following a sedentary lifestyle
abc
Which observation would cause the nurse to suspect an abusive situation? Select all that apply. A child is persistent in trying to please a parent. A caregiver of a cognitively intact older adult dominates the interview. A preschooler rubs her perineum and complains of it hurting. The explanation of an injury seems appropriate. A parent allows the adolescent to speak privately with the nurse.
abc
When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply. Quit or do not start smoking Exercise regularly Undergo regular cholesterol screening Eat a low-fiber diet Undergo regular screening for diabetes
abce
To increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness, what would the nurse teach a client (Mark all that apply.) The importance of physical activity To exercise vigorously 3 or more days a week To "cool down" after exercise so as not to strain muscles To exercise for 30 or more minutes To swim, which is the best exercise
abd
A 57-year-old woman has come to the OB/GYN clinic for her annual physical. She tells the nurse that it has been 14 months since her last period. What should the nurse further assess? a. The client has possibly developed cervical cancer. b. The client is postmenopausal. c. The client is perimenopausal d. The client is premenopausal
b
A client angrily tells the nurse that, "It's a shame that you people can't ever be on time. This interview was supposed to start 30 minutes ago." Which technique should the nurse use to diffuse this client's justified anger? Provide a detailed explanation as to why the interview was delayed. Acknowledge their anger by apologizing for the delay. Offer to reschedule the interview to a time the client prefers. Suggest that the client speak with the administrator about staffing.
b
A client comes to the office for evaluation of fatigue. He has come to the office many times in the past with various injuries, and the nurse suspects that the client has a problem with alcohol. Which of the following questions will be most helpful in diagnosing this problem? You are an alcoholic, aren't you? When was your last drink? Do you drink 2 to 3 beers every weekend? Do you drink alcohol when you are supposed to be working?
b
A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is a. "How often are your menstrual periods?" b. "Do you experience mood swings or bloating?" c. "Are you experiencing regular menstrual cycles?" d. "How old were you when you began to menstruate?"
b
A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition? Phimosis Hypospadias Epispadias Paraphimosis
b
A nurse assesses a 22-year-old client who has never had a Pap test. Which factor should the nurse explain to the client as being a risk for cervical cancer? a. Lack of exercise b. Having multiple sex partners c. Smoking d. Having the HPV vaccination
b
A nurse has selected several nursing diagnoses in the process of data analysis of a client with poorly controlled type 1 diabetes. One of these diagnoses is Ineffective Health Maintenance related to infrequent blood glucose monitoring as manifested by elevated HgA1C. How would the nurse best corroborate this diagnosis with the client? "Based on my assessment, I think you have a nursing diagnosis of Ineffective Health Maintenance." "Would you agree that there's room for improvement in your routines around blood sugar monitoring?" "After assessing you, I believe that you're not maintaining your health effectively, specifically around your diabetes." "I need you to tell me a few things you could begin doing to better maintain your health."
b
A nurse is assessing an older adult client's risk for pressure ulcers using the Braden Scale for Predicting Pressure Sore(skin breakdown) Risk. Which aspect of the client's current health status would be reflected in her score on this scale? The client has a full-time caregiver. The client is consistently incontinent of urine. The client has a surgical diagnosis. The client adheres to a vegetarian diet.
b
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible congestive heart failure Angina. Palpitations. acute anxiety reaction.
b
An adult woman presents at the clinic with a grayish vaginal discharge with a 'fishy' odor. What should the nurse suspect? A. Candidiasis B. Bacterial vaginosis C. Chlamydia D. Gonorrhea
b
Jean has just given birth 6 months ago and is breastfeeding her child. She has not had a period since giving birth. What does this most likely represent? a. Primary amenorrhea b. Secondary amenorrhea c. Oligomenorrhea d. Dysmenorrhea
b
Moving a part of the body away from the midline is called? Abduction Adduction Rotation Extension
b
The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment? in a circle head to toe right to left alphabetical
b
The nurse is performing a health history on a client with mild chest pain who came to the Emergency Department. When asked about his allergies, the client states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a client states an allergy? How many doses did the client take of codeine? What type of reaction did the client experience? Who prescribed the codeine? Who administered the codeine to the client?
b
When the mental health nurse asks the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination? Judgment Orientation Abstract reasoning Insight
b
Which of the following would the nurse suspect when a client with a cardiac condition complains of not sleeping well and having to get up frequently at night to urinate? This indicates the heart is working efficiently. Increased urination at rest may indicate heart failure. The client has decreased performance levels of activities of daily living. The client most likely sleeps without a pillow at night.
b
A client complains of chest pain. The nurse understands that chest pain can have causes other than cardiac pain, thus follows up with the client regarding the timing and quality of this pain. Which of the following would indicate cardiac pain as opposed to other types? Select all that apply. Tends to occur after meals Worsens with activity Is relieved with antacids May occur at any time Radiates to left shoulder and down the left arm Has a squeezing sensation around the heart
bdef
A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client? "Are you looking for a new job?" "How are you managing financially?" "Have you thought of hurting yourself?" "Have you considered a job placement agency?"
c
A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement? "Tell me about your relationship with your children?" "Tell me what you eat in a normal day?" "Are you allergic to any medications?" "What is your typical day like?"
c
A nurse teaches a male client how to perform testicular self-examination when the client's history reveals that he does not do it. The nurse would instruct the client to perform the self-examination at which frequency? Weekly Bimonthly Monthly Quarterly
c
During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time? Lifestyle Substance use Sexual history Alcohol and tobacco
c
Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview? Establish the agenda, negotiate a plan, establish rapport, and invite the client's story. Invite the client's story, negotiate a plan, establish the agenda, and establish rapport. Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan. Negotiate a plan, establish an agenda, invite the client's story, and establish rapport.
c
The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action? Hang the IV solution the client's assigned nurse left on the pole. Obtain an IV bag of the current solution and hang it. Review the client's prescribed medication orders. Discontinue the current solution and disconnect it from the client.
c
The nurse is preparing to examine a client's skin. What would the nurse do next? Ensure that the room is hot to prevent chilling. Wear gloves when preparing to inspect the skin and nails. Expose only the body part that is being examined. Have the client remove clothing from the upper body.
c
The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should analyze data that have already been collected. review any past collaborative problems. avoid premature judgments about the client. consult with the client's family members.
c
The nursing instructor is discussing unprofessional actions. What would the instructor cite as the clearest example of unprofessional conduct? Establishing a social relationship Allowing a personal relationship Violating a sexual boundary Creating an economic relationship
c
When assessing the external genitalia of a female client, the nurse notes several parasites crawling on the skin with nits attached to the pubic hair. Which action by the nurse would be most appropriate? Instruct the client to wash and shave the pubic hair. Scrub the pubic area with soap to remove all the nits. Advise the client to obtain over-the-counter pediculosis treatment. Evacuate the living quarters for 1 month.
c
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what? Squamous cells Sweat glands Subcutaneous tissue Sebum production
d
During a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database? Biographic Family health history Review of systems Personal health history
d
During an interview, the client begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the client is providing? Write down the information as the client is speaking. Key the information into the electronic medical record as the client is speaking. Avoid maintaining eye contact while the client is discussing spouse abuse. Stop documenting in order to maintain eye contact with the client.
d
The nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? "How bad was the tingling and numbness?" "How long did the spell last?" "Where did the numbness and tingling occur?" "What other symptoms occurred during the spell?"
d
Which of the following questions is most useful in the assessment of a client's diabetes management? "You check your sugars before each meal, don't you?" "Are you still using your glucometer 4 times a day?" "Are you staying vigilant with your blood sugar monitoring?" "What is your routine for checking your blood sugar these days?"
d
