Health Assessment
While listening to a lecture, the students learn that there are three dimensions of cultural humility, which include (select all that apply)
collaborative partnerships respectful communication self-awareness
Despite having high blood pressure readings in the office, Mr. Kelly tells the nurse that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. Which of the following should the nurse do?
consider the possibility of "white coat" hypertension or anxiety
When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have a single disease.
True
While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?
emotional
What general goals do you organize your comprehensive or focused examination around? (select all that apply)
enhancing clinical efficiency avoiding unnecessary changes in position emaximizing the patient's comfort
A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the
focused assessment
Which factors contribute to the patient's individual makeup?
geographic location nutrition genetic composition cultural norm ethnicity of a patient
The nurse is grouping subjective and objective data. Which data would the nurse list as subjective?
headaches began 3 days ago
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
healthy lifestyle
Which of the following has been found to influence pain sensitivity in women?
hormonal changes
The new RN is now performing the examination of the abdomen. What order of examination techniques would be correct?
inspection auscultation percussion palpation
Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process?
patient ambulated 3/3 times during a planned 8-hour period
The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process?
planning
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is
primary prevention
The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply)
reposition the stethoscope consider shock be certain there is full skin contact with the bell
The nurse is having difficulty auscultating Korotkoff sounds. The nurse should (Select all that apply.)
reposition the stethoscope consider shock be certain there is full skin contact with the bell
The client states "What does it matter? I have no purpose in this life". This client is questioning what?
spirituality
The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first
take a complete health history
The nurse is going to take a blood pressure on a patient who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?
take the blood pressure in the right arm
Which of the following are part of the preinterview of the nurse:patient interview? Select all that apply.
taking time for reflection taking notes setting goals for interview
The nurse discusses ear plugs for a patient with low tone deafness when working in a noisy environment. The nurse is utilizing
tertiary prevention
When performing a cultural assessment, an important point to remember would be
that definitions of family differ
When performing a physical examination, the nurse should examine the body in which order?
tongue movement thyroid heart murmur CVA tenderness groin gait
The nurse is asking the patient about the history of the present illness (HPI). The narrative should include onset of the problem, the setting in which it developed, its manifestations, and __________ __________.
treatments used
To adhere to standard precautions, the nurse should remember to (Select all that apply.)
wash hands before and after patient contact change white coat frequently
Spirituality is a human experience that (Select all that apply.)
• includes a supreme being • seeks to transcend self
When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the patient about alcohol use. The question most appropriate to ask next would be
"Do you ever drink then drive?"
Mr. Smith presents to the clinic stating, "My face looks funny". You note that his face is asymmetric. What might you suspect is the patient's problem?
Palsy
Which of the following is the most reliable indicator for chronic pain?
Patient self-report
What type of pain is short and self-limiting and dissipates after the injury heals?
acute
When planning a community program related to Healthy People 2020, the critical first step involves
defining the community
when utilizing the website health people.gov, the nurse notes completion of the first two areas in the acronym MAP-IT while working on a project for a hispanic community within a large city. what action by the nurse would fulfill the next step in this process
developing a goal for the community involved-the acronym MAP-IT
A new RN is being observed by the preceptor when doing a patient examination. The preceptor notes the appropriate order of examination techniques on the lungs. The preceptor observed what order of the lung examination techniques?
inspection palpation percussion auscultation
Specialized nerve endings that are designed to detect painful sensations are:
nociceptors
The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of
orthostatic hypotension
Neuropathic pain implies an abnormal:
processing of the pain message.
The nurse should use the handle of the reflex hammer to detect the plantar reflex.
True
To determine the sources of strength for a patient, the nurse could ask, "In what ways do they help?
True
When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?"
True
Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?
"Do you have family who visit you regularly?"
Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym?
"Does the pain come and go or is it constant?"
A nurse knocks and enters a patient room, makes introductions to the patient and visitors, and explains to the patient that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate?
"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk."
The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include
"Palpation will increase bowel motility and alter the sounds heard on auscultation."
When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be
"Why do you think you have (name the specific symptom)?"
When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient 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 nurse should know that some disease processes affect facial expression. What are they?
Depression Parkinsonism Hyperthyroidism
While discussing family history with a patient who is healthy except for a current UTI requiring IV antibiotics, the patient tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner?
3 circles and 3 squares, with lines through 2 of the circles
A __________ __________ is the most appropriate tool to use when the nurse is evaluating a previously implemented treatment plan for a patient who is in the clinic for a second appointment.
Follow-up history
A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way is to think about the anagram
ADPIE
The nurse is taking a health history and the patient is describing symptoms experienced in the last few days. The nurse asks, "Have you noticed anything else that accompanies it?" The nurse's question is what part of the seven attributes of a symptom?
Associated manifestations
During assessment of a client's vital signs, the nurse has palpated the client's radial pulse and noted an irregular rhythm. What action should the nurse take based on this assessment finding?
Auscultate the cardiac apex.
You have finished the physical exam. What do you do immediately after finishing?
Give your general impressions Tell patient what to expect
To hear Korotkoff sounds best, the nurse should use the ___ part of the stethoscope.
Bell
Universal precautions are primarily designed to protect the health care worker from what?
Blood borne pathogens
A nurse documents periods of deep breathing followed by periods of apnea. The appropriate term for this type of breathing is
Cheyne-stokes
A patient is being admitted to a medical unit with an acute illness. The nurse would plan to gather information using which tool?
Comprehensive health history
Students are learning about death and dying. One of the students describes how she saw a family member go through the five stages described by Kubler-Ross. The order of these five stages is
Denial Anger Bargaining Depression Acceptance
Equipment used in conducting a physical exam includes a 2 x 2 gauze pad. What is this used for?
Examining the tongue
When planning an interview with a patient who has diabetes mellitus, the nurse would choose which tool to help find out the patient's perspective on this illness?
FIFE
Cultural influences are limited to minority groups.
False
Dying patients typically want to talk about their illness each time they see their medical practitioner.
False
OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process.
False
The meaning of ethnicity is broader than the term culture.
False
The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds.
False
When documenting assessment data for a patient experiencing a loss of muscle power, it is acceptable to state, "Patient is experiencing muscle fatigue."
False
When interviewing a patient with a language barrier, it is best to use a family member to help interpret so the patient has a level of comfort with the process.
False
When interviewing, the nurse should logically move from specific to open-ended questions.
False
the nurse is performing a physical exam and is using a stethoscope to listen to lungs sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds
False
Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of
Healthy People 2020
When taking a blood pressure on an average-sized patient, the nurse chooses a cuff that is 10 cm wide. The blood pressure reading can be expected to be
High
A patient is trying to explain how he feels about his eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be
I can understand why you feel the way you do.
The nurse gathers the follow data: complaint of headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6%F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be
Impaired comfort related to headache and sore throat pain
Culture determines __________ communication style, as well as __________ beliefs, values, and practices.
Interpersonal, health
A patient asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6%F. The nurse would expect the new temperature reading to be
Lower than previous
The nurse is preparing to discuss sexual abuse with a patient. When asking questions, the nurse should remember to keep personal feelings out of the questions and to remain
Nonjudgemental
While listening to a lecture, the students learn that there are three dimensions of cultural humility, which include (Select all that apply.)
Respectful Communication Collaborative Partnerships Self-awareness
Mrs. Helms is admitted to your unit with an exacerbation of COPD. When you enter her room to do your initial assessment, you note that she is sitting on the side of the bed, leaning forward, with her arms on the bedside table. What would this indicate to you?
Respiratory distress
Which of the following are part of the preinterview of the nurse:patient interview? Select all that apply.
Setting goals for the interview, taking time for reflection, taking notes
The nurse is gathering equipment for a patient physical examination and makes sure the room has a __________ on the wall to measure the patient's height.
Stadiometer
A new nurse asks her preceptor if the new baby she is caring for is breast- or bottle-feeding. The preceptor tells the new nurse that the mother is Hispanic and to give the baby a bottle because Hispanics do both until the mother's milk comes in. This is an example of
Stereotyping
What is used to gauge central and peripheral nervous system disorders?
Strength of a reflex
While doing a physical examination, the nurse shines a light across the surface of the patient's abdomen. This type of lighting is called
Tangential
The ulnar edge of the hand is highly receptive to which of the following sensations?
Temperature and vibrations
An elderly chinese man is touring the US and has a heart attack. When admitting the patient to the coronary care unit, what would be important to note in the family history?
The decision makers for the family
Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse.
True
The experienced nurse understands that active listening is the key element when interviewing a patient
True
When performing a physical exam, the nurse should examine the body in which order?
Tongue movement Thyroid Heart murmur CVA tenderness Groin Gait
The nurse is asking the patient about the history of the present illness (HPI). The narrative should include onset of the problem, the setting in which it developed, its manifestations, and __________ __________.
Treatment used
"Tell me about your pain" is an example of an open-ended question.
True
A patient with a subdural hematoma may have an odor of alcohol.
True
It is recommended that a left-handed examiner adopt a right-sided position.
True
Pain is frequently a motivator for people to seek health care and is considered the fifth vital sign.
True
An older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) Scale. The nurse should:
administer prescribed pain medication.
Ideally, when taking a blood pressure, the patient should be instructed to what?
avoid smoking for 30 minutes prior to the assessment
The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to
discuss the plan with the patient
The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except:
blood pressure
What is the source of deep somatic pain?
bones and joints
A past history is being taken by the nurse for a patient with COPD. The nurse includes which elements in this part of the health history? Select all that apply.
childhood illness health maintenance allergies
A past history is being taken by the nurse for a patient with COPD. The nurse includes which elements in this part of the health history? Select all that apply.
childhood illnesses allergies health maintenance
