Health Assessment PrepU

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status? "Is your spouse living with you?" "Are you living with your spouse?" "Do you live alone or with someone?" "Are you married, divorced, or widowed?"

"Do you live alone or with someone?"

Which of the following terms is used to describe the arrangement of skin lesions? Annular Exposed Localized Generalized

Annular

Which of the following would be most important for the nurse to do immediately before beginning the physical exam? Practice interviewing skills. Construct the client's family genogram. Establish the client's reliability as historian. Collect necessary equipment essential to the exam.

Collect necessary equipment essential to the exam.

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? Fingerpads Ulnar surface Palmar surface Dorsal surface

Doral Surface

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform? Emergency Focused Comprehensive Nonfocused

Emergency

What is the nurse's best defense if a patient alleges nursing negligence? Testimony of other nurses Testimony of expert witnesses Patient's record Patient's family

Patient's record

The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing? Situation Background Assessment Recommendation

Recommendation

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? Vesicle Papule Wheal Cyst

Vesicle

A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following? "Documentation helps support reimbursement but gives little epidemiologic data." "Documentation provides a permanent legal record of care given and not given." "Documentation is a viable means of communication but is repetitious." "Documentation helps determine client education needs but not staff mix."

"Documentation provides a permanent legal record of care given and not given."

The nurse is assessing a client who has been sexually abused by an ex-boyfriend. What would be an example of subjective data from this client? Ecchymosis on the left temple area "He beat me and then raped me." Multiple lacerations and abrasions Tearful crying and shaking

"He beat me and then raped me."

The nurse is performing an admission assessment with a patient and is questioning the patient about religious preference. The patient says that they have no religious or spiritual preference. What statement by the nurse demonstrates a non-judgmental attitude? "Religion is very important to me. I don't know what I would do if I were ill and did not have my religion." "Don't you believe in something?" "What provides you strength in dealing with stress or illness in your life?" "I will call the hospital chaplain to talk with you. Maybe they will be able to help you."

"What provides you strength in dealing with stress or illness in your life?"

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? 9 or lower 10 to 12 13 to 18 19 to 23

19 to 23

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's A perception of pain. B height. C weight. D temperature.

A perception of pain

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed? Age Occupation Environment Support systems

Age

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status? palpation inspection percussion auscultation

Auscultation

The nurse receives the following report. A patient was admitted for a left hip fracture following a fall at home. The patient was diagnosed with osteoarthritis 7 years ago. The left leg is shorter than right. Ecchymosis noted over left hip and groin areas. Pedal pulses palpable and strong bilaterally. Patient reports a pain rating of 8. An orthopedic case management consult is needed. Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent? Situation Background Assessment Recommendation

Background

The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of: Batch charting Point-of-care documentation Organized charting Accurate documentation

Batch Charting

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? Newton scale Head-to-toe assessment Norton scale Braden scale

Braden Scale

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question? A: "I just thought I might know them; I know pretty much everyone in this town." B: "I'm just being friendly. We like to get to know our clients at this practice." C: "I just wanted to see what kind of social support you might have to help care for you during your illness." D: "With you having a terminal illness, you will need someone to help you plan your funeral."

C: "I just wanted to see what kind of social support you might have to help care for you during your illness."

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? May affect a person's body image negatively Can be caused by an underlying systemic illness Local irritation can cause damage to the nail bed Abnormalities may be a sign of poor hygiene

Can be caused by an underlying systemic illness

What intervention should a nurse implement to become culturally competent when assessing a client from another culture? Engage in intercultural encounters and cultural competence Become appreciative and sensitive to the values and beliefs of clients Seek and obtain a sound educational foundation of varied cultures Collect relevant cultural data of client's health history

Collect relevant cultural data of client's health history

Which skin characteristics can a nurse observe by using inspection? Color Temperature Texture Elasticity

Color

During a health history, a patient tells the nurse about having pain that has lasted for longer than 6 weeks. What action should the nurse make at this time? Begin high-yield screening questions. Conduct a mental health screening. Document the information. Ask what medication is used for relief.

Conduct a mental health screening

During a home visit an older client asks the nurse to find out what papers the client signed "the other day." What should the nurse do first? Assess for signs of physical abuse Complete a mental health assessment Continue to assess for indications of abuse or neglect Ask the client for the name of the person who had the papers to sign

Continue to assess for indications of abuse or neglect

What is one way nurses use critical thinking in regard to the nursing process? Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions Nurses do not need to think critically; they just need to follow the doctor's orders Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what? Society Community System Culture

Culture

The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic? A Criteria, opportunity, label, direction, stamina, progress, action B Category, occasion, length of time, decision, strength, plan, attitude C Choices, outcomes, learning, determination, status, protrusion, activity D Character, onset, location, duration, severity, pattern, associated factors

D Character, onset, location, duration, severity, pattern, associated factors

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process? A Glance at the clock at the wall. B Tap the pen on the paper while the patient talks. C Leave the interview and contact security. D Courteously interrupt the patient to clarify some information.

D Courteously interrupt the patient to clarify some information

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? Feel for deep organs or structures covered by thick muscles Determine tenderness, moisture, and the surface of skin texture Determine if a structure is filled with air or fluid or is a solid structure Observe for abnormalities on the skin's surface

Determine if a structure is filled with air or fluid or is a solid structure

What guidelines should the nurse keep in mind while performing auscultation? Eliminate distracting noise from the environment Use good lighting, preferably sunlight Look and observe before touching the client Compare appearance of symmetric body parts

Eliminate distracting noise from the environment

What should a nurse be aware of before effectively assessing for the presence of family violence? Need to create a safe and confidential environment Discuss any legal, mandatory reporting requirements Examine feelings, beliefs, and biases about violence Demonstrate a concerned and nonjudgmental attitude

Examine feelings, beliefs, and biases about violence

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition? Around the mouth and lips Chest and abdomen Fingers and toes Nose and earlobes

Fingers and toes

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? Fluid-filled lesions greater than 1 cm in diameter Purulent, fluid-filled, raised lesions of any size Raised, reddened, edematous papules or plaques, varying in size and shape Fluid-filled lesions less than 1 cm in diameter

Fluid-filled lesions less than 1 cm in diameter

A group of student nurses is presenting information on Gordon's framework for assessing a client. What type of assessment would they be talking about? Comprehensive Focused Functional Emergency

Focused

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? Handwashing Wearing latex gloves Using eye protection Gowning

Handwashing

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

Head to toe

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: Human violence Hypertension Inability of the patient to perform ADLs Anorexia nervosa

Human Violence

Which of the following assessment findings most likely constitutes a secondary skin lesion? Keloid formation at the site of an old incision Facial acne Facial lesions associated with herpes simplex Psoriasis

Keloid formation at the site of an old incision

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? Light Intermediate Moderate Deep

Light

When documenting that a patient has freckles, the appropriate term to use is macules patches vesicles bullae

Macules

The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding? Hypoxia Recent trauma Iron deficiency Normal finding

Normal Finding

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this? Stethoscope Otoscope Ophthalmoscope Sphygmomanometer

Otoscope

Your lab instructor explains that physical examination relies on what cardinal assessment technique? Assessment Percussion Organization Communication

Percussion

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? Perioral Palms Facial Chest

Perioral

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? Purpura Petechiae Ecchymosis Cherry angioma

Petechiae

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary? Completes the client's health record. Assures a trusting interpersonal relationship. Evaluates the seriousness of the client's risk factors. Provides a focus for the physical exam.

Provides a focus for the physical exam.

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes what the client has just said. What type of communication is the nurse using? Reflection Active listening Restatement Silence

Reflection

A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation? Client appears upset about upcoming surgery. Client was interviewed about previous history of hypertension Skin pale, warm, and dry without evidence of lesions Client's oral intake is satisfactory

Skin pale, warm, and dry without evidence of lesions

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment? Tenting indicates dehydration Tenting indicates malnutrition Tenting indicates dramatic weight loss Tenting indicates vitamin B12 deficiency

Tenting indicates dehydration

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse? The client had a recent infestation The client has had lice for quite some time This is not lice; it is scabies The nits indicate the infestation is over

The client had a recent infestation

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers? The confidentiality of electronic protected health information The confidentiality of printed protected health information The confidentiality of electronic and printed health information The confidentiality of the client's financial information

The confidentiality of electronic and printed health information

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students? The focus system of documentation organizes entries by data, assessment, and response The problem, intervention, evaluation(PIE) system of documentation does not use assessment as part of the PIE note Narrative charting is the most reliable form of charting Charting by exception (CBE)system allows the nurse to establish independent standards for assessment

The problem, intervention, evaluation(PIE) system of documentation does not use assessment as part of the PIE note

How should the nurse palpate the skin of a client to assess its texture? Touch with the palmar surface of the three middle fingers. Press the fingertips to the skin surface Rub the dorsal surface of the hand over the skin Pinch and roll the skin between the fingers

Touch with the palmar surface of the three middle fingers.

A nurse implements which skin assessment to determine the presence of dehydration in a client? Temperature Texture Turgor Thickness

Turgor

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? When palpating the texture of the client's skin When palpating the client's hair When palpating lesions on the client's skin When palpating the client's nail beds for texture and capillary refill

When palpating lesions on the client's skin

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? Sunlight Artificial light Wood's light Flashlight

Wood's light

A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this client is culturally appropriate? use an interpreter avoid eye contact limit interaction with the client be respectful of the client's culture

be respectful of the client's culture

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? Sympathy Therapeutic communication Empathy Caring

empathy

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate calcium. vitamin D. carbohydrates. fluid intake.

fluid intake

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the focused assessment comprehensive health history follow-up history emergency history

focused assessment

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? chief complaint past health history review of symptoms history of present illness

history of present illness

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? palpation inspection percussion auscultation

inspection

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is palpation. percussion. auscultation. inspection.

inspection.

A patient with a zosteriform rash 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

is distributed along a dermatome

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? neurologic cardiovascular musculoskeletal peripheral vascular

neurologic

Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to encourage new beliefs. dispel religious teachings if they conflict with the nurse's belief system. promote harmony between health and spirituality. raise doubt and point out flaws in one's faith.

promote harmony between health and spirituality.