Health assessment
What are some critical thinking criteria for clinical judgments?
- keep an open mind - reflect on thoughts - use past clinical experiences - be aware of interactions and influences of others - be aware of the influences of the environment
The nurse develops a plan of care for a newly admitted client. The nurse revises the plan of care when which of the following occurs
- new symptoms develop - client refuses treatment - symptoms worsen with interventions
What are the 3 assessment forms for documentation?
1. Initial assessment 2. Frequent or ongoing 3. Focused or speciality
A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?
Adequate lighting
A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client
Adequate lighting
The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?
Ask the client to repeat the statement or question.
Markedly dismissed emotional expression
Blunted
What does COLDSPA spell out?
Character Onset Location Duration Severity Pattern Associated factors
Head and Neck Assessment
Check for size, shape, symmetry, lumps, positions, and masses on the neck and head area
What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?
Closing the door may help to limit background noise
Mildly diminished range of intensity of emotional withdrawal
Constricted
During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing
Deep palpating
Normal, steady
Euthymic
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
Evaluation
A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?
Explain the importance of the examination and the risks of breast cancer
Severely reduced emotional expressiveness
Flat
Learning about the effects of the illness does what for the nurse and the client
Gives them the opportunity to create a complete and congruent picture of the problem
Steps to Make a Clinical Judgment From Assessment Data
Identify —> Cluster —> Draw —> identify —> validate —> document
Emotional response that are not keeping with the situation or are incompatible with expressed thoughts or wishes
Inappropriate
Which of the following techniques are used in a physical assessment? Select all that apply. Inspection Palpation Auscultation Questioning Subjectivity
Inspection Palpation Auscultation
Irregular and severe mood swings
Labile
tonsillar nodes
Lymph nodes at the back of the jaw (angle of the mandible)
narrative description is an _________-ended question
Open
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
Perform an emergency assessment
The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?
Sensory abilities
What are the types of headaches?
Sinus Cluster Tension Migraine Tumor related
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
To determine any changes from the baseline data
True/False: Tell me about your pain" is an example of an open-ended question.
True
How do you validate when talking to a patient?
Validate what the receiver has heard by questioning or asking the receiver to summarize or read back what you have written down
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
acromegaly
abnormal enlargement of the extremities
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client
airway
Posterior cervical lymph nodes
behind the sternomastoid muscle
This type of assessment includes a health history and physical assessment
comprehensive
deep cervical lymph nodes
deep under the sternomastoid muscle
Data Analysis
diagnostic or clinical reasoning phase
occipital nodes
felt at the base of the skull
submandibular lymph nodes
gland located underneath the neck
preauricular nodes
in front of the ear
postauricular nodes
lymph nodes behind the ear
submental lymph nodes
lymph nodes beneath the chin
The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?
otoscope
superficial cervical lymph nodes
overlying the sternomastoid muscle
Which of the following questions is most useful in the assessment of a client's diabetes management?
"What is your routine for checking your blood sugar these days?"
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
Assess the nasogastric tube for proper functioning
After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?
Ongoing
When should the nurse perform hand hygiene? Select all that apply. When hands are visibly soiled After removing gloves After providing mouth care After reconciling the client's medications After taking the blood pressure of a client with intact skin
When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin
You should use the bell of the stethoscope when auscultating what type of sounds?
low frequency sounds
An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?
nursing intervention
When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using
blunt percussion
supraclavicular nodes
located just above and behind the clavicle, at the sternomastoid muscle
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
"How do you manage your stress?"
Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply A. Make sure that dress and appearance are professional B. Do not use facial expressions such as rolling the eyes or looking bored or disgusted C. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally D. Laugh a lot, which puts the client at ease E. Do not look the client in the eye
A. Make sure that dress and appearance are professional B. Do not use facial expressions such as rolling the eyes or looking bored or disgusted C. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally
nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
The nurse would use what part of the hand when assessing temperature during palpation
dorsal surface
While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?
to clarify