Lab Manual Questions-Health Assessment
a 90 year old pt is crying and states to the nurse "ive had such a wasted life" the most appropriate response from the nurse would be
"you are feeling like you have has a wasted life..?"
during a comprehensive assessment of an adult client the nurse can best hear high pitched sounds by using a stethoscope with a
1 and 1/2 inch diaphragm
developmental tasks correspond to biophysical maturity and societal expectations
Erikson's theory
the result of a nursing assessment is the
Formulation of nursing diagnoses
id, ego, and superego
Freud's theory
viewed justice or fairness as the goal of moral judgement
Kohlberg's theory
which of the following statements best describes Sigmund Freud's view of human behavior
a person is generally not aware of the underlying reasons for his behavior
creation of a new schema or the modification of an old one
accommodation
the nurse is beginning a health history interview with an adult client who expresses anger at the nurse the best approach for dealing with an angry client is for the nurse to
allow the client to ventilate his or her feelings
before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to
arrive at conclusions about the client's health
the nurse is interviewing a 78 year old client for the first time the nurse should first
assess the client's hearing activity
adaptive process whereby information is incorporated into an already existing schema
assimilation
the nurse is preparing to meet a client in the clinic for the first time. after reviewing the client's record, the nurse should
avoid premature judgments about the client
during a client interview the nurse uses nonverbal expressions appropriately when the nurse
avoids excessive eye contact with the client
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
bell of stethoscope
an adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infections. to detect tenderness over the client's kidneys the nurse should instruct the client that he or she will be performing
blunt percussion
when the nurse places one hand flat on the body surface and used the fist of the other hand to strike the back of the hand flat on the body surface the nurse is using
blunt percussion
while percussing an adult client during a physical examination the nurse can expect to hear flatness over the client's
bone
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next,
check for the presence of defining characteristics
which of the following statements correctly discuss jean piagets theory of cognitive development
cognitive development occurs as a result of the persons organization and adaptation to the perceived environment
problem that requires the attention or assistance of other health care professionals
collaborative problem
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive
begins to think and reason logically about objects in the environment
concrete operational
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
continuous
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 palpation
the person who has attained kohlbergs conventional level of moral development is best described as
desiring to avoid disapproval from others and be considered a respectful helpful person
which of the following statements is true regarding developmental theories
developmental theory often reflects the culture life experiences of the theorist
larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds
diaphragm of stethoscope
Part of the examiner's hand used to feel for temperature
dorsal surface of hand
while examining a client the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand
the nurse is interviewing a client in the clinic for the first time. when the client tells the nurse that he smokes "about two pack of cigarettes a day" the nurse should
encourage the client to quit smoking
assessing whether outcome criteria have been met and revising the plan of care if necessary
evaluation
to alleviate a clients anxiety during a comprehensive assessment, the nurse should
explain each procedure being performed and the reason for the procedure
the nurse is preparing to interview an adult client for the first time the nurse observes that the client appears to be very anxious the nurse should
explain the role and purpose of the nurse
the nurse is planning to interview a client who is being treated for depression when the nurse enters the examination room the client is sitting on the table with shoulders slumped the nurse should plan to approach the client by
expressing interest in a neutral matter
part of examiner's hand used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus
fingerpads
an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern
focused or problem-oriented assessment
the person who is able to correctly calculate algebraic equations has most likely attained which piagetian stage of cognitive development
formal operational
the nurse completes her interview or a 39 year old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor the nurse would be able to conclude that this client is in which of the following psychosocial developmental stages
generativity
while interviewing an adult client about the clients stress levels and coping responses an appropriate question by the nurse is
how do you manage your stress
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
hyperresonance
during a client interview the nurse asks questions about the clients past health history the primary purpose of asking about past health problems is to
identify risk factors to the client and his or her significant other
carrying out the plan of care
implementation
the nurse has interviewed a hispanic client with limited english skills for the first time. the nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. the nurse should
indicate acceptance of the client's cultural differences
the most commonly used method of percussion is
indirect percussion
during a comprehensive assessment, the primary technique used by the nurse throughout the examination is
inspection
for a nurse ot be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality the nurse should have
knowledge of his or her own thoughts and feelings about these issues
back lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
lithotomy position
while interviewing a client for the first time the nurse is using a standardized nursing history form the nurse should
maintain eye contact while asking the questions from the form
generativity versus stagnation
middle adult
lawrence kohlberg based his theory of moral development on the premise that
moral development is determined in part by decisions that challenge the person
collection of subjective and objective data
nursing assessment
analysis of subjective and objective data to make a professional nursing judgement
nursing diagnoses
clinical judgement about individual, family, or community responses to actual or potential health problems and life processes
nursing diagnosis
findings directly observed or indirectly observed through measurements
objective data
during an interview, the nurse collects both subjective and objective data from an adult client, subjective data would include the client's
perception of pain
while performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
percussion
a medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the clients
physiologic status
growth and development of intellectual structures
piaget's theory
developing a plan of nursing care and outcome criteria
planning
a 50 year old pt tells the nurse that she enjoys babysitting her grandchildren while their parents are attending night classes at the local college she also shares that on many days she volunteers at a neighborhood food bank. erikson would most likely place this pt as
positively resolving a sense of generativity versus stagnation
ability to make a mental representation for something not present using language
preoperational
client lies on abdomen with head turned to side; may be used to assess back and mobility of hip joint
prone position
the nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits during the interview process the nurse should plan to
provide structure and set limits with the client
during the interview of an adult client the nurse should
provide the client with information as questions arise
Sigmund Freud postulated that
puberty allows sexual impulses to reappear
the depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of
rapid advance in biomedical knowledge and technology
physiologic complications that nurses monitor to detect ehir onset or changes in status
referral problem
during an interview with an adult client for the first time the nurse can clarify the client's statement by
rephrasing the client's statements
while interviewing an adult client about her nutrition habits the nurse should
review the ChooseMyPlate information with the client
to prepare for the assessment of a client visiting a neighborhood health care clinic the nurse should first
review the client's health care record
thoughts are demonstrated by physical manipulation of objects/stimuli
sensorimotor
side-lying position used during the rectal examination
sims' position
position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
sitting position
position used to examine male genitalia and to assess gait, posture, and balance
standing position
sensations or symptoms that can be verified only by the client
subjective data
back lying position used for examination of the abdomen, this position allows easy access for palpation and peripheral pulses
supine position
The client frequently chews his nail to the point that his fingers are bleeding. when questioned about this he has attacked people who question him about his nail biting and bit them. Freud would interpret this as which of the following
the id is controlling this patients behavior
each of erik erikson's central developmental tasks is composed of opposing viewpoints erikson thus theorized taht
the person must accomplish a healthy balance between these opposing viewpoints in order to progress to the next psychosocial stage
which of the following statements is true regarding piagets concept of transductive thinking
transductive thinking can be used by formal operational thinkers
Part of the examiner's hand used to feel for vibration, thrills, or fremitus
ulnar surface or palm of hand
while performing a physical examination on an older adult the nurse should plan to
use minimal position changes
the nurse is interviewing a client in the clinic for the first time. the client appears to have a very limited vocabulary. the nurse should plan to
use very basic lay terminology
during an interview with an adult client the nurse can keep the interview from going off course by
using closed-ended questions
Before beginning a physical assessment for a client, the nurse should first
wash both hands with soap and water
during an interview between a nurse and a client the nurse and the client collaborate to identify problems and goals this occurs during the phase of the interview termed
working