Physical Assessment
The nurse is completing a wound assessment on the client's left lower extremity. Which assessments are noted using inspection? Select all that apply. Poor skin turgor around wound Non-pitting edema around wound Diminished pedal pulses Wound drainage is yellow and thick Skin is dry and brown Pain with elevation
-Non-pitting edema around wound -Wound drainage is yellow and thick -Skin is dry and brown
The nurse prepares to complete a health history with a new client at the clinic. The individual accompanying the client insists on remaining in the room. The nurse wants to begin with the health history interview but recognizes there are sensitive questions involved about the client's sexual health, safety in the home, and the use of alcohol and illegal drugs. What steps should the nurse take at this time? Select all that apply. Gently explain that visitors are not allowed in the room with the
-Say to the client, "who did you bring with you to the clinic today?" -Ask the client about the preferences for who is in the room during the interview. -Explain the purpose of the health history to the client and other person. -Say to the other individual, "what is your relationship with the client?"
In the nurse-client interaction below, select the nurse's statements that represent therapeutic communication provided by the nurse during the health interview.
-"Hello, my name is Jaime, and I am your nurse today. What brings you into the clinic?" -[Nurse sits down on the chair in the room. Leans slightly forward in the chair and focuses on the client's response.] -"Let me make sure I understand the order of these events. You have felt sick on and off for about a month but now you feel you have something different. You have had the flu in the past but did not have the flu this year." -[short pause] "It is difficult to not feel well and be uncertain of what is happening. [Hands client a tissue]. Tell me a little more about what you mean.
What should the preceptor say to the nurse in response to this plan before the gastrointestinal assessment is completed? Select all that apply.
-"You need to rearrange the order that you have planned for the assessment as auscultation should come before palpation." -"Verify if a urine specimen is needed before taking the client to the bathroom." -"Make sure when you position the client that you put a pillow under the client's knees as well as one under the client's head." -"If you don't hear any bowel sounds in a quadrant, make sure to listen for a full 5 minutes in that quadrant before documenting absent sounds." -"Standing at the foot of the bed for inspection gives you one view, but make sure to go to the client's right side as well to check your abdominal contour."
Which assessment findings require immediate action taken by the nurse? Select all that apply. A 3-month-old client who is showing nasal flaring A 17-year-old client who is breathing so quickly that they are unable to speak An 83-year-old client who reports a pain of 4/10 on the Numerical Rating Scale A 1-month-old client who is flailing their arms or legs A 32-year-old client who becomes unresponsive
-A 3-month-old client who is showing nasal flaring -A 17-year-old client who is breathing so quickly that they are unable to speak -A 32-year-old client who becomes unresponsive
What variations to the assessment are needed to meet the unique needs of the older adult? Select all that apply. During the musculoskeletal assessment, have the client move through a full range of motion of the neck in one continuous motion. Adapt the mouth assessment so that it is inspected with the dentures in place as well as outside of the client's mouth. Use terms such as "discomfort" or "aches" in addition to asking about pain. Complete a mini mental status exam on the client at
-Adapt the mouth assessment so that it is inspected with the dentures in place as well as outside of the client's mouth. -Use terms such as "discomfort" or "aches" in addition to asking about pain. -Complete a mini mental status exam on the client at every primary care provider visit. -Ensure that a handlebar is located near the weight scale in the office.
Click to identify which assessment is appropriate for the client. More than one assessment may apply to each client. A client who just arrived on the unit from the post-anesthesia care unit A client who comes to the clinic for their annual well visit and reports that they just lost their spouse A client who is having a follow-up visit after being diagnosed with Alzheimer's disease A client with a closed head injury that has been stable throughout the shift A client who is requesting pain medicat
-Head-to-Toe Assessment -Head-to-Toe Assessment, Mental Status Assessment -Focused, Mental Status -Focused -Focused
click to specify whether the nurse's actions are appropriate or inappropriate as the nurse prepares for and completes this client's focused cardiovascular system assessment. Administer the client's prescribed blood pressure medication. Inspect the precordium for heaves or lifts. Palpate the precordium with the client in the supine position to feel for thrills and abnormal pulsations. Elevate the client's legs on a pillow for comfort after completing the assessment. Auscultate the apical
-Inappropriate -Appropriate -Inappropriate -Inappropriate -Appropriate -Inappropriate -Appropriate -Appropriate -Appropriate
The nurse is performing a functional health assessment on an 82-year-old client. Review the client information below. Select the findings that would be of concern to the nurse. Mary is an 82-year-old female who was diagnosed with multiple sclerosis 6 years ago. She also has a history of hypertension, type I diabetes, and cataracts. The client lives with her adult son. She is currently taking atenolol, regular insulin, and prednisone. Assessment findings include: Diabetic neuropathy in
-MS -cataracts -Diabetic neuropathy -New weakness noted in the upper left extremity
Select the items that place the client at risk for health disorders. The nurse is interviewing Mark (pronouns: he/him/his), who is a 62-year-old male who was admitted to the hospital with pneumonia. The client is a house painter by trade. The client reports smoking 1/2 pack of cigarettes per day for 30 years. Past surgical history includes a right humerus fracture repair 5 years ago. Family history: Mother died last year due to complications of Parkinson's disease. Father is 84-years-old an
-house painter -smoking 1/2 pack of cigarettes -Parkinson's -hypercholesterolemia
Complete the following sentences by choosing from the list of options. The nurse should ______ in response to the inspection assessment results. The client's _____ is concerning because it can indicate ______. Based on the lung sounds assessment, the nurse should ______.
Check the client's oxygen saturation level tactile fremitus assessment pneumonia ask the client to cough to verify the type of lung sounds
Click to specify whether the nurse should complete this assessment now or whether the assessment should be deferred based on the client's presenting findings. Orientation Level Cranial nerve II (optic) with Snellen chart Cranial nerve III (oculomotor), Cranial nerve IV (trochlea), and Cranial nerve VI (abducens) Cranial nerve V (trigeminal) Cranial nerve VII (facial) Romberg's test Sensory function in the upper and lower extremities Motor function in the upper and lower extremities
Complete Now Defer to Later Complete Now Complete Now Complete Now Defer to Later Complete Now Complete Now
Identify if the assessment finding of the respiratory system of an older adult is expected or unexpected. Breathing using abdominal muscles Intercostal retractions Barrel chest Asymmetrical chest expansion Inability to deep breathe
Expected Unexpected Expected Unexpected Unexpected
Review the provider prescriptions in the electronic health record and click to specify when the findings are expected or are abnormal assessment findings. Sooths with cuddling Eating solids; drinking formula Weight 8 lb and 2 oz Two lower incisors present
Expected Finding Expected Finding Abnormal Finding Expected Finding
Click to identify if each assessment finding is expected or unexpected. Select one answer in each row. A 2-month-old who is breathing with abdominal muscles A 24-year-old pregnant female with diminished bowel sounds An 82-year-old adult with urinary incontinence A 32-year-old adult with a pericardial friction rub A 5-year-old with borborygmus
Expected Finding Expected Finding Unexpected Finding Unexpected Finding Expected Finding
The nurse is preparing to conduct a health interview with a pregnant client who has had multiple miscarriages. The client is worried that she will have another miscarriage. Click to indicate which statements made by the nurse are appropriate or inappropriate. "Don't worry, I am sure this time, the baby will be fine." "Why are you so worried? That will increase your blood pressure." "Tell me your concerns about this pregnancy." "If I were you, I would stay home and not work to pro
Inappropriate Inappropriate Appropriate Inappropriate Inappropriate
The home health nurse visits an older client and completes a functional health assessment to determine the client's self-care abilities. After reviewing the client information, select one line in the Nurses' Notes that is the most concerning.
Medical history of osteoporosis and rheumatoid arthritis. Fractured right ankle a month ago.
The nurse completes a health risk assessment with a client who has an abnormal mole. Click to specify whether the information in the client's history is a risk factor or not a risk factor for skin cancer. Darker natural skin color Severe sunburn as a child Family history of colon cancer Client is 23 years-old Reports working as a lifeguard at an outdoor pool Client lives at a lower elevation Client reports smoking a pack of cigarettes a week Client has blonde hair Numerous freckles noted on th
Not a Risk Factor Risk Factor Not a Risk Factor Not a Risk Factor Rick Factor Not a Risk Factor Risk Factor Risk Factor Risk Factor
The nurse receives report on their four clients to start their shift at 0700. Read each report then prioritize the clients in the order the nurse should assess.
Patricia Mike Helen Shelly
Tom (pronouns: he/him/his) is a 56-year-old male who came to the clinic for his annual physical. Review the electronic health record then answer the question. Tom is at greatest risk for ______ and _______.
type II diabetes cardiovascular disease
