PrepU Health Assessment
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 preparing to meet a client in the clinic for the first time, after reviewing the clients record, the nurse should:
Avoid premature judgments about the client
Which assessment finding should the nurse document as objective data?
Body function.
A clinical instructor is teaching a nursing student group about organizing data when documenting and communicating assessment findings. The clinical instructor knows that the method being taught promotes critical thinking and clustering of similar data the instructor is teaching about. Which type of assessment?
Body systems
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed?
Comprehensive
When the nurse clusters the data to make a judgment or statement about the client's condition, this is know as what?
Diagnosis
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?
Disinfect the stethoscope before touching the client
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. which skill will the nurse need to perform this assessment?
Empathy
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the clients temperature at repeated interval. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatments?
Evaluation
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 this client by:
Expressing interest in a neutral manner
What included in personal protective equipment (PPE)
Gloves, gown, mouth nose, eye protection
after completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do?
Go back in to complete a physical examination of the skin
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?
Head-to-toe
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is preceptor talking about?
Head-to-toe
Which of the following is the best example of holistic data collection by a nurse?
Measuring blood pressure, inquiring about a clients nutritional intake, assessment for depression, and asking client how his condition affects family gathers"
How does a nurse decide what health-promotion activities are necessary for a particular client?
Nurses collaborate with clients ti identify areas in which clients are willing to make changes
An older adult client had hip replacement surgery 2 days ago. The nurse enters the clients room and encourages the client to use the incentive spectrometer ten times every hour. What is this action an example of:
Nursing Intervention
The nurse is exhibiting critical thinking in which client care situation?
Performing a focused assessment on a client who is complaining of shortness of breath
A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?
Physiologic, psychological, sociocultural, developmental, and spiritual data
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the clients 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
Sometimes it is necessary to use a tuning fork when performing a physical assessment what would be one instance where a tuning fork would be used?
To determine vibration sense in the neuromuscular system
A nursing instructor is discussing the purpose of health assessment. What is one purpose of health assessment?
To establish a data base against which subsequent assessments can be measured
A nurse is performing over the area of a clients stomach. The nurse should anticipate hearing which type of sound?
Tympany
nurse is discussing with a client the clients personal health history. Which of the following would be an appropriate question to ask at this time?
What disease did you have as a child
a nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse to confirm the presence of fungus?
Woods light (UV/Black light)
During the interview process, the nurse uses both open-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
Working
When assisting a patient with health promotion, what must the nurse also nurture?
a healthy environment
universal precautions are primarily designed to protect the health care worker from what?
blood-borne pathogens
When assessing pulses, the nurse would use which part of the hand for palpation?
fingerpads
Light palpation is most appropriate to assess the:
inflamed areas of skin
You should use the bell of the stethoscope when auscultating what type of sounds?
low-frequency sounds
What is the primary function of the health care team?
to decide the best overall care
The nurse is performing a health assessment with a client who presented to the emergency department after falling as a result of feeling dizzy. Which questions demonstrates that the nurse understands the initial purpose of effectively conducting a health assessment?
"Are you feeling dizzy"; "are you experiencing pain at this time";"Do you know what your blood pressure is usually"
a nurse is assessing the cognitive function of a 13 year old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following.
"Im sorry, but assessment is ongoing and continuous"
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
"im going to assess the client now so that I can begin formulating the care plan"
Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient?
Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examinations. A. shins and ankles B. groin, hips, and knees C. breasts D. chest and thorax E. cardiovascular
C-D-E-B-A
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown again which are of assessment is primarily the nurses responsibility?
Collect subjective and objective data related to overall function
A client presents to the health care facility with reports of new onset of chest pain of three days duration. vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?
Comprehensive
A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?
Critical thinking
A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse, which of the following is the most effective use of inferring that the nurse might implement in this situation?
Do you perform any sustained or continually repetitive motions with that arm?
A nurse is palpating a childs forhead for signs of fever. which part of the hand should the nurse use?
Dorsal surface
The nurse would us what part of the hand when assessing temperature during palpation?
Dorsal surface
while examining a client, the nurse plans to palpate temperature of the skin by using the:
Dorsal surface of the hand
The nurse is conducting a physical examination, of a patient who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?
Dorsi-Flexion of the foot
Revising the plan as needed occurs in what part of the nursing process?
Evaluation
an older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
Exact date validated by daughter
A nurse is preparing to examine a 45 year old female client with family history of breast cancer. The 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
How would the nursing instructor explain the goal of guided questioning to his/her students?
Facilitating the patients fullest communication
The nurse asks a client "Is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing on with this question?
Family violence
An assessment of a client who already has a complete recorded data base in the system and returns to the health care agency with a specific health concern is referred to as a(n):
Focused or problem-oriented assessment
Learning about the effects of the illness does what for the nurse and the patient?
Gives them the opportunity to create a compete and congruent picture of the problem
A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear?
Gloves, mask, protective eye goggles, gown
The nurse is performing a follow-up assessment and interview of a 72 year old woman with a history of congestive heart failure. The nurse asks, the client "have you been experiencing any activity intolerance since I last saw you" what would be more appropriate way for the nurse to elicit this information?
Has this been having an effect on your ability to carry out your routines and get around your home
After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client?
Healthy People 2020
a nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
Heart murmur
A nurse us assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings?
Hospice
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
Individual student interview and questionnaire
A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?
Inspection, palpation, percussion, auscultation
A nurse assess a client with regard to nutritional habits use of substances, education and work and stress levels. The nurse recognizes this as what type of information?
Lifestyle and health practices profile
The nurse is assessing a client with unexplained lesions noted on the clients back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?
Light
After completing health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?
Nursing diagnosis
Which type of question is asked first by the nurse in order to attain a full description of the clients symptoms and to generate and test diagnosis hypothesis?
Open ended questions to encourage the client to tell his/her story
An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?
Open the clients airway
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophogeal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal Health History
The nurse is following a structured head-to-toe approach to identify changes in a patient's body systems. Which component of the health assessment is the nurse completing with the patient?
Physical Examination
A clients spouse answers the interview questions and will not leave the examination room. What should the nurse suspect be occurring with the client?
Physical abuse
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
Physiologic status
The RN is implementing which level of of intervention when administrating immunizations at a pediatric clinic?
Primary
The nurse is conducting a physical examination of the abdomen. What is the nurses best action to ensure she can hear bowel sounds?
Reduce all environmental noise
The nurse plans to follow the health belief model when identifying a clients care needs on what will the nurse focus when using this model?
Sufficient motivation; Making a change would be beneficial; belief of being susceptible to a health problem.
What is an appropriate action by a nurse when providing care for an 18 year old with respiratory problems caused by excessive smoking?
Suggesting methods and provide resource to assist with smoking cessation
Which describes the nurse using the technique of palpation?
The nurse notes increased warmth surrounding an abdominal incision
which describes the nurse using the technique of percussion?
The nurse resonance over the individuals thorax
When a client begins to cry the nurse recognizes the need to focus the assessment on the clients emotional health. What factor will have the greatest effect on the nurses ability to gather information concerning why the client is crying?
The rapport that exists between the nurse and the client
While interviewing a patient, the nurse asks; "What happens when you have low blood glucose?" This type of response to the patient is used for what purpose?
To Clarify
During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during this phase of the interview termed:
Working
During the clients interview, the nurse asks specific questions such as "what were you doing when the pain started" or "was the pain relieved when you rested" in what place of the interview is the nurse involved?
Working
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides:
a baseline for comparison with future findings
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 verbalize his/her feelings
After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressing. The nurses hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?
antibacterial alcohol hand rub
What are nurses able to detect through the health assessment?
areas in need of health improvement
The nurse is caring for a client exhibiting slurred speech after suffering from cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurses best action?
ask the client to repeat the statement or question
When doing overall assessment of a patient, the nurse is able to utilize findings and do what?
identify in what areas the patient needs the most care
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
nonverbal communication is a very important aspect in a nurse client relationships. What can the nurse do to help gain trust in clients?
* Use gestures for clients who cannot communicate verbally * make sure that dress and appearance are professional * Do not use facial expressions such as rolling eyes
The result of a nursing assessment is the
Formulation of nursing diagnoses
A 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
A nurse is preparing perform a physical examination on a obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client. so that the clients progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
Skinfold calipers
During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?
environmental
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
hyperrosonance
what would be the expected tone elicited by percussion of a normal lung?
resonance
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 response to the disease"
A client asks why a health assessment needs to be done. What should the nurse respond to this client?
"it determines your health status, risk factors, and educational needs to develop a plan of care."
When trying to explore a patients perspective on his/her illness, the question That would best determine the patients thoughts on the cause of the problem would be?
"why do you think you have (name specific symptoms)
How does a nurse facilitate the nursing health assessment?
Asking the appropriate questions
A community health nurse is planning individualized care for a community. What does the nurse use as a framework for this plan?
Nursing process
A client scheduled for surgery tells the nurse that he is very anxious about the surgery, What is an appropriate action by the nurse when interacting with this client?
Provide simple and organized information
Which is the priority for the nurse conducting a physical examination of a client with a generalized muscle weakness?
limit position changes as much as possible
a nurse is preparing to physically examine a client. the nurse recognizes that it is best to begin the objective data collection with which procedure?
measure the clients vital signs, height and weight
Which of the following is the best example of assessment in everyday life?
measuring the remaining tread on a car tire to determine whether it is time to replace it
The nurse documents information about a client's activity exercise health pattern. Which information did the nurse most likely document?
unable to go to the gym since having back surgery