Health Assessment: chap 1-6 prepu

A nursing instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following?

Plastic tubing should be longer than 3 feet.

A middle-school child tells his parents that he does not want to go back to school. He states that a group of boys are taking his clothes and towel when he is in the shower after gym class and making fun of his genitals. What type of violence is this?

Punking

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

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 notes resonance over the individual's thorax.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins

Four broad goals describe the role of a professional nurse. What is one of these goals?

To advocate for individuals, families, communities, and populations

The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?

Validate that the client understands how to use the inhalers.

A nurse assesses a non-English-speaking client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Wong-Baker FACES

The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

alert and oriented

The nurse is caring for a client who is experiencing visceral pain. What is this client's most likely diagnosis

appendicitis

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

What site of pulse assessment is used during an emergency assessment for an adult client?

carotid pulse

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

confabulation

In preparing a care plan for a client receiving opioid analgesics, the nurse selects which of the following as an applicable nursing diagnosis associated with side effects of opioid use?

constipation

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population?

death

When obtaining an oral temperature on a client, the nurse inserts the thermometer

deep in the posterior sublingual pocket

An older adult is admitted for altered cognition. The spouse indicates the client has becoming more forgetful over time. The nurse assesses the client's cognition using the Mini-Cog. The client is able to draw a clock correctly but is unable to recall the three words given at the beginning of the assessment. What do the results suggest to the nurse?

dementia

A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is:

diaphoresis

Body temperature is not impacted by which of the following factors?

diet

A client has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain?

endorphins

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

fungal infection

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs

hyperresonant

After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system?

nociceptors

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

What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?

oasis

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

palpation

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?

palpitation

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what ty.pe of pain?

somatic

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?

1+

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

44 mm Hg

A nurse is admitting a 30-year-old female client and recognizes the need to screen the client for abuse. What would the nurse do next?

A) Ensure a private setting.

The community health nurse is caring for an older client who states that she has not been taking the postoperative pain medication that she was prescribed. What question is most likely to be relevant?

Are you able to afford the prescribed medication?

The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. What would be the priority assessment at this time?

Asking whether the client often feels cold

A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first?

Assess the client

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. What would the nurse do next?

Assess the client's pulse at the carotid site.

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?

Collect subjective data related to overall function

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

Pulse pressure is found by subtracting ____ (bottom number) from _____ (top number)

Diastolic, systolic

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment?

Inspection, palpation, percussion, auscultation

What statement about batch charting is most accurate?

It contributes to many potential errors.

Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/min. What does this indicate?

Not all of the heartbeats are reaching the periphery.

When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?

Identify in what areas the client needs the most care.

Before beginning a health assessment with a client, the nurse reviews Healthy People 2030 because of which of the following reasons?

It identifies heath indicators, appropriate interventions, and resources.

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?

Notifies health care providers when clients show clinical signs of deterioration

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope

A client with a history of opioid tolerance will have an altered physiologic response to the pain stimulus. The repeated use of opioids will cause the body to become more sensitive to pain. This sensitivity is known as which of the following?

Opioid hyperalgesia

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure?

Over the client's thigh

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this client?

Patient demonstrates flight of ideas

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal?

Teaching children about healthy touch

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

The exam can provide clues about the validity of the client's responses now and throughout.

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

anxiety

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

focused

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 is referred to as a(n)

focused or problem-oriented assessment.

The most commonly used method of percussion is

indirect percussion

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population?

latex allergy

You should use the bell of the stethoscope when auscultating what type of sounds?

low frequency sounds

When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely:

neuropathic

A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?

time

A client is admitted with right lower abdominal pain with rebound tenderness. The nurse suspects appendicitis and documents this type of pain as which of the following?

visceral

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?

"I'm sorry, but assessment is ongoing and continuous."

A client had ingested hot coffee immediately after having an oral temperature reading obtained of 101°F. The health care provider is asking for the temperature measurement to be repeated using a tympanic membrane thermometer. What temperature will the nurse most likely obtain using this different measurement route?

102.4°F

Which of the following would be most appropriate for the nurse to do to determine stroke volume?

Calculate the difference between the diastolic and systolic pressures.

A client is recovering from a total hip replacement. The plan of care for this client is based on previous standards and uses a multidisciplinary approach. The nurse is aware that this plan of care is also known as which of the following?

Clinical pathway

A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?

Emergency

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam?

Ensuring client's privacy by providing an examination gown

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 whether the client has achieved the outcome criteria of the treatment?

Evaluation

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?

Evaluation

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes

Evidence in a situation of wrongdoing

The nurse is working on a pediatric unit caring for a 4-year-old who is recovering from the surgical repair of the pelvis. When assessing the client's pain, what is the most appropriate pain assessment tool for the nurse to use?

FACES pain scale

The nurse is working in the post anesthesia care unit and assessing pain in a 6 month old infant. Which method should the nurse use to assess the infant's pain?

FLACC scale

The nurse is caring for a 4-week-old postoperative client. The most appropriate pain assessment tool would be the:

Face, Legs, Activity, Cry, Consolability Scale

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure?

Gloves, gown, face shield

The nurse has made a nursing diagnosis of self-esteem disturbance. Which assessment data supports the nursing diagnosis?

Guilt and negative comments about self

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

Increased heart rate, Increased blood pressure, Increased cardiac output

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?

It becomes the foundation for the entire nursing process.

A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?

It provides a chronologic source of client assessment data.

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan syndrome

Which of the following principles should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

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.

After teaching a group of students about blood pressure and Korotkoff's sounds, the instructor determines that the teaching was successful when the students identify which of the following?

Phase II sounds appear muffled and swishing.

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

Which of the following is true about violence against women?

Some experts purport that cultural attitudes influence violence.

The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process?

assessment

Since the nurse is unable to obtain an oversized cuff to assess an adult client with a large arm, the nurse uses an average-sized cuff. What blood pressure reading will the nurse most likely obtain for this client?

reading will be high

A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience?

"I will be asking you a series of questions that I ask of all of my clients."

Pulse scale: 0 = 1+ = 2+ = 3+ =

Absent, weak/diminished, normal, bounding

A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?

Ask the client if they have allergies.

The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of:

Batch charting

A nurse is providing care for an 84-year-old client who has diagnoses of middle-stage Alzheimer disease and a femoral head fracture. What assessment tool should the nurse use to assess the client's pain?

Faces Pain Scale—Revised (FPS-R)

When preparing a discussion about violence, which of the following would the nurse include?

Family violence is a public health problem.

A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain as aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive pain?

somatic

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?"

Recently, lung cancer has metastasized to the bones of a 68-year-old client, precipitating a sudden increase in his pain. The client's wife and daughter are concerned about the consequent increase in the amount of hydromorphone the client requires, citing the risk of addiction. How can the nurse best respond to the family's concern?

"There's a very minimal risk of addiction, and controlling his pain is our first concern."

An emergency department nurse asks a client to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment?

"We routinely screen everyone because violence affects so many people."

Which question asked by the nurse assesses judgment of the client?

"What will you do if you feel the need to use cocaine again?"

During a health assessment, the client identifies having a 1 pack per day smoking habit. What should the nurse initially focus upon when approaching the client about the benefits of smoking cessation?

Determining whether the client wants to stop smoking

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse?

Evaluate patient outcome

The nurse is using a multidimensional pain assessment tool that combines indices measuring pain intensity, mood, pain location (via body diagram), and verbal descriptors, and which includes questions about medication efficacy. Which of these tools is a multidimensional pain assessment tool?

McGill Pain Questionnaire

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?

neuropathic

Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:

sentinel events

A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta primary afferent fibers transmit pain that is felt as which of the following?

sharp

A nursing instructor is teaching a group of students about assessing a client's orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first?

time

When assisting a client with health promotion, what must the nurse also nurture?

to a healthy environment

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment?

Establish a baseline for the comparison of future health changes.

A nurse is conducting a health assessment. How will the information collected from the client be used?

as a basis for the nursing process

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

isolated systolic hypertension

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

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

neuropathic

What would be the expected tone elicited by percussion of a normal lung?

resonance

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?

head to toe

Light palpation is most appropriate to assess the

inflamed areas of skin

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:

orthostatic hypotension

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

resonance

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

temperature, pulse, respirations, and blood pressure

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply.

• Onset of memory lapses • History of hospitalization for a mental health problem • History of Alzheimer's disease in a family member • Use of recreational drugs

What is one way nurses use critical thinking in regard to the nursing process?

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

A client admitted with a pulmonary embolism has been receiving continuous IV Heparin for the past 48 hours. The nurse reviews the client's chart containing the following information: ● 0800 VS: temperature 98.7F, blood pressure 120/74, heart rate 88, SpO2 95% 2L NC ● 1200 VS: temperature 98.6F, blood pressure 100/60, heart rate 99, SpO2 94% 2L NC ● Laboratory values on admission: hemoglobin 15 g/dL, hematocrit 40%, platelets 275,000 mm3 ● Laboratory values today: hemoglobin 11 g/dL, hematocrit 33%, platelets 175,000 mm3 What step of the nursing process should the nurse perform next?

Diagnosis

A nurse obtains the blood pressure in a client who is lying down. Which of the following would the nurse expect?

It will be slightly lower than standing readings.

The nurse is caring for a client following an open reduction, internal fixation of the right hip. The nurse observes the client moans when being repositioned. What type of pain indicator is moaning?

vocalization

Which statement by a nurse concerning the various methods used to measure temperature indicates the need for additional education?

"When monitoring the same client, an axillary temperature is usually higher by a degree than an oral temperature."

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process?

It is ongoing and continuous

A nurse asks a client the following question: "What do you do if you have pain?" The nurse is assessing which of the following aspects of cognitive function?

Judgment

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropathic Explanation: Neuropathic pain can occur from central nervous system brain injury caused by a stroke. Nociceptive pain is caused by tissue damage. Somatic pain is another term used for nociceptive pain. Idiopathic pain does not have an identified cause.

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The client's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Repeating the measurement with a different sphygmomanometer and stethoscope

Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?

The blood viscosity would be thinner, causing the blood pressure to decrease.

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following?

heart sounds

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?

kicking

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?

orthostatic hypotension

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface The dorsal surface is used for temperature. The fingerpads are used for fine discrimination such as pulses, texture and size. The ulnar or palmar surface is used for vibrations, thrills and fremitus.

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

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 nurse is interviewing a 65-year-old client with a history of atrial fibrillation, type 2 diabetes, obesity, and congestive heart failure. The nurse determines the client is experiencing chronic neuropathic pain when the client makes which of the following statements?

"The burning sensation in my feet has gotten worse over the past year."

An _____ is used to view the red reflex and to examine the retina of the eye. A _______ is used to test for bone and air conduction of sound. An _____ is used to view the ear canal and tympanic membrane. A ______ is used to view the mouth and throat and to transilluminate the sinuses.

ophthalmoscope, tuning fork, otoscope, penlight

The nurse recognizes that a barrier to successful pain management for the client with opioid tolerance is:

The client does not experience pain relief with usual doses of opioids.

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."

The nurse plans to administer the CAGE Self-Assessment tool on a client. The nurse explains to the client how and when the tool is used by stating which of the following?

"It is a short tool used to identify people at risk for substance use disorder. It consists of four questions."

The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?

"It looks like someone has hurt you. Tell me about it."

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following?

Avoid biases and judgment