Health Assessment Exam 1

nursing process (5)

1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation

Assessment techniques (4)

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

A nurse is admitting a client who is 162.6 cm (64 in) tall and weighs 68.2 kg (150 lb). Using the BMI table shown below, what should the nurse record as the client's BMI? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

25 Multiply your weight in pounds by 703. Divide that answer by your height in inches (there are 12 inches in 1 foot). Divide that answer by your height in inches again.

Myoclonus

A client who has a myoclonus will exhibit a sudden jerking of a muscle, such as with hiccups or the jerk of an arm when falling asleep.

Tic

A client who has a tic will exhibit an involuntary, repetitive movement of a muscle group, such as a wink or facial grimace

A nurse is conducting a general survey on a client and notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement?

A client who has fasciculation will exhibit a continuous twitching motion of a muscle when the muscle is at rest.

Spasticity

A client who has spasticity has an increase in muscle tonicity. Attempting to passively extend a joint will result in increased resistance.

A nurse is gathering information during a health history interview from a client who reports they have type 1 diabetes mellitus. Which of the following actions should the nurse take?

A health history gathers subjective information from the client about their past and current state of health. It is a screening tool to provide information about the client's positive health actions and potential problems and concerns. The nurse should complete the information gathering stage before moving to other actions.

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings?

A heart rate of greater than 100/min is considered tachycardia. The nurse should further assess the client for a potential cause, such as anxiety, fever, or pain.

Tachypnea

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min. The nurse should identify this as which of the following unexpected findings?

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading?

A nurse might have difficulty obtaining a pulse oximetry reading from a client who has recently undergone testing that involved the injection of a contrast dye into the circulatory system. The dyes can alter the transmission of the LED light used by the pulse oximetry sensor.

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client?

Although rectal temperatures are usually higher than oral temperatures, it is the most accurate method for obtaining a client's core temperature. Because obtaining a rectal temperature is invasive, it is not used often, but it is typically the route selected for a client who is not able to hold an oral probe in their mouth.

A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which of the following ethical principles is the client using?

Autonomy involves the client's right to make decisions about their care, including the right to refuse treatment if they choose. This ethical principle refers to a client's freedom.

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (Select all that apply.)

B. if the client is experiencing abuse or human trafficking C. the environment in which the client resides D. the client's use of substances E. client's ability to perform activities associated with daily living

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?

During the implementation step, the nurse carries out the interventions developed in the plan of care, which will assist the nurse and other members of the health care team to monitor the client's progress. Implementation is when the nurse puts the plan of care into action.

A nurse is teaching a young adult about risk factors for developing melanoma. Which of the following client statements indicates an understanding of the teaching?

Excessive sun exposure and severe or blistering sunburns in childhood increase the risk for developing melanoma as an adult.

A nurse is providing teaching to a client who reports acne on their face and chest. Which of the following client statements indicates an understanding of the teaching?

Frequent washing of the affected areas with warm water and soap will remove oil and dirt from the skin. This will reduce the risk of a secondary infection occurring in the lesions.

A nurse is planning to conduct a health history interview with a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

Gather supplies to take notes Select a position that is 0.6 to 0.9 m (2 to 3 feet) from the client during the interview Ensure face-to-face contact is at eye level **Review the client's medical record at the conclusion of the interview is incorrect. The nurse should plan to review the client's medical record prior to conducting the interview.

A nurse is preparing to assess the skin turgor of a client who has manifestations of dehydration. In which of the following locations should the nurse perform the assessment?

Inferior to the collar bone

A nurse is planning care for a client who has a stage 1 pressure injury on their coccyx. Which of the following interventions should the nurse plan to include?

Limit elevation of the head of the bed to 30º or less. Raising the head of the bed more than 30º increases the risk for skin damage due to shearing forces. Shearing occurs when the client slides downward in the bed. The outer skin layer sticks to the bed linens while the deeper skin layers move downward. This results in twisting of blood vessels and can lead to skin damage.

A nurse is assessing a client's skin color. Which of the following areas should the nurse check to determine the presence of pallor?

Mucous membranes Pallor is a pale or lighter skin color than usual that can be caused by anemia or a circulatory problem. It is best observed by inspecting the color of the lips, mucous membranes, and nail beds.

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via nasal cannula

A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply.)

Penlight is correct. The nurse should use a penlight to inspect the client's pupils and test for pupillary reflexes during the inspection part of the physical examination. Tape measure is correct. The nurse should use a tape measure to measure the size of wounds, bruising, or other abnormalities of the skin during the inspection part of the physical examination. Tongue depressor is correct. The nurse should use a tongue depressor to view the client's uvula and posterior soft palate during the inspection part of the physical examination.

A nurse is assessing a client's skin color. Which of the following findings should the nurse report to the provider? (Select all that apply.)

Pinpoint areas of purplish-red coloration across the abdomen Pale-colored nailbeds is correct.

A nurse is gathering information about a client's personal lifestyle choices. Which of the following information should the nurse seek to gather while investigating substance use? (Select all that apply.)

Prescription medications taken for recreational purposes Determination of when the client last had an alcoholic drink is correct. Frequency of consumption of over-the-counter (OTC) medications is incorrect

A nurse is examining the texture of an older adult client's skin. Which of the following findings should the nurse report to the provider?

Skin that feels smoother and softer than expected, similar to velvet, is associated with thyroid disorders. This is an unexpected finding that should be reported to the provider.

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting?

Subjective data includes feelings and concerns from the client's point of view. The reason why the client sought medical care is usually considered subjective data. This type of data, along with objective data, provides the nurse with information that will be reported to the provider.

A nurse is inspecting the fingernails of an older adult client. Which of the following findings should the nurse report to the provider?

The base of the nail should be firm to palpation. Spongy nail bases are associated with clubbing of the nails, which is a manifestation of chronic hypoxia. The nurse should report this finding to the provider

A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?

The client reported abdominal tenderness, so the nurse should palpate tender areas last because tense muscles make the assessment more difficult for the client.

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate?

The client takes a narcotic pain medication for chronic pain.Some medications for pain, such as narcotics and opioid analgesics, can depress the rate as well as the depth of respirations due to depressing the central nervous system.

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?

The first step of the nursing process is assessment. During this step, the nurse gathers information by performing a physical exam, interviewing a client, and observing a client.

A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

The nurse can make judgments about the findings of the skin, underlying tissue, muscle, and bones by palpating the skin for temperature, moisture, texture, and other abnormalities.

A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?

The nurse may enlist a professional interpreter if the client speaks a different language than the nurse.

A nurse is preparing to conduct an initial survey and assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

The nurse should engage in verbal communication that involves actively listening to the client. The nurse should keep interruptions to emergencies and provide their full attention to the client, which will establish trust.

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

The nurse should ensure that the client's feet, shoulders, and buttocks are in direct contact with the measuring pole or against the wall if the stadiometer is a wall-mounted device.

A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?

The nurse should maintain a personal space of about an arm's length (46 to 102 cm, or 18 to 40 in) when communicating with the client. This is a form of nonverbal communication.

A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?

The nurse should provide physical privacy by only exposing the section of the client's body needed at the time for proper assessment. This action helps the client feel less vulnerable.

A nurse is providing teaching to a client who reports extremely dry skin. Which of the following interventions should the nurse recommend?

The nurse should recommend an alcohol-free lotion that creates a film on the skin to decrease moisture evaporation and dryness. Lanolin, cocoa butter, and petroleum-based lotions are products that retain skin moisture.

A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment?

The nurse will need a stethoscope to be able to listen to the sounds of the client's body.

A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?

Using the nursing process, the nurse should first inspect the client's abdomen and observe for symmetry between the right and left side of the body. The nurse should note the presence of contours and any abnormalities with the skin, rashes, deformities, or masses. *not palpate first

A nurse is evaluating assessment findings of a client's skin. The nurse should identify that which of the following findings is associated with a possible infection?

Vesicles are small, serous, raised fluid-filled skin lesions. The nurse should identify that they are associated with both chickenpox and shingles infections, and should be reported to the provider.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?

When the nurse expresses empathy, the nurse reflects an understanding of the client's feelings and feels the importance of the client's communication. This is a therapeutic communication technique.

A nurse is performing a skin assessment on a client. Which of the following findings should the nurse report to the provider?

Yellow discoloration of the skin, or jaundice, should be reported to the provider. It is caused by an elevated level of bilirubin, which is a by-product of the breakdown of red blood cells. Jaundice can occur in clients who have disorders of the blood or liver

evaluation (5)

assess the effectiveness and achievability of the goals and the need for interventions to be adjusted

Implementation (4)

carry out the interventions that have been established, use clinical judgments to monitor the client's progress towards achieving their goals

A nurse is palpating a client's extremities and notes the lower left leg is cooler to the touch than the client's right leg or arms. How should the nurse interpret this finding?

client might have a blood clot Unilateral coolness is associated with decreased blood flow to the extremity. This can occur when the client is experiencing a blood clot that is blocking the flow of blood

assessment (1)

gather data from the client through interview, physical exam, and observation to make judgements

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply.)

goggles, gown, gloves

auscultation

listening to sounds within the body - heart, lungs, stomach, intestines, and arteries

A nurse is caring for a client who has a stage 1 pressure injury. Which of the following information should the nurse include when documenting the characteristics of the wound? (Select all that apply.)

location, size of the injury in cm, integrity of the skin surrounding the wound incorrect: depth of the injury in cm and color/odor of drainage from the wound

inspection (assessment technique)

looking, listening, and smelling to distinguish unexpected findings observe for symmetry, notice skin tone, rashes, bruising, wounds, deformities, mood

A nurse is collecting information about a client's family history. The nurse should plan to collect information about the health of which of the following client relatives? (Select all that apply.)

parents, siblings, grandparents

A nurse is preparing to perform a skin assessment on a client. Which of the following tools should the nurse plan to use?

penlight The nurse should plan to perform a skin assessment in an area with strong lighting for general visualization. A penlight is used to illuminate suspicious areas of the skin.

A nurse is examining a lesion on a client's back. Which of the following characteristics should the nurse identify as a possible indication of a malignant skin lesion?

size of a pencil eraser Lesions that are greater than 6 mm, or the size of a pencil eraser, in diameter should be recognized as a possible malignant skin lesion and should be reported to the provider.

percussion

tapping on a surface to determine the difference in the density of the underlying structure not typically used by entry level nurses

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply.)

time of day, obesity, diuretic meds (will decrease BP), smoking (increase BP)

therapeutic communication

touch and open-ended questions

analysis (2)

use clinical judgement to evaluate data collected to formulate the client's problems, including actual and potential problems

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply.)

use of assistive devices, height and weight, behavior and mood. current meds and past medical history is incorrect

planning (3)

use of problem solving and decision making skills to prioritize outcomes and goals and develop intervention to meet those goals

palpation

use the palmer side of hands or the pads of fingers