Health Assessment Exam 2
During an interview, the nurse is discussing dietary habits with a client. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
24-hour recall
A client reports a rash that "itches" but denies fever, shortness of breath, or other symptoms. Which questions does the nurse ask to help determine if the client is experiencing an allergic reaction? Select all that apply.
"Are you taking any new medications?" "Have you been using any different soaps?" "Have you been exposed to any new cleaning solutions?"
The nurse needs to take the blood pressure of a thin white female but only has a large cuff available. The nurse would correctly anticipate which of the following readings?
A falsely low reading
When auscultating the right carotid artery, the nurse hears a swishing sound (a bruit). What would this suggest?
A narrowed vessel
The nurse knows that which statement is true regarding the pain experienced by infants?
A procedure that induces pain in adults will also induce pain in the infant
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
An increased loss of elastin and a decrease in subcutaneous fat
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
Color variation
The nurse detects a possible irregularity in the rhythm of a client's radial pulse. Which of the following should the nurse perform?
Count the client's apical pulse for a full minute
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child s respirations?
Count the respirations for a full minute, noting rate and rhythm
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
Dry mucous membranes and cracked lips
A 50-year-old woman with elevated serum, total cholesterol, and triglyceride levels is visiting the clinic today to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests?
Information regarding a low saturated fat diet
When performing a physical assessment, the technique the nurse will always use first is:
Inspection
A client reports the mole on his scalp has started itching and it bleeds when he scratches it. What other finding would be a danger sign for pigmented skin lesions?
Irregular border
When documenting the palpation of a pulse, the nurse is correct in recording which notation about the rhythm?
Irregular rhythm
When documenting the results of palpating the pulse, the nurse is correct in making which of the following notations?
Irregular rhythm
Which of the following statements is true concerning the nutritional assessment?
It identifies patients who are at risk of malnutrition.
"When evaluating a patient s pain, the nurse knows that an example of acute pain would be:"
Kidney stones
All of the following data is collected during a head-to-toe assessment except:
Laboratory results
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin of this client?
Lesion with an irregular border
When the nurse assesses an apical heart rate and notes bradycardia. What was the apical heart rate?
Less than 60 beats/minute
Which statement indicates that the nurse understands the pain experience in the elderly?
Pain indicates pathology or injury and is not a normal process of aging.
To accurately assess the carotid pulse, the nurse would do which of the following?
Palpate in the groove between the trachea and the right and left sternocleidomastoid muscles one side at a time
"Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations?"
Palpation
When the client's chart includes a notation that Petechiae have been observed, what finding does the nurse expect during inspection?
Purplish-red pinpoint lesions
A client presents with small, elevated superficial lesions with purulent fluid and the nurse records these lesions as which of the following?
Pustules
The nurse is assessing capillary refill on a client and notes a color return that takes 4 seconds on each hand. The nurse would correctly document this finding as which of the following?
Sluggish
Which of the following findings should the nurse expect to find when assessing the nails of a healthy adult?
Smooth and rounded nails with a flat surface
Which of the following statements is true regarding the use of standard precautions in the health care setting?
Standard precautions are intended for use with all patients regardless of their risk or presumed infection status.
A 4-year-old boy is brought to the emergency department by his mother. She says he points to his stomach and says, It hurts so bad. Which pain assessment tool would be the best choice when assessing this child s pain?
The Wong-Baker scale
Which of the following situations will result in a falsely high blood pressure reading? (select all that apply)
The blood pressure cuff is too narrow for the extremity The person is sitting with his or her legs crossed
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of the following would be included in the module?
The epidermis is replaced every 4 weeks.
A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors?
The newborn s skin is more permeable than that of the adult.
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:
Xerosis
To assess for jaundice, the nurse would inspect for:
Yellow pigmentation in the sclera
A thorough skin assessment is very important because the skin holds information about:
circulatory status
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment of his skin, the nurse might expect to find the following:
clubbing of the nails
"When performing a general survey, the examiner is:"
observing the patient s body stature and nutritional status.
When assessing the radial pulse of a patient, the nurse should count the:
pulse for 1 minute if the rhythm is irregular
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiologic changes that directly affect the nutritional status of the elderly include:
slowed gastrointestinal motility
When assessing a patient s nutritional status, the nurse recalls that the best definition of optimal nutritional status is:
sufficient nutrients to provide for daily body requirements and for increased metabolic demands
A patient s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the:
thyroid gland
The nurse is preparing to percuss to assess the underlying:
tissue density
Which of the following factors is most likely to affect the nutritional status of an 82-year-old person?
Living alone on a fixed income
When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands
parotid and submandibular
When assessing a patient s pain, the nurse knows that an example of visceral pain would be:
Cholecystitis
During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
Certain drugs can affect the metabolism of nutrients
The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
head and neck, arms, inguinal area, and axillae.
"A patient s thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a:"
"soft, whooshing, pulsatile sound best heard with the bell of the stethoscope."
The nurse is assessing a patient with a heart rate of 55. Which of the following patients would be most likely to have a pulse rate of 55?
A 20-year-old runner who had surgery 4 days ago for a fractured leg
What is being tested when the client is being assessed utilizing a Snellen chart?
Ability to see items from a distance
The nurse is assessing the skin of a client who is at risk for dehydration due to excessive vomiting. The skin appears dry and loose. Where is the best site for the nurse to check skin turgor on this client?
Anterior chest
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient s skin?
Ashen, gray, or dull.
A client came for their yearly health assessment provided by their employer. You are reviewing their heart history. The client mentions that they engages in light exercise. At this time you should do which of the following:
Ask what the client means by "light exercise"
A patient is crying and says, "Please get me something to relieve this pain." What should the nurse do next?
Assess the level of pain and ask patient what usually works for his or her pain, administer pain medication as needed, then reassess pain level.
The best way to assess the general temperature of the skin is for the nurse to use which part of the hand?
Back (dorsum) of the hand
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is
Caused by the complete absence of melanin pigment
"The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby s birth and that it seems to be getting bigger. One possible explanation for this is:"
Cephalhematoma
In a report, a nurse learns that a client has a macular rash. Which of the following best describes a macular rash?
Flat, well defined small lesions less than 1 cm in diameter
When assessing a patient s pulse the nurse should note which of the following characteristics?
Force
A mother brings her newborn in for an assessment and asks, Is there something wrong with my baby? His head seems so big. The nurse knows the following about relative proportions of the head and trunk of the newborn:
Head circumference should be greater than chest circumference at birth.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
Importance of sunscreen and avoiding direct sunlight
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of the following conditions?
In an individual who is severely dehydrated
A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of the following assessment findings indicates an acute pain response to poorly controlled pain?
Increased blood pressure and Pulse
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
Melanocytes
During assessment of a patient s pain, the nurse keeps in mind that certain nonverbal behaviors are associated with acute pain. Which of the following behaviors are associated with acute pain? (select all that apply)
Moaning Diaphoresis
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her?
More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
The nursing student is learning blood pressure technique and asks the instructor what is a normal blood pressure reading? Which of the following responses would be appropriate for the instructor?
Normal is considered to be less than 120/80 and above 100/60
Which of the following clients has the greatest risk of developing hypertension?
Obese men with diabetes mellitus
A mother brings her 2-month old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on top of her head. Is something terribly wrong?" The nurse's best response would be:
The soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life.
Which of the following is true regarding the stethoscope and its use?
The stethoscope does not magnify sound but does block out extraneous room noise.
The nurse is assessing a patient s pain. The nurse knows that which of the following is considered the most reliable indicator of pain?
The subjective report
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
The woman could be at increased risk for infection and lesions because of her chronic disease.
"During an examination, a nurse notes a lesion on the client s upper back. What is the best way to document the size of this lesion?"
Use a centimeter rule to measure the lesion
A nurse notices multiple lesions on a client's back that are 0.5 cm in width, elevated, circumscribed, and filled with serous fluid. The nurse documents these lesions as:
Vesicles
Physical growth is the best index of a child s:
general health