Health Assessment Final

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

CN VII

The nurse notices a large number of positions available for employment in managed care. Which are reasons for the growth in nursing opportunities in this care environment?

Complex acute care Aging of baby boomer generation Expanding health service networks Expanding health needs of single parents

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

II

The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral?

a 50-year-old client newly diagnosed with diabetes

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

as a basis for the nursing process

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?

ask the client about their most recent experiences of pain

How does a nurse best facilitate the nursing health assessment?

asking the appropriate questions

As the nurse is auscultating a client's heart sounds, she hears the first heart sound, which indicates the beginning of systole. The nurse knows that which structure slightly delays the incoming electrical impulses from the atria before relaying the impulse on to the ventricles, causing them to contract during this phase?

atrioventricular node (AV)

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

auscultate with the bell over the lateral lobes

A nurse monitors a client at risk for the onset of premature ventricular contractions. The nurse should monitor the client's cardiac rhythm for which characteristic feature?

beats that occur earlier than the next expected beat

While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for

cardiac murmur

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

cerebellar ataxia

A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what?

chloasma

The chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and lens

What is responsible for the inspiratory splitting of S2?

closure of aortic then pulmonic

What should the nurse assess to test the function of the frontal lobe?

communication

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

coordination

A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?

deep-water fish

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment?

determine any changes from the baseline data

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?

determine whether the client wants to stop smoking

Which characteristic of the first heart sound would the nurse expect to hear in a client with mitral insufficiency?

diminished

When testing the biceps reflex, what type of response should the nurse expect if normal?

elbow flexes and muscle contracts

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 most need to perform this assessment?

empathy

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

Revising the plan as needed occurs in what part of the nursing process?

evaluation

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

fixed to the underlying tissue

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?

flex the neck forward

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal

A nurse auscultates a murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur?

grade V/VI

The nurse's assessment of a client reveals jugular venous distention. The nurse should conduct further assessments related to what health problem?

heart failure

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?

hyperthyroidism

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

knee-chest

The event producing the first heart sound (S1) is closure of which of the following valves?

mitral

While assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. The nurse should refer the client to a physician because this is usually indicative of

mitral valve stenosis

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

pay attention to details while observing

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

What is the most important physical sign of acute pericarditis?

pericardial friction rub

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the client's medications from home to check whether he is taking which medications that may cause the dystonia?

psychiatric medications

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

range of motion of the neck

A nurse is conducting an assessment of an elderly client's nervous system. The client mentions that he has experienced decreased taste and scent sensations recently. Which of the following should the nurse do at this point?

record the findings and proceed with the assessment

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

review the client's medical record

A nurse auscultates the heart rate of a young male and notices that the rate speeds with inspiration and slows with exhalation. S1 and S2 are normal. The nurse recognizes this as what dysrhythmia?

sinus arrhythmia

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

stiff neck

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

sympathetic nervous system

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?

the client's motivation for change

What is the primary purpose of the health history in relation to the eyes?

to identify changes

The diencephalon of the brain consists of the

thalamus and hypothalamus

The nurse is reviewing a client's cardiac output. The nurse identifies which cardiac output as being within the normal?

6

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?

a smoking cessation program

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

abdominal

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

airway

Which of the following is usually the first sign of neurological deterioration?

altered mentation and decreasing level of consciousness

On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?

aphasia

The nurse is collecting data from a client. Which of the following best reflects objective data?

appearance

In response to a client's query, the nurse is explaining the differences between the physician's medical exam and the comprehensive health assessment performed by the nurse. The nurse should describe the fact that the nursing assessment focuses on which aspect of the client's situation?

effect of health on functional status

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 nurse is using the ophthalmoscope to examine the patient's eyes. The nurse holds the scope

in the right hand for the right eye and in the left hand for the left eye

The nursing instructor explains to a group of students that what can shorten diastole?

increased heart rate

The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?

increased jugular venous pressure

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

instruct the client to flex and extend right elbow

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem?

measure the client's blood glucose four times daily

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client?

nodularity

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

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

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 client with heart disease is concerned about the safety of engaging in sexual intercourse with his spouse. He says that he can walk a block or two without feeling any symptoms, but cannot handle any strenuous exercise. How should the nurse respond?

suggest that he take his prescribed nitroglycerin before intercourse to prevent chest pain