health assessment prep u midterm

Flight of ideas

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Personal health history

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

To establish a database against which subsequent assessments can be measured

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?

Practice performing a physical examination on a classmate, friend, or relative

A nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?

Progress note section

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

A baseline for comparison with future findings

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?

Healthy People 2020

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?

Grouping assessment findings to identify commonalities

In the diagnostic process, what should immediately precede the step of identifying a list of possible nursing diagnoses?

To determine vibration sense in the neuromuscular system

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?

Reapply a staple in an incision.

The RN working on a surgical unit should be prepared to question which of these orders?

Pay attention to the details while observing

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?

Progress notes

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Enter the room and auscultate the client's lung sounds.

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action?

attention

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty?

Forgot the word to describe indigestion

The nurse suspects that a client is experiencing normal age-related changes in mental functioning. What assessment finding caused the nurse to come to this conclusion?

percussion

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

Anxious appearance

The nursing student learning about strengths and weaknesses of a patient understands that which of the following is considered to be an example of abnormal objective data?

Repeat the command louder and in a lower tone of voice

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?

Disorientation Looking to a family member to answer questions directed to the client Repeatedly failing to follow instructions

Which of the following are cues that a person may have dementia? Select all that apply

The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment.

Which of the following events during the assessment process most indicates a need for validation?

Let me stress the importance of being medication adherent."

Which statement made by the nurse demonstrates an understanding of the termination phase of the interviewing process?