Health Assessment PrepU

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

"Are you currently taking any diuretic medications?"

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

"Have you been sitting for a long time?"

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

"I feel so tired sometimes." Client complains of a headache "My father died of a heart attack."

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an antiseptic handrub

The nurse is assessing the skin condition and color of an African-American client. Which of the following would the nurse document as an abnormal finding?

Ashen gray skin color

After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as being foundational to all other phases?

Assessment

The principle of confidentiality is of paramount importance in the nurse-patient relationship. When should you inform the patient of with whom his or her information will be shared?

At the beginning of the interview

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

Circle with a cross

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.

Client complains of a headache "I feel so tired sometimes" "My father died of a heart attack"

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

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

Diaphoresis

When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?

Dorsal hand surface

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment?

ED Nurse

After completing a shift assessment on clients, the nurse reviews the early morning laboratory results. One of the clients has a potassium level of 3.0. The nurse knows that this potassium level can cause what?

Fatal cardiac dysrhythmias

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

History of present illness

A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states that her appetite has been low for the past 3 months, and has lost 20 pounds. Which nursing diagnosis should the nurse confirm based on this data?

Imbalanced nutrition

A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following principles should guide the nurse's assessment of a client's pain?

It is likely that the client's pain rating will be influences by his emotional state.

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

During the physical examination of your patient you auscultate the sound of the patient's breathing. What area of the patient are you assessing?

Lungs

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

Neuropathic

A nurse is creating a concept map of the pathophysiology of pain. The nurse should identify which of the following as being responsible for transmitting pain sensations to the central nervous system?

Nociceptors

The client has a murmur. This is what type of data?

Objective

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

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

The patient with a cognitive impairment sometimes cannot rate pain on a scale of 0 to 10. In such a case, the nurse is aware of other cues to assess the patient's pain. Which of the following is correct?

Restlessness, guarding

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure

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

Somatic

A client has a pulse rate of 28 beats/15 seconds. How should the nurse document this finding?

Tachycardia

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice?

The focused assessment addresses a particular client problem.

During a health assessment, the nurse learns that an adolescent is sexually active. What information can the nurse provide the client in order to support the Healthy People 2020 indicator of responsible sexual behavior?

The importance of using a condom when engaging in sexual activity

A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook?

To assess if the patient has the ability to obtain or prepare food

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

as a basis for the nursing process

One of the body's normal physiologic responses to pain is

diaphoresis.

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

The result of a nursing assessment is the

formulation of nursing diagnoses.

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms and to generate and test diagnostic hypotheses?

open-ended questions to encourage the client to tell his or her story

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history?

perform a physical examination

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom?

urinary

While performing a physical examination on an older adult, the nurse should plan to

use minimal position changes.

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs