Health Assessment quiz 2

an approximate reading of the core body temperature can be taken at various anatomic sites. What would not be a correct place to take a core body temperature?

Groin

bowel sounds present in all four quadrants

objective

emesis of 200 mL light beige thin liquid

objective

pale, clammy, and diaphoretic

objective

passing flatus

objective

pattern of request for pain medication every 2 hours

objective

reddened, raised, indurated area on deltoid area of left arm

objective

the nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. the clients blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. what should the nurse ask the client?

"are you having pain from your surgery?"

The nurse has assessed the breath sounds of an adult client. the best way for the nurse to document these findings on a client is to write what?

"bilateral lung sounds clear"

what is the normal respiratory rate?

12 to 20 breaths/minute

what is a normal pulse pressure range for an adult client?

30 to 50 mm Hg

What is the normal pulse?

60 to 100 beats/minute

what is the normal oral temperature?

96-99.9 F

Which of the dimensions of pain listed is being assessed by the question "How does the pain treatment you are getting affect your overall mood?"

Affective

what is 1 degree F lower than the oral temperature?

Axillary temperature

The U.S. government has created guidelines for health care providers caring for clients in pain. Which of the following reflects these guidelines?

Joint Commission Standards for Pain Management

the nurse is preparing to assess the respirations of an alert adult client. the nurse should do what?

observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 to 2 in)

what is the difference between systolic and diastolic pressure?

Pulse pressure

When assessing a client's pulse, the nurse should be alert to which of the following characteristics?

Rate, rhythm, amplitude, and elasticity

A client have an oral temperature of 99F. The nurse interviews the client what could be an influence on this high body temperature?

The client has just run 3 miles outside before coming to the interview

skin color, hygiene, posture, gait, physical build, and development

overall impression

what is a popular pain assessment scale for children?

Visual Analog Scale

what is the fifth vital sign?

pain

why can acute pain be differentiated from chronic pain?

acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months

The nurse is preparing to document assessment findings in a client's record. The nurse should do what?

avoid slang terms or labels unless they are direct quotes

which of the following cultural expressions of pain would be likely to be found in a person of hispanic culture?

pain must be endured to preform gender role duties, but response to it is very expressive

what should the nurse do when assessing a client for pain?

believe the client when he or she claims to be in pain

What is a clients blood pressure affected by?

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

an elderly client it seen by the nurse in the neighborhood clinic. the nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. what does the nurse suspect that the clients cold intolerance s a result of?

decreased body metabolism

one of the body's normal physiologic responses to pain is what?

diaphoresis

lowest pressure exerted on artery walls

diastolic blood pressure

what should a nurse do after assessing a client in pain?

document the exact description given by the client

If the nurse makes an error while documenting findings on a client's record, the nurse should do what?

draw a line through the error, writing "error" and initialing

an assessment form commonly used in long-term care facilities is the nursing minimum data set. one primary advantage to this type of assessment form is that is what?

establishes comparability of nursing data across clinical populations

in some health care settings, the institution uses as assessment form that assesses only one part of a client. these types of forms are termed what?

focused

beliefs of health care providers can serve as barriers to an accurate assessment of a client's pain. Which of the following beliefs will not be likely to impair the assessment of pain?

infants can feel pain and may respond with crying or agitation

Osteoporotic thinning and collapse of the vertebrae secondary to bones loss in an elderly client may result in what?

kyphosis

the nurse is preparing to assess an adult client in the clinic. the nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. what does the nurse anticipate the client may be?

lacking adequate finances

what is the normal systolic blood pressure range?

less than 120 mm Hg

what is the normal diastolic blood pressure range?

less than 80 mm Hg

one advantage for an institution to use an integrated cued/checklist type of assessment data form is that what?

may be easily used by different levels of caregivers, which enhances communication

while caring for an 80 year old client in his home, the nurse determines that the client's oral temperature is 96.5F. The nurse determines that the client is most likely exhibiting what?

normal changes that occur with the aging process

while recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and what else?

pain relief measures

pain that is felt in a part of the body that has been removed

phantom pain

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. what does this type of assessment form?

prevents missed questions during data collection

the nurse assesses the clients vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9F, pulse 88 beats/minute and blood pressure 104/64 mm Hg. what should the nurse do?

record the vital signs

one disadvantage of the open-ended assessment form is that it what?

requires a lot of time to complete

while assessing an older adult client's respirations, the nurse can anticipate that the respiratory pattern may exhibit a what?

shorter respiratory phase

cannot eat seeds or uncooked grains without abdominal discomfort

subjective

complains of lower back pain on movement

subjective

describes severe right-sided headache

subjective

feels nauseated and dizzy

subjective

highest pressure exerted on artery walls

systolic blood pressure

what is more accurate than oral temperature?

temporal artery temperature

Normally about 1.4F higher than the normal oral temperature

tympanic temperature

the nurse is panning to assess a newly admitted adult client. while gathering data from the client, the nurse should do what?

validate all data before documentation of the data

The nurse is assessing an elderly post surgical client in the home. To begin the physical examination, the nurse should first assess the clients what?

vital signs

an example of an objective finding in an adult client is what?

vital signs