Health assessment rationales
A nurse is performing a neurological exam for a client which of the following assessment should the nurse perform to test the clients balance select all that apply
Romberg test and heel to toe walk
A nurse is assessing a client and she places her bell of the stethoscope at the apex of the heart with the patient in a left lateral position what heart sound is she listening for
S4
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma which of the following findings should the nurse identify as a safety risk
Scatter rugs are present in the kitchen
A nurse is performing a pain assessment for a client who is alert the nurse should recognize that which of the following measures is the most reliable indicator of pain
Self report of pain
A nurse is performing an admission assessment on a client which of the following findings should the nurse identify as an indication that the client is dehydrated
Skin tenting present
A nurse is administering a cleansing enema to a client who reports mild cramping the client asked the nurse to stop the enema and allow him to go to the bathroom which of the following action should the nurse take
Slow the flow of the enema solution briefly
A nurse is receiving a transfer report from a client who has had a head injury the client has a Glasgow coma scale score of four for eye opening five for a best verbal response and five for best motor response which of the following is an appropriate conclusion based on this data
The client opens his eyes when spoken to
How does a nurse accurately palpitate carotid pulses
One finger placed along the right and left medial sternocleidomastoid muscle checking side separately
Inhalation of intravenous access can be a painful experience for the patient as a needle is inserted into the skin the patient is calm however the patient pulls the hand away when the needle pierce the vein the time that the patient endorsed the pain before outwardly responding is known as
Pain tolerance
A charge nurse is observing a nurse auscultate a clients bowel sounds which of the following action require intervention by the charger nurse
Palpitate the abdomen prior to performing auscultation
What direction of the blood flow through the heart is best described by these
Right atrium right ventricle pulmonary artery lungs pulmonary veins left atrium left ventricle
A nurse is explaining decorticate rigidity (posturing) to a new nurse which of the following demonstrates that the teaching has been effective
Rigid flexion elbows wrist and fingers flexed and bent inward onto chest legs extended and abducted
A nurse is assessing a client abdomen who reports stomach pain which of the following action should the nurse first take
Inspect
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks which of the following methods of assessment should the nurse use first
Inspection
A nurse is performing an abdominal assessment of a client which of the following position should the nurse tell the client to assume for this examination
Supine
A nurse is planning care for a client who reports abdominal pain and assessment by the nurse reveals the client has a temperature of 102.6 a heart rate of 105 a soft non-tender abdomen and menses overdue by two days which of the following findings should the nurse report
Temperature
A nurse is assessing a client who has a score of three on the Glasgow coma scale the nurse should expect which of the following outcomes based on The score
The client is in a coma
What does the S2 heart sound represent
The closure of the aortic and pulmonic valves
Which patient should be expected to experience acute pain
A patient who had abdominal surgery eight hours ago
How do nurses best assess a patient's pain
By asking a patient to rate the pain being experienced
What is the earliest and most sensitive indication of altered cerebral function
Change in level of consciousness
A nurse is assessing a client cranial nerves as part of the neurological examination which of the following action should the nurse take to assess cranial nerve III
Check the pupillary response to light
A nurse is reviewing an assessment of a patient peripheral pulses and notices that the documentation states that the radio pulses are 2+ the nurse recognizes that this reading indicates what type of pulse
Normal
A nurse is preparing to administer heparin 3000 units by IV bolus available is heparin injection 5000 units/ ML how many ML should the nurse administer round to the nearest 10th
0.6 ML's
A nurse is assessing a client neurologic status in observes the following eyes open spontaneously verbalizes appropriately to the nurse and moves extremities which of the following does the nurse document for the Glasgow coma scale score
15
A nurse is preparing to assess a clients cranial nerve function for the eyes which of the following cranial nerves does the nurse know to assess
2,3,4 and six
A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis the amount available is naproxen 125 mg/ 5 mL oral suspension how many ML should the nurse administer per dose Round to the nearest whole number
20 ML
Health assessment week eight
8
While auscultating a clients heart sounds the nurse hears turbulence between the S1 and S2 heart sounds the nurse should document this finding as which of the following
A systolic murmur
A nurse in a providers office is preparing to test a clients cranial nerve function which of the following direction should the nurse include when testing cranial nerve V
A. "Close your eyes" C. "Clench your teeth." E. "Tell me when you feel a touch."
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment select all that apply
A. Ask the client about having a history of abdominal pain B. Inspect the abdomen for skin integrity C. Auscultate the abdomen for bowel sounds D. Percuss the abdomen in each of the four quadrants E. Palpitate the abdomen lightly for tenderness
How do nurses assess the pain of neonate or adults with dementia or decreased level of consciousness
A. Examine the patient for possible cause of pain B. Identify any psychologic signs of pain D. Ask family or caregivers what indicators they think may indicate the patient's pain
A nurse is teaching a client who has constipation which of the following should the nurse discuss as causes of constipation select all that apply
A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake
A nurse is assessing a client who has diarrhea for four days which of the following findings should the nurse expect select all that apply
A. Hypotension B. elevated temperature C. Poor skin turgor
A nurse is assessing a client who reports frequent vomiting and diarrhea for the past three days which of the following findings should the nurse expect select all that apply
A. Poor skin turgor B. Hypertension C. Flat neck veins
What finding does a nurse expect when assessing the cardiovascular system of a healthy adult select all that apply
A. Pulse of smooth contour with 2+ amplitude B. S1 and S2 present with regular rhythm C. Warm elastic turgor
Nociceptive pain can be what of the following descriptors
Arise from somatic structures such as bone joints or muscles and comes from the activation of the neural system
A nurse is assessing a clients cranial nerves which of the following method should the nurse use to assess cranial nerve II
Ask the client to read a Snellen chart
A nurse inspect the abdomen for skin color surface characteristics and surface movement which part of the abdominal assessment does the nurse perform next
Auscultate for bowel sounds
How is the first heart sound S1 indicated
By closing mitral and tricuspid valve close
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy additional data includes pulse of 100 per minute respiratory rate 24 per minute blood pressure 132/76 MM Hg and a temperature of 98.2 which of the following action should the nurse perform
Complete a neurological check
A nurse is completing a clients history and physical examination which of the following information should the nurse consider subjective data
Nausea
A nurse is performing an initial assessment on a client and notices neck and elbow extension with wrist and fingers flexed the nurse correctly reports which of the following to the provider
Decerebrate posturing
A nurse is admitting a client who has partial hearing loss which of the following is the priority action by the nurse
Determine if the client uses hearing aids
A nurse is completing a client assessment for admission to the medical unit which of the following abdominal assessment findings require further investigation by the nurse
Ecchymosis
A nurse is preparing an older adult client for a physical examination the provider is about to perform which of the following action should the nurse take
Explain to the client what is about to happen
A nurse is performing a cardiac assessment identify where the nurse should place the stethoscope to auscultate the clients apical pulse
Fifth intercostal space on the left side
During an abdominal examination a nurse in a providers office determines that a client has abdominal distention the protrusion is at the midline the skin over the area is taut and the nurse notes no involvement of the flanks which of the following possible causes of dissension should the nurse suspect
Flatus
A nurse is teaching a client about how to use her new hearing aids which of the following statements should the nurse identify as an indication the client needs further instruction
I will clean the hearing aids with alcohol wipes
A nurse is teaching an older adult client who reports constipation which of the following instruction should the nurse include in the teaching
Increase dietary intake of raw vegetables
Thrombophlebitis can be described as
Inflammation of a vein that may or may not be accompanied by a clot
Assessment of circulation motion and sensation is done every eight hours in a patient recovery from a laminectomy three days after surgery the patient had the surgery for consistent low back pain now on day three the patient has had a burning sensation on the lateral edge of the right foot this is best described as
Neuropathic pain
A nurse is performing a neurological assessment for a client who has trauma which of the following assessments will give the nurse information about the function of cranial nerve three
Instruct the client to look up and down without moving his head
To document the palpitation of a pulse the nurse is correct in making which notation about the rhythm
Irregular rhythm
A patient reports right shoulder pain that comes and goes as the chief complaint during the physical examination the patient ask why the upper right abdomen is being examined for shoulder pain what is the appropriate response from the nurse
It does seem odd but the gallbladder does not have pain receptors of its own so the pain shows up in the shoulder
A nurse is assessing an older client who has experienced some loss of bone density the nurse observes a hunchback curvature of the clients spine. The nurse should expect the provider to document which of the following disorders
Kyphosis
The nurse is preparing to assess the dorsalis pedis artery where is the correct location for palpitation
Lateral to the extender tendon of the great toe
A nurse caring for a older adult client who states I am afraid that I may fall when walking to the bathroom during the night which of the following action should the nurse take
Leave a night light on in the clients bedroom
Where does a nurse place a stethoscope to auscultate the mitral valve area choose the letter that corresponds to the correct stethoscope placement
Location of the mitral valve area the fifth intercostal space midclavicular
A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused which of the following action should the nurse take to address a client safety needs
Move the client to a room closer to the nurses station
A patient has chronic back pain for several years on assessment the nurse notes that the client sits quietly in a chair reading a book talking with a companion and does not appear to be in pain when questioned the patient rates the pain as a six on a scale of 0 to 10 how does the nurse interpret this data
Patient may not have the same objective response to chronic pain because of the compensation overtime
A nurse is assessing a client bowel sounds at which of the following points in the assessment should the nurse auscultate the clients abdomen
Prior to percussing the abdomen
A nurse is documenting the findings of an assessment performed on a client the nurse documents which of the following findings related to the eye assessment
Pupils equal round reactive to light and accommodation
A patient who had an amputation on his lower leg comes to the clinic with a complaint of pain he asked how I can be feeling pain in my foot in my foot is gone what is the appropriate response from the nurse
Stimulation of nerves from your leg sends impulses to the brain so that you feel pain even though your leg is no longer there
A nurse is assessing a clients cardiovascular system to palpitate for unexpected Paul stations in pulmonic area at which anatomical location should the nurse place her finger
The second left intercostal space
The nurse reviews an assessment of a patient peripheral pulses and notices that the documentation states that the radial pulse is 2+ the nurse recognizes that this is an indication of which of the following
This is a normal finding
A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain the amount available is gabapentin 300 mg per capsule how many capsules should the nurse administer per dose round to the nearest whole number
Three capsules
A nurse is preparing to administer clonidine 0.3 MG at bedtime to a client the amount available is clonidine 0.1 MG/ tablets how many tablets should the nurse administer per dose round to the nearest whole number
Three tablets
A nurse is preparing to administer amitriptyline 150 MG PO at bedtime the amount available is amitriptyline 75 mg/ tablets how many tablets should the nurse administer per dose round to the nearest whole number
Two tablets
A nurse is preparing to administer levothyroxine 0.175 mg PO once a day the amount available is Levothyroxine 88 MCG/ tablet how many tablet should the nurse administer produce round to the nearest whole number
Two tablets
A nurse in a providers office is preparing to auscultate and percuss a clients abdomen as part of the comprehensive physical exam which of the following findings should the nurse expect select all that apply
Tympany and high-pitched clicks
A nurse is planning to administer pain medication to a client following abdominal surgery which of the following action should the nurse first
Use the pain scale to determine the clients pain level
A nurse is planning care for a client who has a wound infection following abdominal surgery to promote healing and fighting infection which of the following vitamins and minerals should the nurse plan to increase in the clients diet
Vitamin C and zinc
A nurse is implementing a bow training program for a client for the program to be effective the nurse should take client to the toilet at which of the following times
When the client has the urge to defecate
A nurse is teaching a client about foods that are included on a clear liquid diet which of the following food choices made by the client indicates the need for further teaching
Yogurt
The Definition of pain is
an unpleasant sensory and emotional experience associated with actual or potential tissue damage