Health Assessment week 1

A nurse has just received a report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse to perform during the abdominal assessment?

Inspection

A nurse is caring for a client who has a prescription for a fluticasone propionate inhaler with a spacer. The client asked the nurse why the space is needed with the inhaler. Which of the following responses should the nurse make?

More medication is delivered to the lungs when you use a spacer.

A nurse is preparing to administer medication's for a client who has an NG tube. Which of the following action should the nurse take prior to administering the medication?

Observe the amount of residual volume left in the stomach

A nurse is conducting a health history interview and ask the client to describe the pain that they are experiencing. This is an example of what type of question?

Open ended question

A nurse is performing a physical assessment of a client who has reported abominal tenderness. Which of the following action should the nurse take?

Palpate the tender areas of the abdomen last

Which of the following terms indicate that a medication is given via an injection

Parenteral

A nurse is collecting information about a clients family history. The nurse should plan to collect information about the health of which of the following clients relative? (Select all that apply)

Parents siblings grandparents

The nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply)

Penlight tape measure tongue depressor

A nurse is gathering information about the clients personal lifestyle choices. Which of the following information should the nurse it together while investigating substance use? (Selec all that apply)

Prescription medications taken for recreational purposes determination of one client last had an alcoholic drink

A nurse is preparing to conduct a health history interview. Which of the following action should the nurse plants perform during the closing stage of the interview?

Provide an opportunity for the client to ask questions.

A nurse has Just received a report on a newly admitted client who speaks a different language than the nurse. Which of the following action should the nurse take to assist with affective communication with the client during initial assessment process?

Request assistance from an interpreter during the assessment.

Which of the following should be included in an interprofessional or interdisciplinary team? (select all that apply)

Respiratory therapist provider nurses dietian

A nurse is preparing to administer insulin injection to a client. Which of the following action should the nurse take?

Rotate injection sites

A nurse is preparing to administer an intramuscular injection at the ventral gluteal so. Which of the following is the length should the nurse select for an adult of average size?

1 1/2

A nurse is caring for a client who has a new prescription for prednisone 12.5 mg by mouth daily. The medication is available on 5 mg tablets. How many tablets should the nurse administer for each dose?

2.5 tablets

A nurse is conducting a review of systems with the client during a health history interview. Which of the following responses by the client requires additional investigation?

"I have a cough"

A nurse is admitting a client who has schizophrenia. The client states, "The FBI has bugged the phone and is monitoring my calls." Which of the following responses by the nurse is appropriate?

"I understand that you believe this is true, and it must be very frightening for you."

A nurse is caring for a client who has depression. The client states "Things are always going to be bad for me. I wish I could just go to sleep and forget about all of my problems." Which of the following is an appropriate response?

"It seems as though you're expressing feelings of hopelessness."

Which of the following statements is an example of a therapeutic communication technique?

"Tell me about your relationship with your wife"

A nurse is caring for an older adult client who recently lost his spouse following lung cancer. The client states, "No one understands. She was my life." Which of the following response is appropriate?

"This must be a difficult time for you"

Which of the following is an example of the nurse using clarification to facilitate communication? (select all that apply)

"What would you say is the main point of what you are saying?" "I am not sure I am following you"

Which of the following is an example of closed-ended questioning? (select all that apply)

"are you going to group therapy tomorrow?" "How long have you been depressed?" "Do you not want to take your medication?" "Do you have a family history of depression?"

A client presents at a community shelter after surviving the destruction of her home by a fire. Which of the following questions should the nurse ask to determine the client's ability to cope?

"who do you talk to when you have the feeling of being overwhelmed?"

A nurse is gathering information during health history interview from a client reports they have type one diabetes mellitus. Which of the following action should the nurse take?

Ask the client for additional information regarding the management other diabetes.

A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?

Assessment

A nurse has performed a pre-operative care on a client and is transferring the client to the surgical holding area where the client states, "I have changed my mind; I do not want the surgery." Which of the following ethical principles is the client using?

Autonomy

Which of the following should a nurse include in the verbal SBAR report to a provider? (select all that apply)

Background Assessment Situation Recommendation

A nurse is caring for a client who has COPD. For which of the following Inhalation medication delivery method should the nurse assess the clients ability to inhale deeply?

Dry powder inhaler (DPI)

A nurse is preparing to perform a physical examination on a client. Which of the following intervention check the nurse perform to ensure clients privacy?

Do not expose any more of the clients body than required at a time

A nurse is preparing to administer if I find some medication. The client states from medication makes them feel nauseated and refused to take it. Which of the following action should the nose take?

Document the reason for refusal along with the date abs time in the client's medical record.

Which of the following are examples of a nurse using nontherapeutic communication techniques? (select all that apply)

Focusing on the nurse rather than the client changing the subject making value judgment giving advice

A nurse is planning to conduct a health history interview with a client. Which of the following action should the nurse take? (select all that apply)

Gather supplies to take notes. Select a position that is 2 to 3 feet from the client during the interview. Ensure face-to-face contact is at eye level

A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of a personal protective equipment should the nurse wear while performing this task? (Select all that apply)

Goggles gloves Gown

Which of the following types of communication is informal, becomes distorted, and typically involved three or four individuals?

Grapevine

A nurse is conducting a health history interview. Which of the following questions should the nurse asked one gathering information about my clients cardiac and peripheral vascular system? (Select all that apply)

Have you experienced any chest pain, tightness or discomfort? Have you noticed any swelling in your hands, feet or ankles? Do you feel short of breath during the day or while sleeping?

A nurse is teaching The adult child of a client about instilling eyedrops in the clients right eye. Which of the following statements by the clients adult child indicates an understanding of the teaching?

I will pull down her lower eyelid and drop the medication inside

A nurse is preparing to administer subcutaneous injection to a client. Which of the following should the nurse assess first?

If the client has allergies to the medication

A nurse is preparing to collect a health history from a client. Which of the following should the nurse plan to assess as a component of a functional assessment? (Select all that apply)

If the client is experiencing abuse or human trafficking The environment in which the client resides The clients use of substances Clients ability to perform activities associated with daily living

A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse preforming?

Implementation

A nurse is caring for a client who states, "I would like to go out on a date with you." Which of the following is an appropriate response by the nurse?

Inform the client that this is an inappropriate statement.

A nurse manager is discussing formal and informal structures or processes with a newly licensed nurse. Which of the following statements made by the newly licensed nurse requires further teaching?

Informal structures are visible

A nurse manager is reviewing concepts related to organizational communication with a group of charge nurses. Which of the following statements made by a charge nurse requires additional teaching?

Information should be informally distributed

The nurse is preparing to administer several medications to a client who is receiving internal feeding through a small bore nasogastric tube. Which of the following action should the nurse take to ensure the medications are administered correctly?

Infuse each medication by gravity and flush with water before and after instillation.

A nurse has collected biographic data from a client. Which of the following findings in the clients community is considered a social determinants of health of that it can negatively impact the clients health?

Limited access to a pharmacy

A nurse is performing a pre-admission assessment on a client employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of nonverbal communication technique by the nurse?

Maintain a fair distance between self and client

A nurse is preparing to instill anabiotic eardrops into the ear of a two-year-old child. Which of the following techniques should the nurse use when administering eardrops to this client?

Pull the client's auricle down and back to open the canal when administering the war drops.

A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?

Put themselves in a client situation to understand the clients anxiety

A nurse manager is conducting an in-service on ineffective communication patterns. Which of the following should she include when discussing components of passive communication? (select all that apply)

Puts others' needs and wants ahead of self avoids conflict difficult time saying "no"

A nurse is complaining documentation of clients medical record. Which of the following action should the nurse take?

Record the clients most recent assessment results

A nurse is preparing to perform palpation our client during a physical assessment. Which of the following findings is the nurse assessing during palpation?

Skin temperature, moisture and abnormalities

A nurse is collecting your Health history from a client was accompanied by an interpreter. Which of the following action should the nurse take?

Speak directly to the client throughout the interview

A nurse is performing auscultation during it clients physical assessment. Which of the following tools should the nurse use for this part of the assessment?

Stethoscope

A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting?

Subjective

A nurse is a ministering aspirin and 81 mg PO daily to a client who has a history of my ocardidal infarction. The medication is scheduled for 8 AM. Which of the following scenarios demonstrates proper use of them one of 10 rights of medication administration?

The nurse documents that the Astro was given at 8:25 AM

A nurse is conducting a health history interview with a client. Which of the following is accurate about a directive interview technique?

This technique consists of mostly close ended questions.

Under so preparing to a administer and interdermal injection. Which of the following action should the nurse take to ensure proper technique?

Use a tuberculin syringe with a 5/8 inch needle for administering an Intradermal injection

A nurse is preparing to give an intramuscular injection into the left ventrogluteal muscle. Which if the following actions should the nurse take to locate site of injection?

Use the heel of the hand in the index finger to locate the vastus lateralis muscle

A nurse is collecting biographic data from a client who reports they are seeking health care due to persistent cough. The client states they identify as transgender. Which of the following question should the nurse ask?

What pronouns do you use?

A nurse is discussing clients tobacco usage during a health history interview. Which of the following question should the nurse asked to maintain nurse-client rapport?

Would you like any information on smoking cessation?

A nurse is reviewing professional communication skills with a newly licensed nurse. Which of the following is a form of effective communication?

assertive

A nurse manager is discussing aggressive communication with a nurse who is having conflicts with peers due to her ineffective communication patterns. Which of the following should the nurse manager identify as a characteristic of aggressive communication?

infringes on the rights of others

A charge nurse is reviewing organizational structure with a group of newly licensed nurses. Which of the following should she include in her discussion? (select all that apply)

lines of authority organizational size formal structures informal structures

A nurse manager is discussing organizational concepts in a charge nurse meeting. Which of the following statements by a charge nurse indicates a need for further teaching?

smaller organizations find communication more difficult due to size and complex processes

A nurse is implementing theraputic communication techniques with a client in an outpatient mental health facility. Which of the following actions allow the client an opportunity to organize thoughts, consider a topic, or think through a point?

use of silence