prep u practice

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

-A child is persistent in trying to please a parent. -A caregiver of a cognitively intact older adult dominates the interview. -A pre-schooler rubs her perineum and complains of it hurting.

A novice nurse is struggling with making accurate nursing diagnoses. The supervisor, a much more experienced nurse, counsels the novice on what characteristics help nurses make better diagnoses. Which of the following should the supervisor mention? Select all that apply.

-Awareness of when exceptions apply to rules -A focus on the big picture -Years of experience -Seeing shades of gray when making decisions

When conducting the health assessment, the nurse interacts with the client in a caring manner. How would the nurse demonstrate caring to the client? Select all that apply.

-Being nonjudgmental -Showing respect to the client -Valuing the client unconditionally

The purpose of a health assessment includes what? (Select all that apply.)

-Collecting information about the health status of the client -Evaluating client outcomes -Synthesizing collected data

As the nurse completes a review of systems, what is it important to ask the client regarding the review of the area of the thorax and lungs. Select all that apply.

-History of emphysema -History of asthma -Last chest x-ray

Which of the following are aspects of the comprehensive health history? (Mark all that apply.)

-Strengthens the nurse-patient relationship -Provides baselines for future assessments -Creates platform for health promotion through education and counseling

Which is an example of palpation? Select all that apply.

-The nurse detects a small mass in the epigastric area. -The nurse detects crepitus over the individual's thorax. -The nurse detects increased warmth surrounding an abdominal incision.

What is paramount in health promotion? (Select all that apply.)

-working with the individual patient -developing the nursing care plan

When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse?

Conductive hearing loss in the right ear

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

A patient is trying to explain how he feels about his eye problem. He pauses often during the conversation and often repeats himself when expressing his concern about his problem. After listening, the best response by the nurse would be

I can understand why you feel the way you do

You are the office nurse admitting a new patient to the clinic. You have gained your patient's trust, gathered a detailed history, and finished your portion of the physical examination. What is your next step in caring for this patient?

Identify the patient's problems

When you observe the patient for general characteristics including age, gender, and level of alertness, what aspect of assessment are you performing?

Inspecting

Mr. Garcia comes to the office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, the nurse notes a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this?

Neuropathic

When attempting to assess a client's pain, what would the nurse do first?

Obtain a client self-report.

A client has presented with "a terrible head cold," and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply.

Palpation Percussion Transillumination

The nurse is observing a client for evidence of pain. Which finding would lead the nurse to suspect that the client is experiencing pain?

Slumped posture

A quality control nurse is reviewing client satisfaction survey comments. The nurse is most likely to read which positive remark?

Staff nurses report at the bedside so I can hear the information.

A patient reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. What opioid neuromodulator may be responsible for this increased level of comfort?

The release of endorphins

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be:

Using reputable health-education strategies to reduce risk behaviors

Which cranial nerve is associated with the movement of the uvula?

Vagus (CN X)

A nurse is analyzing the assessment data of a client who has been admitted with exacerbation of heart failure. The nurse has determined that the cue clusters meet the defining characteristics of specific nursing diagnoses. What would the nurse do next?

Verify it with the client and with other health care professionals.

A popular pain assessment scale for children is:

Visual Analog Scale

An adult client visits the clinic complaining of recurrent ulcers in the mouth. The nurse assesses the client's mouth and observes a painful ulcer. The nurse should document the presence of

aphthous stomatitis.

During a client interview, the nurse uses nonverbal expressions appropriately when the nurse

avoids excessive eye contact with the client.

A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for this client?

comprehensive

A nurse is assessing a client and collecting only the most important information. What type of assessment is the nurse doing?

emergency

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

A client plays doubles tennis every Saturday and golfs on Wednesday afternoons. In which part of the comprehensive health history is this information utilized?

health patterns

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?

percussion

Before the nurse analyzes the data collected, the nurse should

perform the steps of the assessment process accurately.

The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique?

vagal nerve function

A client tells the nurse about her experience with prolonged therapy for her breast cancer. The nurse responds, "That must have been a very trying time for you." What is this an example of?

validation

To adhere to standard precautions, the nurse should remember to (Select all that apply.)

wash hands before and after patient contact change white coat frequently

When using the CAGE questionnaire, the nurse elicits three affirmative responses when asking the patient about alcohol use. The question most appropriate to ask next would be

"Do you ever drink then drive?"