Putting it Together

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with? A) Developmental stage B) Stated age C) Overall physical development D) Vital signs

a

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? A) The client has the right to refuse. B) Permission maintains the client's confidentiality. C) It ensures that the client will answer personal questions. D) The client's level of comfort will be increased

a

Which of the following would be an example of information obtained during the health history about a review of the client's body systems? A) Wears dentures; denies problems with eating, chewing, and swallowing. B) States her father died of a heart attack at age 60 C) Uses over-the-counter antacid for occasional heartburn D) Vaginal delivery of two children without complications

a

The nurse would auscultate for voice sounds during which part of the comprehensive examination? A) Posterior chest B) Abdomen C) Head and face D) Neck

a

At which time would a nurse observe and evaluate jugular venous pressure? A) After examining the breasts B) When moving from the posterior to the anterior chest C) After assessing the heart D) Before examining the abdomen

a

Before performing a complete assessment, which of the following would be most important for the nurse to do? A) Check the state's Nurse Practice Act. B) Review the client chart. C) Gather personal protective equipment. D) Get necessary supplies ready.

a

During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing? A) Abdomen B) Anterior chest C) Neck D) Heart

a

A nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example. Which of the following would the instructor describe as being included in this assessment? Select all that apply. A) Skin color and condition B) Cardiovascular system C) Peripheral vascular system D) Neurologic system E) Musculoskeletal system

a c d e

When assessing a client's cognitive capabilities, which of the following would the nurse assess? Select all that apply. A) Remote memory B) Posture C) Speech D) Abstract reasoning E) Judgment F) Perceptions

a d e

When assessing the legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply. A) Femoral B) Brachial C) Temporal D) Dorsalis pedís E) Popliteal F) Posterior tibial

a d e f

A nurse has completed examining a client's nose and sinuses and is about to examine the client's mouth and throat. Which of the following would be most important for the nurse to do? A) Warm the hands B) Put on gloves C) Obtain a tuning fork D) Collect a saliva specimen

b

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? A) Ophthalmoscope B) Tuning fork C) Tongue depressor D) Stethoscope

b

A nurse would expect to assess the epitrochlear lymph nodes when assessing which of the following? A) Neck B) Arms C) Posterior chest D) Sinuses

b

After teaching a group of students about areas to include when examining a client's mental status, the instructor determines that the teaching was successful when the students identify which of the following as important? A) Ability to concentrate B) Thought processes C) Level of orientation D) Recall ability

b

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? A) "I try not to let the pain affect my life." B) "I haven't had a checkup in over 5 years." C) "I had my appendix removed when I was 14 years old" D) "I have an aunt who had breast cancer."

b

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? A) Mental status examination B) Head and face C) Ears D) Mouth and throat

b

A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember? A) Gather health history information first. B) Intersperse the physical exam with the history. C) Establish a routine for the assessment. D) Allow the client a break between the two parts of the history/exam.

c

A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, a client states, "I'm really having a good deal of pain in my hip now." Which of the following would be most appropriate for the nurse to do? A) Begin the comprehensive assessment. B) Explain the reason for the assessment. C) Delay the full exam until the client is more comfortable. D) Encourage the client to talk about how she is feeling. .

c

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame? A) 2 hours B) 1 hour C) ½ hour D) ¼ hour

c

The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following? A) Mental status B) Cognitive abilities C) Vital signs D) Thought processes

c

The nurse is palpating the tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? A) Nose and sinuses B) Abdomen C) Neck D) Face

c

The nurse would test for stereognosis during which part of the comprehensive exam? A) Posterior and lateral chest B) Nose and sinuses C) Arms, hands and fingers D) Legs, feet, and toes

c

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey? A) Hair neat clean with white and gray streaks; no scalp lesions noted B) Sclera white; conjunctiva slightly reddened without lesions C) Client alert and cooperative; sitting comfortably on chair with hands in lap D) Head symmetrically round; neck nontender with full range of motion

c

A nurse is going to complete a comprehensive assessment on a client. When collecting objective data, which of the following would the nurse do first? A) Assess the client's vital signs B) Take body measurements C) Assess mental status D) Observe the overall appearance

d

The nurse would palpate the axillae during examination of which area? A) Neck B) Anterior chest C) Heart D) Breasts

d