312 Prep-U Exam 1

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

"Have you ever had a problem with mental or emotional illness?"

The nurse is preparing to meet Mr. James Smith, a 70-year-old client. How should the nurse greet this client?

"Hello Mr. Smith"

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

A client's elevated body mass index (BMI) has prompted the nurse to assess the client's activity and exercise level. Which statement would indicate to the nurse that the client is getting the recommended amount of exercise?

"I go to a step class for an hour three times a week."

A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the mostappropriate phrase for the nurse to use to clarify the expression's meaning from the client?

"Tell me what you mean by ________?"

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

"What diseases did you have as a child?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.

-Make sure that dress and appearance are professional -Do not use facial expressions such as rolling the eyes or looking bored or disgusted -Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

Alcohol-based rub

After the physical examination of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an alcohol-based hand rub

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question.

Nurses weave the individualization of the client interview through all aspects of the encounter. The nurse should avoid assuming that clients follow cultural beliefs. In place of making this assumption, what should a nurse do?

Assess the degree to which the client perceives the cultural beliefs

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

Mrs. T. comes for her regular visit to the clinic. Her regular provider is on vacation, but the client did not want to wait. The nurse has heard about this client many times from colleagues and is aware that she is very talkative. Which of the following is a helpful technique to improve the quality of the interview for both provider and client?

Briefly summarize what the client says in the first 5 minutes and then try to have her focus on one aspect of what she discussed

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?

Ensuring that contact with the skin is maintained

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients?

Friends and family who are unfamiliar with medical terminology may misinterpret information

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

Gloves Gown Face shield

A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use?

Goniometer

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

Hand hygiene

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?

Hyperresonant

Which of the following techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

When entering a client's room, the nurse washes the hands and asks the client for his name. What is the nurse's next best action?

Introduce self and explain what will be done.

The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview?

Knock and announce self before entering the client's room.

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible

A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?

Lithotomy

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room?

Lower the bed height.

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight.

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Menarche at age 13

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

Otoscope

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation

For which assessment would the nurse plan to use light palpation?

Papular rash

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history

When gathering information about medication use, a nurse should ask a client about which types of drugs?

Prescription and OTC medications

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows clients to what?

Provide accurate answers

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

What would be the expected tone elicited by percussion of a normal lung?

Resonance

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?

Skinfold calipers

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

During an interview, the client begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the client is providing?

Stop documenting in order to maintain eye contact with the client.

What is used to gauge central and peripheral nervous system disorders?

Strength of a reflex

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement for this technique?

The middle finger of one hand is placed on the body surface and the other middle finger strikes.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath.

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

The nurse notes gurgling sounds over the individual's abdomen. The nurse notes crackling over the individual's thorax. The nurse notes a rhythmic lub-dub over the client's anterior thorax.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?

To clarify

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the client

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

What is your major health concern at this time?

During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?

Working

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview?

be nonjudgmental

An adult client visits a clinic and tells the nurse that she suspects she has urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing

blunt percussion.

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

bone

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c, d, e, b, a

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative?

circle with a cross

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram

A nurse in a community clinic is attempting to collect a health history on a 26-year-old female new client who appears anxious. Drag words from the choices below to fill in each blank in the following sentence. To help reduce the client's anxiety, the nurse should

decrease environmental stimuli, introduce oneself, ask simple, concise questions, and explain the nurse's role.

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

deep palpation

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

deep palpation

The nurse asks a client "is there any time when you feel unsafe?" On which part of the comprehensive health history is the nurse focusing with this question?

family violence

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

health maintenance

The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should

indicate acceptance of the client's cultural differences.

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection.

An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?

last surgery date validated by adult daughter

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

light palpation

As the density of tissue decreases, the percussion note becomes:

lower pitched

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

palpation

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination?

prone

A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?

relaxed

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?

rephrasing

While interviewing an adult client about her nutrition habits, the nurse should

review the ChooseMyPlate information with the client.

A nurse in a clinic is preparing to meet with a new, 35-year-old male client. Complete the following sentence by choosing from the lists of options. Prior to meeting the new client, the nurse should first

review the client's medical record and then explain the purpose of the interview.

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this?

summary

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?

unable to go to the gym since having back surgery

How should the nurse place the ear of an adult when using the otoscope?

up and back

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief

Before beginning a physical assessment of a client, the nurse should first

wash both hands with soap and water.

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed

working