Assessment exam 1

A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?

"Nurses focus on the diagnosis of actual human responses to disease or life events."

A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply.

1) rising educational costs and focus on primary care that affect the numbers and availability of medical students; 2) increasing complexity of acute care; 3) growing aging population with complex comorbidities; 4) expanding health care needs of single parents; 5) increasing impact of children and the homeless on communities; 6) intensifying mental health issues; 7) expanding health service networks; and 8) increasing reimbursement for health promotion and preventive care services.

niacin deficiency

Altered mental status

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task?

Constructional ability

miosis

Contraction of the pupil, which can be temporary or permanent, depending on the cause. Common causes of this symptom Small pupils can have causes that aren't due to underlying disease. Examples include bright lights, opiate intoxication, medication side effects, or aging.

Iron, zinc, and B vitamins like niacin (B3), riboflavin (B2), and B12.

Cracks in the corners of the mouth

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII

The nurse is conducting a physical examination of a patient 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 Assessment of dorsiflexion can offer information about problems with the cardiovascular and musculoskeletal systems. Dorsiflexion is best assessed when the client is lying down. Spine range of motion is assessed with the patient in the standing position. Posterior chest excursion and head and neck range of motion are assessed with the patient in the sitting position.

In which disease process should a nurse expect to see a client with the presence of pitting edema?

End stage renal disease

nails to be excessively dry

Exposure to chemicals

Having the client draw the face of a clock is one way to assess visual, perceptual, and constructional ability. The SLUMS exam tests cognitive function.

Giving directions to the client to perform a series of tasks, such as picking up and manipulating a pencil, is an assessment of concentration. Asking the client today's date is an assessment of orientation.

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock

The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?

Head to toe

The nurse prepares to analyze a list of a client's health problems. In which order will the nurse complete critical thinking of these problems? Drag statements into the proper order.

Identify abnormal data and strengths Cluster the data Draw inferences and identify problems Propose possible nursing diagnoses Check for defining characteristics of the diagnoses Confirm or rule out nursing diagnoses

During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?

Just below the cricoid cartilage

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision A secondary lesion emerges from an existing primary lesion, such as the keloids that can emerge from the site of a healed wound. Acne and the lesions associated with psoriasis and herpes do not meet this criterion.

A patient has sustained burns over 50% of the body. When planning care for this patient, the nurse will include interventions to address which alteration in the skin's barrier function? (Select all that apply.)

Mechanical or chemical injuries Penetration by microorganisms Loss of water and electrolytes

A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data.

Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living.

The health assessment allows data to be collected that is specific to the client and his or her nursing care needs. Initially, the nurse must be aware that any change to the client's health status may require an change to this plan of care. If changes are required, the health care team will be asked to consider and recommend them.

Monitoring the client for changes is always considered a nursing responsibility. Notifying the primary health care provider is not directly related to the nursing plan of care.

A client admitted with reports of nausea and vomiting has not reported any vomiting in the last 6 hours. What initial response should the nurse have regarding this assessment information and its effect on the client's nursing plan of care?

Recognize the need to reevaluate the client's plan of care.

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to the touch

Osteomyelitis

Stage IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible.

The Diagnostic Reasoning Process

Step One—Identify Strengths and Abnormal Data Step Two—Cluster Data Step Three—Draw Inferences Step Four—Propose Possible Nursing Diagnoses Step Five—Check for Defining Characteristics Step Six—Confirm or Rule out Diagnoses

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid. Atelectasis is one of the most common breathing (respiratory) complications after surgery.

Headache Impact Test

The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living.

cognitive dimension concerns "beliefs, attitudes, intentions, and motivations related to the pain and its management."

The affective dimension concerns feelings, sentiments, and emotions related to the pain experience.

temperature

The palmar and dorsal surfaces of the hand

What are the primary frameworks used in conducting a health assessment? Select all that apply. You Selected:

Three major frameworks for organizing assessment data are functional systems, body systems, and head-to-toe assessment.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

Vitiligo

Vitiligo is a disease that causes the loss of skin color in blotches.

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness diagnosis

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.

When conducting a head-to-toe assessment for a client in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

Blue-green fluorescence indicates fungal infection.

Wood light

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's lightWood's light is an ultraviolet light filtered through a special glass that shows a blue-green fluorescence if the lesion is due to fungal infection. The lesion can be inspected in sunlight and artificial light, but it may not indicate the type of infection in the lesion

Bullous impetigo

a bacterial skin infection caused by Staphylococcus aureus that results in the formation of large blisters called bullae, usually in areas with skin folds like the armpit, groin, between the fingers or toes, beneath the breast, and between the buttocks.

wheal

an elevated mass with transient borders that is often irregular

psoriasis

are plaque lesions.

mnemonic assessment tool

assess for the character, onset, location, duration, severity, pattern, and associated factors of pain

neuropathic pain

burning, painful tingling, pins and needles, and painful numbness

Referred pain

but the patient experiencing the pain feels it at another site along the innervating spinal nerve.

Acne presents as an inflammatory and non-inflammatory skin disorder characterized by one or a combination of the following lesions:

comedo, papule, pustule, or cyst.

Visceral pain

crampy or gnawing.

moisture on the skin

dorsal or palmar surfaces

What are the types of nursing assessments? (S

emergency, focused, and comprehensive.

Tumor-related headaches

have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.

A 20-year-old client visits the outpatient center and tells the nurse that he has been experiencing sudden generalized hair loss. After determining that the client has not received radiation or chemotherapy, the nurse should further assess the client for signs and symptoms of

hypothyroidism.

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning?

identifying abnormal or positive findings

Pustular lesions

include acne, furuncles and carbuncles.

Somatic pain

originates from the skin, muscles, bones, an

The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?

preauricular

The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply.

rhinorrhea ptosis miosis lacrimation

Iron deficiency

spoon shaped

iodine deficiency

swollen neck

lacrimation

tears

splinter hemorrhages

trauma to the nail bed

red, beefy tongue

vitamin B deficiency

The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?

"Has this been having an effect on your ability to carry out your routines and get around your home?" Explanation: When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.

Pitting edema is a sign of fluid retention ; is commonly seen in client with cardiac or renal disease because the circulatory system cannot handle the excess fluid; it leaks into the tissues. Pitting edema is most commonly seen in the lower extremities

. Colon cancer, diabetes mellitus, and liver disease do not normally cause pitting edema because these disease processes do not involve fluid retention.

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?

. Of the data provided, the client's impaired hearing poses the greatest safety risk and has the greatest impact on the client's quality of life and so has priority. While the other options could be potential factors related to quality of life and safety, the nurse will need to assess them further.significantly impaired hearing

bullae.

An area of skin covered by a raised, fluid-filled bubble. Bullae (pronounced as "bully") is the plural word for bulla. To be classified as a bulla, the blister must be larger than 0.5 centimeters (5 millimeters) in diameter. Smaller blisters are called vesicles.

A focused assessment consists of a thorough assessment of a particular client problem. A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment.

An elevated blood pressure with no previous history of heart problems requires an initial or comprehensive assessment.

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance

The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first?

Ask the patient to sip and swallow water.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes f a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

A client visits the clinic for a routine physical examination. The nurse prepares to assess the client's skin. The nurse asks the client if there is a family history of skin cancer and should explain to the client that there is a genetic component with skin cancer, especially

Cancerous lesions can be either primary or secondary lesions and are classified as squamous cell carcinoma, basal cell carcinoma, or malignant melanoma.

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?

Common benign skin lesions include freckles, birth marks, skin tags, moles, and cherry angiomas. Skin tags will not turn into skin cancer and are not early precursors to other more serious skin cancer conditions. Skin tags do not keep growing if not removed.

A client presents to the health care facility with reports of new onset of chest pain of three 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 perform for this client?

Comprehensive This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.

Cyanosis

Cyanosis is of two kinds. If the oxygen level in the arterial blood is low, cyanosis is central and indicates decreased oxygenation in the patient. If the oxygen level is normal, cyanosis is peripheral. Peripheral cyanosis occurs when cutaneous blood flow decreases and slows, and tissues extract more oxygen than usual from the blood. Peripheral cyanosis may be a normal response to anxiety or a cold environment.

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

For which client should a nurse perform a focused assessment?

Four-day history of sore throat and fever with enlarged lymph nodes

angle between the nail base and the skin is greater than 180 degrees

History of cigarette smoking

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

Notify the healthcare provider immediately.Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the patient's oxygenation level is within normal levels. The nurse knows that the blue color the patient described is caused by what?

Peripheral cyanosis

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

Physiologic, psychological, sociocultural, developmental, and spiritual data

ptosis

Ptosis /ˈtoʊsɪs/ is a drooping or falling of the upper eyelid. The drooping may be worse after being awake longer when the individual's muscles are tired. This condition is sometimes called "lazy eye," but that term normally refers to the condition amblyopia.

A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

Range of motion of the neck Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.

During the examination, one body part should be exposed at a time. The sheet serves as a drape to keep the other body parts covered. The sheet is not used to pad the table, collect body fluids, or to be a head support.

The client's position will not affect the accuracy of the blood pressure reading. Asking the client to take deep breaths will promote relaxation; however, it will not assist in ensuring accuracy of the assessment.

A 4-year-old child presents to the health care clinic with circular lesions. Which of the following conditions should the nurse most suspect in this client, based on the configuration of the lesions?

Tinea corporis

A nurse in the community is completing a manual blood pressure assessment. Which action should the nurse take to ensure the assessment is accurate?

Turn down the television volume. When completing a manual blood pressure assessment, it is important to ensure external noise does prevent the nurse's ability to hear the systolic and diastolic blood pressure sounds. Turning the television volume down assists the nurse in obtaining a more accurate measurement of the blood pressure.

Short, pale, and fine hair that is present over much of the body is termed

Vellus hair (peach fuzz) is short, pale, fine, and present over much of the body.

Vesicles

circumscribed elevated, palpable masses containing serous fluid. Vesicles are less than 0.5 cm. Examples of vesicles include herpes simplex/zoster, varicella (chickenpox), poison ivy, and second-degree burn.

Pressure ulcers are staged as I through IV. Put the following in order from stage I through stage IV.

intact, firm skin with redness ulceration involving the dermis full-thickness skin loss necrosis with damage to underlying muscle

Rhinorrhea

rhinorrhoea is a condition where the nasal cavity is filled with a significant amount of mucus fluid. The condition, commonly known as a runny nose, occurs relatively frequently. Rhinorrhea is a common symptom of allergies (hay fever) or certain viral infections, such as the common cold.

Varicella and herpes

simplex are vesicular lesions