Assessment exam 1.1

Vascular lesions

1 mm to 2 cm. Their color ranges from fiery red to blue. Their shape can be round, flat, raised, and have radiating legs

DAR

A DAR note is a method of charting problems that arise in patient care. By using this acronym to help you chart, you can be sure that all necessary data is recorded in your notes. DAR stands for data, action and response.

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

A hyperresonant lung sound is very loud, low in pitch, long in duration, and booming in quality. This is the sound heard from emphysematous lungs.

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many maternal and paternal relatives as the client can recall

A nurse needs to auscultate the heart sounds of a patient who is in a hospital room watching his favorite television show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment?

Ask the client if it would be okay to mute the volume on the TV during the assessment.

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?"

When caring for hospitalized clients, the nurse should recognize which potential safety hazards? (Select all that apply.)

Call bell on bedside table Multiple intravenous infusions Urinary catheter under leg Dim lighting

During the physical assessment of a client, a nurse observes that the client tends to lean forward and brace himself with his arms. The nurse recognizes this as a sign of what disease process?

Chronic pulmonary obstructive disease

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

Coin or key

What should the nurse do prior to analyzing data collected on a patient with Addison's disease?

Collect and organize assessment data. Validate data. Document data.

Which clinical manifestation should the nurse expect to find in a client with edema?

Decreased skin mobility

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?

Evidence in a situation of wrongdoing

A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?

Explaining the reason for taking down notes

In the diagnostic process, what should immediately precede the step of identifying a list of possible nursing diagnoses?

Grouping assessment findings to identify commonalities

The client is exercising. The nurse understands that exercise has what effect on the body? Select all that apply.

Increased heart rate Increased blood pressure Increased cardiac output Explanation:

Which of the following statements is true of the role of inspection in the physical examination?

It is often the source of the most physical signs.

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

A client comes to the health care facility with reports of abnormal bleeding from his gums, chills, and recurrent infection. How should the nurse cluster the data collected from the client?

Look for related cues in the abnormal findings and strengths

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

Meaningful use of electronic health records

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

Before delegating an assignment, the nurse should determine that which rights have been confirmed?

Right task; Right circumstances; Right person; Right directions and communication; Right supervision and evaluation.

Which of the following is a collaborative problem?

Risk for osteoporosis

The nurse is explaining the difference between acute pain and chronic pain to the patient. Which should the nurse include in the explanation?

The cause of acute pain can be identified.

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds

Why do nursing students review medical records?

To enhance clinical learning To better understand complex clinical situations

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

Up and back

dysarthria

Weakness in the muscles used for speech, which often causes slowed or slurred speech. Slurred speech

P.I.E.

charting, or the pie system, as i know it is where P stands for the problem, I for interventions and E for evaluation.

Assessment

collection of data.

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

The nursing student has learned that diagnostic reasoning has several pitfalls. The second set of pitfalls usually occurs during the analysis phase and involves which of the following?

cues that are clustered yet unrelated

The nurse divides collected data into subjective and objective categories. What should the nurse do next in the critical thinking process?

identify abnormal data and strengths

Hirsutism, or facial hair on females,

is a characteristic of Cushing's disease and results from an imbalance of adrenal hormones.

A patient with a zosteriform rash has a rash that

is distributed along a dermatome

Pityriasis

is limited to the trunk and proximal extremities.

Lupus erythematosus

patchy hair loss but does not cause excessive facial hair

Herpes zoster

produce exudate but it is usually confined to one area of the body (dermatome) and not a diffuse rash.

During the interview of an adult client, the nurse should

provide the client with information as questions arise.

The nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that

squamous cell carcinomas are most common on body sites with heavy sun exposure.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for

symptoms of stress.

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?

termination

To adhere to standard precautions, the nurse should remember to

wash hands before and after patient contact change white coat frequently

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor?

"A way of processing information using to formulate conclusions or diagnoses."

Stage 1 hypertension

140 to 159/90 to 99 mm Hg

The nurse is conducting a skin assessment on a client who suffered a burn injury. The client's wound exhibits rapid capillary refill, is moist, red, and painful. What depth of burn should the nurse document?

A superficial burn exhibits brisk bleeding, is painful, has rapid capillary refill, and is moist and red. This description does not apply to the other options.

A pathophysiology instructor is discussing pain and its treatment across cultures. The instructor points out that patients from racial and ethnic minorities often receive less pain medication compared to Caucasians for what specific conditions?

Acute pain in the ED African Americans, Hispanic Americans, and other patients of racial and ethnic minority heritage receive less pain medication compared to Caucasians across a range of conditions, including cancer pain, acute postoperative pain, chest pain, acute pain presenting in the ED, and chronic low back pain.

How may a nurse demonstrate cultural competence when responding to patients in pain?

Avoid stereotyping responses to pain by patients.

niacin deficiency

Cracks in the corners of the mouth

acromegaly

Elongated bones of the face and hands

A nurse is teaching a class on hypertension in a community setting. What risk factor would the nurse be sure to address to the class?

Family history

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

Fixed to underlying tissue

A nurse inspects a client's nails and notes the angle between the nail base and the skin is greater than 180 degrees. What additional data should the nurse collect from this client?

History of cigarette smoking

risk diagnoses

Identified potential weaknesses

How does the client's medical record affect financial reimbursement?

Insurance companies audit client records to ensure that billing is accurate

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Progress notes Multiple members of the health care team document in a progress note the patient's progress toward recovery.

While assessing a patient's arms, the nurse notes a 3-mm oval lesion located on left forearm. The lesion is primarily purple with areas of green and yellow. Which descriptive term should the nurse use to document this lesion in the client's medical record?

Purpuric Purpuric lesions are deep red or purple in color that fades to green, yellow, or brown over time. They can range in size from 1 mm to greater than 3 mm and can be round or oval in shape.

Select the following nursing diagnosis that is correctly stated.

Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin.

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

Somatic

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is the instructor describing?

Tympanic

nursing minimum data set

a computerized document and is often used in long-term care facilities.

stereognosis

ability to recognize objects by touch

Health maintenance

any preventative diagnostics or health-promoting activities the client completed in the past

he patient has difficulty when the nurse asks him to say "No ifs, ands, or buts." The nurse understands that this may indicate a form of

aphasia loss of ability to understand or express speech, caused by brain damage.

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

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should

maintain eye contact while asking the questions from the form.

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status.

The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?

Normal readings vary according to age

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

In addition to pain intensity, what is another basic element of a pain assessment?

Some prefer to use mnemonics to remember the elements of pain assessment. One of these is PQRST: O: Onset; P: Provocative or palliative; Q: Quality; R: Region and radiation; S: Severity; T: Timing.

Which source of biographic information should the nurse view as primary?

The client Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client is considered the primary source and all others (including the client's medical record) are secondary sources.

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

The client's acuity. Data that nurses collect during a physical assessment vary depending on a client's acuity (condition), health history, and current symptoms.

A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer?

To have up-to-date information on which to base clinical decisions

A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply.

Use rationale to support opinions and decisions. Reflect on thoughts before reaching a conclusion. Use past clinical experience to build knowledge.

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?

Vision and hearing When assessing the mental status of an older adult, the nurse should first check vision and hearing before assuming the client has a mental problem. Speech may be affected by a decrease in hearing.

When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply.

What the nurse heard What the nurse palpated What the nurse observed

integrated cued checklist

assessment data with identified nursing diagnoses.

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write

bilateral lung sounds clear.

Diagnosis

data has been analyzed and a professional judgment occurs.

planning

determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.

A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information?

gastrointestinal

Secondary skin lesions

have crusts, lichenification, or scars. They can also be described as erosions, excoriations, fissures, or ulcers.

Kyphosis

hunchback Hunchback (kyphosis) usually refers to an abnormally curved spine. It's most common in older women and often related to osteoporosis.

The patient states he has lost 30 pounds in the last couple months without really trying.

hyperthyroidism

that addresses which client-centered goals? Select all that apply

living a healthy lifestyle disease prevention improving one's quality of life increasing the longevity of one's life

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should

record the vital signs.

deep tendon reflexes

reflex hammer

The nursing student demonstrates understanding of the different types of patient problems when he identifies which of the following to be a collaborative problem?

risk for complication: pneumothorax

On examination, the nurse finds that the rash is serpiginous. The nurse would know that the rash is most probably caused by

scabies A serpiginous rash is snaking. This type of rash can be caused by scabies.

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Iron deficiency anemia

spoon-shaped nails but not with excessive hair

tongue depressor

test for the rise of the uvula and gag reflex.

tuning fork

test for vibratory sensation

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

up and back

indirect percussion

using the non-dominant hand as a barrier between the nurse's dominant hand and the patient to assess organs, such as the gallbladder, kidneys, and liver.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

validate all data before documentation of the data.

A nurse understands that the identified strengths found during the assessment of a patient are used for which of the following nursing diagnoses?

wellness diagnosis

A nurse measures a client's blood pressure and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading?

"Do you need to empty your bladder?" Blood pressure can be altered (elevated) with intake of caffeine or nicotine and with a full bladder, walking, or talking. Taking blood pressure medication would lower the blood pressure, not elevate it.

A nursing instructor is teaching about respiratory problems in the patient with chronic obstructive pulmonary disease (COPD). The instructor realizes that the student needs more teaching when the student states which of the following?

"Impaired gas exchange and ineffective breathing pattern can be interchanged."

A client comments that the nursing staff spend a great deal of time writing things down. What should the nurse respond to this statement?

"It's a legal requirement to document the care that you receive."

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

Which general survey questions will provide the nurse information regarding the client's personal makeup? Select all that apply.

"What ethnic culture do you identify with?" "What role does regular exercise play in your life?" "Do you experience any traumatic physical injuries as a child?" "How would you describe your typical mood?" Many factors contribute to the patient's makeup—genetic composition, early illnesses, socioeconomic status, culture, gender identity and expression, nutrition, degree of fitness, mood state, geographic location, and age cohort.

When trying to explore a patient's perspective on his or her illness, the question that would best determine the patient's thoughts on the cause of the problem would be

"Why do you think you have (name the specific symptom)?"

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular

Pallor

Extreme or unnatural paleness Pallor results from decreased redness in anemia and decreased blood flow, as occurs in fainting or arterial insufficiency.

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?

Eye opening, and appropriateness of verbal and motor responses. E 5 V 5 M 5

An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the patient's vital signs to be what?

Higher than normal COPD is often a result of smoking and likely result in an increase in vital signs.

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

Waist circumference guidelines may not be accurate for adult clients who are shorter than 152.4 cm (5 ft) in height. This restriction is also a concern for which other anthropometric measurement?

Body mass index (BMI).

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension systolic greater than 140 but diastolic under 90

A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action?

Notify the healthcare provider. Uncontrolled pain, especially after narcotic administration, requires urgent reassessment and intervention. Without an order to administer other pain medication, the nurse must notify the healthcare provider.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

Ophthalmoscope An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses.

The admitting nurse has just met a new patient. As the nurse introduces himself, he begins the process of inspection on this patient. What does the admitting nurse know it is important to do while observing during the process of inspection?

Pay attention to the details while observing

What is used to gauge central and peripheral nervous system disorders

Strength of a reflex

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

Uses evidence-based techniques

A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what?

Using silence Using touch Communicating nonverbally through facial expression

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Verify the data by having another nurse come in to perform the percussion.

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

accurate organized complete timely concise

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes.

A client's blood pressure is affected by

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

Primary skin lesions

flat, raised, or fluid filled. They can be of various colors, shapes, and textures.

Question 4 See full question16s Report this Question When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma?

notched border diameter great than 6 cm asymmetry

Cushing's syndrome

weight gain in the chest, stomach and neck.

The nurse is focusing an interview on a patient's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breathe for me? During an interview, questions should proceed from general to specific. The question that is the most general is "describe your breathing." This provides the patient with an opportunity to discuss the current breathing pattern with the nurse.

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action?

Enter the room and auscultate the client's lung sounds.

A nurse notices that a client's nails on the right hand have separated from the nail bed and appear yellow. What could be a cause of this condition? Select all that apply.

Fungal infections Trauma Warts

A nurse collects nutritional information on a client. Which statement by the client needs to be validated by careful objective data?

I drink two large bottles of caffeinated beverages every day.

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially amongst professions such as physicians and nursing.

A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record?

To investigate the quality of care in the agency

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have

knowledge of his or her own thoughts and feelings about these issues.

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

palpation Palpation is the use of touch to assess texture, temperature, moisture, size, shape, location, position, vibration, crepitus, tenderness, pain, and edema.

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use?

Checklists

The nurse is reviewing the chart of a newly admitted client and identifies the client has Marfan's syndrome. What assessment finding would the nurse expect to find?

Elongated fingers

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?

Facility level

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 A goniometer is a device used for measuring the degree of flexion and extension available at a joint.

An older adult client is admitted to the hospital, While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

Impaired comfort related to possible neck injury

Impetigo u

Impetigo is a common and highly contagious skin infection that mainly affects infants and children. Impetigo usually appears as red sores on the face, especially around a child's nose and mouth, and on hands and feet. The sores burst and develop honey-colored crusts.J

A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis?

Inflamed appendix is causing severe abdominal pain.

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

Inspection means observation of the patient for general appearance and specific details related to the body system, anatomical region, or condition under examination.

A nurse admits a client to the health care facility. The nurse gathers data about the client's social history and wants to make this information available to the social worker. Which initial assessment documentation form is best for the nurse to use?

Integrated Cued Checklist The integrated cued checklist allows assessment data to be identified with nursing diagnoses and promotes use by different levels of caregivers, resulting in enhanced communication among the disciplines

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Orthostatic blood pressure is measured by recording blood pressure and heart rate with the client in two positions supine after the client is resting up to 10 minutes, then within 3 minutes after the client stands up.

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

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

Progress notes All members of the healthcare team use the progress notes to record the patient's progress and any changes.

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings?

Psoriasis

A young man comes to the clinic with an extremely pruritic rash over his knees and elbows, which has come and gone for several years. It seems to be worse in the winter and improves with some sun exposure. Examination reveals scabbing and crusting with some silvery scales. The nurse also notices small "pits" in the nails. What would account for these findings

Psoriasis psoriasis affects the extensor surfaces.

When educating a patient about the risks of malignant melanoma, what would you know to include?

Risk factors for melanoma: history of previous melanoma; mole changing; male gender; 50 or more common moles; one to four atypical or unusual moles, especially if dysplastic; red or light hair; actinic keratoses, lentigines, or macular brown or tanned spots usually on sunexposed areas, such as freckles; ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths; light eye or skin color, especially skin that freckles or burns easily; severe blistering sunburns in childhood; immunosuppression from HIV or chemotherapy; family history of melanoma.

A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique?

Risk for injury

Which describes the nurse using the technique of palpation?

The nurse notes increased warmth surrounding an abdominal incision.

The Joint Commission mandates that nurses assess and reassess a client's pain level. A nurse's healthcare facility mandates pain reassessment at 30 minutes for any drug given intravenously. This mandate is based on what?

The time it takes a pain medication to decrease pain intensity