HEALTH ASSESSMENT BATTERY EXAM REVIEWER Prelim

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 A. introductory B. ongoing C. working D. closure

C. working

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is A. "Do you feel stress at work?" B. How often do you feel stressed?" C. "ls stress a problem in your life?" D. "How do you manage your stress?"

D. "How do you manage your stress?"

During a comprehensive assessment of an adult client, the nurse can best hear high pitched sound by using stethoscope with a A. 15 inch flexible tubing B. 1 inch diaphragm C. 1 inch bell D. 11/2 inch diaphragm

D. 11/2 inch diaphragm

I. Ambulatory care nurse performs a focused assessment then incorporates assessment findings with a multidisciplinary team to develop a comprehensive plan of care. II. Acute care nurses assess and screen clients to determine the need for physician referrals. A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

D. Both statements are incorrect

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed A. entry B. exploratory C. focused D. Comprehensive

D. Comprehensive

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is A. inspection B. Percussion C. Palpation D. Auscultation

A. inspection

An example of objective finding in an adult client is A. A client's symptoms of pain B. Vital Signs C. genetics disorders D. Family history data

B. Vital Signs

Nurse Dianne while performing Physical examination on an adult client, she can detect the density of an underlying structure by using A. Palpation B. Doppler Magnification C. Percussion D. Inspection

C. Percussion

During a client interview Nurse Shaina uses nonverbal expressions appropriately when the patient A. Avoids excessive eye contact with the client B. Uses touch in a friendly manner to establish rapport C. Remains expressionless throughout the interview D. Displays mental distancing during the interview

A. Avoids excessive eye contact with the client

Although the assessment phase of the nursing process precedes the other phases the assessment phase is A. Continuous B. completed on admission C. linear D. performed only by nurses

A. Continuous

During palpation of the client's organ, the nurse palpates the spleen by applying pressure between 2.5 and 5cm. The nurse is performing A. Deep Palpation B. Moderate palpation C. Bimanual Palpation D. Light palpation

A. Deep Palpation

During the interview of an adult client, Nurse Mara should: A. Provide the client with information as questions arise B. Use leading questions for valid responses C. Complete the interview as quickly as possible D. Read each question carefully from the history form

A. Provide the client with information as questions arise

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the A. Client's occupation B. Pain relief measures C. Client's caregiver D. Cause of the pain

B. Pain relief measures

I. In dealing or assessing angry client the nurse should be: calm, reassuring, in-control manner. II. In dealing or assessing angry client the nurse should avoid any arguments with or touching the client. A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

C. BOTH statements are correct

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should A. discuss the client's symptoms with other team members. B. Plan for potential laboratory procedures C. review the client's health care record D. determine potential health care resources

C. review the client's health care record

One disadvantage of the open-ended assessment form is that it A. does not allow individualization B. Does not provide a total picture of the client C. asks standard questions D. Requires a lot time to complete

D. Requires a lot time to complete

Nurse Chantemayne is interviewing a 78 year old client for the first time. The nurse should first: A. Obtain biographical data B. Use medical terminology appropriately C. Establish rapport with the client D. Should assess first the client's hearing acuity

D. Should assess first the client's hearing acuity

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's A. physiologic status. B. holistic wellness status C. developmental history D. level of functioning.

A. physiologic status.

While examining a client, the nurse palpate the temperature of the skin by using the A. finger tips of the hands B. Dorsal surface of the hands C. Ulnar surface of the hands D. Palmar surface of the hands

B. Dorsal surface of the hands

I. The nurse should use closed-ended questions to elicit the client's feelings and perceptions. II. Silence is the most effective therapeutic communication technique. A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

D. Both statements are incorrect

During a client interview, the nurse asks questions about the client's past health history. The purpose of asking about past health problems is to A. determine whether genetic conditions are present. B. summarize the family's health problems. C. evaluate how the client's current symptoms affect his or her lifestyle. D. identify risk factors to the client and his or her significant others.

D. identify risk factors to the client and his or her significant others.

The nurse is beginning a health history interview with an adult client who expresses anger at the best approach for dealing with an angry client is for the nurse to A. allow the client to ventilate his or her feelings B. offer reasons why the client should not feel angry C. provide structure during the interview D. refer the client to a different health care provider

A. allow the client to ventilate his or her feelings

The nurse is preparing to document assessment findings in the client's record. The nurse should A. Record how the data were collected B. Write in complete sentences with few abbreviation C. use the "normal" to describe non-pathologic findings D. Avoid slang words or labels unless they are direct quotes

D. Avoid slang words or labels unless they are direct quotes

Nurse Mae is interviewing client for the first time. The client tells her that he smokes about two packs of cigarette a day, the nurse should A. Encourage the client to quit smoking B. look at the client with a frown C. tell the client that he is spending a lot of money foolishly D. provide the client with a list of dangers associated with smoking

A. Encourage the client to quit smoking

I. Nursing assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment II. Medical assessment focuses primarily on the client's physiologic development status. A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

A. Only Number I statement is correct

During an interview with an adult client for the first time, the nurse can clarify the client's, statement by: A. Rephrasing the client's statement B. Offering a "laundry list" of descriptors C. Inferring what the client's statement means D. Repeating verbatim what the client has said

A. Rephrasing the client's statement

While performing physical examination on an older adult, the nurse should plan to A. Use minimal position changes B. Complete the examination as quickly as possible C. Ask client to change position frequently D. Provide only minimal teaching related to health care

A. Use minimal position changes

Before the beginning of a physical examination of a client, the nurse should first: A. Wash both hands with soap and water B. Request a family member to be present C. Ask the client to remove the clothing D. Examine whether the client is anxious

A. Wash both hands with soap and water

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to A. arrive at conclusions about the client's health. B. document any physical symptoms the client may have. C. contribute to the medical diagnosis D. validate the data collected.

A. arrive at conclusions about the client's health.

While interviewing an adult client about her nutrition habits, the nurse should A. ask the client for 3-day recall of food intake. B. review the Choose My Plate information with the client. C. ask the client about limitations to activity. D. encourage the client to drink three to four glasses of water daily

A. ask the client for 3-day recall of food intake.

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have A. knowledge of his or her own thoughts and feelings about the issues B. Advance preparation in this area C. personal experience with death, dying and sexuality D. experience in dealing with these types of clients.

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

Nurse Steve has assess the breath sounds of an adult client. The best way for a nurse to document these findings on a client is to write A. The client's lung sound we're clear on both sides B. Bilateral lung sounds clear C. The client's lung sounds were auscultated with stethoscope and were clear on both sides D. After listening to client's lung sounds, both lungs appeared clear

B. Bilateral lung sounds clear

Nurse Paulo has interviewed a Hispanic client with limited English skills for the first time. He observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. Nurse Paulo should A. Remain in a standing position during the interview B. Indicate acceptance of client's cultural differences C. Request a family member to interpret for the client D. Use slang terms to identify certain body parts

B. Indicate acceptance of client's cultural differences

While interviewing the client for the first time, Nurse Karl is using a standardized nursing history form. The nurse should: A. Ask the client to complete the form B. Maintain eye contact while asking the questions from the form C. Read the question verbatim from the form D. Ask leading questions throughout the interview

B. Maintain eye contact while asking the questions from the form

I. Focused assessment: Very rapid assessment performed in life-threatening situations. II. Ongoing or partial assessment are data collection that occurs after the comprehensive database is established A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

B. Only Number II statement is correct

During an interview, Haren collects both subjective and objective data from an adult client. Subjective data would include the client's A. height B. Perception of pain C. Temperature D. weight

B. Perception of pain

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) A. ongoing or partial assessment B. focused or problem-oriented assessment C. emergency assessment. D. initial comprehensive assessment

B. focused or problem-oriented assessment

The nurse is planning to interview a client who has demonstrated manipulative behaviours during clinic visits, During the interview process, the nurse should plan to A. give the client rules with which he must agree to comply. B. provide structure and set limits with the client C. tell the client that the nurse is aware of his past behaviours D. approach the client in an authoritative manner

B. provide structure and set limits with the client

The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of A. the growing elderly population with chronic illness. B. rapid advances in biomedical knowledge and technology. C. an increase in the number of baccalaureate programs in nursing. D. an increase in the number of nurse practitioners.

B. rapid advances in biomedical knowledge and technology.

During an interview with an adult client for the first time, the nurse can clarify the statements by an offering A. laundry list of descriptors B. rephrasing the client's statements C. repeating verbatim what the client has said D. inferring what the client's statements mean

B. rephrasing the client's statements

I. The positions: Fowler's, Semi-Fowler's, High Fowler's and knee chest position are best to position the client who is suffering from dyspnea II. Sim's position, Lateral or Side lying and Dorsal Recumbent position are used to examine the perineum. A. Only Number I statement is correct B. Only Number II statement is correct C. BOTH statements are correct D. Both statements are incorrect

C. BOTH statements are correct

To alleviate a client's anxiety during comprehensive assessment, the nurse should: A. Ask the client to sign a consent for the physical examination B. Remain in the examination room while the client changes into a gown C. Explain each procedure being performed and reason for the procedure D. Begin with intrusive procedure first to get them completed quickly

C. Explain each procedure being performed and reason for the procedure

During an interview with an adult client, Nurse Trisha can keep the interview from going off course by A. Using open ended question B. Inferring information C. Use closed-ended questions D. Rephrasing the client's statements

C. Use closed-ended questions

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's records the nurse should A. analyze data that have already been collected. B. review any past collaborative problems. C. avoid premature judgments about the client. D. consult with the client's family me

C. avoid premature judgments about the client.

Nurse Cecelia makes an error while documenting findings on a client's record, she should: A. Draw a line through the error, writing error and initialing B. Obliterate the error and make the correction C. Erase the error and make the correction D. Draw a line through the error and have it witnessed

D. Draw a line through the error and have it witnessed

Nurse Angela is interviewing a client in the clinic for the first time, The client appears to have a very limited vocabulary. Nurse Angela should plan to A. show the client's pictures of different symptoms, such as "faces pain chart" B. request family members to interpret for the client C. Use standard medical terminology D. Use very basic terminology

D. Use very basic terminology

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of a of data. After proposing possible nursing diagnoses, the nurse should next A. cluster the data collected. B. draw inferences and identify problems C. document conclusions. D. check for the presence of defining characteristics

D. check for the presence of defining characteristics

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should A. allow the, client time to calm down. B. avoid discussing sensitive issues C. set time limits with the client D. explain the role and purpose of the nurse

D. explain the role and purpose of the nurse

The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by A. providing the client with simple explanations. B. offering to hold the client's hand. C. using a highly structured interview process D. expressing interest in a neutral manner

D. expressing interest in a neutral manner

The result of a nursing assessment is the A. prescription of treatment B. documentation of the need for a referral C. client's physiologic status D. formulation of nursing diagnoses

D. formulation of nursing diagnoses