Health Assessment ch.1,8,9,10 NCLEX review questions

A 5-year-old's mother presents the child for evaluation of "pharyngitis." The most appropriate way for the nurse to collect information from the child would be to ask: Hint: Nursing Considerations a. "Your mom tells me you have pharyngitis, is that so?" b. "I understand your throat is painful." c. "Does it hurt when you swallow?" d."Rate your throat pain using a scale of 0 for no pain to 10 for worst pain."

"Does it hurt when you swallow?"

The nurse is gathering family history data on a young adult who was adopted as an infant. The client reports having no knowledge about the birth parents. Which information should the nurse include in the family history section of the health assessment? Hint: Family History a. The nurse should not include any information under family history since it is unknown. b. Mother (age 60) thyroid disease c. Father (age 62) early emphysema (smoker) Brother (age 25) type 1 diabetes

Father (age 62) smoker with early emphysema

The nurse places the bell of the stethoscope on a client in order to assess: Hint: Equipment; Stethoscope a. heart murmur b. lung sounds c. normal heart sounds d. abdominal sounds

heart murmur

The nurse understands evidence-based practice is based on: Select all that apply a. malpractice claims b. insurance company mandates c. provider expertise d. patient preferences scientific evidence

provider expertise, patient preferences scientific evidence

A client tells the nurse, "I need a physical exam because I am starting college next month and it is required." Which section of the health history should the nurse record this assessment data? Hint: Components of Health History a. Health beliefs and practices b. Reason for seeking care c. Biographic d. Past history

reason for seeking care

The nurse uses the APIE method to document the health assessment of a client. Which information should the nurse include in the 'A' (Assessment) of the client? Hint: Documentation a. Subjective and objective data b. Interventions c. Problems d. Response of client to plan

subjective and objective data

While performing a physical assessment, the nurse explains, "I'll be placing my stethoscope on your abdomen to listen for bowel sounds. The presence of bowel sounds indicates that the intestines are working." This nurse is functioning as a: Hint: Role of the Professional Nurse a. teacher b. caregiver c. client advocate d. manager

teacher

The nurse is preparing to conduct a physical assessment on a young adult with a gaping wound on the right forearm. Before beginning this assessment, the nurse should first: Hint: Providing a Safe and Comfortable Environment a. wash hands b. put on goggles c. put on a sterile gown d. put on a gloves

wash hands

A client tells the nurse, "It's okay that I'm 20 pounds overweight. Everyone in my family is much fatter." Which would be the best response for the nurse to make at this time? Hint: Measuring Height and Weight a. "Being overweight contributes to the development of diabetes." b. "Do your family members have health problems related to being overweight?" c. "Being the lightest in your family must make you feel good." d. "How do you feel about being 20 pounds overweight?"

"how do you feel about being 20 pounds overweight?"

Which assessment finding does the nurse identify as one that would be obtained during the subjective assessment of a client? Hint: Assessment client's perception a. "It hurts when I put weight on my leg." b. Abdomen soft and nontender to palpation c. Blood pressure 110/68 d. Pulses present in lower extremities

"it hurts when i put weight on my leg"

The nurse is collecting data about a client's occupation and the reliability of the source of information. In which section of the health history will the nurse document this information? Hint: Components of the Health History a. Past history b. Family history c. Biographical data d. Psychosocial history

Biographical data

A client with a lower respiratory tract infection mentions feeling "very stressed about a situation at home." The nurse is concerned that this stressor may negatively impact the healing process of this client. The nurse's concern is based on: Hint: Interpretation of Findings; Holism a. cultural factors b. holistic factors c. developmental factors d. communication

holistic factors

The nurse is preparing to assess a middle-aged client. What should the nurse do first? Hint: Basic Techniques of Physical Assessment; Inspection a. Inspection b. Percussion c. Palpation d. Auscultation

inspection

The nurse notices that a client walks with a limp and has long legs. Which aspect of the general survey is the nurse assessing?Hint: Components of the General Survey; Mobility a. Physical appearance b. Mental status c. Mobility d. Behavior

mobility

A client comes into the clinic with acute right lower quadrant abdominal pain. During the abdominal assessment of this client, the nurse should: Hint: Basic Techniques of Physical Assessment; Palpation a. palpate the area first b. palpate the area last c. assess the area using deep palpation techniques d. not palpate the area

palpate the area last

A client comes into the clinic with the complaint of swollen ankles. The nurse will utilize which assessment technique to find out more information about this client? Hint: Basic Techniques of Physical Assessment; Palpation a. Inspection b. Percussion c. Palpation d. Auscultation

palpation

The nurse is measuring an adult client's blood pressure and hears Korotkoff sounds. Which sound should the nurse recognize as being the diastolic measurement for this client? Hint: Measuring Vital Signs; Assessment of Blood Pressure a. Phase 1 b. Phase 3 c. Phase 4 d. Phase 5

phase 5

During the assessment of an obese client, it is necessary for the nurse to place the client in the supine position. The nurse understands while the client is supine, it is most important to monitor this client for: Hint: Assessment of the Obese Patient a. abdominal pain b. respiratory distress c. difficulty swallowing d. fatigue

respiratory distress

As part of a complete health assessment, the nurse reviews the client's laboratory data. Laboratory data is an example of: Hint: Types of data a. constant data b. primary source data c. subjective data d. secondary source data

secondary source data

To assess a client's blood pressure, the nurse will need: Select all that apply. Hint: Table 9.1 Equipment Used During the Physical Assessment a. flashlight b. sphygmomanometer c. gloves d. stethoscope e. watch with a second hand

stethoscope

Prior to measuring a client's height and weight, the client states, "I am 5 feet 10 inches tall and weigh 160 pounds." Upon assessment, the nurse finds the client is shorter and weighs 15 pounds more than reported. The nurse suspects: Hint: Measuring Height and Weight a. the client might have a self-image disturbance b. the client is lying c. the client is embarrassed about his/her weight d. the client hasn't been weighed or measured in a long time

the client might have a self-image disturbance

The nurse inquires about a client's sexual orientation label in order to assess: Hint: Sexual Orientation a. the client's risk for real or potential health risks b. the trustworthiness of the nurse-client relationship c. the client's gender d. the client's marital status

the client's risk for real or potential health risks

During a health interview of a client with residual radiculopathy after spinal surgery, the nurse learns that the client holds a full-time job, is married, and does at least half of the routine household activities. From this information, the nurse can accurately document: Hint: Pain-The Fifth Vital Sign a. The client takes pain medication routinely. b. The pain doesn't interfere with normal activities of daily living. c. The client uses work to cope with the pain. d. The client is stoic.

the pain doesn't interfere with normal activities of daily living

During the health history, a client reports having an allergy to penicillin. In addition to documenting this allergy, the nurse should document: Hint: Past History a. the dose the client was taking at the time of the reaction b. the symptoms experienced as a result of the allergic reaction c. the reason the client was taking the medication d. the route the medication was taken

the symptoms experienced as a result of the allergic reaction

The nurse is preparing to measure the temperature of a client with an endotracheal tube. Which method of temperature measurement should the nurse use for this client? Hint: Measuring Vital Signs; Measuring Body Temperature a. Tympanic b. Rectal c. Axillary d. Oral

tympanic

During the percussion of a client's abdomen, the nurse hears a loud, high-pitched, drumlike tone. The nurse should document this finding as: Hint: Basic Techniques of Physical Assessment; Percussion a. resonance b. hyperresonance c. tympany d. flatness

tympany

While assessing the lower extremities of a client, the nurse notices several small scabs along the inner aspects of both lower extremities. What is the most appropriate response by the nurse? Hint: Professional Responsibilities; Cues a. "You really did a job on yourself while shaving!" b. "Are you in an abusive situation at home?" c. "Can you tell me what caused these scabs on your legs?" d. "Those scabs look painful. What happened to you?"

" can you tell me what caused these scabs on your leg"

The nurse assesses a client's apical pulse immediately after the client walks the length of the hallway. The finding will most likely be: Hint: Measuring Vital Signs; Measuring the Pulse Rate a. a reduced heart rate b. an elevated heart rate c. a heart rate that is the same as her resting heart rate d. an irregular heart rate

an elevated heart rate

The nurse finds the blood pressure reading for an older adult to be 88/60. What should the nurse do first after measuring this blood pressure? Hint: Measuring Vital Signs; Assessment of Blood Pressure a. Ensure that the correct cuff size was used to measure this blood pressure. b. Place the client in a standing position. c. Call the healthcare provider. d. Nothing. Extremely low blood pressures are normal in the elderly.

ensure that the correct cuff size was used to measure this blood pressure

A client describes feeling increasingly short of breath when sitting in city traffic. The nurse understands that this is likely the result of a/an: Hint: Environmental Factors a. cultural factor b. internal environmental factor c. external environmental factor d. family factor

external environmental factor

During an interview, the nurse learns that a client wants to stop smoking but needs help making this behavior change. Which model of health will be most useful to the nurse in developing a plan to help the client quit smoking? Hint: Health; Models of Health a. Health promotion model b. Ecologic model c. Clinical model d. Eudaemonistic model

health promotion model

The nurse begins to document the health and physical assessment of a client that was performed approximately 3 hours ago. The nurse's documentation: Hint: Documentation a. will be highly accurate because the nurse has had more time to interact with the client b. may not be as detailed due to the time that has elapsed since the assessment c. will be focused and concise d. will be thorough and complete

may not be as detailed due to the time that has elapsed since the assessment.

The nurse is developing a formal teaching plan for a client recently diagnosed with diabetes. At the completion of the teaching session, the client will demonstrate self-administration of insulin. This is an example of a/an: Hint: Formal Teaching; Objective a. learning need b. content c. objective d. teaching method

objective

After conducting the health interview, the nurse begins to measure the client's vital signs. Vital signs are considered: Hint: Types of data a. subjective data b. objective data c. secondary data d. constant data

objective data

An older adult comes into the pain clinic for follow-up care. The nurse notices that the client grimaces with position changes and has difficulty walking. What would be appropriate for the nurse to say to this client? Hint: Pain-The Fifth Vital Sign; Behavior a. "Tell me what your pain level is right now." b. "I see that you are moving better." c. "Did you stop taking your pain medication again?" d. "Your provider isn't going to be happy to see how much pain you are in."

" tell me what your pain level is right now"

The nurse interviews a client about lifestyle, social support, and activities of daily living. This information should be included in a: Hint: Components of health assessment a. physical assessment b. musculoskeletalassessment c. fall-risk assessment d. health assessment

health assessment

A client states, "I have had an earache for about 2 days." The nurse should record this information in which section of the health history? Hint: Components of the Health History a. Reason for seeking care b. Review of systems c. Health beliefs and practices d. Health patterns

Reason for seeking care

After conducting a health assessment on a new client, the nurse uses critical thinking to develop an appropriate plan of care for the client. Which step of the critical thinking process does the nurse use when developing the plan of care? Hint: Critical Thinking a. Analysis of the situation b. Collection of information c. Selecting alternatives d. Evaluation

selecting alternatives

The nursing staff on a rehabilitation unit is attending an educational session to review the newest treatment options for clients with knee injuries. This program is most likely being presented by a: Hint: Role of the Professional Nurse; Clinical Nurse Specialist a. nurse researcher b. clinical nurse specialist c. nurse practitioner d. nurse administrator

clinical nurse specialist

During the admission assessment on an older adult, the nurse learns the client has been taking four different medications, all for the same health condition. What action should the nurse take first? Hint: Components of the General Survey; Age-Related Considerations a. Document the medication in the client's medical record. b. Contact the primary care provider. c. Send an order for the medications to the pharmacy. d. Nothing. This is typical for older adults and requires no action.

contact the primary care provider

The purpose of the nursing health history is to: Hint: Health History a. gather detailed data related to the cause and course of an illness or injury b. develop individualized client-centered care c. identify the need for genetic counseling or testing d. evaluate the client's health insurance plan and out of pocket expenses

develop individualized client-centered care

The nurse is looking at the information collected during the health interview in an effort to cluster or group the data together. The nurse is demonstrating which phase of the nursing process? Hint: Nursing Process a. Assessment b. Diagnosis c. Planning d. Evaluation

diagnosis

While auscultating the abdomen of a client, the nurse recognizes the bowel sounds are long. The nurse understands this refers to: Hint: Basic Techniques of Physical Assessment; Auscultation a. intensity b. pitch c. duration d. quality

duration

A client complaining of ear pain is assessed by the nurse. What equipment will the nurse use in the assessment of this client? Hint: Special Equipment a. Skin-fold calipers b. Goniometer c. Penlight d. Otoscope

otoscope

The nurse understands that the Healthy People 2020 objectives are evaluated and revised every 10 years based on: a. health concerns of the dominant cultural group in the United States b. health concerns of the largest cities in the United States c. public health concerns in the United States d. the needs of the people in the most populated states in the United States

public health concerns in the united states

The nurse assesses the respiratory rate of an adult client. Which would indicate a normal finding for this client? Hint: Measuring Vital Signs; Measuring Respiratory Rate a. Respiratory rate of 30 to 80 per minute b. Respiratory rate of 20 to 40 per minute c. Respiratory rate of 15 to 20 per minute d. Respiratory rate of 8 to 10 per minute

respiratory rate of 15 to 20 per min

A client is brought into the emergency department after being rescued from a major motor vehicle accident. The nurse notes that the client's body temperature is 99.6°F. The nurse realizes that this finding might suggest: Hint: Measuring Vital Signs; Measuring Body Temperature a. The temperature elevation is due to a diurnal variation. b. The client is ovulating. c. The client is stressed. The client has an underlying illness not yet diagnosed

the client is stressed

A client with lower-extremity edema comes into the clinic. During the assessment, the nurse is unable to palpate the client's pedal pulses. The nurse should: Hint: Doppler Ultrasonic Stethoscope a. do nothing b. elevate the client's legs and reassess later c. obtain the client's blood pressure d. use a Doppler to assess the pulses

use a doppler to assess the pulses

Which inquiry by the nurse will provide the most data about a client's use of medications? Hint: Medications a. "Do you take any prescription medications every day, such as a heart pill or a blood pressure pill?" b. "Do you use laxatives or anything like that?" c. "Tell me about any medications or remedies you take for your health." d. "Do you use any folk remedies or herbs regularly?"

"Tell me about any medications or remedies you take for your health."

A client has been having headaches for the past 3 days. The nurse should document the client's reason for seeking care as: Hint: Components of the Health History a. "headaches" for the past 3 days b. "migraines" for the past 3 days c. "headaches" d. headaches for 3 days

"headaches" for the past 3 days

The nurse is preparing to assess a client with flank pain, discomfort with voiding, and pink-tinged urine. Which assessment technique should the nurse use? Hint: Basic Techniques of Physical Assessment; Percussion a. Direct percussion b. Reflexive percussion c. Indirect percussion d. Blunt percussion

blunt percussion

Which client should the nurse carefully assess for signs of respiratory distress? Hint: Measuring Respiratory Rate; Life Span Considerations a. A 3 year old with a sore throat and fever b. A 4 month old with cold symptoms and nasal congestion c. A 9 month old with a rash and runny nose d. A 6 year old with a cold and cough

a 4 month old with cold symptoms and nasal congestion

After completing the health history, the nurse begins to ask more detailed questions to clarify points and follow up on concerns expressed by the client during the interview. This portion of the health assessment is known as: Hint: The Health History a. informal teaching b. objective data c. a focused interview d. interpretation of findings

a focused interview