Health Assessment Exam #1 PrepU

A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?

Chronic obstructive pulmonary disease (COPD)

A nurse is instructing a client on how to assess himself for herpes simplex lesions by their configuration. Which configuration should the nurse tell the client to look for?

Clustered

A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?

Consult with the healthcare provider about increasing the dose of medication.

A nurse observes the presence of hirsutism on a female client. The nurse should perform further assessment on this client for findings associated with which disease process?

Cushing's disease

The skin plays a vital role in temperature maintenance, fluid and electrolyte balance, and synthesis of vitamin

D.

The terms "generalized," "exposed surfaces," "upper arm," and "skin folds" are used to describe which major characteristic of skin lesions?

Distribution

The nurse is beginning the examination of the skin of a 25-year-old teacher. She previously visited the office for evaluation of fatigue, weight gain, and hair loss. The previous clinician had a strong suspicion that the client has hypothyroidism. What is the expected moisture and texture of the skin of a client with hypothyroidism?

Dry and rough

Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?

Extremely obese

Based only on anthropometric measurements, which set of clients listed below are at the greatest risk for diabetes and cardiovascular disease?

Females with 88.9 cm (35 in) or greater waist circumference.

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. What would the nurse include?

Flexion

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. After determining the client's venous filling and emptying each take approximately 10 seconds, the nurse would perform further assessments related to what health problem?

Fluid volume deficit

A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?

Gouty arthritis

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect?

Gouty arthritis

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

Have a nurse who is the same sex as the client examine him

In planning to meet the nutritional needs of a critically ill patient in the intensive care unit, which factor will increase the patient's basal metabolic rate?

Infection

Mrs. Hill is a 28-year-old woman of African ancestry with a history of systemic lupus erythematosis (SLE). She has noticed a raised dark red rash on her legs. When the nurse presses on the rash, it doesn't blanch. What would the nurse tell the client regarding her rash

It is likely to be related to her lupus.

A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client?

Kicking

A school age client has been diagnosed with genu valgum. What is the other name for this disease?

Knock kneed "two g's= two k's"

A patient admitted to your unit from the emergency room is noted to have "grownout" nail polish. What might this indicate?

Length of an illness

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?

Lordosis "oh lordy im pregnant!"

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse?

Macule

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan's syndrome

Which of the following best describes neuropathic pain?

May be labelled as central pain

After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system?

Nociceptors

The nurse is admitting an elderly client with a diagnosis of congestive heart failure. Admission vital signs are respirations 38; pulse 172; blood pressure 86/72. How should the nurse best respond?

Notify the rapid response team

You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered?

Obese

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

Place the tape measure behind the client and measure at the umbilicus

The patient comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the patient is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain

An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?

Sebum production

A nurse is providing nutritional instruction at a health fair. She instructs passersby on the characteristics of a nutrient that is the body's first source of energy, sparing use of other nutrients for this purpose, that raises the blood glucose level, is found in fruit juices, and that can be converted quickly into energy. To which of the following nutrients is the nurse referring?

Simple carbohydrates

A nurse is using calipers to assess a client. Which of the following measurements is the nurse taking?

Skinfold thickness

A nurse has been asked to assess an older adult resident of a long-term care facility. During assessment of the resident's skin, the nurse notes a break in the skin, erythema, and a small amount of serosanguineous drainage over the resident's sacrum. Inspection reveals that the area appears blister-like. The nurse should interpret this finding as indicating which stage of pressure ulcer?

Stage II

A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source?

Sunshine

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding? Respirations 12 breaths/minute or Systolic pressure 180 mm Hg.

Systolic pressure 180 mm Hg.

The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate?

Teaching the client muscle-building exercises

A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them?

Temperature, pulse, respirations, and blood pressure

The nurse is assessing a client with joint pain and is trying to decide whether it is inflammatory or non-inflammatory. Which of the following symptoms is consistent with an inflammatory process

Tenderness

The nurse is completing a comprehensive nutritional assessment and has assessed and documented the client's triceps skin fold thickness (TSF). This assessment finding allows the nurse to determine which of the following?

The amount of the client's subcutaneous fat stores

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The client's ability to change position

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5°F. How should the nurse best interpret this assessment finding?

The client's normothermic temperature does not rule out the presence of an infection.

After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect?

The head is midline and aligned with the spine

The nurse might expect the patient admitted with dehydration to have tachycardia. T/F?

The nurse might expect the patient admitted with dehydration to have tachycardia.

A nurse is conducting a comprehensive nutritional assessment on a patient with suspected malnutrition. Why would it be important to assess this patient's ability to cook

To assess if the patient has the ability to obtain or prepare food

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?

To see the client before the client assumes a social face or behavior

When beginning a height measurement on a 14-year-old, the nurse should instruct the patient to stand on the scale with his back to the wall. T/F

True

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

Use of two middle fingers lightly applied to wrist area along the thumb side

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines?

Variety

When performing a nutritional assessment on a client, a nurse observes that the client has a red, beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient?

Vitamin B

A nurse assesses a client's orientation. What are the questions that the nurse should ask? Select all that apply?

What is your name? Where are you? What is the date today? Why are you here?

The nurse is conducting a general survey of a patient new to the clinic. In what part of the survey would the nurse assess the hair distribution on the patient's body?

When assessing the skin

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

Wood's light

The apocrine glands are dormant until puberty and are concentrated in the axillae, the perineum, and the

areola of the breast

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 nails, located on the distal phalanges of the fingers and toes, are composed of

keratinized epidermal cells.

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances.

While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of

macules.

Which of the following is an average normal temperature in centigrade for a healthy adult?

oral: 37.0°C

The nurse assesses an older adult bedridden client in her home. While assessing the client's buttocks, the nurse observes that a small area of the skin is broken and resembles an erosion. The nurse should document the client's pressure ulcer as

stage II.

Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client

who is a bodybuilder.

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer?

3

An individual is considered obese when his or her BMI is:

30-39

An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no longer able to climb the stairs to the second floor of her house due to her knee pain. What nursing diagnosis is suggested by this client's statement?

Activity intolerance related to knee pain

A golden yellow pigment that is heavily keratinized and is found in subcutaneous fat is called what?

Carotene

Higher sodium intake is associated with all of the following except:

Osteomalacia

You note that your patient has developed mental status changes and paresthesias. What would you know to assess as a possible cause for these changes?

Patient's hydration status

Assessment reveals that an older adult client has osteomalacia. What would be most important to include in the client's teaching plan?

Practice risk prevention for fractures.

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

A client has just had abdominal surgery and the nurse is consulting with the patient about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Protein

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high.

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

A client has an oral temperature of 37.2 °C (99 °F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temperature?

The client has just run 4.82 km (3 miles) outside before coming to the interview.

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The patient may have been abused.

A client injures his thumb by accidently slamming the car door shut on it. He arrives at the emergency department in intense pain. Which of the following processes is associated with the transduction process of this pain?

Tissue injury leading to inflammation

What is the most common measurement used to determine abdominal visceral fat

Waist circumference.

The nurse notes that a client's nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?

pulse oximetry

A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment?

"Having bad sunburns when you're a child puts you at risk for skin cancer later in life."

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

"These are considered a normal age-related change in the skin."

The nurse is preparing to perform a nutritional assessment of a newly admitted client. What question would be most appropriate for the nurse to ask when initiating the assessment?

"What have you eaten in the last 24 hours?"

A client is brought to the health care facility with a sudden loss of movement on the right side of the body. Upon assessment, the nurse finds that the client has a slight flicker of contraction in the muscles on the right side. What should the nurse document as the muscle strength rating?

1

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mmHg

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore?

19 to 23

An adult client weighs 175 pounds and is 5 feet 6 inches tall. The nurse determines that the client's body mass index is which of the following?

28

A nurse is measuring an adult female client's mid-arm circumference (MAC) as part of her overall assessment of the client's nutritional status. Which of the following is the standard reference for the MAC for an adult female?

28.5 cm

The nurse has completed the initial assessment of a client and is now performing data analysis. The nurse obtained a blood pressure reading of 114/70 mm Hg. What is this client's pulse pressure?

44 mm Hg

You are counseling a 44-year-old woman about ways to maintain her weight, which is within normal range for her height. What should you suggest for her?

60 minutes per day of physical activity at a moderate intensity

Which of the following clients most likely has the greatest need for a folic acid supplement?

A 31-year-old woman trying to become pregnant

A client presents to the health care clinic with reports of two-day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute Pain related to sore throat

A client presents to the health care clinic with reports of a 2-day history of sore throat, ear pressure, fever, and stiff neck. The client states she has taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute pain related to sore throat

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?

Alert the healthcare provider to the client's somatic pain complaints.

When can the general inspection be started?

As soon as the examiner first sees the client

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next?

Assess the client's pain using a mnemonic device

A nurse is admitting a client to the postsurgical unit from the postanesthetic care unit. The nurse has transferred the client from the stretcher to a bed and asked the client if he is experiencing pain. The client acknowledges that he is in pain. What would the nurse do next?

Assess the client's pain using a mnemonic device.

Question 4 See full question 25s A client asks a nurse to look at a raised lesion on the skin that has been present for about 5 years. Which is an "ABCDE" characteristic of malignant melanoma?

Asymmetrical shape

where fat cells, blood vessels, and nerves are located

Beneath the dermis lies the subcutaneous tissue, a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of sweat glands and hair follicles.

A burn victim of a house fire is brought to the emergency department. The burn is classified as dermal. The nurse knows that the structures destroyed by the burn are what?

Blood vessels Lymphatic vessels Sweat glands

The nurse enters a client's hospital room and the client asks the nurse to raise him up in the bed. What is the nurse's best action?

Call for help and use the draw sheet to move the client.

The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take?

Call the prescribing physician see about changing the pain medication.