Health Assessment Exam review
stoll's guidelines for spiritual assessment
-concept of God or Deity - sources of hope and strength - religious practices - relation between spiritual beliefs and health
Nonverbal communication
-physical appearance - posture - gestures - facial expressions - eye contact - voice - touch
urticaria
AKA hives; itchy wheals caused by an allergic reaction. spread together
4 A's for acute and chronic pain management
Analgesia (pain relief) activities of daily living adverse effects aberrant drug related behaviors
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm? - anxiety - imbalanced nutrition: less than body requirements - impaired verbal communication - risk for self directed violence
Anxiety
A nurse has completed gathering some basic data about a client and then reflects on personal feelings about the client. The nurse does this primarily to accomplish which of the following? - identify the need for referral - construct a plan of care - avoid biases and judgements - determine if pertinent data has been omitted
Avoid biases and judgments
Recommended protective measures to avoid skin cancer include which of the following? - seek biannual examination by a clinician after age 40 - knowing signs of skin cancer - avoiding sun exposure - performing monthly skin self-examinations
Avoiding sun exposure
At which location would a nurse palpate a client's submental lymph nodes? - at the angel of the mandible -posterior base of the skull - area behind the ears -behind the tip of the mandible
Behind the tip of the mandible *the submental lymph node is midline under your chin.
The nurse is beginning examination of the client. All the following areas are important to observe as part of the general survey except: - blood pressure - apparent age - dress, grooming, and personal hygiene - signs of distress
Blood pressure
Traumatic brain injury
Blow to the head or a piercing head injury that interferes with function of the brain
A nurse provides care in a rural hospital that serves a community that has few minority residents. When interviewing a client from a minority culture, the nurse has enlisted the assistance of a "culture broker." How can this individual best facilitate the client's care? - by teaching the client about health care - by evaluating the clients culturally based health practices - by making the client feel comfortable and safe - by interpreting the clients language and culture
By interpreting the client's language and culture
The nurse attends an Alcoholic Anonymous support group that is for members of a single culture other than her own, and develops close relationships with three group members. The nurse is demonstrating which of the following? - cultural encounter - cultural desire - cultural knowledge - cultural awareness
Cultural encounter
An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform? - emergency - head-to-toe - focused - comprehensive
Emergency * it is emergency because client is in the ED for an obvious problem
Which of the following is a primary goal of cultural safety? - develop and use knowledge about the practices of different cultures - treat everyone the same - develop sensitivity to differences among ethnic groups - examine how our own perspectives shape how we see clients
Examine how our own perspectives shape how we see clients.
Cranial Nerve 7 ( facial)
Facial muscles, responsible for facial expression (smile, puff cheeks, close eyes, etc) motor
The nurse prepares to complete a past medical history with a client. Which areas should the nurse include in this history? (Select all answer choices that apply) - location - medications - exacerbating factors - adult illnesses - allergies
Medications Adult illnesses Allergies
The nurse is assessing the client's perception of pain and its intensity and quality. Which dimension is the nurse evaluating? - cognitive - sensory - behavioral - physical
Sensory
The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness? - to establish an accurate diagnosis - to obtain primary data - to assess if the client is a reliable historian - to obtain demographic data
To establish an accurate diagnosis
A client with a subdural hematoma may have an odor of alcohol. - true - false
True
How should the nurse place the ear of an adult when using the otoscope? - down and back - up and back - down and forward - up and forward
Up and back
A popular pain assessment scale for children is: - FLACC pain assessment scale - memorial pain assessment card - descriptive analog scale - visual analog scale
Visual Analog Scale.
When should the nurse wear gloves? Select all that apply. - prior to washing hands - in anticipation of body fluid contact - when touching blood or body fluids - when taking an oral temperature - when monitoring vital signs
When touching blood or body fluids In anticipation of body fluid contact
A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? - summary - introduction - closing - working
Working * the working phase consists of obtaining patient information.
patch
a flat, discolored area on the skin larger than 1 cm
Bulla
a large blister that is usually more than 0.5 cm in diameter
While assessing the nails of an adult client, the nurse observes Beau lines. The nurse should ask the client if he has had - chemotherapy - a recent illness - steroid therapy - radiation
a recent illness. * beau lines are transverse depressions of the nail plates, usually bilateral, resulting from temporary disruption of proximal nail growth from systemic illness. seen in severe illness, trauma, and cold exposure if raynaud disease is present
religion
a system of beliefs or a practice of worship
verbal communication
communication that uses written or spoken words (Yes/no)
during the examination of a patient, it is very important to - control your nonverbal communication - share everything you see - have a chaperone in the room
control your nonverbal communication * avoid showing distaste, alarm, or other negative reactions
acantosis nigricans
dark, velvety patches in body folds and creases.usually seen in diabetes (type 2). metabolic problems
The nurse is preparing to interview a newly admitted client. What should be done prior to hearing the client's story? - establish the agenda for the interview - ask specific questions about the reason for admission - review the clients issues in a chronologic order - review the attributes of a symptom
establish the agenda for the interview
Edema
excess fluid in interstitial spaces - pitting (interstitial fluid mobile) -nonpitting ( local infection/trauma; brawny edema)
The nurse is performing a physical examination and is using a stethoscope to listen to lung sounds. When using the diaphragm, the nurse would expect to hear lower-pitched sounds. -true -false
false * the bell is used to hear lower pitched sounds. the diagram is used for higher pitched sounds
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess? -sunken face -drooping of one side -mask like expression -asymmetry of earlobes
mask-like expression * parkinsons disease is a progressive nervous system disorder that affects movements.
tumor
mass that is deeper and firm/soft. cant see as well. TUMORS DO NOT ALWAYS MEAN CANCER
systolic pressure
maximum pressure felt on artery during left ventricular contraction
characteristics of lymph nodes
mobile, soft, non-tender
the neck consists of
neck vessels neck muscles anterior and posterior triangles thyroid gland
Percussion
percussion is striking the chest or another part of the body to elicit a sound from a hollow organ.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? - submental -superficial cervical -preauricular -supraclavicular
preauricular The correct order: -preauricular -posterior auricular -occipital -submental -submandibular -jugulodigastric -superficial cervical -deep cervical -posterior cervical -supraclavicular
mean arterial pressure
pressure forcing blood into tissue
cultural humility
process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners
functions of the skin
protection, perception, temperature regulation, identification, communication, wound repair, absorption/excretion, production of vitamin D
The nurse is preparing to complete a comprehensive assessment of a newly admitted client. Why is the nurse completing this type of assessment? - addresses specific concerns - establishes routine care needs - provides a baseline for future assessments - assesses symptoms of one body system
provides a baseline for future assessments
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? - sweat glands - subcutaneous tissue - sebum production - squamous cells
sebum production
The nurse is taking a health history on a newly admitted client. When the nurse asks, "How would you describe yourself?" the nurse is assessing which of the following? - values/beliefs - role/relationship - self-perception/self concept - coping/stress tolerance
self-perception/self-concept
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 - african americans are the least susceptible to skin cancers - usually there are precursor lesions for basal carcinomas - squamous cell carcinomas are most common on body sites with heavy exposure - melanoma skin cancers are the most common types of cancers
squamous cell carcinomas are most common on body sites with heavy sun exposure.
The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as - stage IV - stage III - stage II - Stage I
stage II
The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's - bullae - nodules -wheals - vesicles
vesicles. * bullae: blister filled with fluid * nodules: slightly elevated, larger than papules * wheals: irregular and often reddish or deeper brown on patients with dark complexions
The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health? - vision - mental status - neurologic status - hearing
vision * the temporal artery is located on side of forehead
Inspection
visual observation
cachectic appearance
wasting appearance, loss of elasticity, prominent bone structure
An emergency department nurse is assessing a client's complaint of upper abdominal pain. To assess the character of the pain, the nurse would begin with what assessment question? - is your pain affecting your ability to cope? - can you describe to me how your pain feels? - would you describe your pain as acute, or as chronic? - how would you rate your pain on a 10 point scale?
"Can you describe to me how your pain feels?" * since you are assessing the character of the pain, you want the patient to describe it
A nurse begins to assess pain in a client admitted to the hospital for new onset of severe nausea and vomiting. What question should the nurse ask the client to assess the pattern of pain? - how often do you experience the pain? - where is the pain located? - when did your pain start? - what therapies have you tried to control the pain?
"How often do you experience the pain?" * since we are assessing pattern, we need to know how often it occurs.
The nurse begins an assessment of a client's religion and spirituality. Which statement indicates that the client is spiritual? - "i am responsible for myself since there is no god" - " i attend church every Sunday" - " i attend an adult education class at my synagogue every Friday" - " i am at peace when i spend time out of doors"
"I am at peace when I spend time out of doors."
The nurse is concerned that a client is experiencing spiritual distress. Which client statement caused the nurse to have this concern? - " i want to just go home to die" - "will you please call my priest for me?" - " members from my church are planning to visit" - "when does the hospital chaplain visit?"
"I want to just go home to die." * spiritual distress results when the patient experiences a disruption in the life principle that pervades a persons being
A client has questioned why the nurse asked him how his family members usually treat their pain. Which response, by the nurse, would be the most appropriate? - "It helps me to determine how the family understands and perceives pain." - "It is just a way for me to more fully understand you and your upbringing." - "It helps me to direct interventions toward your cultural history." - "It will allow me to see if you are more likely to react to pain in a negative manner."
"It helps me to determine how the family understands and perceives pain."
A client expresses frustration that the nurse is assessing his spirituality, stating, "I thought I was here to have my tumor removed, not to figure out what I believe or don't believe about God." How should the nurse best justify the need for a spiritual assessment? - "your beliefs determine whether we will focus more on your body or on your spirit" - "spirituality actually has a significant effect on your overall health", -" we need to make plans in case there are unexpected outcomes of your surgery" - " its important that we plan to make sure that we dont offend you"
"Spirituality actually has a significant effect on your overall health."
when should you initiate the general survey?
- at the beginning of the physical examination - while taking vital signs - at the first encounter - at the time of discharge
when should hand hygiene be performed
- before touching patient, even if gloves are worn - before exiting patients care - after contact with blood, body fluids, etc. - prior to performing aseptic tasks - if hands will be moving from a contaminated body site to clean site -after glove removal
what are the challenges of note taking?
- breaks eye contact - shifts attention away from patient - interrupts patients narrative flow - diminishes their sense of importance - impedes observation of patients nonverbal behavior - may be threatening during discussing sensitive issues
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 muscles
general survey: the aging adult
- physical appearance: prominent landmarks, angular facial features - distribution of fat changes - weight decreases (muscle shrinkage) - posture: general flexion occurs - gait: often use wider base to compensate for diminished balance and steps may be shorter or uneven - height decrease
vital signs
- temperature: oral, axillary, rectal, tympanic membrane, temporal artery - heart rate (60-100 based on ppt) - respirations: (12-20 based on ppt) - blood pressure
objective data: measurement
- weight - height - BMI - waist circumference
A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply - date and location of the clients last blood pressure check - onset and character of the clients chest pain - blood pressure - a list of all the clients current medications - respiratory rate - core body temperature
-Date and location of the clients last blood pressure check -Onset and character of the clients chest pain -A list of all of the client's current medications
the "FIFE: mnemonic is used to explore the patients perspective. what is FIFE
-F: feelings/concerns about problem -I: idea about the nature/cause of the problem -F: function (how does the problem impact patients life/function -E: expectations of disease, HCPs, HC, based on prior experiences
A nurse is teaching a group of 5th grade children about characteristics of the skin. Which of the following should she mention? Select all that apply. - helps make vitamin D in the body - largest organ of the body - protects against damage to the body from sunlight - circulates blood throughout the body - involved in digestion of food - aids in maintaining body temperature
-Largest organ of the body -Protects against damage to the body from sunlight -Helps make vitamin D in the body -Aids in maintaining body temperature
A client enters the emergency department moaning and complaining of severe pain in his lower back. Which of the following clinical manifestations should the nurse expect to see in this client as a physiologic response to pain? Select all that apply. - sleeplessness - increased intestinal motility - increased heart rate - hypoglycemia - perspiration
-Perspiration -Increased heart rate -Sleeplessness
The nurse prepares to assess a client's spiritual needs. What should the nurse keep in mind about suffering, beliefs, and spirituality when completing this assessment? Select all that apply. - beliefs about suffering have no impact on the course or response to an illness - suffering is often associated with illness - suffering has to occur in order for the spiritual aspect of life to mature - spiritual beliefs about the meaning of life affects the course of illness and reaction to suffering - beliefs about the cause and meaning of suffering affect illness
-Suffering is often associated with illness -Beliefs about the cause and meaning of suffering affect illness -Spiritual beliefs about the meaning of life affects the course of illness and reaction to suffering
Which is an example of percussion? Select all that apply. - the nurse notes dullness over the clients liver - the nurse notes rustling over the clients thorax - the nurse notes gurgling throughout the clients abdomen - the nurse notes tympany over the clients lower abdomen - the nurse notes resonance over the clients thorax
-The nurse notes dullness over the client's liver. -The nurse notes resonance over the client's thorax. -The nurse notes tympany over the client's lower abdomen.
A nurse is preparing a client for a physical examination of his skin, hair, and nails. Which of the following interventions should the nurse implement? Select all that apply. - have the client remove his toupee - use sunlight, if possible, to inspect the skin - wear gloves when palpating lesions - asl the client to remove only his shirt - have the client stand for the entire examination - keep the room door closed
-Use sunlight, if possible, to inspect the skin -Have the client remove his toupee -Wear gloves when palpating lesions -Keep the room door closed
developmental competence of the pregnant womans skin
-linea nigra: increased pigmentation midline of abdomen . - chloasma: discoloration changes on face representing the "mask of pregnancy" - striae gravidarum: stretch marks
components of the general survey
-physical appearance - body structure - mobility - behavior
culture
-the system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people - is NOT limited to ethnic or minority groups
What are the phases of the interview?
1. Pre-interview: set stage for interview (self reflection, reviewing patient record, setting interview goals, reviewing own clinical behavior and appearance) 2. introduction: put patient at ease and establish trust ( greet patient, establish rapport, establish agenda for interview, chief complaint) 3. working: obtaining patient info 4. termination: summarize points and discuss plan of care
4 types of health histories
1. comprehensive health assessment: admission of new patient 2. focused or problem oriented assessment: returning patient 3. follow up history: problem/treatment evaluation 4. emergency history: focused on emergent problem
sequence of examination
1. maximize the patients comfort 2. maintain patient safety 3. avoid unnecessary changes in position 4. enhance clinical accuracy and efficiency 5. in general move "head to toe" 6. minimize how often you ask the patient to change positions 7. examine the patient from the right side, moving to the opposite side or foot as needed
A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client? - 12 - 11 - 18 - 23
18
Due to a change in the client's level of consciousness, a nurse is now assessing a client's temperature by the axillary route. Previously, the client had an oral temperature of 98.4ºF. Which finding would the nurse interpret as corresponding most closely to the client's previous temperature? - 97.4 F -99.4 F -97 F - 98.9 F
97.4ºF * axillary temp is lower by approximately 1 degree
The review of systems component of the health history is best described as which of the following? - a focus on symptoms related to each of the different body systems - a focus on diseases of the major body systems - a series of questions that start the head and finish at the feet - a large number of questions about major body systems
A focus on symptoms related to each of the different body systems
While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information? - analyze as a contributing factor to the current problem - use to determine health teaching to prepare - determine if a family history of the problem exists - speculate a genetic reason for the health problem
Analyze as a contributing factor to the current problem
Before assessing vital signs, the nurse knows that it is important to assess what? - a complete family history - any medications the client is currently taking - the clients mental status - the clients height and weight
Any medications the client is currently taking
A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading? - shoulder - arm - wrist - thigh
Arm
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? - ask the client about the use of an over-the-counter medications - ask the client to identify which medications taken every day - ask the caregiver whether the client is taking prescribed medications - ask the client to bring all the medications and supplements to an interview
Ask the client to bring all the medications and supplements to an interview.
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiological cause for this finding is related to what disease process? - endocarditis - bronchitis -atelectasis -tuberculosis
Atelectasis The trachea being pushed to one side is caused by severe damage. Atelectasis is severe because it is the collapse of the lungs. * atelectasis: complete/partial collapse of lung or lobe * endocarditis: life threatening inflammation of the inner lining of the heart chambers and valves (caused by infection) * bronchitis: inflammation of the lining of bronchial tubes * tuberculosis: infection that affects lungs
An obese client has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the client's peripheral pulses. How should the nurse proceed with this assessment? - arrange for cardiac monitoring - auscultate the clients brachial artery - auscultate the clients apical pulse - palpate the clients apical pulse
Auscultate the client's apical pulse * you would not be able to palpate the pulse because the edema would not allow you to feel the pulse due to inflammation. you would have to listen (auscultate) the apical pulse if you are trying to assess it.
Ideally, when taking a blood pressure, the client should be instructed to what? - take several deep breaths to help relax prior to the assessment - avoid smoking for 30 minutes prior to the assessment - abstain from drinking caffeine fro 45 minutes prior to the assessment - sit quietly for at least 10 minutes in a chair, rather than on the examining table, with feet flat on the floor and legs uncrossed
Avoid smoking for 30 minutes prior to the assessment
Which technique demonstrates the proper position of the arm by a nurse when measuring a blood pressure? - clients arm bent at the elbow and resting on the thigh - clients sitting with arm outstretched and even with the heart - clients are above the level of the heart and resting on a bedside table - clients standing with arm outstretched and at the level of the heart
Client sitting with arm outstretched and even with the heart
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of - tension headaches -tumor-related headaches - migraine headaches -cluster headaches
Cluster headaches * pain is in and around one eye. headaches occurs in patterns/clusters. This is a cluster headache because it has the pattern of occurring late in the evening and is an intense stabbing.
A client has presented to the clinic for the treatment of an ovarian cyst. What would be most important for the nurse to do immediately before performing the client's physical exam? - collect necessary equipment essential to the exam - establish the clients reliability as historian - explain the purpose of the interview to the client - construct the clients family genogram
Collect necessary equipment essential to the exam.
During the admission process, the client states, "I am allergic to sulfa drugs." How would the nurse verify this information? - ask the client about the response to the allergen - compare against the clients medical records - ask the physician - ask family members
Compare against the client's medical records
A nurse assesses a client with acute small-bowel obstruction who reports intermittent pain. He only noticed symptoms of this condition earlier today. Which questions are appropriate for the nurse to ask when assessing the client's pain? Select all that apply. - mention past experiences with pain - when did the pain start? - describe the pain - where is the pain located? - what therapies were used?
Describe the pain. Where is the pain located? When did the pain start?
What should a nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds? - develop a cultural habit and build effective relationships - consider ethnicity as the sole aspect of culture - know that nonverbal communications are common across cultures - rely only on textbooks for information on cultural groups
Develop a cultural habit and build effective relationships
A new graduate nurse, attending a hospital orientation, is asked to explain what the goals of a cultural assessment include. What would be the graduate nurse's best answer? - developing and implementing a culturally congruent plan of care - comparing social care needs of the specific person - comparing social and health beliefs of public health agencies - acquiring knowledge about the community cultural beliefs and practices
Developing and implementing a culturally congruent plan of care
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? - refer the client to the primary care provider promptly - document this as an expected assessment finding - position the client supine and reattempt palpation -perform a focused endocrine assessment
Document this as an expected assessment finding * the normal gland is usually invisible on inspection so it is difficult to palpate. When the thyroid gland is enlarged, it is palpable and not normal.
The nurse is having trouble obtaining the pulse and BP in a client who is in shock. What device would assist the nurse in obtaining the needed vital signs? - vital signs monitor - sphygmomanometer - pulse oximeter - doppler ultrasound
Doppler ultrasound * doppler ultrasound estimate the blood flow through your blood vessels by bouncing high-frequency sound waves (ultrasound) off circulating red blood cells
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph? - enlargement of a node may be a sign of pathology that is distant from that node - nurses need to follow lymph patterns to track the course of a disease - the drainage pattern may help pinpoint a fluid of electrolyte imbalance - the drainage pattern can help the nurse understand why the disease is spreading.
Enlargement of a node may be a sign of pathology that is distant from that node.
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure? - using the bell to detect high pitched sounds - application of firm pressure when using the bell - ensuring that contact with the skin is maintained - using the diaphragm to listen to low-pitched sounds
Ensuring that contact with the skin is maintained * the bell is used to detect lower pitched sounds * the diaphragm is used to detect high pitched sounds * pressing firmly can alter sounds
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? - remaining standing during the interview - maintaining eye contact with the client at all times - reading questions from the history form - explaining the reason for taking down notes
Explaining the reason for taking down notes
When interviewing, the nurse should logically move from specific to open-ended questions. - true - false
False
A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client? - follow up - comprehensive - emergent - focused
Focused
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 - normal aging - warts - hemochromatosis - trauma
Fungal infections Trauma Warts
A client reports a weight loss and fatigue during the review of systems. In which area should the nurse document this information? - general - gastrointestinal - rest and sleep - appetite
General
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? - flexible metric measuring tape - goniometer - skinfold calipers - reflex hammer
Goniometer
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding? - a tumor -hypothyroidism -nephrotic syndrome -Graves disease
Graves disease * graved disease: overproduction of thyroid hormones (hyperthyroidism) * hypothyroidism: thyroid doesn't create/release enough thyroid hormone into blood. metabolism slows down, tiredness, weight gain, unable to tolerate in cold temps. * nephrotic syndrome: kidney disorder that causes body to pass too much protein in urine
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? - cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus - hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid - hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland - thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid * order of the neck: hyoid bone, thyroid cartilage, cricoid cartilage, thyroid gland, isthmus of thyroid (middle center of thyroid gland), trachea
A mother brings her child to the health care clinic and reports that her son has a four-day history of intense itching to his legs. On inspection of the child's legs, the nurse notes a honey-colored exudate coming from a vesicular rash bilaterally. The nurse recognizes this finding as what skin condition? - viral exanthem - psoriasis - herpes zoster - impetigo
Impetigo * impetigo: (crust) dried residue of skin exudates such as serum, pus, or blood; can e red-brown, orange, yellow * viral exanthem: eruptive skin rash that is often related to viral infection *psoriasis: plaque/papule * herpes zoster are vesicles in a unilateral dermatomal pattern
When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care? - improvement of the clients health outcomes - to enhance the clients social system - to enhance cultural connectedness - improvement of communication with the client and family
Improvement of the client's health outcomes
The nurse is performing a physical assessment. The nurse does what first? - auscultation - inspection - palpation - percussion
Inspection
Which of the following statements is true of the role of inspection in the physical examination? - to maximize findings, local inspection should be conducted prior to general inspection - it should be performed after auscultation but before palpation and percussion - it is often the source of most physical signs - the acuity of the client will determine whether general or local inspection should be implemented in the examination
It is often the source of the most physical signs.
An instructor is describing culture and minority. Which statement would be most accurate for the instructor to include related to minority? - it means that a group has smaller population numbers - it refers to a group with less power or prestige in society - the members fail to act in appropriate ways - the group does not hold the accepted primary values
It means that a group has smaller population numbers.
A nurse is planning a spiritual assessment of a client who is experiencing intractable losses in function as a result of disease. Which of the following principles should inform the nurse's assessment? - it is of little importance for a nurse to understand his/her own spirituality - spirituality is a complex phenomenon that is not normally describable - reviewing all religious denominations before approaching a client is important - knowledge of the most common spiritual practices in the community is a priority
Knowledge of the most common spiritual practices in the community is a priority.
A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply. - occupation: brick mason - lamar P. Thompson - caucasian - head and neck: sore throat and enlarged lymph nodes - mother: sugar L thompson, died 7/14/2006 from heart attack - 1212 South Maple st. sylvan, va 23236
Lamar P. Thompson 1212 South Maple St., Sylvan, VA 23236 Caucasian Occupation: Brick mason * biographic data: name, DOB, Race, Ethnicity, Address, occupation, marital status
A nurse obtains a client's blood pressure (BP) on admission in both arms: right arm BP is 130/75 mm Hg and left arm BP is 140/80 mm Hg. Which arm should the nurse use for subsequent blood pressure reading? - right arm - left arm - dominant arm - both arms
Left arm * use left arm bc the heart is on the left side
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? - Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing. - Estimate systolic blood pressure by palpation while the client is lying, then measure blood pressure when the client is standing. - Alternate the scheduled blood pressure measurements between the standing and lying positions. - Measure the client's blood pressure and heart rate while she is standing then after 10 minutes of lying supine.
Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.
When using an interpreter to facilitate an interview, where should the interpreter be positioned? - next to the client, so the examiner can maintain eye contact and observe nonverbal cues of the client - behind the examiner, so the interpreter can pick up the movements of the lips of the client and the clients nonverbal cues - between the examiner and the client, so all parties can make the necessary observations - in a corner of the room, so as to provide minimal distraction to the interview
Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client
A 49-year-old factory worker has been admitted to the emergency department with chemical burns on his hand and wrist. Which of the following types of pain has the man most likely experienced? - nociceptive somatic - neuropathic - nociceptive visceral - gate control
Nociceptive-somatic * nociceptive-somatic is pain related to tissue damage * neuropathic pain: pain resulting form direct injury to the peripheral or CNS * pain that is typically less well localized
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? - modulation - nociceptors - cytokines - transduction
Nociceptors * nociceptors is a sensory receptor for painful stimuli that goes to the CNS * modulation: to regulate or adjust to a certain degree. * cytokines: cell signaling * transduction: virus transfers genetic material from one bacterium to another
An older client has an oral body temperature of 99.80F. Which action should the nurse take first? - notify the HCP - encourage the client to drink more fluids - prepare to catheterize for a urine specimen - document the temperature
Notify the health care provider
OLD CART
O: onset L: Location D: Duration C: Characteristic symptoms A: associated manifestations R: relieving factors T: treatment
When attempting to assess a client's pain, what would the nurse do first? - search fro possible causes of pain - observe behaviors in the client - obtain a client self report - ask family members about the clients pain
Obtain a client self-report
A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? - tuning fork - penlight - ophthalmoscope - otoscope
Ophthalmoscope * ophthalmoscope is used for inspecting retina and the eye * otoscope is used for examination of the ear
What steps are involved in the client-to-client transmission of pathogens? (Select all that apply.) - the nurses use an alcohol based hand sanitizer for hand hygiene - organisms survive on the nurses hands for less than 1 minute - organisms are transferred from the client to the nurses hands - the nurses contaminated hands come into direct contact with another client - organisms are present in the clients immediate environment
Organisms are transferred from the client to the nurse's hands The nurse's contaminated hands come into direct contact with another client Organisms are present in the client's immediate environment
The charge nurse on a geriatric unit should further educate a new staff nurse who makes which statement? - there is little information about the effects of increased age on pain - transmission of pain along A -delta and C fibers may be altered in older adults -pain sensation is diminished in older adults - older adults tent to be undertreated for pain
Pain sensation is diminished in older adults. *pain sensation is not diminished in older adults.
A nurse is palpating a client's chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case? - palmar surface - dorsal surface - fingertips - finger pads
Palmar surface * use palmar surface when palpating large areas. use dorsal surface for temperature. use finger pads for palpating smaller surfaces. never use fingertips
Mr. Smith presents to the clinic stating, "My face looks funny." You note that his face is asymmetric. What might you suspect is the client's problem? - muscular dystrophy - myocardial infarction - parafacial macrosimia - palsy
Palsy * palsy: affects body movement and muscle coordination on one side * muscular dystrophy: a group of genetic diseases that cause progressive weakness and loss of muscle mass * myocardial infraction: heart attack * parafacial macrosimia: growth beyond specific threshold on one side of face
While assessing an adult client, the nurse observes an elevated, palpable, solid mass with a circumscribed border that measures 0.75 cm. The nurse documents this as a - patch - papule - macule -plaque
Papule * patch: less than 1 cm, plat discoloration * papule: less than 1 cm, raised (wart) * macule: less than 1 cm, flat discoloration (freckles) * plaque: less than 1 cm, raised, (ex: psoriasis)
A nurse observes the gait of an elderly client admitted for surgery. The client's gait is stiff with rigid movements. The nurse should ask this client questions about which disease? - parkinsons disease - lordosis of the cervical spine - chronic obstructive pulmonary disease (COPD) - multiple sclerosis
Parkinson's disease * parkinsons disease is a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination * lordosis of the cervical spine: natural curve of the spine in the neck * COPD: airflow blockage and breathing related problems - multiple sclerosis: disease in which the immune system eats away at the protective covering of nerves
Which of the following is a component of the general survey? - patients state of hygiene - patients breath sounds - patients blood pressure - patients oral temperature
Patient's state of hygiene
A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as? - edema from fall - pigmented nevi - pilar cysts - signs of abuse
Pillar cysts
Which technique should the nurse use to properly assess a client's skin turgor? -pinch the skin on the abdomen and observe for color changes - palate the skin around the umbilicus to assess for intactness - palpate the skin on the sternum to determine its flexibility - pinch the skin over the clavicle and observe its return to the original shape
Pinch the skin over the clavicle and observe its return to the original shape
What occurs during the termination phase of an interview? - letting the client know you understood all he or she has told you - planning for follow up care - assessing the clients mental status - addressing topics that have not yet been addressed
Planning for follow-up care * Termination phase includes summarizing important points and discussing plan of care.
The nurse wears gloves for which of the following purposes? Select all that apply. - facilitate contamination of the hands of the nurse - increase the risk of the nurse acquiring infection from the client - prevent transmission of flora from client to client - limit exposure to body fluids and secretions
Prevent transmission of flora from client to client. Limit exposure to body fluids and secretions
The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client? - tertiary - primary - objective - secondary
Primary
A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called? - neurologic onset -prodrome -aberrant sign -aura
Prodrome * prodrome is an early sign or symptom. these include euphoria, craving for food, fatigue, dizziness * aura: change in vision, numbness, weakness, photophobia (fear of light)
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? - pityriasis rosea - eczema - tinea infection - psoriasis
Psoriasis * Psoriasis takes place on elbows and knees. gets worse in dry weather . scabbing, crusting, silvery scales. small pits in nails * eczema: itchy inflammation of the skin * pityriasis rosea: red, oval papules across antieror and posterior torso * tinea infection: ringworm. round scaling patches
A nurse assesses a client for past history of nail problems. The nurse should ask questions about which of these conditions? - vitiligo, hirsutism, vitamin deficiency - alopecia, dermatitis, chemotherapy - psoriasis, fungal infections, trauma - eczema, melanoma, herpes zoster
Psoriasis, fungal infections, trauma
A nurse in a dermatology clinic cares for an adolescent client with multiple purulent, fluid-filled lesions on her face, shoulders, back, and chest. What is the most likely medical diagnosis for this client? - bullous impetigo - pustular acne - cystic acne - chickenpox
Pustular acne * pustular acne: filled with pus * bullous impetigo: bacterial skin infection that results in the formation of large blisters (armpits, groin, between fingers/toes, crests, etc) * cystic acne: occurs when the hair follicles plug with oil and dead skin cells
The nurse is interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of guided questioning? - reassure the client that the urinary symptoms are most often treated successfully - ask the client to tell you exactly what she means when she states that she has a urinary tract infection - use directed questioning: start with the general and proceed to the specific in a manner that does not make the client give a yes/no answer - offer the client multiple choices to clarify the character of the urinary symptoms that she is experiencing
Reassure the client that the urinary symptoms are most often treated successfully. * do not provide false reassurance. this blocks further disclosures
A nurse is completing an admission assessment of an adult client, during which the client states, "I've never been a religious man, but I'm definitely spiritual." How should the nurse best understand an aspect of the relationship between spirituality and religion? - religion is the state of spiritual certainty that results from cultural influences - spirituality is an eastern concept, whereas religion is associated with western cultures - religion consists of the spirituality focused rituals and practices of a group -spirituality is the codification of principles that are absed on religion
Religion consists of the spiritually focused rituals and practices of a group.
A hospice nurse is admitting a new client who states, "I'm not religious but consider myself spiritual." What change in attitude has been noted when illness stresses such a client's beliefs and values? - religious activities may blend with national identity - religious activities may lose importance - religious activities may take a central position in life - religious activities may become formalized
Religious activities may take a central position in life.
The nurse is asking a client to describe the history of the present illness. On which areas should the nurse focus at this time? (Select all answer choices that apply) - risk factors - review of system information - reliability of the client - past occurrences - self treatment
Risk factors Self-treatment Past occurrences Review of system information
The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first? - irrational cognition - sensory abilities - severe phobias - general intelligence
Sensory abilities
Cranial nerve 5 (trigeminal)
Sensory/motor sensory and motor function to face to test: brush a cotton ball against face to evaluate reflex allows us to bite down and chew, cheeks
Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description? - timing -severity - setting in which the symptoms occur - associated symptoms and signs
Severity
In the assessment of a client, the nurse is having her complete a daily spiritual experiences self-assessment scale. Which of the following should the nurse mention to the client before giving her this assessment tool? - she should confirm all of her answers with a spiritual leader whom she trusts - she may substitute another word for God in the scale, if she would like - she should not complete the scale if she is a member of an organized religion - she should base her answers on whether she feels that she should have the indicated experiences
She may substitute another word for God in the scale, if she would like.
The nurse is assessing the pain of an older adult client who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the client's pain? - genetic history - sleep patterns - family history - elimination pattern
Sleep patterns * Important clues about etiology often emerge from a good psychosocial history, exploration of sleep patterns, and a thorough review of systems.
A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis? - white spots, or leukonychia, on the nail surfaces - beaus lines - small pits in the surfaces of the nails - transverse white lines in the nails
Small pits in the surfaces of the nails
Which factor if present in a client's lifestyle and health practices assessment would alert the nurse to the need for performing a more thorough head and neck assessment? - multiple sex partners -alcohol abuse -recreational drug use -smokeless tobacco use
Smokeless tobacco use
When assessing a client with Graves disease, how would you expect the thyroid gland to be? - firm - nodular - tender -soft
Soft * Hashimoto thyroiditis and nodules are firm * thyroiditis is tender
A client is admitted to the oncology floor with a terminal illness diagnosis. Upon completing the spiritual assessment the nurse realizes that this client has no connection to others such as God, nature, family, or peers. The client has a pessimistic attitude and has not identified any coping resources and does not want to adapt to any. The best nursing diagnosis for this client is what? - readiness for enhances spiritual wellbeing - risk for spiritual distress - spiritual distress - risk for hypertension
Spiritual distress * client is in spiritual distress because they have no connection to others. they do not want to adapt to coping mechanisms.
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? - pain that is temporary - pain without new symptomatology -stiff neck - pain centered behind the eyes
Stiff neck * other red flags: elevated BP, Signs of infection, presence of canter, HIV, pregnancy, vomiting
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? - working - analysis - summary - introductory
Summary
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? - superficial - dermal - full thickness - superficial dermal
Superficial
The nurse is preparing to assess a client's peripheral pulses. The nurse would place the client in which position? - prone - sitting - sims - supine
Supine * supine: laying face upward * prone: laying face down * sims: patient lies on one side with the arm behind back and upper thigh flexed * sitting: examination of head, neck, thorax and lungs are best done sitting.
The ulnar edge of the hand is highly receptive to which of the following sensations? - moisture and contour - vibrations and moisture - temperature and vibrations - contour and temperature
Temperature and vibrations * the ulnar edge of the hand is the area of sensation.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? - Analgesic rebound - tension -migraine -cluster
Tension * tension headache: pain is like a band squeezing the head * analgesic rebound: result of overusing headache medication, causing it to be less effective * migraine : pain, nausea, and visual changes, unilateral, sensitivity to light and sound * cluster: pain is in and around one eye
The nurse is using the Verbal Descriptor Scale to assess a client's pain. What data will the nurse prioritize? - the clients report on a 1 to 10 numeric scale - the clients explanation of how her pain feels - the clients facial expressions - the clients rating on a 0 to 10 visual analog scale
The client's explanation of how her pain feels
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first? - the clients general intelligence - the presence of any phobias - the clients judgement and insight - the clients sensory abilities
The client's sensory abilities
Which of the following describes how the health history interview differs from a social conversation? - the interview focuses on the clients needs to improve health and well being - the interview is restricted to actual or potential illnesses - the interview allows more time for the client to demonstrate self awareness - the interview permits the clinician to express his/her needs and interests
The interview focuses on the client's needs to improve health and well-being.
Which describes the nurse using the technique of palpation? - the nurse notes increased warmth surrounding an abdominal incision - the nurse notes gurgling sounds over the individuals abdomen - the nurse notes tympany over the individuals lower abdomen - the nurse notes asymmetry of the individuals abdomen
The nurse notes increased warmth surrounding an abdominal incision. * warmth is felt by palpation. gurgling sounds is heard, not felt. tympany is sounds that are hallow, high, or drumlike. Asymmetry is observed
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 versicolor - herpes simplex - multiple nevi - tinea corporis
Tinea corporis * tinea corpris: ringworm. creep from one part to another. margin has a wavy or serpentine border * herpes simplex: vessicle less than 2 cm filled with serous fluid * multiple nevi: nevi are moles * tinea versicolor: tan, flat, scaly lesions across the upper anterior and posterior torso
The nurse is taking a comprehensive health history on a new client. Why would it be essential for the nurse to obtain a complete description of the present illness? - to obtain primary data - to obtain demographic data - to establish an accurate diagnosis - to assess if the client is a reliable historian
To establish an accurate diagnosis
The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic? - to remember the parts of a focused assessment - to remember the order of the assessment - to remember the elements that are important to assess with a symptom - to remember how to document assessment findings
To remember the elements that are important to assess with a symptom
While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible -trigeminal neuralgia -arterial occlusion -inner ear disease -cancerous lesions
Trigeminal neuralgia *trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve. (eye, cheek, jaw) * arterial occlusion: sudden loss of limb perfusion * inner ear disease: causes episodes of vertigo
It is recommended that a left-handed examiner adopt a right-sided position. -true -false
True
The nurse should use the handle of the reflex hammer to detect the plantar reflex. -true -false
True
The nurse is gathering the necessary equipment in preparation for examining a client's ears. The nurse will be checking bone and air conduction of sound. What equipment would the nurse obtain? - tongue depressor - penlight - otoscope - tuning fork
Tuning fork * otoscope is also used to examine the ears but is used to help visualize and examine the condition of the ear canal and eardrum. the tuning fork is used to check conduction of sound.
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 - oral - axillary - rectal
Tympanic * tympanic temp is quick and easy * oral temp is easy and reliable * rectal is inconvenient and invasive but most accurate * axillary takes 5-10 min to register and less accurate
A community health nurse is caring for a diaphoretic client and wishes to measure the client's temperature. The nurse asks if the client has a thermometer in her home, and she states that she owns an "ear thermometer." What principle should guide the nurse's use of a tympanic thermometer? - in adults, tympanic temperature is equal to axillary temperature - tympanic temperature is slightly higher than oral temperature - tympanic temperature is only used if all other methods are unavailable - tympanic temperature varies more widely than oral, rectal, and axillary temperatures
Tympanic temperature is slightly higher than oral temperature.
Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash? - purpura - psoriasis - urticaria or hives - insect bites
Urticaria or hives
The nurse is the primary care provider for a 21-year-old man who, as the result of a brain injury suffered in a mountain-biking accident in his teens, has the cognitive abilities of a 9-year-old. How should the nurse accommodate the client's cognition and comprehension during assessment? - use the clients family as a source of information - perform objective assessments rather than eliciting subjective information - address interview questions to the clients mother rather than the client - rely on the clients documented history rather than the client interview
Use the client's family as a source of information.
The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique? - make a fist with one hand - tap directly over the lung tissue - use the middle finger to deliver two taps - place one hand flat on the body area
Use the middle finger to deliver two taps * always use the distal third finger (middle finger) during percussion.
A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply. - using silence - using touch - discussing alternative treatment options - communicating nonverbally through facial expressions - giving advice
Using silence Using touch Communicating nonverbally through facial expression
Short, pale, and fine hair that is present over much of the body is termed - terminal - lanugo - dermal - vellus
Vellus * there are 2 types of hair. Vellus hair (which is short, fine, inconspicuous, and relatively unpigmented) and terminal hair (coarser, thicker, more conspicuous, pigmented) * lanugo: fine, soft hair that covers the body/limbs of newborns
An older adult client reports that he is experiencing severe trunk pain and is concerned that he might have shingles. Which type of lesion would the nurse most likely assess? - vesicle - bulla - papule - crust
Vesicle
A nurse assesses a non-English-speaking client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain? - verbal descriptor - numeric rating - wong baker faces - visual analog scale
Wong-Baker Faces * since the patient is grimacing and pointing instead of verbalizing, we assume the client cannot speak. the wong baker faces is best used when patients are unable to speak. the verbal descriptor requires the patient to describe pain. the numeric rating also requires patient to verbalize the number.
A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care? - summary - working - closing - introductory
Working * pre-interview: setting the stage fir smooth interview * introduction: putting the patient at ease and establishing trust * working: obtaining patient information * termination: (summarizing and discussing plan of care)
During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement? - document it within health history - designate it as a health promotional goal - identify it as referral information - write it as the chief complaint
Write is as the chief complaint * the client is coming in with the main concern of his swollen feet. this is the main complaint
cultural sensibility
a deliberative pro-active behavior by HCP who examine cultural situations through thoughtful reasoning, responsiveness and discreet interactions
hydrocephalus
accumulation of fluid in the spaces of the brain. structures not fused
During the working phase of an interview the nurse encourages the client to continue and expand on the health issues. What technique is the nurse using? - empathy - summarizing - empowering - active listening
active listening active listening is the process of paying close attention to what the patient is communicating
influences of BP
age sex race diurnal rhythm weight exercise emotion stress
spirituality
all behaviors that give meaning to life and provide strength to the individual
A past history is being taken by the nurse for a client with COPD. The nurse includes which elements in this part of the health history? Select all that apply. - childhood illness - health maintenance - allergies - treatment options
allergies childhood illnesses health maintenance
An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis? - traction alopecia - trichotillomania - alopecia areata - tinea capitis
alopecia areata * alopecia areata: patchy hair loss. no visible scaling or inflammation * traction alopecia: acquired hair loss from prolonged or repetitive tension * trichotillomania: hair loss form pulling, plucking, or twisting hair. * tinea capitis: ringworm of scalp. round scaling patches of alopecia. usually caused by fungal infection
secondary headaches
arise from other conditions
Cyanosis
blue tint to the skin
you note a lesion during a skin assessment. which is the best way to document this finding? - raised, irregular lesion the size of a quarter, located on dorsum left hand - open lesion with no drainage or odor, approximately 14 inch in diameter - pedunculated lesion below left scapula with consistent ref color and no drainage or odor - dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, no drainage
dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, no drainage
Parkinsons disease
decreased facial mobility blunts expression. a mask-like face with decreased blinking and a characteristic stare. patient seems to peer upward toward the observer. facial skin becomes oily, and drooling may occur
The nurse spends a day off in a part of a non-English speaking community in order to learn more about the culture to improve interactions when providing client care. What cultural activity is this nurse demonstrating? - desire - skill - competence - awareness
desire
pulse pressure
difference between systolic and diastolic pressures
developmental competence in the aging adults skin
elasticity decreases. sweat and sebaceous glans decrease, leaving skin dry. senile purpura: discoloration due to increasing capillary fragility. skin breakdown due to multiple factors. hair matrix: melanocytes decrease, leading to grey fine hair. senile lentigines (liver spots, sign of sun damage)
common places for pressure ulcers
elbow, inner knees, back of head and ears, shoulder, lower back & buttocks, hip, heel, greater trochanter
what are the external factors in the process of communication?
ensure privacy refuse interruptions physical environment dress note taking tape and video recording
Palpation
feeling with ones hands
Nodule
firm solid mass less than 1 cm
vesicle
fluid filled blister (clear fluid)
blood pressure
force of blood pushing against side of its container, vessel walls
stage 4 pressure ulcer
full thickness skin and tissue loss. exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, bone
stage 3 pressure ulcer
full thickness skin loss. adipose fat is visible in the ulcer
The nurse is assessing a client's range of motion. Which equipment should the nurse use to validate the degrees of joint mobility? - stadiometer - speculum - goniometer - test tubes
goniometer * goniometer is used to measure an angle * stadiometer is used to measure height
plaque
greater than w cm, raised (psoriasis)
Primary headaches
have no identifiable underlying cause
A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? - chief complaint - review of symptoms - past health history - history of present illness
history of present illness * this is history of present illness because the client is experiencing abdominal pain at the moment.
During a comprehensive assessment the client reports having a college education, is employed as a human resource director, and is 45 years old. Which part of the assessment should the nurse document this information? - family history - chief complaint - identifying data - history of present illness
identifying data
Because the nurse realizes that spirituality varies, information gained will assist the nurse in - individualizing interventions to meet specific needs - providing an overview of widely held beliefs form the major religions - teaching strict adherence to rituals and practices to improve outcomes - diagnosing the client with spiritual distress
individualizing interventions to meet specific needs.
Objective data
information that is seen, heard, felt, or smelled by an observer; signs
A new RN is being observed by the preceptor when doing a client examination. The preceptor notes the appropriate order of examination techniques on the lungs. The preceptor observed what order of the lung examination techniques? - percussion - auscultation - inspection - palpation
inspection palpation percussion auscultation
Stage 1 pressure ulcer
intact skin with a localized area of nonblanchable erythema
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus? - just above the thyroid cartilage - between the thyroid and the cricoid cartilages - just below the cricoid cartilage -in front of the sternocleidomastoid muscle
just below the cricoid cartilage
what are the internal factors in the process of communication?
liking others empathy ability to listen
auscultation
listening to the body sounds with the aid of stethoscope
A client with acute onset of shoulder pain is answering questions during a health history. The nurse is utilizing a mnemonic specific to the attributes of a symptom. The nurse first asks about the onset of symptoms followed by - duration - location - associated manifestations - characteristic symptoms - relieving/exacerbating factors - treatment
location duration characteristic symptoms associated manifestations relieving/exacerbating factors treatment * refers to OLD CART
A client asks to have her temperature taken because she feels hot and is sweating. The previous oral temperature 3 hours ago was 101.6°F. The nurse would expect the new temperature reading to be - within a afebrile range - lower than previous - within a subnormal range - higher than previous
lower than previous * feeling hot and sweating accompany falling temperature. feeling cold and shivering accompany rising temp
While assessing an adult client, the nurse observes freckles on the client's face. The nurse should document the presence of - bulla - macules - plaques - papules
macules
While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should - read the question verbatim from the form - maintain eye contact while asking the questions from the form - ask leading questions throughout the interview - ask the client to complete the form
maintain eye contact while asking the questions from the form.
SNOOP mnemonic
mnemonic used to screen for red flags in headaches * S: systemic signs, symptoms, or illness * N: neurologic deficits (altered mental status, seizures, etc) * O: Onset * O: other associated conditions * P: prior history
During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? - peripheral vascular - musculoskeletal - cardiovascular - neurologic
neurologic * its neurologic because the nerves in the hands are causing them to feel numb
When using the ABCDE criteria for assessment of a mole, the nurse understands that which criteria could indicate a melanoma? (Select all that apply.) - notched border - pink color - diameter greater than 6 mm - asymmetry
notched border diameter great than 6 mm asymmetry
chronic pain
often diagnosed when pain continues for more than 3-6 mo
An adult white client visits the clinic for the first time. During assessment of the client's skin, the nurse should assess for central cyanosis by observing the client's - palms - sclera - nail beds - oral mucosa
oral mucosa * central cyanosis: cyanosis (blue) found on "central" parts of the body
The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of: - supine hypotension - postural hypertension - hypertensive crisis - orthostatic hypotension
orthostatic hypotension. * orthostatic hypotension is a drop in systolic BP of at least 20 mm Hg or in diastolic B of at least 10 mm Hg within 3 minutes of standing. this happens because the heart is not elevated with the rest of the body, so the blood goes down. supine hypotension is not accurate, bc the BP increases when in a supine position causing it to be supine hypertension. this is because the heart is elevated with the rest of the body. Hypotension is decrease in BP. Hypertension is increase in BP
Cluster headache
pain is in and around one eye, unilateral
tension headache
pain is like a band squeezing the head
sinus headache
pain is usually behind the forehead and/or cheekbones
migraine headache
pain, nausea, and visual changes are typical of classic form. Unilateral. visual and auditory changes. sensitivity to light and sounds
The client with psoriasis is admitted to a medical unit for unrelated reasons. When documenting the type of lesion represented by psoriasis, the nurse should document a - pustule - bulla - wheal - papule
papule
Stage 2 pressure ulcer
partial thickness skin loss with exposed dermis
the technique of tapping on the body to elicit a sound is know as - inspection - palpation - percussion - auscultation
percussion
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using - inspection - doppler magnification - precussion - palpation
percussion. * percussion: used to determine size and density - inspection: observed by looking - palpation: feeling with hands/fingers
cultural competence
recognizes the need for a set of skills necessary to care for people of different cultures
erythema
redness of the skin
cultural assessment
refers to they systematic, comprehensive examination of individuals, families, groups, and communities regarding their health-related cultural beliefs, values, and practices
While listening to a lecture, the students learn that there are three dimensions of cultural humility, which include (Select all that apply.) - respectful communication - religious structures - collaborative partnerships - self awareness
respectful communication collaborative partnerships self-awareness
diastolic pressure
resting pressure that blood exerts constantly between each contraction
Myxedema
severe hypothyroidism. patient has a dull, puffy facies. the edema, often pronounced around the eyes, does not pit with pressure. the hair and eyebrows are dry, coarse, and thinned. the skin is dry
acute pain
short term, arises quickly and self-limiting. associated with a physical cause
developmental competence in adolescents skin
skin problems such as pimples, blackheads. secretions from apocrine sweat glands increase. subcutaneous fat deposits increase. secondary sex characteristics
microcephaly
small head in proportion to the body and an underdeveloped brain
wheal
small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions. fluid filled
papule
small, solid, raised lesion on surface of the skin. less than 1 cm (wart)
what are the "7 facets" of health?
social well-being physical health emotional health environmental influences cultural influences spiritual influences developmental level
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: - pigmentation irregularities - allergies to certain foods - symptoms of stress - recent radiation therapy
symptoms of stress
developmental competence of infants skin
thin, smooth, elastic and is more permeable than adult; thus, at greater risk for fluid loss
When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?" - true/false
true
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a - migrane headache - tumor-related headache -cluster headache -tension headache
tumor-related headache * tumor related headaches may be aggravated by coughing, sneezing, or sudden movements of head (pg 227)
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? - self perception - role relationship - coping stress tolerance - value belief
value-belief
subjective data
what the patient tells you, history, pain, etc.
the incidence of melanoma is 20 times higher among - whites - blacks - hispanics - american indians
whites because they have less melanin in skin
carotenemia
yellow-orange color in light-skinned persons from large amounts of foods containing carotene
Parents bring a child to the clinic and report a "rash" on her knee. On assessment, the nurse practitioner notes the area to be a reddish-pink lesion covered with silvery scales. What would the nurse practitioner chart? -eczema -psoriasis - contact dermatitis - seborrhea
psoriasis * psoriasis typically affects the knees and elbows. covered in scales * eczema: itchy inflammation of skin
ABCDEFG rule to detect lesions
A: asymmetry B: border C: color D: diameter E: elevation and evolving F: firm on palpation G: growing progressively over weeks
Developmental considerations of the Head, neck, lymph nodes for the aging adult
- facial bones and orbits appear more prominent - facial skin sags resulting from decreased elasticity - decreases subcutaneous fat -decreased moisture in the skin - lower face may look smaller if teeth have been lost
A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention about the thyroid gland? Select all that apply. - located anterior and inferior to the ears and behind the mandible - covered mostly by the sternomastoid muscles - consists of two lateral lobes - a large endocrine gland in the body - produces hormones that increase the metabolic rate of most body cells - produces saliva
-A large endocrine gland in the body -Produces hormones that increase the metabolic rate of most body cells -Consists of two lateral lobes -Covered mostly by the sternomastoid muscles
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 -immediately notify the health care provider -ask the patient about past history of hypothyroidism - document the findings in the nurse notes
Auscultate with the bell over the lateral lobes
A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands? - on the area behind the clients ears - behind the tip of the clients mandible -at the base of the clients skull - at the angle of the clients mandible
Behind the tip of the clients mandible * posterior auricular is on the area behind the clients ears * occipital is at the base of the skull * jugulodigastric is at the angle of the mandible
A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal? - palpations, limp hair, and sweating - fatigue, cold intolerance, and constipation - muscle weakness, increased metabolic rate, and anxiety - weight loss, rapid pulse, heart intolerance
Fatigue, cold intolerance, and constipation.
macrocephaly
large head in proportion to the body and an underdeveloped brain
macule
less than 1 cm. flat discoloration (freckles)
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 melanoma - the client has asthma - the client has COPD - the client has chronic hypoxia
The client has chronic hypoxia
variables that influence skin color
emotional states, temperature, smoking, prolonged elevation/dependent position of extremities, prolonged inactivity
developmental competence in children skin
epidermis thickens, darkens, and becomes lubricates. hair growth accelerates
Nephrotic syndrome
face is edematous and often pale. swelling usually appears first around the eyes and in the morning. the eyes may become slitlike when edema is severe
A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause? - domestic violence prevention -defensive driving - fall prevention -correct use of fire arms
fall prevention * falling is the cause of most TBIs for adults and elderly. Driving is the most for teens since they are just learning how to drive. Domestic violence and fire arms are also risk but isn't the leading cause
characteristics of hair with hypothyroidism and hyperthyroidism
fine hair = hypothyroidism coarse hair - hyperthyroidism
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing? - hypothyroidism - hyperthyroidism - crushing syndrome - scleroderma
hypothyroidism * edematous: abnormally swollen *hypothyroidism makes you gain weight because the thyroid doesn't create/release enough hormone in bloodstream. causes metabolism to slow, make you feel tired, and unable to tolerate the cold (under activate thyroid)
Cushing syndrome
increased adrenal cortisol production of Cushing syndrome produces a round of "moon" face with red cheeks. excessive hair growth may be present in mustache and sideburn areas on chin.
Acromegaly
increased growth hormone produces enlargement of bone and soft tissue. head is elongated, with bony prominence of the forehead, nose, and lower jaw. soft tissues of the nose, lips, and ears are enlarged. facial features appear generally coarsened
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
