health assessment in class quizzes

every 5 years

A 35-year old female patient is scheduling a Pap smear. She has never had an abnormal result. What is the recommended timeline for this type of screening? Every year Every 2 years Every 3 years Every 5 years

Occupation and hobbies

A nurse assesses a patient's respiratory status. Which information is of highest priority for the nurse to obtain? Average daily fluid intake Height and weight Occupation and hobbies Neck circumference

tachycardia

A nurse is assessing a client who has late stage hypoxia. Which of the following findings should the nurse expect? Pallor Bradypnea Tachycardia Somnolence

industry

An 8-year old child completes reading their first chapter and expresses pride in doing so. What stage in Erikson's theory would this child be placed? Intimacy Initiation Identity Industry

older adults

Falls can lead to complications including fractures and soft tissue injury. Which of the following patient populations are most at risk for these types of complications? Adolescents Middle-aged adults Toddlers Older adults

Generativity vs stagnation

Knowing Erikson's theory which of the following categories would you place a middle-aged adult? Identity vs role confusion Generativity vs stagnation Integrity vs despair Intimacy vs isolation

"Tell me what this fable means to you."

The emergency department nurse is caring for a 78-year old patient whose daughter reports a decrease in cognition. Which nursing statement directed to the patient helps the nurse to assess cognition? "Tell me how you were transported to the hospital today." "I will write a word on this paper, and you copy it." "Tell me what this fable means to you." "Please count backward from 100 by 7s."

VII

The nurse asks the patient to close their eyes tightly. By doing so, the patient is demonstrating that which of their cranial nerves is intact? VII III IV VI

physical health

There are many factors that influence psychosocial health. Which of the following is an example of an internal factor? Family responsibility Physical health Culture Economic status

OD

What is the abbreviation for the right eye when documenting its score on the Snellen chart? OS OU OD

Close monitoring is needed because toxic levels may develop.

When administering a new GI medication to an older patient, the nurse anticipates what? Older adults always require a lower-than-normal dose than younger patients. Close monitoring is needed because toxic levels may develop. A higher-than-normal dose may be needed. Nausea and vomiting may develop rapidly and are common side effects in older adults.

tertiary

A patient with diabetes is administering insulin as directed by their physician. This is an example of what type of disease prevention? Secondary Primary Tertiary

Walking

You are educating a patient with osteoporosis. They are interested in learning more about weight-bearing activities. Which of the following would you suggest? Swimming Biking Walking Using resistance bands while seated

Aggressive

A nurse comes into a patient's room to perform an assessment and administer medication. When asked if they would like to take their medication with water or juice, the patient starts yelling at the nurse and tells her to get out of the room. How should the nurse document this patient's response? Confused Impulsive Flat affect Aggressive

Breathing ranging from very deep to very shallow with periods of apnea

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? Breathing ranging from very deep to very shallow with periods of apnea Shallow to normal breaths alternating with periods of apnea Rapid respirations that are unusually deep and regular An inability to breathe without dyspnea unless sitting upright

Skin tenting Dry mucous membranes 250 mL amber urine documented over last 12 hours

A nurse is completing a basic assessment on a 79 year old female admitted to the hospital for increased weakness and a fall. What objective data correlates to the patient being dehydrated? (Select all that apply). Skin tenting Dry mucous membranes Rubor 250 mL amber urine documented over last 12 hours Erythema

focused

A patient comes to the emergency room with a suspected fracture of their lower leg. Which of the following assessments would the nurse complete? Focused Basic Comprehensive

Anteroposterior-to-transverse diameter ratio of 1:1

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? Increased tactile fremitus Unequal chest expansion Atrophied neck and trapezius muscles Anteroposterior-to-transverse diameter ratio of 1:1

secondary

A patient has made an appointment for a physical exam. This is an example of which of the following types of disease prevention? Tertiary Secondary Primary

clanging

A patient is speaking in rhymes. This speech pattern is described as: Neologisms Flight of ideas Echolalia Clanging

Damage to the trigeminal nerve

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: Damage to the trigeminal nerve Scleroderma Bell's palsy Frostbite with paresthesia to the cheeks

smoking is a major risk factor for coronary artery disease and peripheral vascular disease

A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate? "You are correct, smoking only hurts the lungs." "What concerns you most about smoking?" "Smoking is a major risk factor for coronary artery disease and peripheral vascular disease." "The primary impact of smoking is only on the heart."

Ibuprofen 800 mg by mouth every 4 hours as needed for pain

A patient with a history of kidney disease is admitted with acute shoulder pain. Which order should the nurse question? Ibuprofen 800 mg by mouth every 4 hours as needed for pain Pan cultures for a temperature >38.5º C Metoprolol 50 mg by mouth twice daily Digoxin 0.125 mg by mouth daily

9

A patient with cerebral edema after a motor vehicle accident opens their eyes to noise, grunts when the nurse asks questions and withdraws from painful stimuli. When documenting these findings, what is the associated Glascow Coma Scale score? 13 9 5 11

"Dandruff looks like patchy or diffuse white or gray scales on the scalp surface." "It is a cosmetic problem." "Untreated severe dandruff can lead to hair loss." "Your scalp is very oily, which contributes to dandruff."

A patient with dandruff asks the nurse for information about this condition. What is the appropriate nursing response? (Select all that apply.) "Dandruff looks like patchy or diffuse white or gray scales on the scalp surface." "It is a symptom of a dry scalp." "It is a cosmetic problem." "Untreated severe dandruff can lead to hair loss." "Your scalp is very oily, which contributes to dandruff."

Answer Administer oxygen by nasal cannula.

A patient with kidney failure reports dyspnea. The patient's pulse oximeter reading is 95% on room air, but is visibly distressed with a respiratory rate of 32 breaths/min. What is the priority intervention? Notify the respiratory therapist. Answer Administer oxygen by nasal cannula. Administer lorazepam as the patient's tachypnea is related to anxiety. Administer a respiratory nebulizing treatment.

Extension Flexion

Knowing the intended range of motion for joints, which of the following would the nurse anticipate the patient being able to perform using their elbow? Select all that apply. Abduction Supination Extension Flexion Circumduction

punch biopsy

The nurse explains to the patient that the surgeon will inject a local anesthetic and then use a small circular instrument to cut and remove a small plug of tissue. Which procedure has the nurse described? Punch biopsy Excisional biopsy Unroofing Shave biopsy

Murmur

The nurse hears a blowing/swooshing sound when auscultating the heart. How should this be documented in the patient's chart? Normal heart sounds Bruit Thrill Murmur Irregular rhythm

notify the physician

The nurse is assessing a patient's AV fistula and notes there is not a thrill present. What is the priority action? Reassess in 1 hour. Reschedule dialysis for tomorrow. Notify the physician. Administer dialysis via the AV fistula.

ask the patient to lay on his left side

The nurse is assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate? Listen only for higher pitched sounds. Listen at the base of the heart. Ask the patient to hold their breath for 15 seconds. Ask the patient to lay on his left side.

Diameter of 8 mm

The nurse is assessing a patient's skin. Which lesion finding requires further nursing intervention? Consistent color Symmetry Regular border Diameter of 8 mm

Erbs point

The nurse is auscultating at the left 3rd intercostal space. What is the associated valve area? Pulmonic Aortic Mitral Erb's Point Tricuspid

Enable the bed alarm safety system.

The nurse is caring for a 30-year-old patient who experienced a frontal lobe infarction after a motorcycle accident. What is the appropriate nursing intervention? Use a picture board to assist with communication. Enable the bed alarm safety system. Place all items directly in front of the patient. Instruct the patient to use a call light prior to getting out of bed.

Whisper test Rinne test Weber test

The nurse is caring for a patient with an acoustic neuroma. When preparing to assess the patient further which of the following tests should the nurse anticipate doing? Select all that apply. Whisper test Snellen test Rinne test Weber test Romberg test

Oxygen insufficiency

The nurse is caring for an older adult who is usually alert and oriented. When the patient exhibits a change in mental status, which cause does the nurse assess for first Electrolyte imbalance Oxygen insufficiency Infection Use of sedatives

39 year old Caucasian American

The nurse is caring for four female patients. Which patient is identified as being at greatest risk for low bone density? 39 year old Caucasian American 22 year old Asian American 44 year old Native American 50 year old African American

Wheezes

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? Diminished Wheezes Rhonchi Crackles

severe dehydration

When assessing a patient with an indwelling catheter the nurse notes the color as brown. Which of the following is most likely the cause of this finding? Old urinary tract bleed Severe dehydration 10-year history of diabetes mellitus Congestive heart failure

Document as a diminished response/1.

When assessing a patient's deep tendon reflexes, the nurse does not get a strong response with their patellar reflex. What is the most appropriate action? Have the patient tighten their quadriceps to aid in a response. Notify the physician of the unexpected finding. Try again and have the patient use a distraction technique Document as a diminished response/1.

strep throat

When assessing a patient's tonsils, the nurse notes many red spots. The cause of this is most likely ________. post nasal drip tonsillitis strep throat fungal infection

Anosmia present bilaterally

When assessing a patient, the nurse notes that they cannot identify the scent as coffee. How should the nurse document this? Anosmia present bilaterally. Olfactory nerve is intact. Cranial nerve III is not intact. Ptosis of nares bilaterally.

drainage

When assessing the pediatric patient's ears with an otoscope the nurse notes an excess of wax. Another way to document is excess__________. tinnitus drainage furuncle cerumen

Inflammation

When assessing your patient you notice their knee joint is red, swollen and warm to the touch. Which of the following would best describe your findings? Inflammation Atrophy Crepitus Effusion

A burning sensation occurring on urination Urinating 10 times daily although fluid intake remains unchanged A new inability to hold urine A foul odor from the urine

When obtaining a health history from a 22-year-old female client who has new-onset urinary incontinence, which finding or factors does the nurse consider significant? Select all that apply. A burning sensation occurring on urination Chemical exposure in the workplace Urinating 10 times daily although fluid intake remains unchanged A new inability to hold urine A foul odor from the urine A recent change in the client's oral contraceptive prescription

ocular misalignment

When the nurse performs the corneal light reflex, the light reflects on different parts of each eye and not directly in the center of each pupil. This finding is documented as: ocular deviation anisocoria hyperopia ocular misalignment

Decrease in respiratory muscle strength

Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process? Tightening of the vocal cords Decrease in respiratory muscle strength Decrease in residual volume Decrease in the anteroposterior diameter

Extreme SOB

Which of the following findings would cause the nurse to halt/stop a respiratory exam? Anxiety Cough Eupnea Extreme SOB

have a plan to attempt suicide

Which of the following is the most alarming sign for suicide and would require a sitter to be present at all times? Giving away treasured belongings A history of suicide attempts Feelings of worthlessness Having a plan to attempt suicide

"I take ibuprofen three times daily for arthritis."

Which patient statement alerts the nurse to perform a thorough GI history and focused assessment? "I got dentures four years ago." "I take ibuprofen three times daily for arthritis." "I don't like the taste of spicy foods." "I experience occasional constipation."

Assess for symptoms of left-sided heart failure

While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? Transfer the patient to the intensive care unit. Call the healthcare provider immediately. Assess for symptoms of left-sided heart failure. The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted Document this as a normal finding.

comprehensive

You are caring for a newly admitted patient with congestive heart failure. Which of the following assessments would you complete? Comprehensive Basic Focused

Lips Conjunctiva Palms

You are completing an assessment on a patient with dark skin who is experiencing dyspnea. Vital signs are SPO2 89% room air, RR 30, HR 102, BP 96/58. Where will you assess for pallor? (Select all that apply) . Lips Toes Conjunctiva Palms Anterior thorax

basic

You are starting your shift and begin to see your patients. One of which has been on the unit for two days with Covid. Which of the following assessments would be most appropriate? Comprehensive Focused Basic