HEALTH ASSESSMENT (NUR 104) FINAL EXAM

During an assessment of the family, which question should the nurse ask to determine the function of the family?

"Can the family carry out routine activities?"

Actual Nursing Diagnoses

(1) The patient's identified need or problem (2) The etiology or underlying cause (3) Signs and symptoms

Steps of the Nursing Process

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

7 Steps of Diagnostic Reasoning Process

1. Identify abnormal data and strengths 2. Cluster data 3. Draw inferences 4. Propose possible nursing diagnosis 5. Check for presence of defining characteristics 6. Confirm or rule out nursing diagnosis 7. Document conclusions

Steps in Data Analysis

1. Identify abnormalities 2. Cluster data 3. Draw inferences 4. Propose nursing diagnoses 5. Check defining characteristics 6. Confirm or rule out diagnoses 7. Document

A waist circumference of greater that which of the following is indicative of excess abdominal fat in men?

40

The nurse is discussing the need for a child to stay for one more day in the hospital until they receive the results of a diagnostic test. The parents react aggressively, saying that they will take the child out now because they have plans for the evening. What does the nurse understand about the level of differentiation they are exhibiting?

A low level of differentiation

Which of the following would lead the nurse to suspect a hydrocele versus other causes of scrotal swelling?

A positive transillumination test

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?

Assessment data in the medical record

Standard Precautions

Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting, and apply the following infection control practices during the delivery of health care.

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?

Beaded or thickened cord

A client waiting to be seen for a clinic appointment is observed periodically shaking the left wrist. On what should the nurse focus when assessing this client?

Carpal tunnel syndrome

A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse?

Critical Thinking

A nurse palpates for tactile fremitus and notes that the vibrations diminish towards the base of the lungs. What should the nurse recognize about this finding?

Decreasing intensity is normal at the base

Risk Nursing Diagnoses

Describes human responses to health conditions/life processes that may develop

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

Deviated septum

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client?

Document findings and refer the client for follow-up

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

Dry and rough

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?

Enlarged, reddened

FICA

Faith and Belief Importance Community Address in care

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his or her breath; if the rub persists, it is pericardial

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

Hearing intact bilaterally on whisper test

Katz Assessment Tool

Helps to assess an elderly patient's ability to perform ADL's

A client has a history of emphysema. The nurse percussing the client's chest expects to hear what characteristic sound?

Hyperresonance

What term would the nurse use to document a client's report of pain in the lower-middle area of the abdomen?

Hypogastric

While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown. What is the purpose of this action?

Increase reflex activity

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

Increased pulse rate

A nurse inspects the genitalia of an elderly client and notices that the mucosa is dry and atrophied. The nurse should educate the client about her increased risk of what condition?

Infection

A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination?

Irregular, large liver

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the client record simultaneously

Interventions for Ineffective Gas Exchange

Maintain an oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater.

A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?

Measure movement with a goniometer

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

Myasthenia gravis

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate the carotid arteries

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment?

Prone

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?

Psychological

A teenage boy is embarrassed by his tender and enlarged breasts. What would be the most appropriate nursing intervention to help the teen manage this problem?

Reassuring the teen that this is both normal and temporary

After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?

Reduced hearing in one ear

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

Referred pain

A client relates having nasal stuffiness and sneezing during the spring and fall of each year. Where should the nurse document this information in the comprehensive assessment?

Review of Systems

A client is unable to perform abduction with the right arm and reports pain when attempting to do so. The nurse notices that the muscles surrounding the right shoulder are smaller than those on the left shoulder. The nurse recognizes this finding as the possibility of what condition?

Rotator cuff tear

A nurse examines a client diagnosed with fibroadenoma. Which characteristic of the lump should the nurse expect to find in the client?

Round, firm, well-defined

Mental Status Tolls for Elderly

SLUMS & CAM

SPIRIT

Spiritual Belief System Personal Beliefs Integration w/ a spiritual community Ritualized practices & rituals Implications for medical care Terminal events planning

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?

Spiritual distress

Interventions for Ineffective Tissue Perfusion

Submit patient to diagnostic testing as indicated.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases.

Working Phase

The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals.

A client has an abnormal consensual pupillary reaction to light. A nurse understands that what reaction occurs in the client's eyes?

There is no reaction in the opposite pupil to light.

What is the primary purpose of the health history in relation to the eyes?

To identify changes

An otherwise healthy elderly client develops the sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status?

Urinalysis for the onset of a urinary tract infection

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

A nurse interacts with the family of a client who is admitted to the health care facility for surgery. Which action by the nurse indicates a therapeutic conversation? a. Invites the family to accompany the client to the unit or the clinic b. Explains his or her role for the time that will be spent with the client or the family

a

An elderly client is admitted with new onset of left-sided weakness, slurred speech, and hypotension. The client's husband states that she has stopped taking her blood pressure medications for the past week because they were making her feel dizzy and lacking in energy. Which nursing diagnosis can be confirmed from this data? a. Dressing self-care deficit b. Risk for activity intolerance

a

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse? a. notify the health care provider b. document findings c. palpate for thyroid d. ask about recent injuries

a

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely? a. Venous insufficiency b. Neuropathic ulcer

a

The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor? a. Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis." b. "Data analysis is when the nurse gathers the data and the diagnostic phase is when the nurse evaluates her plan of care."

a

When the nurse asks the client for the reason for coming to the health clinic, the client responds by saying, "bad blood." The nurse recognizes that the client is most likely referring to which of the following? a. Sexually transmitted infection b. Sudden collapse preceded by dizziness

a

Health Promotion Nursing Diagnoses

a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. a. Hypertension b. Diabetes c. Sleep apnea

a, b, c

The nurse suspects that a client has experienced emotional abuse. For what should the nurse specifically assess this client? Select all that apply. a. insults b. harassment c. intimidation d. financial harm

a, b, c, d

The wet mount prepared after a female client's pelvic examination reveals motile organisms greater than 10 WBCs per high powered microscopy. The nurse should gather supplies for which diagnostic follow-up? (Select all that apply.) a. Syphilis serology b. Chlamydia culture c. Gonorrhea culture d. HIV testing

a, b, c, d

What questions should be included in a spiritual assessment? Select all that apply. a. "Do you need a private place to pray?" b. "What gives you meaning to your life?" c. "Are you a practicing Catholic?" d. "How does your spiritual practices help you to deal with pain?

a, b, d

A client is concerned about a right breast lump. What questions can the nurse ask to effectively assess the associated manifestations of this mass? (Select all that apply.) a. "Is there pain with the lump?" b. "Does anything make the lump go away?" c. "Is there any discharge from the lump?" d. "Are you menstruating when the lump is present?"

a, d, e

The nurse notes that a client has a history of peripheral arterial disease. What should the nurse expect when assessing this client? Select all that apply. a. Cold skin over the feet b. Ankle edema c. Toe wound that will not heal d. Pain in the calves when walking

a, d, e

Which diagnoses would be best for a set of signs & symptoms? a. ineffective airway clearance b. ineffective gas exchange c. ineffective breathing pattern d. activity intolerance e. impaired verbal communication f. impaired swallowing g. impaired physical mobility h. imbalanced nutrition i. fatigue j. acute pain k. ineffective tissue perfusion l. impaired skin integrity

a, d, e, g, k, l

When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician? a. "I am a registered nurse caring for your client." b. "The client's blood pressure is 180/85, pulse is 94 and client appears anxious."

a; "I am a registered nurse caring for your client."

After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client? a. Healthy People 2020 b. the client's past medical history

a; Healthy People 2020

Dyspnea, an uncomfortable awareness of breathing that is inappropriate to the level of exertion, is what?

air hunger

An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

angina.

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

The nurse is assessing the eyes of an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

arcus senilis

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

areola of the breast

A 35-year-old archaeologist comes to the office for a regular skin examination. She has just returned from her annual dig site in Greece. She has fair skin and reddish-blonde hair. She has a family history of melanoma. She has many freckles scattered across her skin. From this description, which of the following is not a risk factor for melanoma in this client? a. Actinic lentigines b. Age

b

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a. Document the findings in the nurse notes b. Auscultate with the bell over the lateral lobes

b

A nursing instructor is teaching about systems theory in relation to the family and its function. The instructor is accurate when stating which of the following? a. All systems have the same characteristics. b. The whole is greater than the sum of the parts.

b

Body temperature is not impacted by which of the following factors? a. age b. diet c. infection

b

During assessment of the family, which question is appropriate for the nurse to ask to determine the expressive function of the family? a. "What are the expected behaviors of the men in your family?" b. "Do family members express both negative and positive emotion?"

b

The nurse begins an assessment of a client's religion and spirituality. Which statement indicates that the client is spiritual? a. "I attend church every Sunday." b. "I am at peace when I spend time out of doors."

b

The nurse is assessing a new client's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the client's systolic blood pressure? a. The first sound that is audible after the auscultatory gap b. The first appearance of faint but distinctive tapping sounds

b

The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation? a. "My boyfriend hits the kitchen wall with his fist just inches from my head." b. "I have not seen my parents in 6 months; they live only 30 minutes away."

b

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action? a. Notify the healthcare provider immediately of the finding. b. Enter the room and auscultate the client's lung sounds.

b

Which technique demonstrates the proper positioning of the client's arm by a nurse when measuring a blood pressure? a. Client's arm bent at the elbow and resting on the thigh b. Client sitting with arm slightly flexed and even with the heart

b

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.) a. Only validate data that you see, not what the client tells you. b. Acquire an adequate knowledge base that continues to build. c. Be nonjudgmental and keep an open mind. d. Use rationale to support opinions or decisions.

b, c, d

A client reports having difficulty smelling food aromas over the past month. Which questions should the nurse include in the health history? a. "Do you have frequent nosebleeds?" b. "Have you had nasal surgery before?" c. "Are you taking any antibiotic medication?" d. "Have you had a cold or flu recently?" e. "Do you smoke cigarettes?'

b, c, d, e

The nurse prepares to perform a cardiovascular examination. The nurse understands the components of this examination include (Select all that apply.) a. auscultating the lungs b. inspecting and palpating the precordium c. examining the neck d. examining the face e. inspecting the hands and lower legs

b, c, d, e

The nurse is completing an admission database entry and must include priority nursing diagnoses for the plan of care. Which statement describes a nursing diagnosis? a. The collection of subjective and objective data b. A clinical judgment about client responses to health difficulties

b; A clinical judgment about client responses to health difficulties

A parent brings her 5-year-old child to the clinic, reporting that she has noticed the child does not seem to be hearing well. There also has been a noticeable speech delay. What does the nurse understand can be a predisposing factor to possible hearing loss?

chronic middle ear infection

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

confabulation

The visible portion of the clitoris is termed the

glans

Holistic Care

health care that takes into account the whole person interacting in the environment

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

malignancy

A nurse assists the client to perform the position change test for arterial insufficiency. While the client is dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test?

normal

Healthy Macro-Breakdown

o 10-35% Proteins o 20-35% Fats o 45-65% Carbohydrates

Nutritional Crisis

o 2/3 adults are overweight o 1/3 are obese o 17% children under 18 are obese

Types of Nonverbal Communication

o Appearance o Demeanor o Facial Expression o Attitude o Silence o Listening

Health History Components

o Biographical data o Reasons for seeking health care o History of present health concern o Personal health history o Family health history o ROS for current health problems o Lifestyle and health practices profile o Developmental level

Questioning Tips (Child Abuse)

o Do not convey a lack of comfortability o Establish the child's mental age and understanding o Keep questions direct o Avoid asking 'yes' or 'no' questions

Assessment Procedure (Families)

o Family Composition o Determine gender roles o Evaluate rank order o Subsystems & boundaries o Family power structure o Extended families o External systems o Context

Questions (Elder Abuse)

o Has anyone ever made you sign papers that you did not understand? o Are you alone often? o Has anyone refused to help you when you needed help? o Has anyone ever refused to give you or let you take your medications?

Questions (Domestic Violence)

o Has anyone in your home ever hurt you? o Do you feel unsafe in your home? o Are you afraid of anyone in your home? o Has anyone made you do anything you didn't want to do? o Has anyone ever touched you without you saying it was OK to do so? o Are you in a relationship with someone who physically or sexually hurts you? o Has anyone ever threatened you at home, in public, at school? o Have you ever been forced into dating, marital relationships, or sexual activities? o Are you or someone you know being trafficked? Is human trafficking happening in your community? o Have you ever been a victim of a hate crime or war-related violence? o Have you ever thought or suspect that you might suffer from PTSD?

Types of Assessments

o Initial Comprehensive o Ongoing or Partial o Emergency

7 Essential Characteristics of Critical Thinking

o Keep an open mind. Use rationale to support opinions or decisions. o Reflect on thoughts before reaching a conclusion. o Use past clinical experiences to build knowledge. o Acquire an adequate knowledge base that continues to build. o Be aware of the interactions of others. o Be aware of the environment.

Types of Verbal Communication

o Open-ended questions o Close-ended questions o Laundry List o Rephrasing o Well-placed phrases o Inferring o Providing info.

Phases of an Interview

o Preparatory o introductory o working o termination

Preparing for Assessment

o Review client's record (learn basic info.) o Review client's status with other health care team members o Reflect on own personal biases o Educate about client's diagnosis and tests performed

Health History Data to Collect During Mental Status Examination

o What is currently your most urgent health concern? o Why are you seeking health care? o Any other health issues o Headaches o Trouble breathing or palpitations o Insomnia o Irritability or mood swings o fatigue o suicidal thoughts o thoughts of hurting or killing others o medical treatment, hospitalizations, or counseling related to mental health o head injury o meningitis, stroke... o military background o family history

Biographical Data to Collect During Mental Status Examination

o What is your name, address, and telephone number? o How old are you? What is your date of birth? Note if the client is male or female. o With which gender do you identify? o What is your marital status? o What is your educational level and where are you employed?

Data Clustering

occurs when related cues are grouped together, also assists in identification of nursing diagnosis

What information should nurse include in the teaching plan for a client considering a vasectomy?

offers permanent birth control

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this?

opthamalascope

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should

palpate deeply while quickly releasing pressure.

A nurse provides care for a client who experiences anxiety, gastrointestinal complaints, and a fear of being poisoned or killed. The nurse recognizes this as which culture-bound syndrome?

rootwork

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

shrug shoulders against resistance

For which assessment would the nurse plan to use direct percussion?

sinuses

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?

stress

Interventions for Ineffective Airway Clearance

teach effective cough technique such as low pressure coughs) is effective to maintain open airways and it spares energy

The nurse assesses sunken eyes and poor skin turgor in a client. What should the nurse consider as a potential cause for these findings?

vomiting

BMI Equation

weight (kg) / height (m^2) *lbs / 2.2 =m kg 1in = 2.54 cm

During an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed...

working