Introduction to Health Assessment Test

A nurse is conducting a general survey o a client who is being admitted to a long-term care facility. The nurse is assessing the client's emotional state. Which of the following findings should the nurse record as a subjective, unexpected finding?

The client reports they feel sad and lonely most of the time

A nurse assesses a client's respiratory rate and notes that it is below the expected reference range. The nurse should identify that which of the following findings can cause a decreased respiratory rate?

The client takes a narcotic pain medication for chronic pain

A nurse is providing teaching to a client who asks, "What are things that can affect my blood pressure?" Which of the following information should the nurse include as factors that affect blood pressure? (Select all that apply)

Time of day Obesity Diuretic medication Smoking

A nurse is documenting information in a client's medical record during an initial assessment. Which of the following information should the nurse include in the documentation? (Select all that apply)

Use of assistive devices Height ad weight Behavior and mood

A nurse is planning on obtaining an orthostatic blood pressure from a client who has syncope. In what order should the nurse take the following steps?

1 Place the client in supine position and allow them to rest 2 Take the client's blood pressure in the supine position 3 Keep the cuff in place and assist the client to a seated position 4 Take the client's blood pressure in a seated position 5 Assist the client to stand and obtain their blood pressure

A nurse is admitting a client who is 162.6 cm (64 in) tall and weighs 68.2 kg (150 lb). Using the BMI table shown below, what should the nurse record as the client's BMI?

B 25

A nurse is completing an initial assessment checklist on an older adult client. The client is accompanied by their caregiver. For which of the following indicators should the nurse observe when assessing for potential maltreatment of the client? (Select all that apply)

Dirty clothing Unexplained physical injuries Malnourished appearance

A nurse is preparing to conduct an initial survey ad assessment on a newly admitted client. Which of the following actions should the nurse plan to take?

Engage in active listening with the client and allow the client and allow the client to express concerns early in the assessment process

A nurse is preparing to obtain a client's height during a general survey. Which of the following actions should the nurse take?

Ensure the client's feet are in contact with the wall or measuring pole

A nurse is conducting a general survey o a client ad notes a continuous twitching movement of a muscle in the client's left arm. Which of the following terms should the nurse use to describe this involuntary movement?

Fasciculation

A nurse is documenting a client's vital signs in the medical record following a general survey. Which of the following entries should the nurse place in the record?

Oxygen saturation 96% on oxygen 2 L/min via nasal canula

A nurse is having difficulty obtaining a pulse oximetry reading from a client. The nurse should identify that which of the following factors can interfere with obtaining a pulse oximetry reading?

Recent scan with contrast dye

A nurse is caring for a middle adult client who has stomatitis and is unable to hold an oral probe in their mouth. Which of the following alternative routes should the nurse use to obtain the most accurate core temperature of the client?

Rectal

A nurse is obtaining a client's pulse and notes a regular rhythm with a rate of 110/min. The nurse should identify this as which of the following unexpected findings?

Tachycardia

A nurse is assessing a client's respirations and notes they are shallow and at a rate of 24/min, The nurse should identify this as which of the following unexpected findings?

Tachypnea

A nurse is caring for a client who is reporting pain as 4 on a scale of 0 to 10. Upon further assessment, which of the following findings should the nurse identify as manifestations of chronic pain? (Select all that apply)

The client reports that the pain has been present for approximately 4 years The client reports never feeling total relief from pain The client reports that the pain is recurring and does not always originate in the same location