NURSING ASSESSMENT CHAPTERS 1-5 &8

A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about is presenting symptoms?

"How is your wife's illness affecting you"

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse?

"I am very happy with m life right now"

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

"What diseases did you have as a child?"

A nurse is using COLDSPA to collect data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be nest for eliciting information related to the component "associated factors"

"What other symptoms occurred during the spell?"

A nurse notes that the pulse rate of a client is less than 60 bpm. Which question is appropriate for the nurse to ask the client in regards to this finding?

"have you been sitting for a long time"

A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to enhance the sounds of the heart tones?

1.) Angle the binaurals towards the nose 2,) readjust the earpieces to ensure a snug fit 3.) eliminate distracting noises from the environment

A nurse has completed assessing a client and now must validate the collected data. What are the steps the nurse should follow? Select all that apply.

1.) Determine ways to validate the data 2.) decide whether the data requires validation 3.) identify areas where data is missing

A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase? Select all that apply

1.) Nursing history 2.) physical assessment data 3/) information provided by the client

A female client 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

After the physical assessment of a client, a nurse disposes of the used gloves. The nurse has not come in contact with any body fluids or excretion, mucous membranes non-intact skin, or wound dressings. the nurses hands do not appear to be visibly soiled. What hand hygiene should the nurse perform?

Application of an alcohol-based hand rub

A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this patients anxiety?

Before performing each procedure, explain what it involves and its purpose.

During the physical assessment of a client, a nurse observes that the client tends to lean forward and brace himself with his arm. The nurse recognizes this as a sign of what disease process?

COPD

A nurse is busy analyzing data collected for an elderly Indian client with Alzheimer's disease who is in the hospital for pneumonia. The nurse originally had "demonstrates dementia" and "does not respond when spoken to" grouped together as symptoms of Alzheimer's. Later, however, the nurse learned that the client is also hearing impaired, which better explains the fact that the client does not respond when spoken to. Which error did the nurse commit in this case?

Clustering together unrelated cues

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?

Cued or checklist forms

A nurse is preparing to interview a client who is a seventh day Adventist. The nurse does not agree with this religions views of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?

Formation of judgments that may intervene with the interview

A nurse observes the gait of an elderly client admitted for surgery. This clients gait is stiff with rigid movements. The nurse should ask this client questions about which disease?

Parkinsons disease

A nursing student will soon be graduating and beginning a new job at a local health clinic. THe nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills>

Practice performing a physical examination on a classmate, friend or relative

A client with an inability to read billboards while driving arrives at the health care facility for an exam. Which piece of equipment should the nurse use to check the clients distant vision?

Snellen chart

An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. the nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's PCP, who had relayed some concerns to the nurse regarding the progression of:

The client

A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?

The clients range of motion in her right arm

A nurse is performing percussion over the area of a clients stomach. The nurse should anticipate hearing which type of sound?

Tympany

A nurse is trying to decide whether to recommend that a pregnant client be screened for HIV. Which of the following resources would best help in this decision?

US Preventive Services Task Force

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states that he cannot feel his leg. The nurse notes that the client is lethargic and midly confused. What SUBJECTIVE data should the nurse document on this client?

Unable to feel his leg

A nurse analyzes the data obtained from the assessment of a client. The nurse has identified and clustered the abnormal data and strengths of the client. What should the nurse do next when analyzing the data?

Write down the hunches based on the cue cluster.

risk diagnosis

a problem the client is uniquely at risk for developing, but does not currently have

A client is admitted to a health care facility for injuries received in a motor vehicle accident is given to the nursing diagnosis of impaired nutrition: less than body requirement. Which type of nursing diagnosis is this?

actual

A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

adequate lighting

wellness diagnosis

based on patients request; pt has motivation to increase well-being

A nruse obtains a pulse rate on an adult client of 56 bpm. What is the correct term that the nurse should use when documenting this finding?

bradycarida

A nurse proposes a nursing diagnosis for a client based on subjective and objective data. What step should the nurse program before the diagnosis can be confirmed or ruled out?

check for the presence of major and minor characteristics

A nurse is assesing the general status and vital signs of a client. Which of the following are SUBJECTIVE findings, which the nurse is obtained from the client?

date and location of the clients last BP check onset and character of the clients chest pain a list of all the clients current medications

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

heart murmur

A nurse is assessing a clients pain level while taking his blood pressure. Which of the following are signs of the pain that the nurse should look for in an assessment?

holding a shoulder shallow, raid breathing grimacing

A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis?

inflamed appendix is causing sever abdominal pain

A nurse admits a client to the health care facility. The nurse gathers data about the clients social history and wants to make this information available to the social worker. Which initial assessment documentation form is best for the nurse to use?

integrated cued checklist

A nurse obtains a bp on an elderly client of 160/70. The nurse knows that the term for this condition is?

isolated systolic hypertension

A client presents to the clinic with reports of an itchy rash all over his body. The nurse observes lesions on the clients arms and legs as well as the presence of a dry, hacky, couch and sneezing. Which data collected from the client can be classified as SUBJECTIVE abnormal findings?

itchy feeling

a nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be more appropriate for the client?

knee-chest

A nurse obtains a clients blood pressure on admission in both arms; right arm BP is 130/75 mmHg and left arm is 140/80 mmHg. Which arm should the nurse use for subsequent blood pressure reading?

left arm

A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?

light palpation

A nurse is preparing to perform a genital exam of a female client. Which of the following positions should the nurse place the client in?

lithotomy

A client comes to the health care facility with reports of abnormal bleeding from his gums, chills, and a recurrent infection. How should the nurse cluster the data collected from the client?

look for related cues in the abnormal findings and strengths

Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?

maintain a professional distance during assessment

A nurse is palpating a clients chest for vibration as he inhales and exhales. Which part of the hand should the nurse use in this case?

palmar surface

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

personal health history

During a health history interview, a nurse asks a client about childhood illnesses, past surgeries, and allergies. The nurse knows that this information will be charted in what section of the initial comprehensive assessment database?

personal health history

A nurse is preparing to asses a clients vital signs. Which order should the nurse asses them?

temperature pulse respiration blood pressure

A nurse assesses a female clients core body temperature and finds that she has a slightly elevated temp. Which of the following factors could explain this finding?

the client just finished exercising the client is stressed the client is ovulating

A nurse is working with a client who has AIDS. Which of the following is an example of the subjective data that night be gathered for this client?

the clients pain level

A nurse is having a new client complete a health history form acknowledging his rights under HIPPA. The client asks the nurse what HIPPA covers. Which of the following most accurately describes what HIPPA covers?

the confidentiality of electronic and printed health information

A nurse is performing indirect percussion of the lungs on a young woman with pneumonia. Which of the following is the correct hand placement or this technique?

the middle finger of one hand is placed on the body surface and the other middle finger strikes.

A nurse has just discussed with a client the quality, severity, and location of the clients back pain. Which of the following is an appropriate guideline for the nursse to follow when documenting these findings?

use phrases instead of sentences to record data

while performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

to determine whether a structure is filled with air or fluid or is a solid structure

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep on mind while performing this technique?

Eliminate distracting noises from the environment

A nurse notes that a client looks much older than his chronological age. Which of the following conditions would most likely contribute to this appearance?

alcholism

A nurse is assessing the social and spiritual needs of a client who is terminally ill with pancreatic cancer and living at home. This nurse most likely works in which of the following settings?

Hospice

Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 pounds in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the weight will begin to affect the clients health. The nurse makes a note to discuss it with a client at the next visit. Which nursing diagnosis would be the most appropriate for this client>

Imbalanced nutrition: more than body requirements

A nurse is beginning the physical examination of elderly man with COPD. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with the client?

Provide simple and organized information

What is an appropriate action by a nurse when providing care for an 8 year old with respiratory problems caused by excessive smoking?

suggesting methods and provide resources to assist with smoking cessation

A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform her assessment?

Empathy

A nurse is conducting a review of systems with a client and is asking about his ears. The nurse asks, "do you have any problems with your ears or hearing." The client stares blankly at the nurse a moment and then says "Im sorry could you repeat that" The nurse repeats the question, to which the client replies, "no". The nurse then asks "do you ever experience any trouble hearing or any ringing, buzzing or earaches?" The client responds, "No". What should the nurse record under "ears" in the review of systems section of the clients health history/

"Denies any trouble hearing or any ringing, buzzing or earaches"

A nursing student is explained to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?

"Diagnostic reasoning is a form of critical thining used to interpret data correctly"

A nurse is interviewing a man complaining of pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that it is likely from prolonged work at a computer particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this

"Do you perform any sustained or continually repetitive motions with that arm"

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "validate my data? what does that mean?" How should the nurse respond to this client?

"It means I need to make sure that all the information I gathered today is reliable and accurate"

A nurse is interviewing a client who has recently been diagnosed with terminal prostate cancer to establish his health history. In covering his lifestyle and health practices profile, the nurse asks him, "Are you close to any extended family members in the area?" The man objects to the question and asks why the nurse needs to know that. Which of the following is the best rationale for the nurse posing this question?

"I just wanted to see what kind of social support you might have to help care for you during your illness"

A nurse is assessing the cognitive function of a 13 year old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?

"Im sorry but assessment is ongoing and continuous"

On reviewing a clients database following a physical examination, a nurse realizes the clients weight has been steadily increasing over her past three visits. What follow up question would be best fot the nurse to pose the client based on this finding?

"has your diet or exercise changed significantly in the past year"

The nurse assess the amplitude of the clients radial pulse and finds it to be weak and diminished.Which of the following scores should the nurse record?

1+

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?

1.) 1212 south maple street, sylvan VA 23236 2.) Occupation:Brick mason 3.) Lamar P. Thompson 4.) Caucasian

A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process?

1.) Identification of the need for referrals 2.) formulation of nursing diagnosis 3.) identification of collaborative problems

A nurse interacts with four different clients on afternoon at the health clinic. The nurse is able to directly assist three of them and make a referral for the fourth. Which of the following patients should the nurse refer to another professional.

1.) an elderly woman who needs daily therapy sessions to help her walk again after a hip fracture

A nurse has completed the assessment phase of the nursing process with a client and is now moving into the data analysis phase. Which of the following are essential components that the nurse will address in this phase?

1.) clustering data to make inferences 2.) generating possible hypotheses 3.) grouping and organizing data

The hospital where a nurse works is converting from a paper based documentation system to a computer based on. The nurse recognizes that which of the following are advantages of computer based over paper based systems?

1.) eimination of redundant data collected by other heath care team members 2.) ability to link the clients health record to other documents 3.) increased likelihood that clients will receive life saving treatment 4.) potential lowered risk of hospital acquired infections

A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should be stressed hat will promote opportunities for nurses with advanced assessment skills?

1.) increasing complexity of acute care 2.) growing aging population with complex comorbidities 3) declining numbers of medical students due to rising costs and focus on primary care 4.) increasing impact of children and the homeless on communities

A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis?

1.) reflect on thoughts before reaching a conclusion 2.) use past clinical experiences to build knowledge 3.) use rationale to support opinions and decisions

A novice nurse is struggling with making accurate nursing diagnoses. The supervisor, a much more experienced nurse, counsels the novice on what characteristics help nurses make better diagnoses. Which of the following should the supervisor mention?

1.) seeing shades of gray when making decisions 2.) focus on the big picture 3.) years of experience 4.) awareness of when exceptions apply to rules

A nurse is recording some vital signs in a 12 ear old girls chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? SELECT ALL THAT APPLY

1.) to determine the educational needs of the client 2.) to prevent any delays in carrying out the care plan

Which actions should a nurse perform before beginning the initial shift assessment of a client?

1.)review the clients record before meeting the client 2.)reflect on own feelings regarding the initial encounter with the client 3.) revise nursing care plans to reflect improvements in the clients condition

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

120/55 mm HG a drop in MORE than 20 mm Hg

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many genetic relatives as the clients can recall

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

Ashen grey

A nurse needs to auscultate the heart sounds of a patient who is in a hospital room watching his favorite tv show. Before beginning the assessment, which of the following should the nurse do to provide a proper environment for the assessment?

Ask the client if it would be okay to mute the volume on the TV during the assessment

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?

Explain the reason for taking down notes

A nurse is working with an obese man who has type II diabetes mellitus. After interviewing this client, the nurse has established that he is aware of the seriousness and risks of his conditions, is motivated to make lifestyle changes to improve his health, and believes that following the diet and exercise plan that the nurse has helped him create is feasible and would be effective in helping him meet his health goals. The nurse is using which of the following tools or resources in assessment of this client?

Health belief model

A nurse is performing a self-assessment of ability to think critically, making a list of characteristics behaviors. Which of the following behaviors would indicate critical thinking?

Exploring many alternatives before making a decision

A nurse needs to position a client in the supine position for the physical examination. The nurse should ask the client to do which of the following?

Lie on the back with the legs together on the exam table

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile

A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the patients chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?

Making incorrect nursing judgements or diagnoses

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

Marfan's Syndrome

Which of the following is the best example of assessment in everyday life?

Measuring the remaining tire tread on a care tire to determine whether it is time to replace it

A nurse is performing an initial assessment of a client. Which assessment form should the nurse use?

Nursing minimum data sheet

A nurse provided dietary counsel for a client who recently immigrated to the US from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to clients unwillingness to listen to dietary advice". At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background

A client reports chest pain that occurs with exercise but subsides with rest. the nurse recognizes this as what type of data?

subjective

A nurse is performing percussion on a clients back to asses the lungs, and hears a loud, low pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

In which situation should a nurse perform an emergency assessment of a patient?

Shortness of breath

In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?

Some herbal supplements may interact with prescribed medications.

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?

Speak slowly and client, using straightforward language

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the clients skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment

TO determine any changes from the baseline data

A nurse is working with a 14 year old girl who has told the nurse that she would like to try getting into bed a little sooner to get a fill nights sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to clients expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise but wants of increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness dianosis readiness for + diagnostic label + r/t + etiology + AMB + symptoms (Defining characteristics)

Which interview question by the nurse demonstrates a biased or prejudiced attitude?

You're not homosexual, are you?

actual diagnosis

a client problem that is present at the time of the nursing assessment

A nurse is explaining to a new client that the office uses electronic health records (EHR) for all clients. The client says that his last office visit, they used EMR's. He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR?

a record supplied by a physician in which diagnoses and prescribed treatments are recorded

A client reports sudden hair loss and continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance Which abnormal finding should the nurse classify as objective data?

anxious appearance

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format for representing a deceased female relative?

circle with a cross

A nurse receives report on a client admitted for new onset of lung cancer and reviews the initial comprehensive assessment. The nurse recognizes that which information is subjective and needs validation by further data collection?

client denies any feelings of anxiety or distress over the diagnosis

A nurse is documenting a clients headache. Which of the following would be the best entry to include for this finding?

client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

Which technique demonstrated the proper positioning of the clients arm by a nurse when measuring blood pressure?

client sitting with arm slightly flexed and even with the heart

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

For which of the following clients should a nurse perform a focused assessment?

client with a 4 day history of sore throat and fever

A nurse has just finished taking a clients vital signs and is comparing the results with those from his previous 3 months. Which of the following situations would require the nurse to validate the data?

clients weight was 200lbs 3 months ago but 125lbs today

A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. What phrase of the interview process is this?

closing

A nurse is preparing to perform a test for sterognosis in a client. Which piece of equipment should the nurse use?

coin or key

A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurses responsibility?

collect subjective and objective data related to overall function

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection>

color

A nurse assess a pregnant client in her second trimester. The nurse documents the weight of the client and notices that she has gained 6 pounds over a week. How should the nurse validate this data?

compare objective findings with subjective findings

A client presents to the health care facility with reports of new onset chest pain of 3 days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse to perform for his client?

comprehensive

What action is appropriate for a nurse to perform when an irregular radial pulse is palpated on a client?

cont the pulse for a full minute for an accurate rate

a nurse measures a clients BP and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading?

do you need to empty your bladder

A nurse makes an incorrect entry on a clients paper record during documentation of the assessment data. Which is the correct way for the nurse to fix this error?

draw a line through the error, write "error" and initial the entry

An elderly client is admitted with new onset of left sided weakness, slurred speech and hypotension. The clients husband states that she has stopped taking her bp medications for the past week because they were making her feel dizzy and lacking in energy. Which nursing diagnosis can be confirmed by this data?

dressing self care deficit

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?

ensure that contact with the skin is maintained

A nurse provides care for a client with an elevated temperature. the client is given the prescribed medication and the nurse checks the clients temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of treatment?

evaluation

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

focused

Which of the following is an example of a recent trend in nursing roles?

gathering forensic evidence for a legal proceeding

A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity.Which pieces of PPE should the nurse wear?

gloves, mask, protective eye goggles, gown

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?

goniometer

A nurse is preparing to physically examine a client. the nurse recognizes that it is best to begin the objective data collection with which procedure?

measure the clients vital signs, height and weight

Which of the following is the best examples of holistic data collection by a nurse?

measuring blood pressure inquiring about a clients nutritional intake, assessing for depression, and asking the client how his condition affects famil gatherings.

A nurse is conducting client assessments in a long term care facility. The manager of the facility has requested that the clinical staff uses assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long term care facilities in the nation. What form should the nurse use?

nursing minimum data sheet

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

ongoing or partial

A nurse is using COLDSPA mnemonic to collect data on a client's chief complaint, which is pain in the heel of his foot. The nurse asks the client, "when did this pain start?" Which complaint of symptom analysis does this question represent?

onset

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. the nurse suspects that it is just ear wax that is the problem, but needs to view the war canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

otoscope

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

palpate the carotid arteries

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas?

physiologic, psychological, sociocultural, developmental and spiritual data.

A nurse is interviewing a client who seems anxious. Which nonverbal communication by the nurse helps to facilitate a relaxed environment for the client during the interview process?

portraying a neutral and friendly expression

When gathering information about medication use, a nurse should ask a client about which types of drugs?

prescription and over the counter medications

A nurse needs to assess a clients range of motion in the hip joints. Which position is best to facilitate this examination>

prone

What is the best action by a nurse when a client has difficulty describing the chief complaint?

provide the client with a laundry list of words to choose from

A client is admitted to the health care facility with new onset of abdominal pain. the client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview?

remain in control and allow the client to ventilate feelings

A nurse who has been working at the health clinic for 20 years has just taken a clients blood pressure and found it to be 110/70. When consulting the clients record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on anti hypertension medication the whole time. His BP has never been 150/90 and was 180/95 at his last visit a year ago. The patients weight has remained the same. The nurse realizes the data needs to be validated. Which method of validation would be most appropriate in this case?

repeating the measurement with a different sphygmomanoter and stethoscope

A nurse is interviewing a 16- year old girl regarding her health history. When inquiring about her chief complaint, the girl lowers her voice and says "I've been with a guy recently, and I'm worried that I might have caught something from him." The nurse responds by saying, "so you're concerned that you may have a STI?" Which verbal communication technique is the nurse using here?

rephrasing

The nurse is assessing an elderly clients BP and finds it to be high. Which of the following characteristics should the nurse suspect in respect to the clients arteries?

rigid

An inexperienced nurse has just performed percussion a client's chest and detected hyper resonance, which would tend to indicate emphysema. However the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data needs to be validated. Which method of validation would be most appropriate in this case?

verify the data by having another nurse come in to perform the percussion

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

wash hands before examination in the examination room

The nurse is assessing a clients RR. Which of the following should the nurse do to ensure accuracy of this assessment?

watch chest movement before removing stethoscope after counting the apical beat

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

wearing gloves when palpating the tongue, lips and gums

An adolescent client presents to the health clinic for a routine physical examination. Which observations by the nurse needs validation by collection of OBJECTIVE data.

wearing long sleeved clothing in JUly

A nurse is examining a client suspected of having a fungal infection of the skin. Which piece of equipment should the nurse use to confirm the presence of fungus?

woods light

A nurse asses 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?

working