PrepU Exam 1

The nurse at a busy primary care clinic is analyzing the data obtained from the following clients. For which clients would the nurse most likely expect to facilitate a referral? An adult presenting for an influenza vaccination A teenager seeking information about contraception An 80-year-old client who lives with her daughter A 50-year-old client newly diagnosed with diabetes

A 50-year-old client newly diagnosed with diabetes

When assisting a client with health promotion, what must the nurse also nurture? Knowledge of the Healthy People 2020 indicators School/work attendance Family communication A healthy environment

A healthy environment

How does a nurse best facilitate the nursing health assessment? Creating a nursing care plan Formulating a nursing diagnosis Maintaining privacy Asking the appropriate questions

Asking the appropriate questions

Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing? Assessing Intervening where necessary Diagnosing Formulating a discharge plan

Assessing

Revising the plan as needed occurs in what part of the nursing process? Assessment Diagnosis Planning Evaluation

Diagnosis

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? Put on a personal protection gown Disinfect the stethoscope before touching the client Disinfect the stethoscope after touching the client Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface

Disinfect the stethoscope before touching the client

Which describes the nurse using the technique of percussion? The nurse notes resonance over the individual's thorax. The nurse notes symmetry of the individual's thorax. The nurse detects crepitus over the individual's thorax. The nurse detects rustling over the individual's thorax.

The nurse notes resonance over the individual's thorax.

A client has presented for care with complaints of persistent lower back pain. When assessing the client's pain, which statement, made by the nurse, would be most appropriate? "Heating pads usually help relieve my pain." "Did either of your parents have back pain?" "Does this pain really bother you every day?" "What makes your pain better or worse?"

"What makes your pain better or worse?"

Which assessment finding should the nurse document as objective data? Body functions Biographical information Personal relationships Lifestyle practices

Body functions

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first? Validate the data Collect objective data Collect subjective data Document the data

Collect subjective data

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 this assessment? Palpation Inspection Empathy Sympathy

Empathy

A nurse cares for a client with lung cancer who presents with rust-colored sputum and a fever. The nurse performs frequent auscultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? Ongoing Comprehensive Focused Emergency

Ongoing

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? Focused or problem-oriented Ongoing or partial Emergency Initial comprehensive

Ongoing or partial

While discussing family history with a client who is healthy except for a current UTI requiring IV antibiotics, the client tells the nurse that he has three sisters and two brothers. Two of his sisters have died and one brother is in a nursing home after a stroke. The nurse would include the sibling group in a genogram in what manner? 3 circles and 3 squares with lines through 2 squares 3 circles and 3 squares with broken lines connecting 2 of the circles 3 circles and 3 squares with lines through 2 circles 3 circles and 3 squares with two diagonal slashed lines through lines connecting the 2 deceased siblings

3 circles and 3 squares with lines through 2 circles

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what? Alcohol-based rub Use of lotions Hand washing Gloves

Alcohol-based rub

When performing a physical assessment on an older adult client, what should the nurse consider offering this client? A family member in the room A pillow Elevation of the head of the examination table An extra blanket

An extra blanket

The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? Family history Appearance History of present health concern Occupation

Appearance

The nurse is collecting data from a client. Which of the following best reflects objective data? Appearance Religion Occupation Age

Appearance

After the physical examination 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, nonintact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform? Hand wash with antiseptic soap Application of an alcohol-based hand rub No washing is needed because hands are not soiled. Nonantimicrobial soap and water with friction

Application of an alcohol-based hand rub

A client who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption? Ask the client about the most recent experiences of pain. Review the client's medication administration record for analgesic use. Meet with the client's spouse and daughter to discuss the client's pain. Collaborate with the physician who is treating the client.

Ask the client about the most recent experiences of pain.

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? Avoid biases and judgments Identify the need for referral Construct a plan of care Determine if pertinent data has been omitted

Avoid biases and judgments

Universal precautions are primarily designed to protect the health care worker from what? Blood-borne pathogens STDs Respiratory diseases Musculoskeletal injuries

Blood-borne pathogens

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? Determining the client's strengths Making clinical inferences Establishing a trusting relationship Identifying potential health problems

Establishing a trusting relationship

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of? Nursing intervention Nursing assessment Nursing goal Nursing evaluation

Nursing intervention

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? Initial Focused Ongoing Emergency

Ongoing

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following? Quote the client's words. Describe the client's concerns and health goals. Summarize the client's words. Paraphrase the client's words.

Quote the client's words.

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds? Percuss the region before auscultating. Assist the client to a sitting position. Reduce all environmental noise. Palpate the region before auscultating.

Reduce all environmental noise.

What is one way nurses use critical thinking in regard to the nursing process? Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions Critical thinking allows nurses to make decisions regarding client care without involving the client in decisions Critical thinking helps nurses decide which parts of the nursing process are not needed in regard to a particular client Nurses do not need to think critically; they just need to follow the doctor's orders

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what? Assessment Diagnosis Planning Evaluation

Diagnosis

The nurse would use what part of the hand when assessing temperature during palpation? Ulnar surface Palmar surface Dorsal surface Finger pads

Dorsal surface

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique? Compare appearance of symmetric body parts. Look and observe before touching the client. Eliminate distracting noises from the environment. Use good lighting, preferably sunlight.

Eliminate distracting noises from the environment.

A young adult client has come to the clinic for her scheduled Pap (Papanicolaou) test and pelvic examination. The nurse would implement which action to help reduce the client's anxiety during the physical exam? Ensuring client's privacy by providing an examination gown Arranging exam equipment on a bedside tray table Explaining why standard precautions are being used Providing a comfortable, warm room temperature

Ensuring client's privacy by providing an examination gown

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? Identify the most appropriate forms of medical intervention for the client. Identify the status of the client's airway, breathing, and circulation. Establish a baseline for the comparison of future health changes. Determine the most likely prognosis for the client's health problem.

Establish a baseline for the comparison of future health changes

A nurse will complete an initial comprehensive assessment of a 60-year-old client who is new to the clinic. What goal should the nurse identify for this type of assessment? Establish a baseline for the comparison of future health changes. Identify the most appropriate forms of medical intervention for the client. Identify the status of the client's airway, breathing, and circulation. Determine the most likely prognosis for the client's health problem.

Establish a baseline for the comparison of future health changes.

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial? Social concerns Past medical problems Family history Current problem

Family history

An assessment that concentrates on patterns of role performance that all humans share is called what? Functional Focused Head-to-toe Body systems

Functional

Learning about the effects of the illness does what for the nurse and the client? Gives them the basis to establish a trusting relationship Gives them the opportunity to create a complete and congruent picture of the problem Gives them the ability to communicate better Gives them each a better understanding of the other

Gives them the opportunity to create a complete and congruent picture of the problem

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 personal protective equipment should the nurse wear? Gloves, mask, protective eye goggles, gown Mask, protective eye goggles Mask, protective eye goggles, gown Gloves, gown

Gloves, mask, protective eye goggles, gown

The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about? Body system Head-to-toe Functional Focused

Head-to-toe

Staff are talking to the hospital educator and ask about "a government project that is meant to improve the health of people in the United States." The educator bases her response on the knowledge of the Department of Health and Human Services Healthy People 2020 the nursing process the three levels of preventative care

Healthy People 2020

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 Bowel Normal heart Breath

Heart murmur

In the course of performing a client's physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? Breath sounds Heart sounds Bowel sounds Femoral pulses

Heart sounds

A client is providing information about the history of a present illness. What should the nurse keep in mind when documenting this information? (Select all answer choices that apply) Includes smoking and alcohol if contributed to the illness Identifies all childhood illnesses that may contribute to the illness Includes medications if contributing to the illness Includes the client's feelings about the illness Describes how each symptom developed

Includes smoking and alcohol if contributed to the illness Includes medications if contributing to the illness Includes the client's feelings about the illness Describes how each symptom developed

A nurse is completing an assessment that will involve gathering subjective and objective data. Which of the following assessment techniques will best allow the nurse to collect objective data? Therapeutic communication Active listening Interviewing Inspection

Inspection

How does giving false reassurance to a client hurt the nurse-client relationship? Select all that apply. It enhances anxiety, which can increase a client's urge to seek further reassurance It tells the client that the nurse will be there to provide a therapeutic relationship It diminishes his or her trust It validates client concerns It indicates to a client that his or her concerns are not worth discussing

It enhances anxiety, which can increase a client's urge to seek further reassurance It diminishes his or her trust It indicates to a client that his or her concerns are not worth discussing

The nurse has completed an initial assessment of a newly admitted client and is applying the nursing process to plan the client's care. What principle should the nurse apply when using the nursing process? It is used primarily in acute care settings. It involves independent nursing actions. Each step is independent of the others. It is ongoing and continuous.

It is ongoing and continuous.

You should use the bell of the stethoscope when auscultating what type of sounds? Sounds that are partially audible without a stethoscope Low-frequency sounds Abnormal sounds High-frequency sounds

Low-frequency sounds

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 client's 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? Validating information that is already correct Making incorrect nursing judgments or diagnoses Relying on objective and subjective information Interjection of the nurse's thoughts or feelings into the data

Making incorrect nursing judgments or diagnoses

How does a nurse decide what health-promotion activities are necessary for a particular client? Nurses address areas associated with healthy behaviors only Nurses collaborate with clients to identify areas in which clients are willing to make changes Nurses construct their own theories to identify perceptions, barriers, and positive outcomes Nurses assess areas in which clients are willing to make changes only

Nurses collaborate with clients to identify areas in which clients are willing to make changes

A client admitted to the health care facility for new onset of abdominal pain expresses to nurse that they were treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? History of present illness Past health history Chief complaint Review of Systems

Past health history

The RN is implementing which level of intervention when administering immunizations at a pediatric clinic? Tertiary Secondary Holistic Primary

Primary

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 this client? Provide simple and organized information. Approach the client in an in-control manner. Mirror the client's feelings. Refer the client to a spiritual guide.

Provide simple and organized information.

A nurse in the ED is assessing an adult client who, the nurse suspects, has been beaten by her husband. What is the nurse's legal obligation in this situation? Call the police Counsel the client Do not pursue the situation unless the client asks for help Report it to the nurse's supervisor

Report it to the nurse's supervisor

The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following? Resonance Flatness Tympany Dullness

Resonance

During the review of systems, a client reports having difficulty with urination and with establishing an erection. Which additional information should the nurse recognize as the highest priority to assess at this time? Lifestyle Substance use Sexual history Alcohol and tobacco

Sexual history

In which situation should a nurse perform an emergency assessment of a client? Body rash Shortness of breath Ear pain Broken arm

Shortness of breath

A nurse has gathered the necessary equipment for the physical assessment of an adult client. It would be most appropriate for a nurse to use a centimeter-scale ruler for which measurement? Client's height Pupillary size Mid-arm circumference Skin lesion size

Skin lesion size

You are taking a health history on a new client. While performing your assessment, the client informs you that her mother has type 1 diabetes. What is the significance of this information to the health history? The client may be at risk for developing diabetes. The client may need to attend a support group for diabetes. The client may need teaching on preventing diabetes. This may affect the client's diet during hospitalization.

The client may be at risk for developing diabetes.

For which client should the nurse wear gloves to provide care? Select all that apply. The client with vancomycin-resistant enterococci The client who self-administer heparin The client requiring oropharyngeal suctioning The client with Clostridium difficile The client continent of urine

The client with vancomycin-resistant enterococci The client requiring oropharyngeal suctioning The client with Clostridium difficile

A nurse is preparing to perform the physical examination of an adult client who has presented to the clinic for the first time. Which statement would guide the nurse's use of a stethoscope during this phase of assessment? Auscultation can be performed through clothing. The bell of the stethoscope can detect bowel sounds. The binaurals connect the tubing to the chest piece. The diaphragm should be held firmly against the body part.

The diaphragm should be held firmly against the body part.

A nurse on the hospital's subacute medical unit is planning to perform a client's focused assessment. Which of the following statements should inform the nurse's practice? The focused assessment addresses a particular client problem. The focused assessment is done after gathering subjective data. The focused assessment replaces the comprehensive database. The focused assessment should be done before the physical exam.

The focused assessment addresses a particular client problem.

"Tell me about your pain" is an example of an open-ended question. False True

True

Which action by a nurse demonstrates the correct application of the principles of standard precautions? Using an antiseptic hand scrub to cleanse visibly soiled hands. Wearing a gown, gloves, and mask for the physical exam Wearing gloves when palpating the tongue, lips, & gums Change gloves after each body area is examined

Wearing gloves when palpating the tongue, lips, & gums

Identify the steps in order of priority the nurse takes for performing hand hygiene, from first step to last. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Dry hands 2Apply soap. 3Wet the hands. 4Rinse the hands. 5Scrub the hands together vigorously for 15 seconds. 6Turn off faucet with paper towel.

Wet hands Apply soap Scrub the hands vigorously for 15 seconds Rinse the hands Dry hands Turn off faucet with paper towel

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? summarizing empowering active listening empathy

active listening

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status? palpation auscultation percussion inspection

auscultation

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's bone. liver. abdomen. lungs.

bone.

While examining a client, the nurse plans to palpate temperature of the skin by using the dorsal surface of the hand. fingertips of the hand. palmar surface of the hand. ulnar surface of the hand.

dorsal surface of the hand.

The result of a nursing assessment is the formulation of nursing diagnoses. prescription of treatment. documentation of the need for a referral. client's physiologic status.

formulation of nursing diagnoses.

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit tympany. hyperresonance. flatness. dullness.

hyperresonance.

Ability to perform self-care activities (or activities of daily living; ADLs) is a component of the health history that reveals the client's quality of life. When assessing ADLs, the nurse asks if the client can grasp small objects and open jars. This is an example of assessing the client's: values and beliefs home maintenance self-perception mobility

mobility

A client has a 10-year history of being treated for hypertension. Where should the nurse document this information? health patterns past medical history review of systems health maintenance

past medical history

A client comes to the emergency department with severe abdominal pain. When performing a complete assessment, the nurse would focus on which of the following areas when covering past health history? aggravating factors of the pain intensity of the pain previous medical and surgical problems duration of the pain

previous medical and surgical problems

A male older adult client reports a 2-week history of sleep disruption due to frequently waking up to void in the middle of the night. Where in the review of systems should the nurse document this symptom? gastrointestinal neurologic urinary psychiatric

urinary

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to use very basic lay terminology. show the client pictures of different symptoms, such as the "faces pain chart." use standard medical terminology. have a family member present during the interview.

use very basic lay terminology.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? self-perception value-belief role-relationship coping-stress-tolerance

value-belief

While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? To promote objectivity To restate what the client has said To summarize the conversation To clarify

To clarify

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use? Before assessing for vaccinations After assessing for cigarette use While completing the family history During the review of systems

After assessing for cigarette use

A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? Disability Airway Circulation Breathing

Airway

When planning a community program related to Healthy People 2020, the critical first step involves assessing the community formulating questions to ask community leaders planning an introductory program for the community defining the community

defining the community

The nurse is preparing to assess an adult woman's activities related to health promotion and maintenance. Which question should the nurse ask to obtain the most objective and thorough assessment data? "How much beer, wine, or alcohol do you drink?" "Do you use condoms with each sexual encounter?" "Could you describe how you perform self-breast exams?" "Do you always wear your seatbelt when driving?"

"Could you describe how you perform self-breast exams?"

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? "The client has been ordered a nutritional consult; I do the health assessment right after that is finished." "I'm going to assess the client now so that I can begin formulating the care plan." "The health assessment will be more thorough if I wait until the client is pain free." "I'll do the health assessment when the client's family leaves so that distractions will be minimal."

"I'm going to assess the client now so that I can begin formulating the care plan."

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? "I'll just need to evaluate you once more, at the end of your stay." "I'm sorry, but assessment is ongoing and continuous." "Fortunately, assessment only needs to be done at the beginning of your stay." "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end."

"I'm sorry, but assessment is ongoing and continuous."

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply. "My father died of a heart attack." Pupils equal, round, and reactive to light Weight: 145 lbs Lungs clear to auscultation Client complains of a headache "I feel so tired sometimes."

"My father died of a heart attack." Client complains of a headache "I feel so tired sometimes."

A 60-year-old woman with a bunion will undergo surgery later today. The client tells the nurse in the surgical daycare admitting department, "I'm sure I've been asked these questions before. Can't we just focus on my foot and not all these other topics?" How should the nurse best explain the rationale for obtaining a health history? "We don't want to focus solely on the medical problem that brought you here." "The care team needs to cross-reference your diagnostic testing with your medical history." "We want to make sure your nursing care matches your needs as closely as possible." "In general, it's necessary for us to gather as much information about each client as possible."

"We want to make sure your nursing care matches your needs as closely as possible."

Which of the following questions would be most important for the nurse to ask first when obtaining the health history? "What is your major health concern at this time?" "Are you generally fairly healthy?" "Did you bring all your medications with you?" "Do you have adequate health insurance coverage?"

"What is your major health concern at this time?"

A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this? Active listening Restatement Reflection Encouraging elaboration (facilitation)

Active listening

The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data? Select all that apply The medical record Auscultation Palpation Percussion Inspection

Auscultation Palpation Percussion Inspection

A nurse has completed gathering some basic data about a client who has multiple health problems that stem from heavy alcohol use. The nurse has then reflected on her personal feelings about the client and his circumstances. The nurse does this primarily to accomplish which of the following? Determine if pertinent data has been omitted Avoid biases and judgments Identify the need for referral Construct a plan of care

Avoid biases and judgments

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? Collect subjective data related to the client's overall health Perform a rapid assessment for prompt treatment Evaluate whether outcomes of treatment are met Determine any changes from the baseline data

Determine any changes from the baseline data

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply. Do not look the client in the eye Laugh a lot, which puts the client at ease Do not use facial expressions such as rolling the eyes or looking bored or disgusted Make sure that dress and appearance are professional Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

Do not use facial expressions such as rolling the eyes or looking bored or disgusted Make sure that dress and appearance are professional Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

A client has presented to the emergency department (ED) with complaints of abdominal pain. Which member of the care team would most likely be responsible for collecting the subjective data on the client during the initial comprehensive assessment? Admissions clerk Diagnostic technician Gastroenterologist ED nurse

ED nurse

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's 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 the treatment? Implementation Evaluation Diagnosis Assessment

Evaluation

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first? Determine the client's vital signs. Collaborate with the client to identify problems. Explain the purpose of the interview. Obtain family health history data.

Explain the purpose of the interview.

A client comes to the health care provider's office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? Ongoing assessment Emergency assessment Comprehensive assessment Focused assessment

Focused assessment

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? Emergency assessment Ongoing assessment Comprehensive assessment Focused assessment

Focused assessment

Which of the following techniques are used in a physical assessment? Select all that apply. Questioning Inspection Auscultation Palpation Subjectivity

Inspection Auscultation Palpation

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client? Palpation, inspection, auscultation, percussion Inspection, palpation, percussion, auscultation Auscultation, percussion, palpation, inspection Percussion, palpation, inspection, auscultation

Inspection, palpation, percussion, auscultation

In which order should a nurse implement the four physical assessment techniques when initiating a health assessment? Inspection, palpation, percussion, auscultation Inspection, auscultation, percussion, palpation Percussion, palpation, inspection, auscultation Auscultation, percussion, palpation, inspection

Inspection, palpation, percussion, auscultation

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. Mother: Sugar L. Thompson, died 7/14/2006 from heart attack Lamar P. Thompson Occupation: Brick mason 1212 South Maple St., Sylvan, VA 23236 Head and neck: sore throat and enlarged lymph nodes Caucasian

Lamar P. Thompson Occupation: Brick mason 1212 South Maple St., Sylvan, VA 23236 Caucasian

What condition are clients who are frequently hospitalized, as well as nurses, more often diagnosed with than the general population? Medication allergies Latex allergy Inflamed skin Bunions

Latex allergy

An older adult client has been admitted to the hospital with failure to thrive resulting from complications of diabetes. Which of the following would the nurse implement in response to a collaborative problem? Provide the client with a bedtime protein snack. Encourage the client to increase oral fluid intake. Assist the client with personal hygiene. Measure the client's blood glucose four times daily.

Measure the client's blood glucose four times daily.

Which of the following is the best example of holistic data collection by a nurse? Measuring blood glucose level, cholesterol level, blood pressure, and resting heart rate Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Performing an x-ray, ECG, exercise stress test, and complete blood count Assessing the client's range of arm motion, auscultating for heart sounds, testing for pupil dilation, and conducting a vision test

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

Which of the following is the best example of assessment in everyday life? Taking the dog for a walk in the park to get exercise Measuring the remaining tread on a car tire to determine whether it is time to replace it Listening to a favorite song to relax in the evening Texting a friend to let her know that you made it home safely

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

How does a nurse decide what health-promotion activities are necessary for a particular client? Nurses assess areas in which clients are willing to make changes only Nurses collaborate with clients to identify areas in which clients are willing to make changes Nurses construct their own theories to identify perceptions, barriers, and positive outcomes Nurses address areas associated with healthy behaviors only

Nurses collaborate with clients to identify areas in which clients are willing to make changes

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) Obtain and check needed equipment. Identify ways to ensure client privacy. Dim the lighting to promote comfort Wash hands. Turn on relaxing music of the client's choice

Obtain and check needed equipment. Identify ways to ensure client privacy. Wash hands.

A comprehensive health history includes which components? Select all that apply. Past health history History of present illness Employment history Reason for seeking care Income

Past health history History of present illness Reason for seeking care

The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client's health history under which of the following? Identifying data Reliability Personal and social history Review of systems

Personal and social history

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, the nurse periodically performs a partial assessment primarily for which reason? Determine the need for crisis intervention Reassess previously detected problems Address areas previously omitted Provide information for the client's record

Reassess previously detected problems

A nurse often has the option to use an alcohol-based hand rub for hand hygiene, but proper technique is essential in its use. What is the proper technique for the use of an alcohol-based hand rub? Rub the hands and fingers until dry Rub only the palms of the hands Dry the hands on available paper towels Use when the hands are visibly soiled

Rub the hands and fingers until dry

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 primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary? The physician The client's wife The client The client's medical record

The client

A community health nurse is assessing an older adult client in the client's home. When the nurse is gathering subjective data, which of the following would the nurse identify? The client's behavior The client's affect The client's posture The client's feelings of happiness

The client's feelings of happiness

The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following? The client's motivation for change The client's learning style The client's prognosis for recovery The client's medical comorbidities

The client's motivation for change

During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply. To help identify those diseases for which the client may be at risk To identify genetic family trends for which the client is at risk To elicit negative family history To provide counseling and health teaching in high-risk areas To help the client feel at ease and not worry about being sick

To help identify those diseases for which the client may be at risk To identify genetic family trends for which the client is at risk To provide counseling and health teaching in high-risk areas

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? "How do you feel about having to seek health care?" "What diseases did you have as a child?" "Are both of your parents still living?" "What do you usually eat in a typical day?"

What diseases did you have as a child?"

A nurse is conducting a health assessment. How will the information collected from the client be used? to facilitate nurse-client caring as a basis for the nursing process as one component of medical care to illustrate nursing competence

as a basis for the nursing process

A middle-aged client has an appointment for a routine physical. Which type of assessment is the most appropriate for the nurse to complete? comprehensive follow-up emergency focused

comprehensive

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed comprehensive. entry. focused. exploratory.

comprehensive.

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? comprehensive emergency ongoing partial focused

focused

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n) focused or problem-oriented assessment. initial comprehensive assessment. ongoing or partial assessment. emergency assessment.

focused or problem-oriented assessment.

The nurse is completing a health assessment with a newly admitted client. What should the nurse do after completing the health history? perform a physical examination document the findings determine a problem list cluster the data

perform a physical examination

A woman brings her newborn to the clinic for a well-baby visit. The nurse knows that the focus of this health history should be on which of the following: pregnancy, birth, and perinatal histories pattern and relationship of illnesses self-perception and stress tolerance religious and spiritual factors

pregnancy, birth, and perinatal histories

The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority? significantly impaired hearing lives alone widowed 2 years ago greatly concerned about cost of services

significantly impaired hearing

The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information is belongs to which attribute of a symptom? duration associated manifestations treatment onset

treatment