Health Assess. Exam 1

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client 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? A. "I just wanted to see what kind of social support you might have to help care for you during your illness." B. "I just thought i might know them; I know pretty much everyone in this town." C. "I'm just being friendly. We like to get to know our clients at this practice." D. "With you having a terminal illness, you will need someone to help you plan your funeral."

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

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? A. Auscultation B. Inspection C. Percussion D. Palpatation

A. Auscultation

The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of: A. Batch charting B. Point-of-care documentation C. Accurate documentation D. Organized charting

A. Batch charting

Which skin characteristic can a nurse observe by using inspection? A. Color B. Texture C. Elasticity D. Temperature

A. Color

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition? A. Fingers and toes B. Around the mouth and lips C. Nose and earlobes D. Chest and abdomen

A. Fingers and toes

A group of student nurses is presenting information on Gordon's framework for assessing a client. What type of assessment would they be talking about? A. Functional B. Emergency C. Comprehensive D. Focused

A. Functional

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment? A. Head to toe B. Alphabetical C. In a circle D. Right to left

A. Head to toe

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? A. Inspection B. Palpatation C. Percussion D. Auscultation

A. Inspection

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? A. Light B. Deep C. Moderate D. Intermediate

A. Light

When documenting that a patient has freckles, the appropriate term to use is A. Macules B. Patches C. Bullae D. Vesicles

A. Macules

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information? A. Neurologic B. Peripheral vascular C. Musculoskeletal D. Cardiovascular

A. Neurologic

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 ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this? A. Otoscope B. Stethoscope C. Sphygmomanometer D. Opthalmoscope

A. Otoscope

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? A. Perioral B. Facial C. Palms D. Chest

A. Perioral

The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing? A. Recommendation B. Assessment C. Background D. Sitution

A. Recommendation

A nurse implements which skin assessment to determine the presence of dehydration in a client? A. Turgor B. Thickness C. Texture D. Temperature

A. Turgor

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? A. When palpating lesions on the client's skin B. When palpating the client's hair C. When palpating the texture of the client's skin D. When palpating the client's nail beds for texture and capillary refill

A. When palpating lesions on the client's skin

The nurse is assessing a client who has been sexually abused by an ex-boyfriend. What would be an example of subjective data from this client? A. crying and shivering B. "He bet me and then raped me" C. Contusion on head D. Rape kit test result

B. "He bet me and then raped me"

Which of the following terms is used to describe the arrangement of skin lesions? A. Localized B. Annular C. Generalized D. Exposed

B. Annular

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? A. May affect a person's body image negatively B. Can be caused by an underlying systemic illness C. Local irritation can cause damage to the nail bed D. Abnormalities may be a sign of poor hygiene

B. Can be caused by an underlying systemic illness

Which of the following would be most important for the nurse to do immediately before beginning a physical exam? A. Establish the client's reliability as historian B. Collect necessary equipment essential to the exam. C. Practice interviewing skills D. Construct the clients family genogram

B. Collect necessary equipment essential to the exam.

During a home visit an older client asks the nurse to find out what papers the client signed "the other day." What should the nurse do first? A. Ask the client for the name of the person who had to papers to sign B. Continue to assess for indication of abuse or neglect C. Say "I don't know i wasn't there."

B. Continue to assess for indication of abuse or neglect

A shared, learned, and symbolic system of values, beliefs and attitudes that shape and influence how people see and behave in the world is a definition of what? A. Community B. Culture C. Life D. Ecosystem

B. Culture

What guidelines should the nurse keep in mind while performing auscultation? A. Use good lighting, preferably sunlight B. Eliminate distracting noise from the environment C. Look and observe before touching the client D. Compare appearance of symmetric body parts

B. Eliminate distracting noise from the environment

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform? A. Nonfocused B. Emergency C. Focused D. Comprehensive

B. Emergency

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called? A. Therapeutic Communication B. Empathy C. Sympathy D. Caring

B. Empathy

What should a nurse be aware of before effectively assessing for the presence of family violence? A. Need to create a safe and confidential environment B. Examine feelings, beliefs, and biases about violence C. Do nothing and contact social services

B. Examine feelings, beliefs, and biases about violence

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? A. Purulent, fluid-filled, raised lesions of any size B. Fluid-filled lesions less than 1 cm in diameter C. Fluid-filled lesions greater than 1 cm in diameter D. Raised, reddened, edematous papules or plaques, varying in size and shape.

B. Fluid-filled lesions less than 1 cm in diameter

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information? A. Review of symptoms B. History of present illness C. Past health history D. Chief complaint

B. History of present illness

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following? A. Cherry angioma B. Petechiae C. Ecchymosis D. Purpura

B. Petechiae

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes what the client has just said. What type of communication is the nurse using? A. Silence B. Reflection C. Active listening D. Restatement

B. Reflection

A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation? A. Client appears upset about upcoming surgery B. Skin pale, warm, and dry without evidence of lesions. C. Client was interviewed about previous history of hypertension D. Client's oral intake is satisfactory

B. Skin pale, warm, and dry without evidence of lesions

How should the nurse palpate the skin of a client to assess its texture? A. Rub the dorsal surface of the hand over the skin B. Touch with the palmar surface of three middle fingers C. Press the fingertips to the skin surface D. Pinch and roll the skin between the fingers

B. Touch with the palmar surface of three middle fingers

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus? A. Sunlight B. Wood's light C. Flashlight D. Artificial light

B. Wood's light

What intervention should a nurse implement to become culturally competent when assessing a client from another culture? A. Become appreciative and sensitive to the values and beliefs of clients B. collect relevant cultural data of client's health history C. Not help the patient due to religious differences D. Do research on culture

B. collect relevant cultural data of client's health history

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the A. Emergency history B. focused assessment C. Follow-up history D. Comprehensive health history

B. focused assessment

A patient with a zosteriform rash has a rash that A. is distributed equally on both sides of the body B. is distributed along a dermatome C. has lesions distributed over a large body area D. appears with a single lesion in close proximity to a large lesion, as if "orbiting" the larger lesion

B. is distributed along a dermatome

The nurse is performing an admission assessment with a patient and is questioning the patient about religious preference. The patient says that they have no religious or spiritual preference. What statement by the nurse demonstrates a non-judgemental attitude? A. "I am a very religious person so I dont think I'm going to be able to treat you." B. "Let me direct you to the hospital chaplin. He can talk with you. " C. "What provides you strength in dealing with stress or illness in your life?" D. "Let me give you some information about religion."

C. "What provides you strength in dealing with stress or illness in your life?"

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed? A. Environment B. Support-System C. Age D. Occupation

C. Age

A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this is client is culturally appropriate? A. Talk louder B. Use an interpreter C. Be respectful of the client's culture D. Contact a family member

C. Be respectful of the client's culture

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? A. Newton Scale B. Head-to-toe assessment C. Braden Scale D. Norton Scale

C. Braden Scale

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process? A. Glance at the clock at the wall B. Leave the interview and contact security C. Courteously interrupt the patient to clarify some information D. Tap the pen on the paper while the patient talks

C. Courteously interrupt the patient to clarify some information

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

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

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate A. Calcium B. Carbohydrates C. Fluid intake D. Vitamin D

C. Fluid intake

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects: A. Inability of the patient to perform ADL's B. Hypertension C. Human violence D. Anorexia nervosa

C. Human violence

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is A. Auscultation B. Palpatation C. Inspection D. Percussion

C. Inspection

The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding? A. Recent trauma B. Iron deficiency C. Normal finding D. Hypoxia

C. Normal finding

What is the nurse's best defense if a patient alleges nursing negligence? A. Patient's family B. Testimony of expert witnesses C. Patient's record D. Testimony of other nurses

C. Patient's record

Your lab instructor explains that physical examination relies on what cardinal assessment technique? A. Assessment B. Organization C. Percussion D. Communication

C. Percussion

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary? A. Evaluates the seriousness of the client's risk factors B. Completes the client's health record C. Provides a focus for the physical exam D. Assures a trusting interpersonal relationship

C. Provides a focus for the physical exam

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers? A. The confidentiality of electronic protected health information B. The confidentiality of the client's financial information C. The confidentiality of electronic and printed health informaiton D. The confidentiality of printed protected health information

C. The confidentiality of electronic and printed health informaiton

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding? A. Cyst B. Wheal C. Vesicle D. Papule

C. Vesicle

During a health history, a patient tells the nurse about have pain that has lasted for longer than 6 weeks. What action should the nurse make at this time?

Conduct a mental health screening

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status? A. "Are you living with your spouse?" B. Are you married, divorced, or widowed?" C. "Is your spouse living with you" D. "Do you live alone or with someone?"

D. "Do you live alone or with someone?"

A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following? A. "Documentation helps determine client education needs but not staff mix." B. "Documentation helps support reimbursement but gives little epidemiologic data." C. "Documentation is a viable means of communication but is repetitious." D. "Documentation provides a permanent legal record of care given and not give."

D. "Documentation provides a permanent legal record of care given and not give."

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? A. 13 to 18 B. 9 or lower C. 10-12 D. 19-23

D. 19-23

The nurse receives the following report. A patient was admitted for a left hip fracture following a fall at home. The patient was diagnosed with osteoarthritis 7 years ago. The left leg is shorter than right. Ecchymosis noted over left hip and groin areas. Pedal pulses palpable and strong bilaterally. Patient reports a pain rating of 8. An orthopedic case management consult is needed. Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent? A. Situation B. Recommendation C. Assessment D. Background

D. Background

The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic? A. Choices, Outcomes, Learning, Determination, Status, Protrusion, Activity B. Category, Occasion, Length of time, Decision, Strength, Plan, Attitude C. Criteria, Opportunity, Label, Direction, Stamina, Progress, Action D. Character, Onset, Location, Duration, Severity, Pattern, Associated Factors

D. Character, Onset, Location, Duration, Severity, Pattern, Associated Factors

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? A. Observer for abnormalities on the skin's surface B. Feel for deep organs or structures covered by thick muscles C. Determine tenderness, moisture, and the surface of skin texture D. Determine if a structure is filled with air or fluid or is a solid structure

D. Determine if a structure is filled with air or fluid or is a solid structure

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? A. Palmar surface B. Ulnar surface C. Fingerpads D. Dorsal surface

D. Dorsal surface

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? A. Gowning B. Using eye protection C. wearing latex gloves D. Handwashing

D. Handwashing

Which of the following assessment findings most likely constitutes a secondary skin lesion? A. Psoriasis B. Facial acne C. Facial lesions associated with herpes simplex D. Keloid formation at the site of an old incision

D. Keloid formation at the site of an old incision

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's A. Weight B. Height C. Temperature D. Perception of pain

D. Perception of pain

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment? A. Tenting indicates dramatic weight loss B. Tenting indicates malnutrition C. Tenting indicates vitamin B12 deficiency D. Tenting indicates dehydration

D. Tenting indicates dehydration

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse? A. The nits indicate the infestation is over B. This is not lice; it is scabies C. The client has had lice for quite some time D. The client had a recent infestation

D. The client had a recent infestation

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students? A. Charting by exception (CBE) system allows the nurse to establish independent standards for assessment B. The focus system of documentation organizes entries by data, assessment, and response C. Narrative charting is the most reliable form of charting D. The problem, intervention, evaluation (PIE) system of documentation does not use assessment as part of the PIE note

D. The problem, intervention, evaluation (PIE) system of documentation does not use assessment as part of the PIE note

Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to

promote harmony between health and spirituality