Health Assessment Exam 1

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?

"All patients have the same defining characteristics."

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply.

"Do you have any fears about the headaches you experience?" "Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?"

A nurse measures a client's blood pressure 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?"

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

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."

Which question is appropriate for a nurse to ask a client to assess the client's recent memory?

"What did you eat for breakfast today?"

The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image?

"What would you change about your body, if you could?"

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

120/55 mm Hg

A nurse is establishing an ideal body weight for a 5' 9" healthy female. Based on the rule-of-thumb method, what would be this patient's ideal weight?

145 lb

A patient in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what?

20/200 or less

Which of the following is the BMI that indicates the lowest risk of developing health problems?

23

A hospice nurse performs spiritual assessments on four of her clients one afternoon. The nurse knows that, based on recent statistics, which of the following clients is most likely to express nonbelief in God?

A 22-year-old woman

The RN may delegate which care component to a nursing assistant?

Ambulation assistance

What are nurses able to detect through the health assessment

Areas in need of health adjustments

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 maternal and paternal relatives as the client can recall

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions.

A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess characteristics

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiological cause for this finding is related to what disease process?

Atelectasis can cause the trachea to be pushed to one side from its midline position.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

A child whose parents are Christian Scientists is admitted to the hospital after an injury during a school field trip. The child's parents arrive shortly afterwards and refuse to allow their child to receive needed antibiotics to fight off infection and analgesics to lessen the child's severe pain. Which of the following should the nurse do?

Consult the hospital's ethics committee

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

Critical thinking

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

Diabetes

A nurse cares for a client of Asian decent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

Document the findings in the client's record as normal

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

During the working phase, the nurse elicits the client's comments about major biographic data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals.

A client requests to be cared for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care?

Ethnocentrism

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?

Explaining the reason for taking down notes

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?

Faces Pain Scale

The most useful spiritual assessment techniques should have specific introductory questions and be specific to a particular religious denomination to guide precise questions

False

When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve patient care?

Gaining relevant information about the patient's spirituality.

A nursing instructor is teaching about spirituality, major world religions, and common beliefs. The instructor realizes that a student understands the differences based on which of the following statements?

Hindus believe that illness is the result of past and current life actions.

The nurse is being oriented to the oncology unit. Which is a true statement regarding the potential population of this nursing unit?

Hispanic women have higher rates of cervical cancer than white women.

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

A nurse is caring for a Southeast Asian adult client. Why does the nurse know that it is important to incorporate the client's health beliefs and practices into the plan of care?

Improve the client's health outcomes

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examination. Inspection precedes palpation, percussion, and auscultation because the latter techniques can potentially alter the appearance of what is being inspected.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpation

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse

Make a referral to the dietician.

A nurse begins an interview with a client who is a Native American. The nurse should not be surprised to see the client display which type of behavior characteristic of this culture group when responding to questions or engaging in conversation with the nurse?

Native Americans and people from Eastern countries tend to look down to show respect to the person talking.

When patients report pain, it is important to find the source. When patients describe pain as "burning, painful numbness, or tingling," the source is more than likely:

Neuropathic

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

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

Ophthalmoscope

Using Roy's adaptation model, the nurse identifies that the goal of nursing care is to assist the client to achieve what

Optimal mental health Physical health Role function Interdependence

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this patient?

Patient demonstrates flight of ideas

You note that your patient has developed mental status changes and paresthesia's. What would you know to assess as a possible cause for these changes?

Patient's hydration status

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath

A nurse is caring for a client with an amputated limb. The client tells the nurse that he has a burning sensation in his amputated limb. How should the nurse document this pain?

Phantom pain

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

A client presents to the health care clinic with reports of changes in the skin. Which data should the nurse document as objective with regards to the skin?

Skin warm and dry to the touch

A client who suffers from arthritis complains of sharp pain in her knees and elbows. The nurse recognizes this is what type of pain?

Somatic

While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

Speech and language

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension

A student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?

Summarization can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the patient, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the patient next

Which tool is appropriate for a nurse to implement to perform a non-formal spiritual assessment on a client?

The FICA assessment tool is a non-formal tool for spiritual assessment of a client.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

How would the nursing instructor explain the goal of guided questioning to his or her students?

The main goal of guided questioning is to facilitate the patient's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the patient

A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use

The nurses can use the checklist method to share the client's health status with other health personnel involved in the client's care. Some other examples of written forms of communication include the nursing care plan, the nursing Kardex, and flow sheets. Notepads, e-mails, and SMSes are not examples of written forms of communication that the nurses should follow

When would a nurse obtain a mid-arm circumference measurement

To provide percentage of body fat and muscle tissue.

Which action by the nurse demonstrates correct assessment of the corneal reflex of a client during an eye examination?

Touch the cornea with a wisp of cotton

The nurse is admitting a bed-bound patient who is a practicing Muslim. Acting as an advocate for the patient and demonstrating cultural sensitivity, what arrangements should the nurse make?

Transfer the patient to a room that faces east

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

After collecting subjective and objective data for the admission database, what is the nurse's next action?

Validate the client's identified problems.

Pain nociception has various locations.

Visceral pain originates from abdominal organs; patients often describe this pain as crampy or gnawing. Somatic pain originates from skin, muscles, bones, and joints; patients usually describe somatic pain as sharp (D'Arcy, 2014). Cutaneous pain derives from the dermis, epidermis, and subcutaneous tissues. It is often burning or sharp, such as with a partial-thickness burn. Referred pain originates from a specific site, but the person experiencing it feels the pain at another site along the innervating spinal nerve

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?

Wood's light is a special piece of examination equipment that is used to test for fungus

The functional reflex that allows the eyes to focus on near objects is termed

accommodation.

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

chief complaint

An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

cluster headaches.

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

A nurse should assess patients for signs of spiritual distress, which include which of the following?

crying wishing to die anger

A nurse is aware that religion can sometimes negatively affect health. Which of the following is an example?

failure to seek timely and proper medical care

A client who is bedfast responds only to painful stimuli, never eats a complete meal, and moves occasionally in bed. Which term should the nurse use to describe this client's risk for skin breakdown?

high

Care that considers the patient's body, mind, and spirit is which type of nursing care?

holistic care

A client describes pain in the soles of both feet as constantly burning. Which type of pain should the nurse suspect this client is experiencing?

neuropathic

The current blood pressure measurement on a 24-hour uncomplicated postoperative patient while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of

orthostatic hypotension

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

physiologic status

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

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?

value-belief