Health Assessment Exam 1- Ch. 1, 4, 6, & 7

The nurse is using the COLDSPA mnemonic to assess a client's history of chest pain. What interview question addresses the "A" in this assessment model?

"Do you have any other symptoms together with your chest pain, such as nausea, sweating?"

A client who takes oral contraceptives states that she often experiences breast pain just before her menstrual cycle begins. When using the COLDSPA mnemonic to assess the client's pain, the nurse should begin by asking which of the following?

"How would you describe your pain? Is it sharp? Is it an ache?"

The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include

"Palpation will increase bowel motility and alter the sounds heard on auscultation."

The nurse is assessing a client's pain. Which question would be most appropriate to ask the client to identify precipitating factors that might have exacerbated the pain?

"What were you doing when the pain first stated?"

When the nurse is performing a physical examination on admission of a patient to the medical unit, the patient says the doctor already did an exam. The best response by the nurse would be

"the doctor focuses on the treatment of the disease process and the nursing assessment focuses more on the body's response to the disease."

Which observation would cause the nurse to suspect an abusive situation? Select all that apply.

- A pre-schooler rubs her perineum and complains of it hurting. - A caregiver of a cognitively intact older adult dominates the interview. - A child is persistent in trying to please a parent.

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply

- Date and location of the clients last blood pressure check - Onset and character of the clients chest pain - A list of all of the client's current medications

The nurse is assessing a female client's reproductive area during the review of systems. Which information should the nurse document within this section? (Select all answer choices that apply)

- Dysmenorrhea (cramps) - Age of menarche (1st period) - Age of menopause

A pregnant woman comes to the physician's office for her first prenatal visit. The nurse knows the importance of performing a comprehensive health history in this case and understands the following must be included (check all that apply):

- Information about current pregnancy. - Obstetrical and gynecological history. - Family History - Previous pregnancies

The nurse is completing the peripheral vascular section of the review of systems with a client. Which information should the nurse document in this area? (Select all answer choices that apply)

- Leg cramps - Intermittent claudication - Change in color of fingers

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

Pain affects patients in different ways, with no boundaries. Which of the following are possible causes of pain? (Check all that apply.)

- chronic illnesses - Surgery - Injury - No identifiable cause

A nurse is assessing a young woman for injuries who appears to be a victim of domestic violence. The nurse observes from the client's health record that her baseline vital signs are within normal limits. Which of the following objective findings would most tend to indicate pain? Select all that apply.

- slumped shoulders - blood pressure of 140/90 mm Hg - Edema at the elbow joint

During a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a

1 1/2 inch diaphragm

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

120/55 mm Hg

The nurse administers pain medication to a client at 1600. At what time should the nurse return to reassess the client's pain level?

1630

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?

A 5-year-old client newly diagnosed with diabetes.

When assisting a patient with health promotion, what must the nurse also nurture?

A healthy environment.

A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain?

Acute

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

The nurse is assessing a client's lifestyle and habits. At which time should the nurse assess the client for alcohol use?

After assessing for cigarette use.

While completing a history of present illness the nurse asks the client about risk factors. In which way should the nurse use this information?

Analyze as a contributing factor to the current problem

A nurse is conducting a health assessment. How will the information collected from the patient be used?

As a basis for the nursing process

The nurse is auscultating a client's blood pressure, and identifies which of the following as the portion of the blood pressure cycle reflecting the break in sounds occurring between the first and second sounds?

Auscultatory gap

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted.

A middle aged female client presents to the emergency department complaining of indigestion and left arm pain. What is the nurse's best action?

Check the client's vital signs and connect her to a cardiac monitor.

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

As a nurse is assessing a client and asking her questions, the nurse notices that the client stops talking and looks up anxiously each time someone passes by in the hallway outside her hospital room. Which nursing intervention would most likely address the client's concern and promote enhanced communication in this situation?

Close the door to the client's room

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

Comprehensive

Despite having high blood pressure readings in the office, Mr. Kelly tells the nurse that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. Which of the following should the nurse do?

Consider the possibility of "white coat" hypertension or anxiety.

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

Continuous

You are performing a physical examination on a new patient. What would you be assessing if you were testing the patient's sense of smell?

Cranial nerves

When collecting data on the history of the present illness, it is appropriate to include what?

Current medications

Mrs. Williams is an 89-year-old independent woman who lives alone and has severe arthritis in her hands. Over the last few months the arthritis has gotten worse and she is concerned because she can no longer clean her apartment. What question by the nurse would gain the most usable information to assist with this concern?

Do you have family who visit you regularly?

The second standard within the Nursing Scope and Standards of Practice states that the nurse analyzes assessment data to determine the diagnoses or issues. Which activities will the nurse perform when complying with the expectations of the second standard? Select all that apply.

Documents the diagnosis. Derives the diagnosis based on assessment data. Validates the diagnosis with the client, family, and other health care providers

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal Surface

A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature?

Early morning

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 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.

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.

During a health history, a client reports drinking bloody Mary's several mornings a week before going to work. In which part of the CAGE questionnaire should the nurse document this information?

Eye-openers

A nurse is caring for a 4-year-old patient who is crying and appears to be in pain. The nurse begins to assess the pain by showing pictures on a chart and asking the patient to point to the one that best represents the pain he is experiencing. This is an example of which of the following:

FACES scale

A client with hypertension seeks medical attention for a new onset of a nosebleed. Which type of assessment should the nurse complete with this client?

Focused

A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client?

Focused.

A client with a foot wound returns to the outpatient wound clinic for a weekly appointment and treatment. Which type of assessment should the nurse complete with this client?

Follow-up

When caring for clients in any health care environment, what is the most important technique for preventing infection?

Hand Hygiene

During the health history inquiry about alcohol intake, which of the following is a CAGE question?

Have you ever felt annoyed by criticism about drinking?

A client reports feeling depressed for several months since being fired from a long-term job. Which question should the nurse include when assessing this client?

Have you thought of hurting yourself?

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

Healthy People 2020

Which of the following statements best conveys the rationale for health promotion in a school setting?

Healthy child development is a critical health determinant because of its implications for lifelong health.

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood?

A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?

Identify a nursing diagnosis of Ineffective Health Maintenance.

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?

Inspection, palpation, percussion, auscultation.

A patient who was in an automobile accident a week ago is at home recovering from her injuries. She contacts her primary care provider's office to report that she still has severe pain in her back, resulting from an injury to that region, that has not been lessened by two different pain relievers that the physician had prescribed for her. The nurse recognizes this as which type of pain?

Intractable- highly resistant to pain relief.

A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following principles should guide the nurse's assessment of a client's pain?

It is likely that the client's pain rating will be influences by his emotional state.

A nurse educator is presenting an in-service program to a group of oncology nurses. Which of the following characteristics of cancer pain should the nurse describe?

It is typically caused by compressed peripheral nerves.

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 most appropriate for the client?

Knee-chest

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

Marfan's syndrome

A nurse recognizes that it is best to begin the objective data collection with which procedure?

Measure the client's vital signs, height, and weight.

n instructor is reviewing the evolution of the nurse's role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early in the history of the profession?

Natural senses

During the review of systems, a client reports dizziness, tingling, and mood changes. In which area should the nurse document this information?

Neurologic

A 49-year-old factory worker has been admitted to the emergency department with chemical burns on his hand and wrist. Which of the following types of pain has the man most likely experienced?

Nociceptive-somatic

How does a nurse decide what health-promotion activities are necessary for a particular client?

Nurse collaborate with clients to identify areas in which clients are willing to make change.

After completing a health history and physical assessment the nurse prepared to analyze the collected data. In which phase of the nursing process is the nurse focusing?

Nursing Diagnosis

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

An adult client is brought to the ED by ambulance and is anxious and very short of breath. While the nurse is completing the emergency assessment, the client stops breathing. What is the first action of the nurse?

Open the client's airway.

The charge nurse on a geriatric unit should further educate a new staff nurse who makes which statement?

Pain sensation is diminished in older adults.

A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?

Palpation

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?

Palpitation

The nurse prepares to collect objective data on a client new to a health clinic. What will the nurse use to collect this data?

Percussion Inspection Auscultation Palpation

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?

Personal and social history

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

Primary

The patient is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the patient, the nurse is obtaining what other type of data from the patient?

Primary

A nurse needs to assess a client's range of motion in the hip joints. Which position is best to facilitate this examination?

Prone

A patient has come to the physician's office several times in the last month with a black eye, bruises, and lacerations on the lower extremities. The patient always explains having fallen and tripped. The nurse suspects abuse. The next step should be to:

Report the findings to a supervisor.

What would be the expected tone elicited by percussion of a normal lung?

Resonance

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure

The nurse who provides care at an ambulatory clinic is preparing to meet a client and perform a comprehensive health assessment. Which of the following actions should the nurse perform first?

Review the client's medical record

The nurse is admitting a new client to the unit. While reviewing old records of the client, the nurse knows that the data being gathered are what kind of data?

Secondary

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?

Sexual Histroy

The nurse is preparing to assess a client's peripheral pulses. The nurse would place the client in which position?

Supine

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic pressure 180 mm Hg.

When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would the nurse identify as being the primary force?

Technology

nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? You Selected:

Temperature, pulse, respiration's, and blood pressure.

A nurse who provides care in a hospital setting is creating a plan of nursing care for a client who has a diagnosis of chronic renal failure. The nurse's plan specifies frequent ongoing assessments. The frequency of these nursing assessments should be primarily determined by what variable?

The client's acuity

The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

The client's acuity.

The nurse is applying the blood pressure cuff on a client's arm. Which action would be most

The cuff is placed about 1 inch above the antecubital area.

While beginning the assessment of a client's abdomen, the nurse starts in the middle of the abdomen and expects to hear high-frequency sounds. What part of the stethoscope will provide the best sound with firm skin contact?

The diaphragm

Which of the following describes how the health history interview differs from a social conversation?

The interview allows more time for the client to demonstrate self-awareness.

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the patient's breath.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

The nurse is taking a comprehensive health history on a new patient. Why would it be essential for the nurse to obtain a complete description of the present illness?

To establish an accurate diagnosis.

The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?

To remember the elements that are important to assess with a symptom

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?

To see the client before the client assumes a social face or behavior

It is recommended that a left-handed examiner adopt a right-sided position. (True or False)

True

The nurse should use the handle of the reflex hammer to detect the plantar reflex. (True or False)

True

When assessing the gastrointestinal system, the nurse correctly asks, "Do you have any trouble swallowing?" (True or False)

True

The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?

Use evidence-based techniques.

The nurse prepares to use mediate percussion to assess lung tissue. Which action will the nurse take when using this assessment technique?

Use the middle finger to deliver two taps

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

Wearing gloves when palpating the tongue, lips, & gums

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

During a health history, a client states "I want to know why my feet are swelling" whereas the primary diagnosis is arthritis. What should the nurse do with the client's statement?

Write it as the chief complaint

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

deep palpation

One of the body's normal physiologic responses to pain is

diaphoresis (sweating)

While assessing a patient, the nurse notes that the patient is more quiet and subdued after a visit from her sister. The nurse would note this under what facet of the assessment process?

emotional

Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for?

examining the tongue

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression

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 focused assessment

The nurse would use the tuning fork to assess for what?

hearing loss

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?

heart sounds

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be

lacking adequate finances

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

light palpation

You should use the bell of the stethoscope when auscultating what type of sounds?

low-frequency sounds

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

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process.

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?

ongoing

Which of the following is an average normal temperature in centigrade for a healthy adult?

oral: 37.0°C

The nurse wants to determine the presence of air, fluid or solid tissues in the lungs of a client with a cough. Which technique should the nurse use for this part of the examination?

percussion

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

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

physiologic status

When assessing a client's respirations, what is most important to include in the documentation?

presence of dyspnea (shortness of breath)

How do nurses facilitate the achievement of high-level wellness with a client?

promoting health in the client

A client is experiencing weakness of the left side of the body. Which piece of equipment should the nurse use to determine if the client's neurologic system is intact?

reflex hammer

The nurse is taking a health history on a newly admitted patient. When the nurse asks, "How would you describe yourself?" the nurse is assessing which of the following?

self-perception/self concept

The nurse understands that health promotion is a very important part of nursing care. When performing the health history, there are many different opportunities for the nurse to teach healthy behaviors. One way the nurse can do this is by focusing on which of the following topics:

sexual history and pattern

What information aids the nurse in assessing possible biases in the data collected in the health history?

source of information

What is used to gauge central and peripheral nervous system disorders?

strength of a reflex

What is the primary function of the health care team?

to decide the best overall care

How should the nurse place the ear of an adult when using the otoscope?

up and back