Health Assessment Exam 1

During the first assessment of the client, the nurse assesses the blood pressure in both arms. Which of the following findings is an acceptable variation?

118/78 mm Hg in the right arm and 122/80 mm Hg in the left arm

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

Appearance

When can the general inspection be started?

As soon as the examiner first sees the client

The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. What would the nurse do next?

Assess the client's pulse at the carotid site.

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

When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?

Collect subjective data

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

When beginning the collection of the client data base, which of the following would be most important for the nurse to do?

Establish a trusting relationship

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms?

Fungal Infection

The nurse is teaching the client how to self-administer insulin. Which functional health pattern does this nursing intervention address?

Health perception-health management

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?

Inspection

The client has a murmur. This is what type of data?

Objective

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

Ongoing or partial

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

Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?

Reassess previously detected problems

A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

Rectal

The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?

Sensory abilities

A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

Tachycardia

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

Temperature, pulse, respirations, and blood pressure

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?

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

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

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

To determine any changes from the baseline data

A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?

Using a moderate amount of eye contact

The nurse is conducting a general survey of a client new to the clinic. In what part of the survey would the nurse assess the hair distribution on the client's body?

When assessing the skin

A client's blood pressure is affected by:

cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity.

A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?

create a genogram

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand

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.

The nurse is preparing to auscultate sounds that have a lower pitch. Which equipment should be used to complete this assessment?

stethoscope bell

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?"

What included in personal protective equipment? Select all that apply.

* Gloves *Gown * Mouth, nose, eye protection

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

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

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?

Application of an alcohol-based hand rub

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?

Arm

Alexandra, 28 years old, presents to the clinic. She has abdominal pain that she describes as a dull ache, located in the right upper quadrant, and that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago; it lasts for 2 to 3 hours at a time, comes and goes, and seems to be worse a few hours after eating. The client has noticed that the pain starts after eating greasy foods, so she has cut down on this as much as she can. Initially the pain occurred once a week, but now it happens every other day. Nothing makes it better. From this description, which of the attributes of a symptom has been omitted?

Associated symptoms and signs

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

Which assessment finding should the nurse document as objective data?

Body Functions

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

Count the pulse for a full minute for an accurate rate

When obtaining an oral temperature on a client, the nurse inserts the thermometer:

Deep in the posterior sublingual pocket

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

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?

ED Nurse

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 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.

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

Facilitating the client's fullest communication

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads

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?

Focused

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

History of present illness

The nurse is performing a health assessment on a client. Which of the following would be most important for the nurse to do?

Interpret the information about the client in context

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 ongoing and continuous

The nurse uses the mnemonic OLD CART when assessing a client's symptoms. Which letter represents the area of the symptom and if it radiates?

L

During a busy shift, Nurse R. admitted a postsurgical client who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the client's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than actual blood pressure.

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

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

The current blood pressure measurement on a 24-hour uncomplicated postoperative client 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

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

Otoscope

Nurses provide both direct and indirect care. What is an example of indirect care?

Participating in a client care conference

A nurse in the surgical daycare department has called a client in from the waiting room and is meeting the client for the first time. The nurse immediately observes that the client has a noticeably "stooped" posture. How should the nurse best follow up this abnormal assessment finding?

Perform a focused assessment of the client's musculoskeletal system

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

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.

A nurse obtains the blood pressure of a client who is uncharacteristically fatigued and who is lying in bed rather than sitting in a chair. The nurse should interpret the client's blood pressure reading in light of what principle?

The client's blood pressure will be slightly lower than standing readings.

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

The client's range of motion in her right arm

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

U.S. Preventive Services Task Force

A nurse is obtaining a client's radial pulse. Which of the following actions demonstrates correct technique for this assessment?

Use of two middle fingers lightly applied to wrist area along the thumb side

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing what action?

Wearing gloves to palpate the tongue and buccal membranes

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

as a basis for the nursing process

The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?

assists the nurse in formulating appropriate subjective questioning

A nursing instructor is teaching the student during clinical how to take a health history and perform a complete assessment on a client. The student shows understanding of the difference between subjective and objective data by identifying the following as objective data.

decubitus on left heel

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.

The nurse selects a tuning fork to use when assessing a client. Which body system is the nurse most likely assessing?

peripheral vascular

When the client begins to cry, the nurse recognizes the need to focus the assessment on the client's emotional health. What factor will have the greatest effect on the nurse's ability to gather information concerning why the client is crying?

the rapport that exists between the nurse and the client

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

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

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?"

A client who reports having a burning rash in the perianal area says, "Just stop asking questions and look at the rash right now." Which response by the nurse is best?

"I just need to gather more information about your symptoms to help you the best way I can."

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

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

"What diseases did you have as a child?"

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.

* "I feel do tired sometimes" * Client complains of a headache * "My father died of a heart attack"

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

* A preschooler 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

Fatigue is considered a common symptom of what? (Mark all that apply.)

* Infections * Panhypopituitarism * Depression

Which review of systems area is reflected in the nutrition-metabolic functional health pattern? (Select all that apply.)

* Nose, mouth and throat * Abdominal-gastrointestinal * Endocrine and hematological

The nurse explains to the client that smoking has what effect on the body? Select all that apply.

* Peripheral vascular disease * Hypertension * Vasoconstriction

After completing a health history, the nurse determines that a client would benefit from interventions to address the Healthy People 2020 indicator associated with the prevalence and mortality of chronic disease. What assessment data would related to this indicator? (Select all that apply.)

* Prescribed medication for hypertension * Diagnosed with heart disease three years ago * Skin cancer lesion removed surgically four years ago

An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply.

* Speak clearly * Use simple terms * Show respect * Avoid jargon

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

Collect subjective data related to overall function

A student nurse is palpating the neck of a client who reports a lump behind the ear. While palpating, the student nurse notes that the lump is immobile. Which action by the student nurse is best in response to this finding?

Consult with a clinical instructor.

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

Diagnosis

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 if the client has achieved the outcome criteria of the treatment?

Evaluation

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?

Focused assessment

A client is unable to recall the last time an immunization was received. Which part of the client's health should the nurse realize is being the most impacted by this practice?

Health maintenance

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

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?

Light

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?

Making incorrect nursing judgements or diagnoses

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?

Measure the client's blood glucose four times daily.

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

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

When recording the client's reason for seeking care (chief concerns) during the health history, it is recommended that the interviewer:

Quote the client's words

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?

Reassess previously detected problems

A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?

Skinfold calipers

An 84-year-old man has been admitted to the emergency department from an extended care facility. Facility staff suspect that the client has pneumonia, and his malaise, productive cough, shortness of breath, and adventitious breath sounds are consistent with this diagnosis. However, the nurse's assessment of the client's vital signs yields an oral temperature of 97.5°F. How should the nurse best interpret this assessment finding?

The client's normothermic temperature does not rule out the presence of an infection.

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

primary prevention

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first

review the client's health care record.

An elderly client arrives in the Emergency Department with nonspecific symptoms. When the nurse attempts to take the health history, the client appears not to understand and does not answer the questions. The nurse realizes that this might be because of a common problem in the elderly, which is:

sensory deficits

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?

treatment