Health Assessment-Exam 1-Prep U

A 26-year-old male nurse is assessing a 14-year-old girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the patient is what? a) Body systems b) Functional c) Focused d) Head to toe

Correct response: Head to toe Explanation: The head-to-toe method is efficient and provides more modesty for patients. This makes options A, B, and C incorrect. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse use? a) Rationale b) ANA recommendations c) Physical assessment skills d) Diagnostic reasoning

Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Therefore, options A, B, and C are incorrect. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 9.

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? a) Ethnocentrism b) Ethnicity c) Prejudice d) Stereotype

Ethnocentrism Explanation: Ethnocentrism is the barrier that the nurse identifies in this client's nursing care. The perception that one's beliefs, values, and sanctioned behaviors are superior to all others is termed as ethnocentrism. Ethnicity refers to a socially, culturally, and politically constructed group of individuals that holds a common set of characteristics not shared by others with whom they come in contact. Prejudice is based on preconceived notions about certain groups of people. Stereotype refers to accepting that there are people from other cultures, having different beliefs and values, but not recognizing the variation that can exist within any cultural group.

A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care? a) Summary b) Working c) Introductory d) Closing

Explanation: During the working phase, the nurse asks the client about the history of the present health concern and the reasons for seeking care. In the introductory phase the nurse explains the purpose of the interview and assures the client that confidential information will remain confidential. During the summary phase or the closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client. Chapter 2: Collecting Subjective Data, p. 13.

Parts of Hand to Use When Palpating

Fingerpads: fine discriminations: pulses, texture, size, consistency, shape, crepitus Ulnar or Palmar: vibrations, thrills, fremitus Dorsal: temperature

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? a) Breath b) Normal heart c) Heart murmur d) Bowel

Heart murmur Explanation: The bell of the stethoscope is used to listen for low pitched sounds such as abnormal heart sounds or bruits. The diaphragm is used to listen for high pitched sounds such as normal heart, lung, & bowel sounds. *Bellow-bell=low sounds (abnormal heart) *Diaphragm-die rhymes with high (normal heart, breath, bowel)

Auscultaton sounds classified:

High pitched=normal...heart, breath, bowel sounds. [Diaphragm] *press firmly Low pitched=abnormal heart sounds and bruits(abnormal loud, blowing, or murmuring sounds) [Bell] *hold/press lightly

The nurse is being oriented to the oncology unit. Which is a true statement regarding the potential population of this nursing unit? a) American Indians have lower rates of kidney cancer. b) Asian men are more likely to have prostate cancer than African-American men. c) African-American women rarely die from breast cancer. d) Hispanic women have higher rates of cervical cancer than white women.

Hispanic women have higher rates of cervical cancer than white women. Explanation: Hispanic women have higher rates of cervical cancer than white women. Asian men are less likely to have prostate cancer than African-American men. African-American women are 34% more likely to die from breast cancer. American Indians have higher rates of kidney cancer.

Order of Abdomen physical assessment

Inspection Auscultation Percussion Palpation *many times nurses will omit the P and P.

The order in which the 4 techniques of a physical assessment is done on most body parts:

Inspection Palpation Percussion Auscultation

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process? a) Relying on objective and subjective information b) Interjection of the nurse's thoughts or feelings into the data c) Making incorrect nursing judgments or diagnoses d) Validating information that is already correct

Making incorrect nursing judgments or diagnoses Explanation: Assessment is the first and most critical phase of the nursing process. If data collection is inadequate or inaccurate incorrect nursing judgments may be made that adversely affect the remaining phases of the nursing process. Injection of the nurse's thoughts or feeling may lead to bias or the withholding of information. Nursing judgments should rely on both objective and subjective information. Validating information that is correct makes more work for the nurse but will not lead to inaccurate judgments. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 3.

A 72-year-old man had hip replacement surgery 2 days ago. The nurse enters the patient's room and encourages him to use the incentive spirometer ten times every hour. What is this action an example of? a) Nursing assessment b) Nursing evaluation c) Nursing intervention d) Nursing goal

Nursing intervention Explanation: Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the patient's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the patient's health status and current problems.

A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? a) Ophthalmoscope b) Penlight c) Otoscope d) Tuning fork

Ophthalmoscope Explanation: An ophthalmoscope is used to view the red reflex and to examine the retina of the eye. A tuning fork is used to test for bone and air conduction of sound. An otoscope is used to view the ear canal and tympanic membrane. A penlight is used to view the mouth and throat and to transilluminate the sinuses. Chapter 3: Collecting Objective Data, p. 36

The nurse is having difficulty auscultating a patient's bowel sounds during a physical examination of the abdomen. What can the nurse do to improve hearing the patient's sounds of this body area? a) Reduce all environmental noise. b) Percuss the region before auscultating. c) Assist the client to a sitting position. d) Palpate the region before auscultating.

Reduce all environmental noise. Explanation: Auscultating bowel sounds can be difficult because of environmental noise. The nurse should reduce all environmental noise and auscultate the bowel sounds again. The steps used to assess the abdomen are inspection, auscultation, percussion, and palpation. The techniques of percussion and palpation will cause the patient to experience bowel sounds and, therefore, should be performed after bowel sounds are auscultated. Assessment of the abdomen is best performed with the patient in the lying position.

Which illustrates the nurse using the technique of inspection? a) The nurse detects tympany over the patient's lower abdomen. b) The nurse notes a rhythmic lub-dub over the patient's anterior thorax. c) The nurse notes increased warmth surrounding the patient's incision. d) The nurse detects a fruity odor of the patient's breath.

The nurse detects a fruity odor of the patient's breath. Explanation: Inspection involves conscious observation of the patient's physical characteristics and behaviors and smelling for odors. The nurse uses the technique of inspection to detect a fruity odor to the patient's breath. The nurse uses the technique of palpation to note increased warmth surrounding an incision. Auscultation is used by the nurse to assess the lub-dub sounds of the heart. The nurse detects tympanic sounds of the bowel by percussing the abdomen.

To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: a) Understanding the health problems that clients experience in everyday life b) Determining client stress levels related to lifestyle choices c) Ascertaining past and current use of health care services d) Using reputable health-education strategies to reduce risk behaviours

Using reputable health-education strategies to reduce risk behaviours Explanation: A central component of health promotion involves helping clients to develop personal health practices and to enhance coping skills, which are results of health education that emphasizes client knowledge for directing choices and actions. While the other given factors may hold significance for many individuals, they are not as salient as health education. Chapter 1: The Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5.

The nurse is conducting a physical examination of a patient who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular a) c, e, b, d, a b) c, d, e, b, a c) d, b, a, e, c d) d, e, b, a, c e) a, c, b, d, e

c, d, e, b, a Explanation: When conducting a head-to-toe assessment for a patient in the lying position, the nurse should begin with the structures closest to the head and progress downward. The nurse will assess the breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.

Types of Health Assessment: Focused or Problem Oriented

coonsists of a thorough assessment of a particula client problem and does not cover areas NOT RELATED TO THE PROBLEM. Ie. a patient says he has pain. you would ask questions about the character and location of pain, onset, relieving and aggravating factors.

Types of Health Assessment: Ongoing or Partial

data collection that occurs after the comprehensive database is established. consists of a mini-overview of body systems and health patterns as a FOLLOW UP on health status. Ie. Patient with lung cancer requires frequent assessment of lung sounds.

Initial Comprehensive Assessment

involves a collection of SUBJECTIVE data about client's perception of his/her health of all body parts or systems, past health history, family history, lifestyle and health practices. A total health assessment (subjective and objective) is needed when the client first enters a health care system and periodically for baseline comparison.

Auscultation

is a type of assessment technique that requires the use of a stethoscope to listen for heart sound, movement of blood through cardiovascular system, movement of the bowel, movement of air through the respiratory tract.

PPE

personal protective equipment gloves, gown, mouth/nose/eye protection

Types of Health Assessment: Emergency

very rapid assessment performed in life threatening situations. Ie. choking, cardiac arrest, drowning.

Choice Multiple question - Select all answer choices that apply. The purpose of a health assessment includes what? (Select all that apply.) a) Evaluating patient outcomes b) Collecting information about the health status of the patient c) Identifying the patient's major disease process d) Synthesizing collected data e) Clarifying the patient's ability to pay for health care

• Collecting information about the health status of the patient • Evaluating patient outcomes • Synthesizing collected data Explanation: Health assessment is "gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes" (AACN, 2008). While the nurse may elicit financial information and information about disease processes during a health assessment, the purposes of the activity are not to identify the patient's major disease process or ability to pay. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

Choice Multiple question - Select all answer choices that apply. The nurse is conducting a health assessment with a patient. What will the nurse do while completing this health assessment? (Select all that apply.) a) Complete the health history. b) Conduct a physical examination. c) Formulate a plan of care d) Implement a plan of care. e) Interpret findings.

• Complete the health history. • Conduct a physical examination. Explanation: The first part of the health assessment is the health history. The second part of the health assessment is the physical examination. Interpreting findings, formulating a plan of care, and implementing a plan of care are steps within the nursing process and not the health assessment.

Choice Multiple question - Select all answer choices that apply. What are the areas of independent nursing practice? a) Deciding when a patient needs to be turned b) Deciding what diagnosis a patient has c) Deciding when physical procedures should be performed on a patient d) Deciding which medications to give to a patient e) Deciding what patient teaching is necessary

• Deciding when physical procedures should be performed on a patient • Deciding what patient teaching is necessary • Deciding when a patient needs to be turned Explanation: Independent nursing interventions include patient teaching, therapeutic communication, and physical procedures such as turning patients or assisting them with ambulation. The medications a patient receives and the diagnosis of the patient are medical decisions, not nursing decisions.

Describe the technique of inspection, when it's used and what's included in it:

Vision Smell Hearing Used from the moment you meet client and continues throughout the examination.

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? a) "Are you friendly with your neighbors?" b) "Do you have family who visit you regularly?" c) "Have you tried to schedule a cleaning service?" d) "What amount of cleaning have you been doing in the past?"

"Do you have family who visit you regularly?" Explanation: Asking if family visit regularly may provide a link to getting them to assist in cleaning the apartment. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

Percussion sounds: Resonance (over part air & part solid) loud, low, long, hollow Hyper-Resonance (over mostly air) very loud,low,long, booming Tympany (heard over air) loud, high, moderate, drum-like Dullness (heard over more solid tissue) medium, medium, moderate, thud-like Flatness (heard over very dense tissue) soft, high, short, flat

...[normal lung] ...[lung with emphysema] ...[puffed out cheek/gastric bubble] ...[diaphragm, pleural effusion, liver] ...[muscle, bone, sternum, thigh]

A patient of African origin comes to the clinic requesting treatment for "bad blood". The nurse is aware that the patient is most likely referring to which disorder? a) A sexually transmitted disease b) A panic disorder c) Arctic hysteria d) High blood pressure

A sexually transmitted disease Explanation: People of African origin living in America may refer to blood that is contaminated as "bad blood", and it often refers to sexually transmitted diseases.

A triage nurse is interviewing a 36-year-old woman 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. Of what type of communication is this an example? a) Reflection b) Encouraging elaboration (facilitation) c) Restatement d) Active listening

Active listening Explanation: Active listening is the ability to focus on patients and their perspectives. It requires the nurse to constantly decode messages including thoughts, words, opinions, and emotions. For example, if a patient is sad, it is appropriate for a nurse to place a hand over the patient's and to show a facial expression of compassion. The actions of the nurse described in the question are not restatement, reflection, or encouraging elaboration. Chapter 2: Collecting Subjective Data, p. 14.

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, non-intact skin, or wound dressings. The nurse's hands do not appear to be visibly soiled. What hand hygiene should the nurse perform? a) Hand wash with antiseptic soap b) No washing is needed because hands are not soiled c) Application of an antiseptic handrub d) Nonantimicrobial soap and water with friction

Application of an antiseptic handrub Explanation: The nurse could apply an antiseptic handrub if the hands do not appear to be soiled. If during the examination the nurse's hands are soiled due to contact with any body fluids or excretion, mucous membranes, non-intact skin, or wound dressings, the nurse would be required to hand wash with nonantimicrobial soap and water, or antiseptic soap. Chapter 3: Collecting Objective Data, p. 41.

A nurse collects data about a client's family health history. Which family members' health problems should the nurse include when documenting this information in the database? a) As many genetic relatives as the client can recall b) Those with illnesses that resulted in death or disablement c) Only the members with health problems that relate to the client's gender d) Those with diseases that are known to have a genetic link

As many genetic relatives as the client can recall Explanation: Both maternal and paternal genetic relatives are included in the family health history. Problems can arise in families that are not genetically based but are manifest by virtue of exposure to lifestyle practices. Parents, grandparents, aunts, uncles, and children are all included in this history. If the relative is deceased, the cause of death and age of death of the relative is recorded.

Mnemonic to help nurse to complete the assessment of the sign, symptom, or health concern:

COLDSPA: Character Onset Location Duration Severity Pattern Associated factors/how it Affects the client

For which of the following clients should a nurse perform a focused assessment? a) Client with right upper abdominal pain that radiates into the groin area b) Diabetic with elevated blood sugars for the past 2 weeks c) Client with elevated blood pressure with no previous history of heart problems d) Client with 4-day history of sore throat and fever with enlarged lymph nodes

Client with 4-day history of sore throat and fever with enlarged lymph nodes Explanation: A client with a sore throat and fever with enlarged lymph nodes requires only a focused assessment by the nurse. A focused assessment consists of a thorough assessment of a particular client problem. An elevated blood pressure with no previous history of heart problems requires an initial comprehensive assessment. Right upper abdominal pain that radiates into the groin area is an emergency situation and the nurse should collect only the data necessary to make a quick diagnosis for immediate treatment (emergency assessment). A client with diabetes has a chronic, ongoing health problem that needs reassessment and possibly a change in treatment (ongoing or partial assessment). Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 6.

A lead nurse is removing her personal protective equipment after dressing the infected wounds of a client. Which of the following is the highest priority nursing action? a) Remove the garments that are most contaminated. b) Handwashing before leaving the client's room. c) Make contact between two clean surfaces. d) Make contact between two contaminated surfaces.

Correct response: Handwashing before leaving the client's room. Explanation: The most important nursing action is to perform a thorough handwashing before leaving the client's room and before touching any other client, personnel, environmental surface, or client care items. Regardless of which garments they wear, nurses follow an orderly sequence for removing them. The procedure involves making contact between two contaminated surfaces or two clean surfaces. Nurses remove the garments that are most contaminated first, preserving the clean uniform underneath. Chapter 27: Asepsis and Infection Control, p. 684.

When using an interpreter to facilitate an interview, where should the interpreter be positioned? a) In a corner of the room, so as to provide minimal distraction to the interview b) Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client c) Between the examiner and the client, so all parties can make the necessary observations d) Behind the examiner, so the interpreter can pick up the movements of the lips of the client and the client's nonverbal cues

Correct response: Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client Explanation: A priority is for the examiner is to have a good view of the client and to avoid having to look back and forth between client and interpreter. The nurse should remember to use short simple phrases while speaking directly to the client and ask the client to repeat back what he or she understands. Chapter 2: Collecting Subjective Data, p. 17.

Choice Multiple question - Select all answer choices that apply. In the assessment of a Chinese client, a nurse asks the client several questions pertaining to the client's culture. The client asks the nurse why she is asking questions about her culture. Which of the following should the nurse mention? Select all that apply. a) To learn about the client's beliefs and usual behaviors associated with health and illness b) To assess the client's health relative to diseases prevalent in the client's cultural group c) To avoid stereotyping d) To promote ethnocentrism on the part of the nurse e) To compare and contrast the client's beliefs and practices to standard Western health care

Correct response: • To learn about the client's beliefs and usual behaviors associated with health and illness • To compare and contrast the client's beliefs and practices to standard Western health care • To avoid stereotyping • To assess the client's health relative to diseases prevalent in the client's cultural group Explanation: The main purposes of assessing culture in a health care setting are as follows: to learn about the client's beliefs and usual behaviors associated with health and illness, including beliefs about disease causes, caregiving, expected treatments (both Western medicine and folk practices), daily hygiene, food preferences and rituals, and religious beliefs relative to health care; to compare and contrast the client's beliefs and practices with standard Western health care; to compare the client's beliefs and practices with those of other persons from a similar cultural background (to avoid stereotyping); and to assess the client's health relative to diseases prevalent in the specific cultural group. Promoting ethnocentrism, which is the belief that one's culture is superior to others, is not the proper rationale for assessing culture.

A nurse is writing a care plan for a newly admitted patient. When formulating the diagnostic statements in the care plan, what would the nurse use? a) Rationale b) ANA recommendations c) Physical assessment skills d) Diagnostic reasoning

Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Therefore, options A, B, and C are incorrect. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 9.

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? a) Sympathy b) Inspection c) Palpation d) Empathy

Empathy Explanation: Empathy is an intuitive awareness of what the client is going through; it helps the nurse to be effective in providing for the client's needs while remaining compassionately detached. Inspection and palpation are skills that help the nurse in collecting objective data of the client's physical characteristics. Sympathy is a feeling that would make the nurse as emotionally distraught as the client; this hampers the ability of the nurse to provide client care.

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? a) Remaining standing during the interview b) Reading questions from the history form c) Explaining the reason for taking down notes d) Maintaining eye contact with the client at all times

Explaining the reason for taking down notes Explanation: The nurse should explain the reason for taking notes during the interview and ensure that it will remain confidential; this will help the client to provide all the required information during the interview. Some clients may be very uncomfortable with too much eye contact, while others may believe that the nurse is hiding something from them if eye contact is avoided. Therefore, the nurse should maintain only a moderate amount of eye contact and not maintain eye contact with the client at all times. The nurse should not remain standing while taking down notes, as it could indicate being in a hurry to complete the interview; it could also indicate that the nurse is expressing superiority over the client. The nurse should not read questions from the history form, as this deflects attention from the client and results in an impersonal interview process.

The meaning of ethnicity is broader than the term culture. a) True b) False

False Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 11: Assessing Culture, p. 178.

When interviewing, the nurse should logically move from specific to open-ended questions. a) True b) False

False Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 2: Collecting Subjective Data, p. 13.

FIFA-a patients perspective on illness

Feelings Ideas Functions Expectations

Explain the differences between: light, deep, and bimanual palpation:

Palpation: Light-dominant hand-lightly-little to no depression-circular motion-pulses, tenderness, surface skin texture, temperature, moisture. Moderate-dominant hand-depress (0.5-0.75")-circular motion-palpable body organs and masses. Deep-dominant hand on skin surface and non dominant hand on top-depress (0.1-0.2")-very deep organs/structures covered by thick muscle. Bimanual-2 hands (one on each side of body part)-one hand to apply pressure other to feel structure-uterus, breasts, spleen.

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? a) Partial b) Comprehensive c) Emergency d) Focused

Partial Explanation: Ongoing or partial assessments consist of obtaining data to follow up a previously diagnosed problem that may be changing from the baseline. An emergency assessment is a very rapid assessment performed in life-threatening situations such as drowning, choking, or cardiac arrest. It is used when an immediate diagnosis is needed to provide prompt treatment. These situations are those in which a person's airway, breathing, or circulation is compromised. A focused assessment gathers information specific to the problem and does not cover any other areas. A comprehensive assessment is not necessary at this time because the client already has a documented problem. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 5

Explain difference between direct, indirect, and blunt percussion:

Percussion: Direct-direct tapping of body part-one/two fingertips-elicit tenderness. Blunt-one hand on body surface and fist of other hand to strike the back of surface hand-detect tenderness over organs. Indirect (mediate)-{most commonly used} middle finger of your NONdominant hand on body part, pad of Dominant middle finger to strike the middle finger of Dominant hand, 2 quick taps.

Choice Multiple question - Select all answer choices that apply. A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply. a) Stethoscope b) Face shield c) Gloves d) Gown e) Nasopharyngeal airway

Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4

A client admitted to the health care facility has a family history of diabetes mellitus. A nursing health assessment for this client should focus on collection of data in which of these areas? a) Focuses primarily on the client's physiologic development status b) Physiologic, psychological, sociocultural, developmental, and spiritual data c) Involves the client's musculoskeletal system and activities of daily living d) Focuses only on the client's psychological, sociocultural, and spiritual well-being

Physiologic, psychological, sociocultural, developmental, and spiritual data Explanation: A nursing health assessment includes physiologic, psychological, sociocultural, developmental, and spiritual data. Medical health assessment focuses primarily on the client's physiologic development status. The assessment by a physical therapist focuses mainly on the client's musculoskeletal system and activities of daily living. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

What should the nurse do before conducting a physical examination of a patient? (Select all that apply.) a) Assist the patient to a standing position. b) Identify ways to ensure patient privacy. c) Obtain and check needed equipment. d) Wash hands. e) Ensure a quiet environment.

Prior to conducting a physical examination of a patient, the nurse should obtain and check needed equipment, ensure a quiet environment for the examination, identify how to maintain patient privacy during the examination, and wash hands before beginning the examination. Assisting the patient to a standing position would be done to assess specific body systems during the physical examination and is not done before beginning the examination.

A nurse needs to examine a client's hip joint. Which client position would be best for this assessment? a) Knee-chest b) Supine c) Prone d) Lithotomy

Prone Explanation: The prone position, in which the client lies down on the abdomen with the head to the side, is used primarily to assess the hip joint. The supine position, in which the client lies down on the back, is used to assess the head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities. The knee-chest position, in which the client kneels on the examination table with the weight of the body supported by the chest and knees, is used for examining the rectum. The lithotomy position, in which the client lies on the back with the hips at the edge of the examination table and the feet supported by stirrups, is used to examine the female genitalia, reproductive tracts, and the rectum. Chapter 3: Collecting Objective Data, p. 45.

A way to use nonverbal communication is through silence. The purposeful use of silence during the interview allows patients to what? a) Talk about their feelings b) Provide accurate answers c) Communicate verbal concern d) Rest and improve health

Provide accurate answers Explanation: The nurse uses silence purposefully during the interview to allow patients time to gather their thoughts and provide accurate answers. He or she also uses silence therapeutically to communicate nonverbal concern. Silence also gives patients a chance to decide how much information to disclose. Chapter 2: Collecting Subjective Data, p. 14.

A patient who only speaks Spanish is admitted to the unit. The patient's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this patient? a) The sister may not tell the patient exactly what the nurse says b) The patient's sister may not understand medical terminology c) The sister may not be there every time the nurse needs to talk to the patient d) The patient may not want her sister to know her private information

The patient may not want her sister to know her private information Explanation: Using children in the family, other relatives, or close friends as interpreters violates privacy laws, because patients may not want to share personal information with others. Options A, B, and C are therefore incorrect

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? a) To collect subjective data related to the client's overall health b) To evaluate whether outcomes of treatment are met c) To determine any changes from the baseline data d) To perform a rapid assessment for prompt treatment

To determine any changes from the baseline data Explanation: Ongoing or partial assessments help to determine any major changes from the baseline data. The nurse collects subjective data related to the client's overall health and conducts a comprehensive health assessment during the initial comprehensive assessment to determine baseline data. The nurse makes a rapid assessment for prompt treatment in life-threatening situations when an immediate diagnosis is needed to provide prompt treatment (emergency assessment). Evaluation is done after an intervention to determine whether the outcomes have been achieved.

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? a) Pender Health Promotion Model b) Healthy People 2020 c) Health Belief Model d) U.S. Preventive Services Task Force

U.S. Preventive Services Task Force Explanation: The U.S. Preventive Services Task Force (USPSTF) determines risk versus benefit in screenings. The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief that one is susceptible or vulnerable to a serious problem; and the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. The Pender Health Promotion Model proposes that individual characteristics and experiences affect behavior-specific cognitions and affect, which in turn yield the level of commitment to a plan. Healthy People 2020 is a model developed by the U.S. Department of Health and Human Services that focuses on increasing the life span and improving the quality of health for Americans. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

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? a) Using the bell to detect high-pitched sounds b) Using the diaphragm to listen to low-pitched sounds c) Application of firm pressure when using the bell d) Ensuring that contact with the skin is maintained

Using the diaphragm to listen to low-pitched sounds Incorrect Correct response: Ensuring that contact with the skin is maintained Explanation: While using a stethoscope to listen to air movement through the respiratory tract, the nurse should avoid listening through clothing, as it may obscure or alter the sound. However, too much pressure should not be applied when using the bell, as it would cause it to work like a diaphragm. The diaphragm is used to listen to high-pitched sounds, whereas the bell is used to listen to low-pitched sounds. Chapter 3: Collecting Objective Data: The Physical Examination, p. 49

Types of Health Assessment: Initial comprehensive:

a collection of subjective data about the client's perception of his or her health, past health history, family history, and lifestyle and health practices, as well as objective data gathered by physical examination

Choice Multiple question - Select all answer choices that apply. A nurse admits a client to the hospital who is African American. The nurse recognizes that this client is at increased risk for what conditions due to ethnicity or culture? Select all that apply. a) Cardiovascular disease b) Asthma c) Osteoporosis d) Gallbladder disease e) Skin cancer f) Peripheral artery disease

• Cardiovascular disease • Peripheral artery disease • Asthma Explanation: African Americans are at high risk for all diseases of the cardiovascular system, such as hypertension, heart attacks, stroke, and peripheral artery disease. African Americans have the highest prevalence rate of asthma and are more likely to die from the disease than members of other U.S. racial or ethnic groups. Native Americans and Mexican Americans have higher rates of gallbladder disease and cancer. Osteoporosis is more prevalent in small-framed people such as Asians. Fair-skinned people, especially those with light eyes and freckles, are at highest risk for developing skin cancers, although all people who are exposed to high levels of intense sunlight are at risk. Chapter 11: Assessing Culture, p. 190.

Choice Multiple question - Select all answer choices that apply. A nursing instructor is trying to convince the class of the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors should stressed that will promote opportunities for nurses with advanced assessment skills? Select all that apply. a) Declining health care needs of single parents b) Declining numbers of medical students due to rising costs and focus on primary care c) Growing aging population with complex comorbidities d) Increasing complexity of acute care e) Increasing impact of children and the homeless on communities

• Declining numbers of medical students due to rising costs and focus on primary care • Increasing complexity of acute care • Growing aging population with complex comorbidities • Increasing impact of children and the homeless on communities Explanation: There is tremendous growth of the nursing role in the managed care environment. The most marketable nurses will continue to be those with strong assessment and client teaching abilities, as well as those who are technologically savvy. The following factors will continue to promote opportunities for nurses with advanced assessment skills: 1) rising educational costs and focus on primary care that affect the numbers and availability of medical students; 2) increasing complexity of acute care; 3) growing aging population with complex comorbidities; 4) expanding health care needs of single parents; 5) increasing impact of children and the homeless on communities; 6) intensifying mental health issues; 7) expanding health service networks; and 8) increasing reimbursement for health promotion and preventive care services. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 2.

Choice Multiple question - Select all answer choices that apply. What are the primary frameworks used in conducting a health assessment? a) Functional b) Body systems c) Gordon's d) Analytical e) Head to toe

• Head to toe • Body systems • Functional Explanation: The three major frameworks for organizing assessment data are functional systems, head to toe, and body systems. Gordon's framework and an analytical framework are not primary frameworks for conducting a health assessment on a patient. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 4.

Choice Multiple question - Select all answer choices that apply. A nurse has completed assessment of a patient with Alzheimer's disease and documentation of the information obtained from the client and now needs to analyze the data collected. Which nursing actions should be included in this phase of the nursing process? Select all that apply. a) Formulation of nursing diagnosis(es) b) Assessment of the outcome of the care plan c) Identification of the need for referrals d) Development of a nursing care plan e) Identification of collaborative problems

• Identification of collaborative problems • Identification of the need for referrals • Formulation of nursing diagnosis(es) Explanation: The second phase of the nursing process is to identify collaborative problems and the need for referrals as well as formulate nursing diagnoses, for which the nurse must go through the steps of data analysis. Planning is the third phase of the nursing process, which involves development of a nursing care plan and assessment of the outcome of the care plan, based on the nursing diagnosis obtained in the second phase of the nursing process. Chapter 1: Nurse's Role in Health Assessment: Collecting and Analyzing Data, p. 9