Health Assessment exam 4

The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps

1 inspect 2 auscultation 3 palpate

How can a nurse work on developing cultural awareness?

- Reflect on his or her past learning about health, illness, race, gender, and sexual orientation - Develop greater self-knowledge about personal biases - Recognize consciously the multiple factors that influence his or her own world view - Engage in an in-depth self-examination of his or her own background

A nurse is assessing a clients neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items?

A familiar object she places on his hand

Which of the following are examples of problems with healthcare system that contribute to health disparities?

A health care provider assumes that the patient missed two appointments because the patient does not care about his or her health and does not inquire the reasons for missed visits A community hospital lacks an adequate staff of social workers who are able to ensure patients access to resources they need to take care of their health A hospital discharges patient without ensuring that the patient has a primary care provider and has made a follow up appointment A nurse uses a family member as an interpreter to explain the patients meds The hospital conducts quality improvement without stratifying data by race ethnicity language socioeconomic status sexual orientation and other axes of social group identities

During an encounter with an elderly patient, the nurse recognizes that a thorough cultural assessment is necessary because the patient has recently come to the United States from Russia and has never been hospitalized before. The nurse wants to discuss cultural similarities between herself and the patient. Which step of the LEARN mnemonic is this? a. Listen b. Explain c. Acknowledge d. Recommend treatment e. Negotiate agreement

Acknowledge

The nurse in a providers office is preparing to assess a young adult male clients musculoskeletal system as part of a comprehensive physical examination. Which of the following finding ms should the nurse expect?

Concave lumbar spine posterior Muscles slightly larger on his dominant side

When you care for a patient who does not speak English, it is necessary to call on a professional interpreter. Which of the following are proper principles for working with interpreters? (Select all that apply.) a. Expect the interpreter to interpret your statements word-for-word so there is no misunderstanding by the patient. b. If you feel an interpretation is not correct, stop and address the situation directly with the interpreter. c. Pace a conversation so there is time for the patient's response to be interpreted d. Direct your questions to the interpreter. e. Ask the patient for feedback and clarification at regular intervals

B C E

The faith community nurse is teaching the community center women's group about breast cancer risk factors. Which factors does the nurse include?

Family history with BRCA1 inherited gene mutation Age over 40 Onset of Menses before age of 12 Recent use of oral contraceptives

3. Oculomotor

Eye movement, pupil constriction eye opening

7. Facial

Facial expressions, taste

A nurse is caring for a client who reports pain with internal rotation of her right shoulder. The nurse should identify that this discomfort can affect the clients ability to perform which of following activities?

Fastening hey bra behind her back

A nurse is preparing to perform a cultural assessment of a patient. Which of the following questions is an example of a contrast question?

How different is this problem from the one you had previously?

The nurse is teaching a patient how to perform a testicular see examination. Which statement made by the patient indicates a need for further teaching?

I'll recognize abdominal lumps because they are painful

Which of the following are considered social determinants of health

Lack of primary health care providers in zip code Poor quality public school education that prevents a person from developing adequate reading skills Lack of affordable health insurance Employment opportunities that do not provide paid vacation or sick leave Neighborhood safety that prevents a person from walking around the block or socializing with neighbors outside of home

A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the clients balance

Romberg test Heel to toe walk

A nurse is collecting date from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging?

Some vision and hearing decline Slower fine finger movements Some short term memory decline

The new nurse is caring for a hospitalized obese patient who is homeless. This is the first time the patient has been admitted to the hospital and the patient is scheduled for surgery. Which of the following is a universal skill that will help the nurse work effectively with this patient

The nurse asks the patient, "tell me more about the main problem you have had with your health from not having a home."

A patient is admitted through the emergency department after serious car accident. The nurse assesses the patient and quickly learns that he speaks little English. Spanish is his primary language. The nurse speaks some Spanish. Which intervention would be appropriate at this time.

The nurse requests professional interpreter The nurse determines the interpreter qualifications and makes sure that the interpreter can speak with the patients dialect The nurse uses short sentences to explain the treatments provided in the ED The nurse directs questions to the patients by looking at the patient instead of the interpreter

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints Eye opening Verbal response Motor response Less than 8 severe Moderate 9-12 Mild 13-15

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast? A) Supine with both arms overhead with palms upward B) Sitting with hands clasped just above the umbilicus C) Supine with the right arm abducted and hand under the head and neck D) Lying on the right side, adducting the right arm on the side of the body

c) Supine with the right arm abducted and hand under the head and neck Lying on the back allows breast tissue to relax; raising the arm over the patient's head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or tumors, especially cancerous tumors that are fixed against the chest wall.

5. Trigeminal

chewing, face and mouth touch and pain

4. Trochlear

eye movement

6. Abducens

eye movement lateral

10. Vagus

gag reflex swallowing speech sounds

11. Spinal Accessory

head and shoulder movement

8. Auditory

hearing

1 olfactory

smell

9. Glossopharyngeal

taste and swallowing

12. Hypoglossal

tongue movement position

2. Optic

vision