Health Assessment Exam mod 1-4

A male client with a history of a back injury 2 months ago has been taking daily doses of narcotic pain medication. He is currently hospitalized with a leg fracture after falling down the stairs. He complains of 10/10 pain in his back and leg after taking pain medication one hour ago. What is the nurse's best action?

Consult with the healthcare provider about increasing the dose of medication.

The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?

Dorsiflexion of the foot

Upon reviewing the client's medical record, the nurse finds the client has left ptosis. The nurse would assess the client for what?

Drooping of the left eye

A client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury?

Glossopharyngeal (IX)

The nurse wears gloves for which of the following purposes? Select all that apply.

Prevent transmission of flora from client to client. Limit exposure to body fluids and secretions no: Increase the risk of the nurse acquiring infection from the client. Facilitate contamination of the hands of the nurse.

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?"

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client

"Can you repeat brown, chair, textbook, tomato?"

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?"

When the nurse is assessing a client's mental status as part of the screening neurological examination, which question would be most appropriate to ask?

"Can you tell me where you are right now?"

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

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 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?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?"

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

Assess for nonverbal signs.

A nurse is preparing to assess a client's cerebellar function. What aspect of neurological function should the nurse address?

Balance

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 nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area

A nurse draws a genogram to help organize and illustrate a client's family history. Which shape is a standard format of representing a deceased female relative?

Circle with a cross

A nurse is conducting a general survey on a client. Which observation(s) would require follow-up by the nurse? Select all that apply.

Client seems older than the stated age. Client's clothing is loose. Client has poor hygiene. no: Client's posture is erect. Client's skin color is even.

The nurse is performing the Romberg test. Which of the following indicate a normal finding?

Client stands erect with minimal swaying

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise.

What should the nurse assess to test the function of the frontal lobe?

Communication

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

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find?

Decreased sensation in the feet

The nurse is caring for a client in the hospital and identifies the client to be experiencing acute confusion after cardiac surgery. The nurse recognizes this as what?

Delirium

A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize?

Establishing a trusting relationship

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients?

Friends and family who are unfamiliar with medical terminology may misinterpret information

A client on a medical-surgical unit reports pain of 10 on a scale of 0 to 10 and wants more pain medication. The nurse does not think the pain is as bad as the client says. The physician left orders for prn morphine for breakthrough pain. What is the priority nursing action?

Give the prn morphine

Which of the following assessment findings would lead the nurse to suspect that a client has Bell's palsy?

Inability to wrinkle the forehead

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the client's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?

Increased or brisk, but not pathologic

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

L2 to L4

A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information?

Lifestyle and health practices profile

The nurse understands the importance of performing an accurate pain assessment. In addition to having the client rate the pain on a pain scale, other things to assess are the following: (Check all that apply.)

Location and duration Quality and description Alleviating and aggravating factors no: Diet and allergies Urine output and pulse oximetry value

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropathic pain caused by damage or injury to the nerves that transfer information between the brain and spinal cord from the skin, muscles and other parts of the body. The pain is usually described as a burning sensation and affected areas are often sensitive to the touch.

When providing client teaching, what can the nurse assess?

Patient's ability to perform ADLs

When gathering information about medication use, a nurse should ask a client about which types of drugs?

Prescription and OTC medications

A nurse obtains an axillary temperature on a client who underwent extensive oral surgery for removal of several cancerous polyps. The axillary temperature is 95.2° F (35.1° C). Which of the following actions should the nurse take?

Report abnormal findings to the health care provider.

The nursing instructor is discussing standard precautions with a group of students. What else should the instructor talk about to prevent the transmission of pathogens?

Respiratory/cough hygiene

A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?

Somatic

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation

A nurse is working with a client who is victim of a shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?

Sympathetic nervous system

Which of the following assessments is most likely to provide insight into the function of the client's CN VIII?

Test the client's hearing for lateralization and bone and air conduction.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

It is recommended that a left-handed examiner adopt a right-sided position.

True

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

Upon meeting the client and family members

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

Which assessment procedure should a nurse institute to test a client for stereognosis?

With eyes closed, ask the client to identify a familiar object that is placed in their hand

Which of the following assessment techniques should the nurse use to determine a client's stereognosis?

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should

ask the client to purse the lips.

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

When assessing the client for pain, the nurse should

believe the client when he or she claims to be in pain.

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

cerebellum

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

client rated pain level as being a 5 using the rating scale.

The cerebrum is divided into right and left hemispheres, which are joined together by the

corpus callosum.

The nurse observes a student nurse performing a focused assessment on a client presenting with signs and symptoms of appendicitis. The nurse should intervene when the student nurse is observed performing which of the following actions on the client's abdomen?

deep palpation

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal

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

Which type of question is asked first by the nurse in order to attain a full description of the client's symptoms?

open-ended questions to allow full freedom of response

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur?

orthostatic hypertension

A nurse in a clinic is preparing to meet with a new, 35-year-old male client.

review the client's medical record and explain the purpose of the interview

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

smile

The diencephalon of the brain consists of the

thalamus and hypothalamus.

The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. The nurse should

indicate acceptance of the client's cultural differences.

A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?

relaxed

"Tell me about your pain" is an example of an open-ended question.

true

When evaluating a client's risk for cerebrovascular accident, which client would the nurse identify as being at highest risk?

68-year-old African American male with hypertension

A client recovering from total knee replacement is experiencing severe pain. Where should the nurse expect the client to rate this pain on the following scale?

7-10

While the nurse is preparing to begin a physical examination of a client, the nurse notes that the bed is in the lowest position, the client is in a side-lying position, the television is on at a loud volume, and the lights are dimmed. How should the nurse proceed with the assessment? Select all that apply.

Adjust the bed to a comfortable height. Ask the client to reposition for the exam as necessary. Lower the bed when the exam is completed. Don't worry about hanging these: Turn off the television. Keep the lights dim.

During the Romberg test, a client is unable to stand with his feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would identify this as which of the following?

Cerebellar ataxia Ataxia describes poor muscle control that causes clumsy voluntary movements. It may cause difficulty with walking and balance, hand coordination, speech and swallowing, and eye movements.

The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?

Conduct a brief review of the client's charts.

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

Document the findings.

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview.

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem?

Myasthenia gravis

A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?

key or coin

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

Instruct the client to flex and extend the right elbow

The client comes to the emergency department reporting indigestion and left arm pain. The physician orders an EKG along with drawing of cardiac enzymes. When the results are back, the client is informed of the diagnosis of heart attack. The indigestion and arm pain are examples of which of the following?

Referred pain

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

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?

rephrasing

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment

The Glasgow Coma Scale measures the level of consciousness in clients who are at high risk for rapid deterioration of the nervous system. A score of 13 indicates

some impairment.

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

120/55 mm Hg

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?

Cerebellar ataxia