Health assessment nclex style

A 72-year-old teacher comes to a skilled nursing facility for rehabilitation after being in the hospital for 6 weeks. She was treated for sepsis and respiratory failure and had to be on a ventilator for 3 weeks. The nurse is completing an initial assessment and evaluating the client's skin condition. On her sacrum there is full-thickness skin loss that is 5 cm in diameter with damage to the subcutaneous tissue. The underlying muscle is not affected. What is the stage of this pressure ulcer? A) 3 B) 4 C) 2 D) 1

A) 3

A client is reporting pain and rates it as 7 on a scale of 1 to 10. When the nurse asks him to describe the pain, he states, "It feels like a knife is stabbing or cutting me." The nurse knows that this type of pain is conducted by which fibers? A) A-delta fibers B) AC fibers C) C fibers D) P fibers

A) A-delta fibers

A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care? A) Anxiety related to awareness of increasing memory loss B) Risk for powerlessness related to prolonged disability C) Impaired memory related to dementia D) Impaired verbal communication related to hearing loss

A) Anxiety related to awareness of increasing memory loss

When caring for a client from a culturally different background, what is the goal for incorporating the client's health beliefs and practices into the nursing plan of care? A) Improvement of the client's health outcomes B) To enhance the client's social system C) Improvement of communication with the client and family D) To enhance cultural connectedness

A) Improvement of the client's health outcomes

A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumors about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have? A) Manic episode B) Schizophrenia C) Dysthymic disorder D) Major depressive episode

A) Manic episode

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? A) Nursing intervention B) Nursing goal C) Nursing evaluation D) Nursing assessment

A) Nursing intervention

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

A) Ophthalmoscope

The nurse is exhibiting critical thinking in which client care situation? A) Performing a focused assessment on a client who is complaining of shortness of breath. B) Notifying the healthcare provider of a critical lab result. C) Answering the client's call bell alarm while the nursing assistant is at lunch. D) Transcribing medication orders onto the nurse's medication administration record.

A) Performing a focused assessment on a client who is complaining of shortness of breath.

A client with a nursing diagnosis of disturbed sensory perception would be expected to exhibit what characteristics? A) Poor concentration, irritability, agitation, change in behavior B) Poor concentration, blunted affect, violence C) Agitation, depression, extreme anxiety D) Visual or auditory hallucinations, agitation, normal concentration

A) Poor concentration, irritability, agitation, change in behavior

In which situation should a nurse perform an emergency assessment of a client? A) Shortness of breath B) Broken arm C) Body rash D) Ear pain

A) Shortness of breath

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply. A) Sleep apnea B) Cirrhosis C) Hypertension D) Diabetes E) Anorexia

A) Sleep apnea C) Hypertension D) Diabetes

A nurse is teaching a class on diet and nutrition to a group of mothers who are breast-feeding their infants. What would the nurse tell the group is the emphasis of nutritional guidelines? A) Variety B) Decreased intake of grains C) Weight loss D) Increased intake of meats

A) Variety

When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should A) remain calm and accepting in response to any information the client discloses. B) confine the interview to yes/no questions to keep the interview simple. C) offer a reward to the child for answering difficult questions. D) ask leading questions to convince the child to offer information.

A) remain calm and accepting in response to any information the client discloses.

An adult male client visits the outpatient center and tells the nurse that he has been experiencing patchy hair loss. The nurse should further assess the client for: A) symptoms of stress. B) allergies to certain foods. C) pigmentation irregularities. D) recent radiation therapy.

A) symptoms of stress.

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? A) "Are you taking any medications for hypertension?" B) "Are you having pain from your surgery?" C) "What is your typical blood pressure reading?" D) "Do you have enough blankets to stay warm?"

B) "Are you having pain from your surgery?"

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence? A) "I will assess pregnant clients who come to the clinic." B) "I will assess a client for abuse and violence with every client encounter." C) "It is not necessary to assess every client. Some clients get offended when you ask them those questions." D) "I will assess a client for abuse and violence only when they present with bruises or a broken limb."

B) "I will assess a client for abuse and violence with every client encounter."

A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following? A) "Fortunately, assessment only needs to be done at the beginning of your stay." B) "I'm sorry, but assessment is ongoing and continuous." C) "I'll just need to evaluate you once more, at the end of your stay." D) "Typically, assessment occurs once at the beginning of your stay, once in the middle, and once at the end."

B) "I'm sorry, but assessment is ongoing and continuous."

The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client? A) "Can you describe the person who did this to you?" B) "It looks like someone has hurt you. Tell me about it." C) "Why do you think your husband has beaten you?" "D) Is your partner being mean to you?"

B) "It looks like someone has hurt you. Tell me about it."

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? A) A temperature of 97 degrees in an elderly woman B) A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight C) A pulse rate of 98 in a 10-year-old boy D) A blood pressure reading of 110/70 mm Hg in a competitive athlete

B) A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

The nurse prepares to assess an 8-month-old client. According to Freud, which behavior should the nurse expect to assess? A) Anal scratching B) Chewing C) Friendships D) Romantic love

B) Chewing

A young-adult relates returning a wallet that was found lying on the street to the owner with the money and credit cards intact. Which stage of Kohlberg's moral development did this person demonstrate? A) Pre-conventional B) Conventional C) Post-conventional D) Self-transcendence and faith

B) Conventional

Why is accurate and effective documentation most important? A) It ensures that data can be used for research purposes. B) Documentation constitutes a legal record. C) It keeps clients informed about their care. D) It can be used to educate other nurses.

B) Documentation constitutes a legal record.

A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what? A) Ethnicity B) Ethnocentrism C) Egocentrism D) Stereotyping

B) Ethnocentrism

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client? A) Arctic hysteria B) Ghost sickness C) Wacinko D) Hi-Wa itck

B) Ghost sickness

The nurse explains to the client that smoking has what effect on the body? Select all that apply. A) Hypotension B) Hypertension C) Vasoconstriction D) Vasodilation E) Peripheral vascular disease

B) Hypertension C) Vasoconstriction E) Peripheral vascular disease

The nurse suspects that a middle-aged adult is having an issue with generativity. What did the nurse assess to come to this conclusion? A) Desiring to attend an event with small children present B) Lack of interest in future generations C) Observed talking with younger people in the waiting room D) Sharing personal items with a young neighbor

B) Lack of interest in future generations

A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? A) Papule B) Macule C) Vesicle D) Nodule

B) Macule

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding? A) Need for corrective lenses B) Nerve damage caused by repeated eye injuries C) Undiagnosed neurologic disease D) Undiagnosed eye disease

B) Nerve damage caused by repeated eye injuries

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain? A) Idiopathic B) Neuropathic C) Nociceptive D) Somatic

B) Neuropathic

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

B) Next to the client, so the examiner can maintain eye contact and observe the nonverbal cues of the client

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider? A) Clinical information can be interpreted subjectively. B) The quality of the data may be low. C) The client will have a long problems list. D) The client will have multi-system problems.

B) The quality of the data may be low.

The nurse prepares to complete a spiritual assessment with a client. What should the nurse keep in mind when completing this assessment? A) The reason is for the nurse to share personal views in relation to what the client believes B) The reason is to better understand the client's spiritual perspective related to health C) It offers the nurse a chance to subjectively discuss the client's spiritual beliefs D) It gives the nurse an opportunity to speak freely about personal spiritual beliefs and practices

B) The reason is to better understand the client's spiritual perspective related to health

Which of the following are forms of psychological (emotional) abuse? Select all that apply. A) Incest B) Threatening to destroy property C) Rape D) Insulting E) Humiliating

B) Threatening to destroy property D) Insulting E) Humiliating

After collecting subjective and objective data for the admission database, what is the nurse's next action? A) Discuss the action plan with the client. B) Validate the client's identified problems. C) Evaluate effectiveness of nursing actions. D) Set nurse-driven goals for the client.

B) Validate the client's identified problems.

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch over 5 feet? A) 1 B) 3 C) 5 D) 7

C) 5

The student nurse learns that examining the skin can do all of the following except? A) Allow early identification of potentially cancerous lesions B) Identify physical abuse C) Allow early identification of neurologic deficits D) Reveal overhydration

C) Allow early identification of neurologic deficits

The nurse prepares information for an in-service program on the selection of nursing diagnoses to address psychosocial needs. Which diagnosis would be appropriate for any client age? A) Sedentary lifestyle B) Impaired religiosity C) Anxiety D) Parental role conflict

C) Anxiety

How may a nurse demonstrate cultural competence when responding to clients in pain? A) Know the action and side effects of all pain medications. B) Treat every client exactly the same, regardless of culture. C) Avoid stereotyping responses to pain by clients. D) Be knowledgeable and skilled in medication administration.

C) Avoid stereotyping responses to pain by clients.

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population? A) Comorbidity B) Polyhedonia C) Death D) Bankruptcy

C) Death

A nurse assesses a cognitively impaired adult client who grimaces and points to the right knee following a motor vehicle accident. Which pain scale would be most appropriate for the nurse to use to assess the client's pain? A) Numeric Rating Scale B) Visual Analog Scale C) Faces Pain Scale D) Verbal Descriptor Scale

C) Faces Pain Scale

A client complains of pain in several areas of the body. How should the nurse assess this client's pain? A) Mark each site on the client's body with a marker. B) If pain does not radiate, there is no need to rate that area. C) Have the client rate each location separately. D) Ask the client to rate the area with the highest pain level.

C) Have the client rate each location separately.

The nurse wants to support a client's spirituality. To do so, what must the nurse do first? A) Ask the on-call chaplain to come see the client. B) Tell the client that religion is important to you and you are happy to discuss it. C) Keep an objective perspective and meet the client at his or her level. D) Give the client a Bible to read.

C) Keep an objective perspective and meet the client at his or her level.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? A) Recheck blood pressure in 30 minutes B) Have the UAP retake the blood pressure C) Reassess blood pressure D) Notify the physician

C) Reassess blood pressure

How should the nurse place the ear of an adult when using the otoscope? A) Down and back B) Down and forward C) Up and back D) Up and forward

C) Up and back

Connecting the skin to underlying structures is/are the A) sebaceous glands. B) dermis layer. C) subcutaneous tissue. D) papillae.

C) subcutaneous tissue.

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document? A) experiences panic attacks several times a week B) misses seeing friends who used to go for walks together C) unable to go to the gym since having back surgery D) gained 15 lbs. over the last 6 months

C) unable to go to the gym since having back surgery

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should A) document the data after the entire examination process. B) use medical terms that are commonly used in health care settings. C) validate all data before documentation of the data. D) record the nurse's understanding of the client's problem.

C) validate all data before documentation of the data.

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview? A) "What medication do you take for your depression?" B) "When was the last time you talked with a psychiatrist?" C) "Have you considered counseling for your mental problems? D) "Have you ever had a problem with mental or emotional illness?"

D) "Have you ever had a problem with mental or emotional illness?"

A nursing instructor is teaching students about communication in different cultures. When discussing the meaning of hand gestures and body language in different cultures, the nurse realizes that further instruction is necessary when a student makes which statement? A) "If any hand gesture is used, always clarify if there seems to be a strange reaction on the other's part." B) "A major hand gesture is one for indicating height." C) "There are many different elements of body language and hand gestures." D) "I can make a circle with my thumb and forefinger and people of all cultures know it means OK."

D) "I can make a circle with my thumb and forefinger and people of all cultures know it means OK."

A nurse assesses a 350-pound adult client who is 6 feet 1 inch tall. What is the estimated body mass index (BMI) for this client? A) 29 B) 52 C) 34 D) 46

D) 46

A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides? A) Information on the nurse's cultural competence B) Information on the effectiveness of interventions C) Data on the client's prognosis for recovery D) A baseline for comparison with future findings

D) A baseline for comparison with future findings

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"? A) Using pre-written cards that state the interview questions B) Introducing hand gestures whenever it is appropriate C) Asking the client if they are wearing a hearing aide D) Closing the door may help to limit background noise.

D) Closing the door may help to limit background noise.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step? A) Opinions and comments are not relevant in making accurate interpretations of data. B) Final opinions or judgements must be made rapidly. C) The nurse must be an expert in her field in order to interpret data accurately. D) Diagnostic reasoning skills are required to interpret data accurately.

D) Diagnostic reasoning skills are required to interpret data accurately.

A client just died, and the nurse is preparing the body for the funeral home. The client practiced Judaism and a rabbi was present at the time of death. The nurse is careful to do which of the following to honor the client's religious beliefs concerning death? A) Place a medal with the client. B) Burn all bandages with the client's blood. C) Discard all clothes of the client. D) Do not cross the client's arms.

D) Do not cross the client's arms.

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case? A) Diagnosing a client without hypothesizing several diagnoses B) Clustering together unrelated cues C) Incorrectly wording a diagnostic statement D) Overlooking consideration of the clients cultural background

D) Overlooking consideration of the clients cultural background

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? A) Family liaison B) Diagnostician C) Surrogate decision maker D) Patient advocate

D) Patient advocate

A nurse is assessing a 24-year-old client in terms of her psychosocial development, following Erikson's approach. Which of the following would the nurse most likely identify as an abnormal finding in this client? A) Ability to have close caring relationships with friends of both genders B) Continuation of the role of daughter C) Focus on the desire for a permanent love relationship D) Sexual promiscuity

D) Sexual promiscuity

A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source? A) Fortified breads B) Orange juice C) Lentils D) Sunshine

D) Sunshine

Which describes the nurse using the technique of palpation? A) The nurse notes asymmetry of the individual's abdomen. B) The nurse notes gurgling sounds over the individual's abdomen. C) The nurse notes tympany over the individual's lower abdomen. D) The nurse notes increased warmth surrounding an abdominal incision.

D) The nurse notes increased warmth surrounding an abdominal incision.

Spirituality can best be described as A) a part of community identification. B) another way of expressing a connection to a church. C) necessary for healing. D) a source of inner strength.

D) a source of inner strength.

The nurse is conducting a physical examination of a client 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) d, e, b, a, c B) d, b, a, e, c C) c, e, b, d, a D) c, d, e, b, a E) a, c, b, d, e

D) c, d, e, b, a

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client? A) physical B)social well-being C) developmental level D) environmental

D) environmental

While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using A) palpation. B) inspection. C) Doppler magnification. D) percussion.

D) percussion.

One disadvantage of the open-ended assessment form is that it A) asks standardized questions. B) does not provide a total picture of the client. C) does not allow for individualization. D) requires a lot of time to complete.

D) requires a lot of time to complete.

The most effective way for a nurse to learn about an ethnic group within the community in which he/she practices is A) do a community survey of the areas where the ethnic group lives. B) interview the traditional healers within the group. C) study transcultural nursing texts and articles about the group. D) spend time with a variety of individuals of that ethnic group.

D) spend time with a variety of individuals of that ethnic group.

A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing? A) self-perception B) role-relationship C) coping-stress-tolerance D) value-belief

D) value-belief

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning. A) practice B) time C) experience D) knowledge E) seeing things as only right or wrong

E) seeing things as only right or wrong