Health Assessment Test 1

Newborn Vitals

120-160 140 30-60 60-90/20-60

The nurse is palpating the abdomen of a patient. How deep should the hands press while performing deep palpation?

4 cm

Adult vitals

60-100 70 12-20 110-139/60-79

Adolescent vitals

60-90 70 12-16 94-139/62-88

School aged vitals

75-100 85 18-30 84-120/54-80

Toddler vitals

90-140 110 24-40 80-112/50-80

Pulse oximetry is used to

A pulse oximeter estimates the oxygen saturation of arterial blood and pulse or heart rate. A patient may have a normal oxygen saturation measurement even in the presence of severe anemia. Measurements are not taken from the alveoli of the lung; circulating red blood cells are measured.

The nurse is percussing the liver of an obese patient. Which percussion finding would be expected?

A reduced intensity of tone

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Ask the other nurse to read back what first nurse reported

What is the foundation of nursing practice?

Assessment

While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's

Bone

What is a required component of a health assessment?

Critical Thinking

Which are considered basic techniques for physical assessment?

Data for physical assessment are collected using four basic assessment techniques: inspection, palpation, percussion, and auscultation.

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

Determine any changes from the baseline data

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the

History of present illness

When charting by exception is used in a health care agency, the most important aspect of this method is what?

Identifying the standards and norms for the institution

Light palpation is most appropriate to assess the

Inflamed areas of the skin

What physical assessment technique should a nurse use to obtain a pulse on a client?

Light palpatation

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in?

Lithotomy

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.)

Obtain and check needed equipment. Identify ways to ensure patient privacy. Wash hands.

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?

To provide a record of the actual events

The nurse is assessing the temperature of a toddler. Which method is best for this patient? A thermometer is inserted into the patient:

Tympanic

The nurse is percussing a patient's abdomen. What sound will the nurse most likely percuss?

Tympany

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

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

validate all data before documentation of the data.

What are nurses able to detect through the health assessment?

Areas in need of health adjustments

A client presents to the health care clinic with reports of sleeplessness and loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital and he has not been able to visit her much because of transportation problems. Which open-ended question should the nurse ask the client to obtain more information about his presenting symptoms?

"Do you think your wife is getting better?"

A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?

As many maternal and paternal relatives as the client can recall

Which piece of equipment should a nurse use to perform a test for stereognosis?

Coin or key

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

Deep palpatation

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?

Focused

The nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system?

Functional health status

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.

Gown Face shield Gloves

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?

Heart murmur

A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client?

Knee-chest

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress notes

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

Progress notes

When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to:

Validate the data

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?

"It means I need to make sure that all the information I gathered today is reliable and accurate."

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data?

Compare objective findings with subjective findings.

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

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

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings

The nurse knows that the single most important factor in conducting an interview is the communication process. Which factors will most likely affect a positive interview process and therapeutic communication?

Numerous factors affect the interview and the communication process, including the physical setting, nurse's behaviors, the type of questions asked and how they are asked. In addition, the personality and behavior of patients, how they are feeling at the time of the interview, and the nature of information being discussed or problem being confronted may affect the data revealed.

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?

Reassess blood pressure

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication?

SBAR

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 student nurse is conducting her first patient interview. The student suddenly draws a blank on what to ask the patient next. What is a useful interview technique for the student to use at this point?

Summarization

After the nurse has completed the interview, a symptom analysis is performed to derive appropriate interventions. What is the best description of symptom analysis?

Symptom analysis is used most often to document a current illness or injury. Symptom analysis can take place with or without the use of an interpreter.

A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient?

The emergency assessment involves a life-threatening or unstable situation, such as a patient in an ED who has experienced a traumatic injury. Staff members at the ED use triage to determine the level of urgency by considering assessments based on the mnemonic A, B, C, D, E: A—Airway; B—Breathing; C—Circulation; D—Disability; and E—Exposure.

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

A nurse who may be shy in social situations may exhibit excellent therapeutic communication by what? Select all that apply.

Using silence Using touch Communicating nonverbally through facial expression

The nurse is counting an infant's respirations. Which technique is correct?

Watch the abdomen for movement.

The nurse suspects that a patient has a fungal infection of the skin. Which instrument helps confirm this suspicion?

Wood's lamp

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply):

accurate organized complete timely concise

During an interview, how can the nurse best assist the client as the client tells his or her story?

interrupting only if absolutely necessary