NUR 1068 Ch 3 - assessing subjective data

A nurse is preparing to evaluate an elderly client's risk for developing pressure sores after a 2-week stay in the hospital. Which of the following pieces of equipment will this nurse need for this purpose?

Braden scale

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor?

Environmental risk factor

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

The nurse practitioner is discussing health promotion with a group of senior nursing students. What would be the best example of secondary health promotion?

Family counseling

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept?

Focus on what is possible.

Which are characteristics of chronic conditions? (Select all that apply.)

Have a prolonged course Are rarely curable Require lifelong management

What is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity?

Health

What assessment technique is performed for every body part and body system?

Inspection

Which of the following techniques are used in a physical assessment? Select all that apply.

Inspection Palpation Auscultation

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

The nurse is working in an acute care setting and performs primary, secondary, and tertiary prevention. Which activity performed by the nurse is classified as tertiary prevention?

Instructing a client on how to use crutches

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

It has a gradual onset and lasts for a long time.

Which behaviors are necessary for a person to successfully adapt to a chronic illness? Select all that apply.

Learn to live as normally as possible Maintain a positive self-concept Maintain a sense of hope

As the density of tissue decreases, the percussion note becomes:

Lower pitched

Which nursing activity reflects secondary prevention?

Making a referral for a mammogram

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation

While providing client care, a nurse determines that a client adheres to the health belief model. What would the nurse need to assess as a factor possibly affecting the client's response to illness?

Personality characteristics

The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to?

Physical dimension

What level of prevention is represented by educating a group of clients on carseat safety?

Primary prevention

The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?

Reduce all environmental noise.

The nurse is certified in providing Therapeutic Touch and is preparing to initiate this for a client. What activity should the nurse perform first?

Requesting the client's permission to touch the body

The nurse is holding a cholesterol screening at a local pharmacy this Saturday morning. What level(s) of health promotion is this screening an example of?

Secondary

Consultation and diagnostic tests are included in which level of health care?

Secondary care

A mammogram represents which level of prevention?

Secondary prevention

A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision?

Snellen chart

A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client's circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions?

Sociocultural and intellectual

The nurse recognizes that the client who makes the decision to accept a new diagnosis and follow the prescribed treatment plan is in which stage of an illness?

Stage 3-Assuming a dependent role

The emergency department nurse is preparing a care plan for a young child who has suffered a fractured arm after a bicycle accident. Which factor should the nurse consider including in the care plan for this child to best address this issue?

applying for Children's Health Insurance Program (CHIP)

To alleviate a client's anxiety during a comprehensive assessment, the nurse should

explain each procedure being performed and the reason for the procedure.

When chronic illnesses and disabilities are present, individuals benefit most from activities that:

help them maintain independence.

The body's attempt to restore balance through self-regulatory mechanisms is termed:

homeostasis.

The nurse instructor has completed a session detailing major factors differentiating exacerbations from remissions. The instructor determines the session is successful when the students point out which factor(s) can contribute to exacerbations? Select all that apply.

immune system is functioning poorly sleep has been disrupted due to family issues client is facing a potential eviction

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection.

The nurse enters the room of a client and sees that visitors are present. What is the nurse's best action?

Ask permission to talk to the client in front of visitors.

How can the nurse best demonstrate being a role model for health promotion?

Avoid smoking and drinking alcohol

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone?

Sociocultural needs

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath.

An older adult client who has been hospitalized due to a stroke is about to be discharged from a rehabilitation center where the client had to relearn how to perform activities of daily living, including feeding and dressing. The client has often voiced a desire to be as active as possible. The client now expresses a strong desire to go home. The nurse recognizes that these statements made by the client indicate that the client is:

giving up the dependent role.

A 47-year-old woman is traveling overseas on vacation with her husband. He has a sore throat that has been diagnosed as Streptococcus. The woman is the:

host.

Which describes the nurse using the technique of auscultation?

The nurse detects gurgling throughout the abdomen.

While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

To determine whether a structure is filled with air or fluid or is a solid structure

What have the models of health promotion and illness prevention been used for?

To help health care providers understand health-related behaviors.

Is the following statement true or false? There are times when gloves must be changed between procedures on the same patient.

True. Gloves must be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms.

Is the following statement true or false? Sitting upright on the side of the examination table is a useful position while examining the client as it allows full expansion of the lungs.

True. Sitting upright on the side of the examination table, the edge of a chair, or a bed is a good position for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full expansion of the lungs and allows the examiner to assess symmetry of upper body parts.

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

"They make sure that any microorganisms on my hands do not touch your skin."

The nurse is planning care for several clients in an outpatient clinic. Which client requires follow-up care due to a chronic condition?

A client with chronic obstructive pulmonary disease (COPD) who is wheezing and coughing

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

Which nursing intervention is an example of tertiary preventive care?

Assisting with speech therapy a client with a traumatic brain injury

Which nursing activity reflects care given on the tertiary level of healthcare delivery?

Assisting with transplant surgery

An older adult patient has been recently diagnosed with vascular dementia. Because the client lives alone and has poorly controlled hypertension, the client has begun to receive home healthcare. This new aspect of the client's care is characteristic of which stage of illness?

Assuming a dependent role

The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?

Balance

A client makes a decision to quit smoking and joins a smoking cessation class. This is an example of which of Dunn's processes that helps one know who and what one is?

Befitting

Why are health promotion and illness prevention a key responsibility of nurses?

Chronic illnesses are the leading health problem in the world.

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

Color

A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the United States. Which disease process should the nurse address?

Coronary artery disease

The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?

Teaching about adhering to a low-sodium diet

A nurse is caring for a 17-year-old client whose left leg was amputated after being crushed in a motor vehicle accident. Which intervention might the nurse perform to address the client's intellectual dimension?

Teaching her how to care for the stump and explaining the rehabilitation program

A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?

Tertiary

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?

Tertiary prevention

When first diagnosed with cancer, a client was depressed and complained of feeling sick. Now the client has adapted to the diagnosis, recently returned to work, and, since undergoing chemotherapy, reports feeling better than ever. The nurse recognizes that which model of health promotion is most effective in explaining this client's situation?

The Health-Illness Continuum Model

A nurse observes that a client who has pneumonia is in the recovery and rehabilitation stage of the illness. Which statement describes the client response that the nurse would expect at this stage of the illness?

The client gives up the dependent role.

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

bone.

Chronic illness may be characterized by periods of remission. Remission is best defined as:

the presence of a disease with the absence of symptoms.

After completing the physical examination of a client who is 12 weeks pregnant, a new nurse leaves the room only to realize she forgot to complete an examination of the skin. What should the nurse do?

Go back in to complete a physical examination of the skin.

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?

Health belief model

You are performing a physical examination on a new client. What would you be assessing if you were testing the client's sense of smell?

Cranial nerves

What are some examples of healthy self-care behaviors everyone should adopt? Select all that apply.

Eating regular healthy meals Maintaining an ideal body weight Sleeping 7 to 8 hours each night

Is the following statement true or false? Percussion that is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface is known as direct percussion.

False. Blunt percussion is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface.

Is the following statement true or false? Good overhead lighting is an effective substitute for sunlight during an assessment.

False. It is best to use sunlight when available. However, good overhead lighting is sufficient. A portable lamp is helpful for illuminating the skin and for viewing shadows or contours.

Which are factors that impact how a client defines health? Select all that apply.

Family Culture Society Community

When assessing pulses, the nurse would use which part of the hand for palpation?

Finger pads

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

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

Depressing the skin surface with the dominant hand and using a circular motion to palpate falls under which palpation type?

Moderate palpation. Moderate palpation involves depressing the skin surface 1 to 2 cm with the dominant hand and using a circular motion to feel for easily palpable body organs and masses.

The nurse is giving a talk to a local community group on the harms of smoking. The nurse tells the group that a risk factor is something that increases a person's chances for illness or injury. What type of risk factor is smoking?

Modifiable

The nurse is caring for a client admitted to the hospital with pneumonia and associated pleuritic chest pain. Which would be a priority when creating the nursing care plan?

Monitoring airway clearance.

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

Otoscope

A nurse in the community is completing manual blood pressure assessments at a recreation center. Which action should the nurse take to ensure the assessment is accurate?

Turn down the volume if the television or radio is on.

The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?

What people believe to be true about their health

A nurse assists the client in the development of a healthy lifestyle. The adoption of these lifestyle changes in the client's life is considered:

self-care.