Nurs 114 Exam 1

What makes up the nursing process?

ADOPIE Assessment Diagnosis Outcome Planning Implementation Evaluation

sympathy

Feeling sorry for the patient

Closing an interview

Lead into it... "Our interview is about over..." Summarize Say "thank you"

S/O Passing flatus

Objective

S/O: Describes severe right sided headache

Subjective

risk nursing diagnosis

a nursing diagnosis that indicates the client does not currently have a problem but is at high risk for developing it

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's a) perception of pain b) height c) weight d) temperature

a) perception of pain

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's a) physiologic status b) holistic wellness status c) developmental history d) level of functioning

a) physiologic status

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form a) prevents missed questions during data collection b) covers all the data that a client may provide c) Clusters the assessment data with nursing diagnoses d) establishes comparability of data across populations

a) prevents missed questions during data collections

The nurse assess the client's VS as follows: resp = 20 bpm, tympanic temp 100.9F, pulse 88 bpm, and BP 104/4. The nurse should a) record the VS b) instruct patient to drink more fluids c) refer the client to primary care provider d) administer tylenol

a) record the VS (vital signs)

While percussing an adult client during a physical exam, the nurse can expect to hear flatness over the client's a) lungs b) bone c) liver d) abdomen

b) bone

During the interview of an adult client, the nurse should a) use leading questions for valid responses b) provide the client with information as questions arise c) read each question carefully from the history form d) complete the interview as quickly as possible

b) provide the client with information as questions arise

Supine position

back-lying position used for examination of the abdomen (with one small pillow under the head and another under knees); this position also allows easy access for palpation of peripheral pulses

implementation

carrying out the plan of care

collaborative problem

certain physiologic complications that nurses monitor to detect their onset or change in status

Prone position

client lies on abdomen with head turned to side; may be used to assess back and mobility of hip joint

nursing diagnosis

clinical judgment about individual, family, or community responses to actual or potential health problems and life processes

Nursing assessment

collection of subjective and objective data

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed a) entry b) exploratory c) focused d) comprehensive

d) comprehensive

while performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using a) inspection b) palpation c) Doppler magnification d) percussion

d) percussion

one characteristic of a nurse who is a critical thinker is the ability to a- form an opinion quickly b- offer advice to clients c- be right most of the time d- validate information and judgments

d- validate information and judgments

planning

developing a plan of nursing care and outcome criteria

s/o pale, clammy, and diaphoretic

objective

intuition

quick and ready insight

the nurse notes which of the following vital signs findings as abnormal in an 88 yo pt? a) 55 mmHg pulse pressure b) Resp rate of 22 breaths per minute c) oral temp of 37.7 C (100F) d) BP of 140/90

C) oral temp of 37.7 C (100F)

Techniques to a successful interview

Keep it short Introduce self, shake hands if appropriate State that you're a student Call person by surname Reason for interview and time frame Start with open ended questions

What tools are needed for inspection

Otoscope, ophthalmoscope, speculum, penlight

The nurse is interviewing a 78 year old client for the first time. The nurse should first a) assess the client's hearing acuity b) establish a rapport with the client c) obtain biographic data d) use medical terminology appropriately

a) assess the client's hearing acuity

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is a) continuous b) completed on admission c) linear d) performed only by nurses

a) continuous

An assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n): a) ongoing or partial assessment b) focused or problem oriented assessment c) emergency assessment d) initial comprehensive assessment

b) focused or problem oriented assessment

Lithotomy position

back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract and rectum

referral problem

problem that requires the attention or assistance of other health care professionals

When formulating a nursing diagnosis, the format that is most useful to clearly document the clients problem is a) NANDA label (for problem) + r/t + etiology + AMB + defining characteristics b) NANDA label + defining characteristics+ AMB the etiology c) NANDA label + definition + defining characteristics + AMB etiology d) NANDA label + definition + etiology + AMB + defining characteristics

A) NANDA label+ r/t+ etiology+ AMB+ defining characteristics

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write a) bilateral lung sounds clear b) the clients lung sounds were clear on both sides c) clients lung sounds were auscultated with stethoscope and were clear on both sides d) after listening to client's lung sounds, both lungs appeared clear

A) bilateral lung sounds clear

A clients BP is affected by a) cardiac intake, elasticity of arteries, blood flow, blood cells and blood thickness b) cardiac intake, elasticity of veins, blood flow, blood cells, and blood thickness c) cardiac output, distensibility of the veins, blood volume, blood velocity and viscosity d) cardiac output, distensibility of the arteries, blood volume, blood velocity and viscosity

D) cardiac output, distenisbility of the arteries, blood volume, blood velocity and viscosity

During a comprehensive assessment, the primary technique used by the nurse throughout the exam is a) palpation b) percussion c) auscultation d) inspection

D) inspection

An approximate reading of core body temp can be taken at various anatomic sites. Which of the following would not be a correct place to take body temp? a) under the tongue b) forehead and temporal artery c) opening of ear d) rectum e) groin

E groin

During palpation, fingerpads are used for:

Fine discrimination Texture, pulsation, size, shape, consistency

Laundry list questions

Giving a client a list of symptoms, conditions or feelings to choose from Example: "Is the pain sharp, dull, piercing, cutting or severe?"

Elder abuse

Includes neglect, physical abuse, sexual abuse, financial abuse, psychological abuse (humiliation, intimidation, threats), exploitation, abandonment, or prejudicial attitudes that decrease quality of life and are demeaning to those over the age of 65

Order of assessment for abdomen

Inspection, auscultation, percussion, palpation (look, listen, feel)

Order of assessment for body

Inspection, palpation, percussion, auscultation

What are the parts of an interview?

Introductory phase, working phase, and closing/summary phase

Pitfalls of interviewing

Note taking - breaks eye contact - shifts attention - can interrupt person if asked to repeat information - impedes observation of nonverbal cues - threatening to person if discussing issues of ETOH, IVDA, sexual partners

S/O: Reddened, raised, indurated area on deltoid area of left arm

Objective

Open-ended question

Provokes an open answer— allows for more feelings or perceptions Usually begins with "what", "how" Example: How have you been feeling lately?

Verbal communication

Using the voice— watch for loudness and tone

Objective Data

What we can see and test; a measurement If information is given to you by a CNA or assistive personnel, it is classified as objective

A female client is assessed to have a score of 8 points on the AUDIT. This would alert the nurse that this client a) has a hazardous alcohol consumption b) is a heavy drinker c) is an at risk drinker d) is not at any risk for alcohol harm

a) has a hazardous alcohol consumption

While assessing an older adult client's respirations, the nurse can anticipate that the resp pattern may exhibit a A) shorter inspiratory phase b) longer inspiratory phase c) shorter expiratory phase d) longer expiratory phase

a) shorter inspiratory phase

The nurse is interviewing a client in the clinic for the first time. The client appears to have a very limited vocabulary. The nurse should plan to a) use very basic lay terminology b) have a family member present during the interview c) use standard medical terminology d) show the client pictures of different symptoms, such as the "faces pain chart"

a) use very basic lay terminology

the nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should a) validate all data before documentation of the data b) document the data after the entire examination process c) record the nurses understanding of the clients problem d) use medical terms that are commonly used in health care settings

a) validate all data before documentation of the data

The nurse is preparing to meet a client in the clinic for the first time. After reviewing the client's record, the nurse should a) analyze data that have already been collected b) review any past collaborative problems c) avoid premature judgments about the client d) consult with the clients family members.

c) avoid premature judgments about the client

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is a) "Do you feel stress at work?" b) "How often do you feel stressed?" c) "is stress a problem in your life?" d) "How do you manage your stress?"

d) "How do you manage your stress?"

the nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should a) allow the client time to calm down b) avoid discussing sensitive issues c) set time limits with the client d) explain the role and purpose of the nurse

d) explain the role and purpose of the nurse

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to a- formulate too many nursing diagnoses for the client and family b- include too much data about the client in the history c- obtain an insufficient number of cues and cluster patterns d- quickly make a diagnosis without hypothesizing several diagnoses

d) quickly make a diagnosis without hypothesizing several diagnoses

An example of an objective finding in an adult client is a) a client's symptom of pain b) family history data c) genetic disorders d) vital signs

d) vital signs

empathy

feeling WITH the patient; recognizing and accepting the person's feelings without criticizing them

objective data

findings directly observed or indirectly observed through measurements (e.g. body temperature)

diaphragm of stethoscope

larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds

S/O Bowel sounds present in all four quadrants

objective

s/o emesis of 200 mL light beige thin fluid

objective

Standing position

position used to examine male genitalia and to assess gait, posture and balance

Evidence Based Practice

problem solving approach to clinical practice that involves the conscientious use of current, best evidence along with clinical expertise and patient preferences and values in making decisions about patient care

s/o complains of lower back pain on movement

subjective

s/o feels nauseated and dizzy

subjective

s/o pattern of request for pain medication every two hours

subjective

knowledge

the fact or condition of knowing something with familiarity gained through experience or association

Subjective Data

what the patient tells us and feels

Why should inspection be done first?

If others (palpation, percussion, auscultation) are done first, it can distort what you are looking at

diagnostic phase

analysis of data

Nursing diagnostic phase

analysis of subjective and objective data to make a professional nursing judgment

during a comprehensive assessment of an adult client, the nurse can best hear high-pitched sounds by using a stethoscope with a a) 1 inch bell b) 1.5 inch diaphragm c) 15 inch flexible tubing d) 1 inch diaphragm

b) 1.5 inch diaphragm

the most commonly used method of percussion is a) direct percussion b) mild percussion c) indirect percussion d) blunt percussion

c) indirect percussion

osteoporotic thinning and collapse of the vertebrae secondary to bone loss in an elderly client may result in a) lordosis b) scoliosis c) skeletaldosis d) kyphosis

d) kyphosis

health promotion and nursing diagnosis

nursing diagnosis that indicates the client has an opportunity to enhance a health status

Fingerpads

part of examiner's hand used to feel for fine discrimination's: pulses, texture, size, consistency, shape, and crepitus

subjective data

sensations or symptoms that can be verified only by the client (pain)

Sims' position

side-lying position used during the rectal examination

bell of stethoscope

smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)

analysis of data

the way in which one processes information using knowledge, past experience, intuition, and cognitive abilities to formulate conclusions or diagnoses

Critical thinking

the way in which one processes information using knowledge, past experience, intuition,, and cognitive abilities to formulate conclusions or diagnoses

What is a closed-ended question?

Asking for specific information; eliciting a short, one or two word answer Usually a yes or no response Begin with "when" or "did" Example: "When did your headache start?"

Double barreled Questions

Asking two questions at one time Example: Do you want to eat breakfast now? Or do you want me to do your laundry?

Non-verbal communication

Attitude, physical appearance, posture, gestures, facial expressions, eye contact, voice, touch

The nurse is preparing to document assessment findings in a clients record. The nurse should a) write in complete sentences with few abbreviations b) avoid slang terms or labels unless they are direct quotes c) record how the data were collected d) use the term "normal" to describe nonpathologic findings

B) avoid slang terms or labels unless they are direct quotes

Select the following nursing diagnosis that is correctly stated. a) risk for impaired skin integrity related to immobility, bedrest, pain in legs, and the client states "I will not go to physical therapy" b) Risk for impaired skin integrity related to immobility as manifested by constant bedrest and the inability to ambulate the client twice a day c) risk for impaired skin integrity related to immobility secondary to right sided paralysis, dehydration, and reluctance to participate in physical therapy AMB reddened coccyx and very dry skin d) Risk for impaired skin integrity related to bedrest, lack of time to ambulate client, right-sided paralysis, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin

C- risk for impaired skin integrity related to immobility secondary to right sided paralysis, dehydration, and reluctance to participate in physical therapy AMB reddened coccyx and very dry skin

Biased or Leading Questions

Implies one answer is better than another answer "You don't smoke, do you?"

interviewing traps

Providing false (re)assurance Giving unwanted advice Using authority (doctor/nurse knows best) Using avoidance language Engaging in distance Using professional jargon Using leading/biased questions Talking too much Interruptions Using "Why" Questions

S/O: Cannot eat seeds or uncooked grains without abdominal discomfort

Subjective

actual nursing diagnosis

a nursing diagnosis that indicates the client is currently experiencing the stated problem or has a dysfunctional pattern

the nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to a) allow the client to ventilate his or her feelings b) offer reasons why the client should not feel angry c) provide structure during the interview d) refer the client to a different health care provider

a) allow the client to ventilate his or her feelings

Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to a) arrive at conclusions about the client's health b) document any physical symptoms the client may have c) contribute to the medical diagnosis d) validate the data collected

a) arrive at conclusions about the client's health

During a client interview, the nurse uses nonverbal expressions appropriately when the nurse a) avoids excessive eye contact with the client b) remains expressionless throughout the interview c) uses touch in a friendly manner to establish rapport d) displays mental distancing during the interview

a) avoids excessive eye contact with the client

A client has an oral temp of 37. C (99F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on his high body temp? a) client has just run 4.82 km (3 miles) outside before coming to the interview b) the client drinks eight glasses of water a day c) the client has a history of hypothyroidism d) the client reports having a toe infection treated with antibiotics three months ago

a) client has just run 4.82 km outside before coming to the interview

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temp is warm outside. The nurse suspects that the clients cold intolerance is a result of a) decreased body metabolism b) neurologic deficits c) recent surgery d) pancreatic disease

a) decreased body metabolism

An assessment form commonly used in a long term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it a) establishes comparability of nursing data across clinical populations b) clusters all the nursing and medical diagnoses in one place c) allows for individualization for each client in the health care setting d) uses a flowchart format for easy documentation of objective data

a) establishes comparability of nursing data across clinical populations

during a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit a)hyperresonance b) tympany c) dullness d) flatness

a) hyperresonance

Which of the following sequences describes the correct order of steps for analyzing data? a) identify abnormal data and strengths, cluster data, draw inferences, propose possible nursing diagnoses, check for the presence of defining characteristics, confirm or rule out nursing diagnoses, document conclusions b) identify abnormal data and strengths, cluster data, draw inferences, check for presence of defining characteristics, propose possible nursing diagnoses, confirm or rule out nursing diagnoses, document conclusions c) Identify abnormal data and strengths, draw inferences, cluster data, check for the presence of defining characteristics, propose possible nursing diagnoses, confirm or rule out nursing diagnoses, document conclusions d) identify abnormal data and strengths, draw inferences, cluster data, check for the presence of defining characteristics, confirm or rule out nursing diagnoses, propose possible nursing diagnoses, document conclusions

a) identify abnormal data and strengths, cluster data, draw inferences, propose possible nursing diagnoses, check for the presence of defining characteristics, confirm or rule out nursing diagnoses, document conclusions

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 a) indicate acceptance of the client's cultural differences b) request a family member to interpret for the client c) use slang terms to identify certain body parts d) remain in a standing position during the interview

a) indicate acceptance of the client's cultural differences

While interviewing a client for the first time, the nurse is using a standardized nursing history form. The nurse should a) maintain eye contact while asking the questions from the form b) read the questions verbatim from the form c) ask the client to complete the form d) ask leading questions throughout the interview

a) maintain eye contact while asking the questions from the form

While caring for an 80 year old client in his home, the nurse determines that the client's oral temp is 35.8 C (96.5F). The nurse determines that the client is most likely exhibiting a) normal changes that occur with the aging process b) hypothermia that occurs before infectious process c) a metabolic disorder resulting in circulatory changes d) an immune disorder resulting in low platelet count

a) normal changes that occur with the aging process

before beginning a physical assessment of a client, the nurse should first a) wash both hands with soap and water b) determine whether the client is anxious c) ask the client to remove all clothing d) request a family member to be present

a) wash both hands with soap and water

When assessing a client's pulse, the nurse should be alert to which of the following characteristics? a) rate, rhythm, amplitude and contour, and elasticity b) rate rhythm, temp, rigidity, color, and elasticity c) tenderness, moistness, contour, elasticity, and pressure d) pain, temp, amplitude and contour, elasticity

a)rate, rhythm, amplitude and contour, elasticity

the nurse is caring for an adult client who tells the nurse "for weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is a- fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue b- sleep deprivation related to noisy neighborhood and inability to sleep c- chronic fatigue syndrome related to excessive levels of noise in neighborhood d- readiness for enhanced sleep related to control of noise level in the home

a- fatigue r/t excessive noise levels as manifested by the clients statements of chronic fatigue

cognitive abilities

aptitude involving the act or process of knowing, including both awareness and judgement

evaluation

assessing whether outcome criteria have been met and revising the plan of care if necessary

A normal pulse pressure range for an adult client is typically a) 20-40 mmHg b) 30-50 mmHg c) 40-60 mmHg d) 60-80 mmHg

b) 30-50mmHg

To alleviate a client's anxiety during a comprehensive assessment, the nurse should a) begin with intrusive procedures first to get them completed quickly b) explain each procedure being performed and the reason for the procedure c) remain in the examination room while the client changes into a gown d) ask the client to sign a consent for the physical exam

b) explain each procedure being performed and the reason for the procedure

one advantage for an institution to use an integrated cued/checklist type of assessment data form is that it a) allows a comprehensive and thorough picture of the client's symptoms b) may be easily used by different levels of caregivers, which enhances communication c) provides for easy and rapid documentation across clinical settings and populations d) includes the 11 health care patterns in an easily readable format

b) may be easily used by different levels of caregiveres, which enhances communication

The nurse is preparing to assess the respirations of an alert adult client. the nurse should a) explain to the client that he or she will be counting the client's respirations b) observe for equal bilateral chest expansion of 2.54 to 5.08 cm (1 - 2 in) c) count for 15 secs and multiply the number by four to obtain the rate d) ask the client to lie in a supine position, which makes counting respirations easier

b) observe for equal bilateral chest expansion (1-2 in)

the nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should pan to a) give the client rules with which he must agree to comply b) provide structure and set limits with the client c) tell the client that the nurse is aware of his past behaviors d) approach the client in an authoritative manner

b) provide structure and set limits with the client

The depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of a) the growing elderly population with chronic illness b) rapid advances in biomedical knowledge and technology c) an increase in the number of baccalaureate programs in nursing d) an increase in the number of nurse practitioners

b) rapid advances in biomedical knowledge and technology

During an interview with an adult client for the first time, the nurse can clarify the client's statements by a) offering a "laundry list" of descriptors b) rephrasing the client's statements c) repeating verbatim what the client has said d) inferring what the client's statements mean

b) rephrasing the client's statements

While interviewing an adult client about her nutrition habits, the nurse should a) ask the client for a 3-day recall of food intake b) review the ChooseMyPlate information with the client c) ask the client about limitations to activity d) encourage the client to drink three to four glasses of water daily

b) review the ChooseMyPlate information with the client

The nurse is caring for a client who is having NPO on the first postop day. The clients BP was 120/80 approx 4hrs ago. Not is is 140/88. the nurse should ask the client which of the following questions? a) "Are you taking any meds for HTN?" b) "Do you have enough blankets to stay warm?" c) Are you having pain from your surgery? d) what is your typical BP reading?

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

during palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5cm. The nurse is performing a) light palpation b) moderate palpation c) deep palpation d) bimanual palpation

c) deep palpation

while examining a client, the nurse plans to palpate temperature of the skin by using the a) fingertips of the hand b) ulnar surface of the hand c) dorsal surface of the hand d) palmar surface of the hand

c) dorsal surface of the hand

For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have a) advanced preparation in this area b) experience in dealing with these types of clients c) knowledge of his or her own thoughts and feelings about these issues d) personal experiences with death, dying, and sexuality

c) knowledge of his or her own thoughts and feelings about these issues

The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temp is below freezing outside. The nurse anticipates that the client may be a) abusing drugs b) a victim of abuse c) lacking adequate finances d) anxious

c) lacking adequate finances

One disadvantage of the open-ended assessment form is that it a) does not allow for individualization b) asks standardized questions c) requires a lot of time to complete d) does not provide a total picture of the client

c) requires a lot of time to complete

To prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first a) discuss the client's symptoms with other team members b) plan for potential laboratory procedures c) review the client's health care record d) determine potential health care resources

c) review the client's health care record

Sensations of temp, pain and crude and light touch are carried by way of the a) extrapyramidal tract b) corticospinal tract c) spinothalmic tract d) posterior tract

c) spinothalamic tract

The nurse is assessing an elderly postsurgical client in the home. To begin the physical exam, the nurse should first assess the clients a) height and weight b) ability to swallow c) vital signs d) gait

c) vital signs

during an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. This occurs during the phase of the interview termed a) introductory b) ongoing c) working d) closure

c) working

syndrome nursing diagnosis

clinical judgments that describe a specific cluster of nursing diagnoses that occur together and have similar nursing interventions to resolve the situation

an adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. To detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing a) moderate palpation b) deep palpation c) indirect oercussion d) blunt percussion

d) blunt percussion

when the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using a) firm percussion b) direct percussion c) indirect percussion d) blunt percussion

d) blunt percussion

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next: a) cluster the data collected b) draw inferences and identify problems c) document conclusions d) check for the presence of defining characteristics

d) check for the presence of defining characteristics

If the nurse makes an error while documenting findings on a client's record, the nurse should a) erase the error and make the correction b) obliterate the error and make the correction c) draw a line through the error and have it witnessed d) draw a line through the error, writing "error" and initialing

d) draw a line through the error, writing "error" and initialing

The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two pack of cigarettes a day", the nurse should a) look at the client with a frown b) tell the client that he is spending a lot of money foolishly c) provide the client with a list of dangers associated with smoking d) encourage the client to quit smoking

d) encourage the client to quit smoking

the nurse is planning to interview a client who is being treated for depression. when the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by a) providing the client with simple explanations b) offering to hold the client's hand c) using a highly structured interview process d) expressing interest in a neutral manner

d) expressing interest in a neutral manner

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed a) progressive b) specific c) checklist d) focused

d) focused

The result of a nursing assessment is the a) prescription of treatment b) documentation of the need for a referral c) client's physiologic status d) formulation of nursing diagnoses

d) formulation of nursing diagnoses

during a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to a) determine whether genetic conditions are present b) summarize the family's health problems c) evaluate how the client's current symptoms affect his or her lifestyle d) identify risk factors to the client and his or her significant others

d) identify risk factors to the client and his or her significant others

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of pain and the a) cause of the pain b) client's caregiver c) client's occupation d) pain relief measures

d) pain relief measures

before the nurse analyzes the data collected, the nurse should a- determine collaborative problems with the health care team b- group the data into clusters or groups of problems c- generate possible hypotheses for the client's problems d- perform the steps of the assessment process accurately

d) perform the steps of the assessment process accurately

While performing a physical examination on an older adult, the nurse should plan to a) complete the physical examination as quickly as possible b) ask the client to change positions frequently c) provide only minimal teaching related to healthcare d) use minimal position changes

d) use minimal position changes

During an interview with an adult client, the nurse can keep the interview from going off course by a) using open-ended questions b) rephrasing the clients statements c) inferring information d) using close-ended questions

d) using close-ended questions

Dorsal surface of hand

part of examiners hand used to feel for temperature

Ulnar surface or palm of hand

part of examiners hand used to feel for vibration, thrills, or fremitus

collaborative problem

physiologic complications that nurses monitor to detect their onset or changes in status

Sitting position

position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities