Questions for 366

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 group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following?

"Documentation provides a permanent legal record of care given and not given."

Question 3 See full question 2s A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet.

Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent?

Background

The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of

Batch charting

The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic?

Character, onset, location, duration, severity, pattern, associated factors

Which of the following would be most important for the nurse to do immediately before beginning the physical exam?

Collect necessary equipment essential to the exam.

Which skin characteristics can a nurse observe by using inspection?

Color

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

Correct response: The client and the examiner see the examiner's finger at the same time

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question?

Correct response: "I just wanted to see what kind of social support you might have to help care for you during your illness."

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?

Courteously interrupt the patient to clarify some information.

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

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

Determine if a structure is filled with air or fluid or is a solid structure

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

Dorsal surface

What guidelines should the nurse keep in mind while performing auscultation?

Eliminate distracting noise from the environment

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform?

Emergency

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called?

Empathy

A group of student nurses is presenting information on Gordon's framework for assessing a client. What type of assessment would they be talking about?

Functional

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client?

Handwashing

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects:

Human violence

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?

Otoscope

What is the nurse's best defense if a patient alleges nursing negligence?

Patient's record

Your lab instructor explains that physical examination relies on what cardinal assessment technique?

Percussion

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?

Provides a focus for the physical exam.

The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing?

Recommendation

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes what the client has just said. What type of communication is the nurse using?

Reflection

A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation?

Skin pale, warm, and dry without evidence of lesions

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?

The confidentiality of electronic and printed health information

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students?

The problem, intervention, evaluation(PIE) system of documentation does not use assessment as part of the PIE note

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status?

auscultation

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

head to toe

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information?

history of present illness

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system?

inspection

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

inspection.

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information?

neurologic

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's

perception of pain.