ADN 140 - PrepU - Focused Assessment 1

A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the abdomen. Which of the following would the nurse perform next?

Auscultation.

Assessment of the patient's bowel sounds is best obtained performing which assessment technique?

Auscultation.

A middle-aged client is complaining of acute joint pain to a nurse who is assessing the client's pain in a clinic. Which of the following questions related to pain assessment should the nurse ask the client?

"Does your pain level change after taking medications?"

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?

"What does the pain feel like?"

A nurse is conducting an interview with a patient who complains of abdominal distress. What is an appropriate interview question for this patient?

"What is your problem as you see it?"

The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all that apply. - "How long have you experienced this pain?" - "Please point to where you are experiencing pain." - "You've never had this pain before, have you?" - "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." - "What aggravates your chest pain?"

- "How long have you experienced this pain?" - "Please point to where you are experiencing pain." - "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." - "What aggravates your chest pain?"

The nurse is developing a plan of care for a client in acute pain. Which of the following should the nurse include? (Select all that apply.) - Encourage deep breathing. - Play the client's favorite music. - Promote a restful environment. - Encourage increased protein. - Encourage the use of a sitter.

- Encourage deep breathing. - Play the client's favorite music. - Promote a restful environment.

A nurse is assessing an adult client with back pain. The client is unable to speak in English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?

0-10 Numeric rating scale.

To assess subjective data related to a client's elimination pattern, the nurse

Asks the client about changes in elimination patterns.

After surgery, a postoperative patient has not voided for 8 hours. Where would the nurse assess the bladder for distention?

Between the symphysis pubis and the umbilicus.

A nurse collects objective data on a client during a health assessment that includes the client's

Blood Pressure

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

Breathe deeply.

Melinda reports to the nurse that her joint pain has gotten worse over the last year and she has gradually increased her doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint?

Chronic pain.

Which of the following is the first portion of the small intestine?

Duodenum

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following?

Fissure

A home health nurse is visiting a patient who recently was hospitalized for repair of a fractured hip. The patient tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct?

Focused

A client at a healthcare facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

Greater than normal urinary volume.

When performing an abdominal assessment, the nurse uses a different order of techniques than other systems. Which of the following represents this order?

Inspection, auscultation, percussion, palpation.

A nurse asks an adolescent female client to describe her pain using a number between 0 and 10 where 0 means no pain and 10 means severe pain. The nurse is assessing which of the following?

Intensity of pain.

Before conducting a health assessment on a client, the nurse should first

Introduce herself or himself to the client.

A nurse is conducting an abdominal assessment. What is the rational for palpating the abdomen last when conducting an abdominal assessment?

It disturbs normal peristalsis and bowel motillity.

The nurse collects a urine sample from a client for urinalysis. Which of the following would the nurse document as a normal characteristic.

Light yellow color.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessement.

Location, onset, alleviating factors, and aggravating factors.

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client?

Loss of urine without any identifiable pattern or warning.

Which of the following describes awakening at night to urinate?

Nocturia

At the end of the shift, the nurse documents that the patient has voided 475 mL during the shift via an indwelling urinary catheter. What type of data has the nurse documented?

Objective.

A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication?

Rates pain 8/10, states nauseated for the last 30 minutes.

A nurse is using inspection as an assessment technique. What does the nurse use during inspection?

Senses of vision, hearing, smell.

The nurse preparing to perform an abdominal assessment on a client places the client in which of the following positions?

Supine

What would a nurse ensure before beginning a health assessement?

That the room is private, quiet, warm, and has adequate light.

Of the following individuals, who can best determine the experience of pain.

The person who has the pain.