assessment 1

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breathe for me

Body temperature is not impacted by which of the following factors?

Diet

A nurse measures a client's blood pressure and obtains a reading of 150/85 mm Hg. Which question should the nurse ask the client in regards to this reading?

Do you ned to empty yout bladder

Psychological-

Emotional/Mental pain (suicide, depression

How would the nursing instructor explain the goal of guided questioning to his or her students?

Facilitating the client's fullest communication

FDAR

Focus- Data Action Response

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

ISBAR

Introduction Situation Background Assessment Recommendation

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation?

It provides quick access to abnormal findings.

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

Memory and attention

A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?

Neuropaathic

A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?

Ongoing or partial

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

A nurse finds a radial pulse that is weak and thready. What action should the nurse take next?

Palpate carotid artery

Assessment of the pulse amplitude is accomplished by which of the following?

Palpate the flow of blood through an arertey

The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age?

Provides a reference point for psychosocial developmental level

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his left leg, and the pain is worse with ambulation. The nurse will document this type of pain as which of the following?

Somatic

While conducting a mental status history, the nurse notes that the client is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

Speech and language

A client reports chest pain that occurs with exercise but subsides with rest. The nurse recognizes this as what type of data?

Subjective

A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client as reasons for documenting assessment findings? Select all that apply.

To prevent delays in carrying out the plan of care, To determine the educational needs of the client

How should the nurse place the ear of an adult when using the otoscope?

Up and back

A nurse is preparing to physically examine a client. Which action is most important to take before beginning the examination?

Wash hands

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client

answered "yes" to three of the four CAGE questions.

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

The nurse is preparing to document assessment findings in a client's record. The nurse should

avoid slang terms or labels unless they are direct quotes.

Neuropathic-

damage or dysfunction of the nervous system

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 temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism

Which clients are most at risk for depressive symptoms? (Select all that apply.)

female. Divorce, chronically ill

When clients report pain, it is important to find the source. When clients describe pain as "burning, painful numbness, or tingling," the source is more than likely:

neuropathic

Visceral-

occurs with nerves in internal organs- feels vague, generalized, deep squeeze, pressure, or aching

Phantom-

pain in part of the body that has been removed

A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's

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

prevents missed questions during data collection.

Referred-

sensation of pain in body region distant from

The client states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the client is at risk for:

suicide risk

Psychosomatic-

when psychological pain becomes physical. Converting uncomfortable feelings to physical symptoms (limb paralysis),

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event?

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

For which assessment would the nurse plan to use light palpation?

A papular rash. Light palpation (1-2 cm) deep palpation (4-5 cm),

The nurse is completing a mental health assessment. When the nurse asks the client to interpret a proverb, the nurse is assessing which of the following?

Abstract reasoning

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray

During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?

Chief complaint

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

What are nurses able to detect through the health assessment?

Areas in needed of health adjustment

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

Dysphasia

problem expressing thoughts

Dysarthria

problem forming words

A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?

Comprehensive

A nurse is caring for a client with dull ache in her abdomen. On the way to the health care facility, the client vomits and shows symptoms of pallor. What kind of pain is the client experiencing?

Visceral

A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?

What diseases did you have as a child

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

Use as a Drape