Class Four Chapters 14 26 ACTUAL Prep U
A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? - whether they have home maintenance skills - whether they have proper dietary habits - whether they have a program of regular physical activity - whether they have anemia
whether they have a program of regular physical activity
Which question or statement would be an appropriate termination of the health history interview? - "Well, I can't think of anything else to ask you right now." - "I wish you could have remembered more about your illness." - "Can you think of anything else you would like to tell me?" - "Perhaps we can talk again sometime. Goodbye."
"Can you think of anything else you would like to tell me?"
A nurse is using the assistance of an interpreter. When interviewing a client who does not speak the dominant language, the nurse should: - assess the client's vital signs first. - observe the client's body language. - interpret the effect of deep palpation. - inspect the symmetry of the facial features.
observe the client's body language.
A nurse is conducting a health history interview for a client at an assisted-living facility. The client says, "I have been so constipated lately." How should the nurse respond? - "Do you take anything to help your constipation?" - "Do you have a family history of chest problems?" - "Why don't you use a laxative every night?" - "Everyone who ages has bowel problems."
"Do you take anything to help your constipation?"
A nurse is conducting an interview with a client. Which example best demonstrates use of open-ended questions in an interview? - "Are you feeling well?" - "How are you feeling?" - "Do you smoke?" - "Do you use any illicit drugs?"
"How are you feeling?"
After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? - "Is there anything else we should know in order to care for you better?" - "What practices have you found especially helpful in other settings?" - "What are your expectations from us and from yourself in your care?" - "What do you envision for your care while you're here at the facility?"
"Is there anything else we should know in order to care for you better?"
Which question or statement would be appropriate for eliciting further information when conducting a health history interview? - "If I were you, I would not wait to get help next time." - "Why didn't you go to the physician when you began to have this pain?" - "Tell me more about what caused your pain." - "Are you feeling better now than you did during the night?"
"Tell me more about what caused your pain."
The nurse is preparing to interview several clients during clinic hours. What language difficulty(ies) might a nurse encounter while performing various interviews in a diverse population of clients? Select all that apply. - Clients speaking the same language as the nurse - Clients having a limited education - Clients demonstrating mild anxiety - Clients fearing saying the wrong thing - Clients not being fluent in the same language as the nurse
- Clients not being fluent in the same language as the nurse - Clients having a limited education - Clients fearing saying the wrong thing
The nurse identifies which types of data when performing an assessment? Select all that apply. - Critical thinking - Intuition - Subjective - Hunches - Objective
- Subjective - Objective
Which assessment data cue does the nurse recognize as subjective data? - Pupils equal and accommodate and react to light - A pain rating of 7 - Bilateral pedal edema 2+ - Wheezing throughout lung fields
A pain rating of 7
The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? - Avoid the impulse to interrupt. - Fill in the words for the client. - Focus mainly on verbal comments. - Fill in quiet spaces and pauses.
Avoid the impulse to interrupt.
The nurse is conducting a health assessment on a client. Which subjective data would the nurse gather about the client's sleep habits? - Client has dark circles under the eyes - Client frequently yawns - Client has decreased attention span - Client reports only sleeping 2 hours per night
Client reports only sleeping 2 hours per night
A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse? -Assist the client with activities of daily living. -Contact the health care provider. -Complete an assessment. -Review the client's past medical records.
Complete an assessment.
The nurse is using an assessment guide that includes a hierarchy of five life requirements universal to all persons. Which model for organizing assessment data is the nurse using? - Functional Health Patterns model - Human Response Patterns model - Body System model - Human Needs (Maslow) model
Human Needs (Maslow) model
A client presents to an outpatient health care office for the first time. What step would the nurse take first, prior to taking a health assessment from the client? - Tell the client the amount of time planned for the assessment. - Introduce oneself to the client. - Inform the client of the procedures done in the assessment. - Ask a family member to be present for the assessment.
Introduce oneself to the client.
Which is the most appropriate reason for a nurse to ask a client what the client would like to be called? - It communicates respect for the client. - It allows the client to control the situation. - It ignores the policies of the facility. - It signifies that the nurse wants to be friendly.
It communicates respect for the client.
Which statement describes the physical exam technique of auscultation? - It is a technique in which one or both hands are used to strike the body surface in a precise manner to produce a sound. - It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify sounds. - It is a visual examination of the client that is done in a methodical and deliberate manner. - It is the specialized use of touch for data collection.
It is the technique of listening to body sounds with a stethoscope placed on the body surface to amplify sounds.
A client comes to the emergency department with flulike symptoms. The nurse records the vital signs and listens to the client's lung sounds. Vital signs and lung sounds are examples of which type of data? - Hunches - Subjective - Intuitive - Objective
Objective
A nurse working on a medicine unit is mentoring a new graduate. The new nurse asks why it is necessary to perform an assessment on the same client twice during a 12-hour shift. What would be the nurse's best response to the new graduate? - Ongoing data collection is critical to the deletion or modification of old problems and finding new ones. - It is policy and we have to follow the facility's rules. - It will give you lots of chances to practice your assessment skills. - We have always done it this way for as long as I have worked here.
Ongoing data collection is critical to the deletion or modification of old problems and finding new ones.
A nurse is collecting data from a home care client. In addition to information about the client's health status, which is another critical observation the nurse should make? - Friendliness of the client and family - Number of rooms in the house - Frequency of home visits to be made - Safety of the immediate environment
Safety of the immediate environment
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position oneself? - Standing at the side of the bed - Standing at the end of the bed - Sitting at a 45-degree angle to the bed - Sitting at least 6 feet from the beside
Sitting at a 45-degree angle to the bed
The nurse is performing an assessment on a newly admitted client. The client states, "I feel really nervous." This is an example of which type of data? - Hunch - Intuition - Objective - Subjective
Subjective
A nurse assesses a client, obtaining the information from a primary source. The nurse has gathered the information from which source? - The client - The client's health care records - A primary care physician - The client's spouse
The client
The nurse is preparing to begin a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment? - The room is private, quiet, warm, and has adequate light. - The assessment should be conducted after all tests and procedures. - Family members are present to answer specific questions. - There is adequate time to perform the assessment.
The room is private, quiet, warm, and has adequate light.
Which traits of the nurse are most important for an assessment to be successful? - Low-key and timid - Competent and forceful - Enthusiastic and aggressive - Trustworthy and confident
Trustworthy and confident
The nurse has entered the client's room to ask questions and complete the nursing admission database. The client is wearing a hearing aid in the left ear. Noise is emanating from the television set. What action will the nurse take to facilitate obtaining the history? - Speak into the client's left ear. - Use a loud voice to speak with the client. - Turn off the television with permission. - Stand about 1 ft (0.3 m) of the client.
Turn off the television with permission.
While doing an assessment, the nurse identifies questionable data. Which should the nurse do first? - Inform the client that the data are not correct. - Inform the physician of the questionable data. - Disregard the questionable data. - Validate the questionable data.
Validate the questionable data.
The nurse is assessing the client's abdominal wound and notes yellow-green purulent wound drainage. The nurse recognizes that the drainage is an example of: - an inference. - a judgment. - subjective data. - objective data.
objective data.
Which statement made by the nurse indicates data that would be documented as part of an objective assessment? -"The client's sister reports that the client has unrelieved pain." -"The client's right leg is cold to the touch, from the knee to the foot." -"The client reports nausea following eating." -"The client reports having heartburn after breakfast."
"The client's right leg is cold to the touch, from the knee to the foot."
A nurse is performing an assessment on a client. Which should the nurse record as subjective data? Select all that apply. - "My leg hurts when I move." - Weight: 132 lb (60 kg) - "I am so afraid of what my diagnosis is." - Blood pressure: 120/78 mm Hg - "I am always anxious."
- "My leg hurts when I move." - "I am so afraid of what my diagnosis is." - "I am always anxious."
Which are examples of subjective data? Select all that apply. - A client reports being cold and requests an extra blanket. - A client feels nauseated after eating breakfast. - A client describes pain as an 8 on the pain assessment scale. - A nurse observes a client wringing the hands before signing a consent for surgery. - A nurse observes redness and swelling at an intravenous site. - A client's blood pressure is elevated following physical activity.
- A client describes pain as an 8 on the pain assessment scale. - A client feels nauseated after eating breakfast. - A client reports being cold and requests an extra blanket.
A nurse has just taken vital signs on a newly admitted client. Vital signs would be entered on the client record as which type of data? - Hunches - Intuitive - Subjective - Objective
Objective
When documenting subjective data, the nurse should: - validate the information with the client's family prior to documentation. - record the information using nonspecific words. - use the client's own words placed in quotation marks. - paraphrase the information stated by the client.
use the client's own words placed in quotation marks.
