Exam 1 Practice
A client asks why a health assessment needs to be done. What should the nurse respond to this client?
"It determines your health status, risk factors, and educational needs to develop a plan."
A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?
"They make sure that any microorganisms on my hands do not touch your skin."
The nurse is working in an ambulatory care clinic. Which client would the nurse determine to be in most need of an emergency assessment?
A 35 year old man with chest pain and diaphoresis for 1 hour
For which of the following clients should the nurse choose to perform a focused examination?
A man who has presented with an acute onset of chest pain
A client angrily tells the nurse that, "It's a shame that you people can't ever be on time. This interview was supposed to start 30 minutes ago." Which technique should the nurse use to diffuse this patient's justified anger?
Acknowledge their anger by apologizing for the delay.
During a physical assessment the client asks the nurse repeatedly, "Is everything ok?" The nurse concludes which for this client?
Anxiety
The school nurse provides care for a child who fell on the school playground and sustained multiple abrasions to the lower extremities. Which actions by the school nurse are appropriate when caring for this child? Select all that apply.
Asking the child permission to assess the injuries. Performing handwashing before touching the child. Putting on nonsterile gloves prior to assessing the child's injuries.
The nurse is preparing to assess a client's mental status within the general survey. Which data should the nurse use to assess this status?
Asking the client to describe elements of his health history.
Using both verbal and nonverbal clues given by the patient, what is the nurse constantly doing?
Assessing
Data collection occurs where in the nursing process?
Assessment
What is the foundation of nursing practice?
Assessment
The nurse is conducting a physical examination of a patient who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular
B. c, d, e, b, a
Which skin characteristics can a nurse observe by using inspection?
Color
This type of assessment includes a health history and physical assessment.
Comprehensive
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.
A genogram is developed to visually show what?
Family health patterns
The nurse asks the patient about whether other family members have been diagnosed with diabetes. Which component of the comprehensive health history is the nurse addressing?
Family history
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's abdomen. Which sound is expected when percussion is used during the assessment?
Loud, low-pitched
A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?
Neuropathic
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
Nurse
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
Objective
The client has a heart murmur that the nurse hears utilizing the stethoscope. This is what type of data?
Objective
The nurse is conducting a physical assessment of a new patient. What data does the nurse collect that are measurable?
Objective
As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?
Orientation to time is usually lost first and orientation to person is usually lost last.
The nurse is performing an abdominal assessment and has just completed auscultation. Which technique would the nurse correctly choose to use next in this assessment?
Percussion
Which nonverbal communication by the nurse helps to facilitate a relaxed environment for a client during the interview process?
Portray a neutral and friendly expression.
During the interview process, the nurse obtains what type of data from the client?
Primary
As a nursing student you learn that mastering all the components of the comprehensive history provides what?
Proficiency
A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?
Relaxed
The nurse is assessing an older adult client a hospice unit. The client cannot speak or communicate, but the client's daughter is there and answers all the questions as best as she can. What type of data source is the daughter?
Secondary
The nurse is teaching a group of unlicensed assistive personnel about the stethoscope. Which statements about the stethoscope are appropriate for the nurse to include in the teaching session?
Short tubing provides the listener with the most accurate sounds. The stethoscope works by blocking out environmental sounds. The binaurals should fit snugly in the ears.
The nurse educator is observing a student nurse who is performing cervical palpation on an adult client. Which technique is appropriate for this assessment?
Side to side pressure of 1/2-1 cm using the finger pads
The nurse is going to conduct a physical assessment on a patient who is on bed rest. The best position for the nurse to begin the head to toe assessment would be to:
Stand on the right side of the bed
What tool does the nurse use to auscultate the client's abdomen?
Stethoscope
The client has a headache. What type of data is this?
Subjective
A nurse is gathering data from a client during a health assessment. Which assessment finding should the nurse document as objective data?
The client's range of motion in her right arm
Which of the following would the nurse use as the primary assessment for a client's pain?
The client's report of the pain
Which describes the nurse using the technique of auscultation?
The nurse detects gurgling throughout the abdomen
"Tell me about your pain" is an example of an open-ended question.
True
The nurse is applying standard precautions by performing which of the following?
Wears gloves to palpate the tongue and buccal membranes
Which question is appropriate for a nurse to ask a client to assess the client's recent memory?
What did you eat for breakfast today?"
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
The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview?
be nonjudgmental
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? Select all that apply.
bruits abnormal heart sounds/murmurs
Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
continuous
A patient comes to the ED complaining of chest pain. This would be considered
subjective primary data
Before beginning a physical assessment of a client, the nurse should first
wash both hands with soap and water
What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?
Ensure that contact with the skin is maintained
After completing the interview process, the nurse analyzes the data collected for what priority reason?
Establish a baseline from which to start interviewing the family
The nurse is admitting a client with a fractured hip. The client points to the painful hip and describes it as a constant throbbing. Which would the nurse include when continuing the pain assessment on this client?
Intensity, precipitating and relieving factors, impact on ADLs, and coping strategies
During a comprehensive health history, a client reports smoking cigarettes for 20 years. The nurse will document this information in which of the following sections?
Past history
The nurse is collecting data for a comprehensive health history on a patient new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?
Past history
The experienced nurse understands that active listening is the key element when interviewing a patient.
True
The new grad asks the preceptor to explain why the order of the examination is different for the abdomen. The best response by the preceptor would include
"Palpation will increase bowel motility and alter the sounds heard on auscultation."
A nurse is interviewing a client who uses an expression with which the nurse is unfamiliar. What is the most appropriate expression for the nurse to use to clarify the expression's meaning from the client?
"Tell me what you mean by ______________?"
The nurse is assessing an adult client when suddenly the client refuses to continue the examination. Which action by the nurse is the priority?
Document what was done and what was refused.
A patient arrives at the Emergency Department reporting shortness of breath. She is cyanotic with bilateral wheezing. The patient begins to gasp for air and cannot speak. The nurse begins to gather information so that interventions can resolve the immediate breathing problem. Her assessment and interventions are concurrent. The nurse is performing what type of health history?
Emergency
A nurse is preparing to interview a client who is a Seventh Day Adventist. The nurse does not agree with this religion's view of modern medicine. Reflection of the nurse on her personal feelings regarding this patient and her religious beliefs prior to the initial encounter with a client may help to avoid the occurrence of what situation?
Formation of judgments that may interfere with the interview.
Suzanne, 25 years old, comes to the clinic to establish care. The student nurse is preparing to enter the examination room to interview the client. Which of the following is the most logical sequence for the client-provider interview?
Greet the client, establish rapport, invite the client's story, establish the agenda, expand and clarify the client's story, and negotiate a plan.
When caring for a client, what aspect is important in conducting a conversation?
Keep the conversation at the knowledge level of the client.
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?
Quote the client's words.
A young adult client notes height as "5 feet 11 inches" and weight as "200 lbs." Upon assessment, the client is found to be 5 feet 9 inches tall with a weight of 225 lbs. Which is the most likely cause of this discrepancy?
The client may have an image of self that is inconsistent with actual findings.
The nurse is assessing a client who has suffered a cerebral vascular accident (CVA or stroke) and has difficulty with verbal expression, but no other deficits. What approach should the nurse use to assess this client's level of pain?
The nurse uses the Wong-Baker "FACES" pain rating scale.
Which is an example of subjective data from a primary source?
The patient states, "My chest hurts and my left arm feels numb."
What is the primary purpose of health assessment?
To gather information about the health status of the client.
When teaching students how to perform an assessment, the nurse informs the students that the reason this information needs to be accurate and complete is:
o develop a plan with interventions that promote health
