Fundamentals: Health and Physical Assessment

When interviewing and assessing a 17-year-old client, which findings alert the nurse to explore substance abuse with the adolescent? Select all that apply. One, some, or all responses may be correct. 1 Failing grades 2 Blood spots on clothing 3 Absenteeism from school 4 Long-sleeved shirts in warm weather 5 Separating emotionally from the family

1 Failing grades 2 Blood spots on clothing 3 Absenteeism from school 4 Long-sleeved shirts in warm weather

What is the inflammation of the skin at the base of the nail called? 1 Paronychia 2 Koilonychia 3 Beau lines 4 Splinter hemorrhage

1 Paronychia

While caring for four different clients, the nurse assesses their breathing pattern. Which client's assessment findings indicate Cheyne-Stokes respiration? 1. Client 1: Regular and abnormally slow breathing pattern, 11RR 2. Client 2: Regular but abnormally rapid breathing patter, 25RR 3. Client 3: Irregular, alternating apnea and hyperventilation breathing pattern, 12RR 4. Client 4: Abnormally shallow for two breaths followed by apnea, 30RR

3. Client 3: Irregular, alternating apnea and hyperventilation breathing pattern, 12RR

The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct. 1 "I had a late onset of menarche." 2 "My first child was born when I was 32." 3 "I noticed a slight discharge from a nipple." 4 "I perform breast self-examinations frequently." 5 "I consume two to four glasses of alcohol a day."

2 "My first child was born when I was 32." 3 "I noticed a slight discharge from a nipple." 5 "I consume two to four glasses of alcohol a day."

Which factor would elevate the oxygen saturation during an assessment? 1 Nail polishes 2 Carbon monoxide 3 Intravascular dyes 4 Skin pigmentation

2 Carbon monoxide

The community nurse is assessing an older adult client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select all that apply. One, some, or all responses may be correct. 1 Instruct the client to apply bedside rails. 2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 4 Ask the client to install handrails in the bathroom. 5 Help the client rearrange furniture in the house

2 Encourage the client to wear nonskid shoes. 3 Suggest that the client use an assistive device. 5 Help the client rearrange furniture in the house

A 50-year-old client seen for a routine physical asks why a stool specimen for occult blood testing has been ordered. Which is the correct nursing response? 1 "You will need to ask your health care provider; it is not part of the usual tests for people your age." 2 "There must be concern of a family history of colon cancer; that is a primary reason for an occult blood stool test." 3 "It is performed routinely starting at your age as part of an assessment for colon cancer." 4 "There must have been a positive finding after a digital rectal examination performed by your health care provider."

3 "It is performed routinely starting at your age as part of an assessment for colon cancer."