Health and physical assessment

Older adults The incidence of chronic illness increases in older adults because of the multiple stresses of aging. Younger individuals have greater physiologic reserves, and chronic illnesses are not common

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 1 Older adults 2 Adolescents 3 Young children 4 Middle-aged adults

Precontemplation The client is experiencing a relapse while attempting to make behavioral changes to his or her lifestyle. When relapse occurs, the client returns to the contemplation or precontemplation stage before attempting to change again. The action stage lasts for up to 6 months during which the client is actively engaged in strategies to change behavior. During the preparation stage, the client begins to believe that advantages outweigh disadvantages of behavior change. The maintenance stage begins 6 months after the change has started and continues indefinitely.

A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing? 1 Action 2 Preparation 3 Maintenance 4 Precontemplation

Brown or black mole with red, white, or blue areas Melanomas have an irregular shape and lack uniformity in color. They may appear brown or black with red, white, or blue areas. Petechiae are pinpoint red dots that indicate areas of bleeding under the skin. A red birthmark is a vascular birthmark and often fades with time. A patchy loss of skin pigmentation indicates vitiligo.

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, which would the nurse expect to find? 1 Large area of petechiae 2 Red birthmark that has recently become lighter in color 3 Brown or black mole with red, white, or blue areas 4 Patchy loss of skin pigmentation

Fainting Weakness Lightheadedness Head trauma may cause blood loss, and clients with recent blood loss are at risk for orthostatic hypotension. Symptoms of hypotension include fainting, lightheadedness, and weakness. Headaches and shortness of breath are symptoms of hypertension.Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client with a recent history of head trauma is at risk for orthostatic hypotension. Which assessment finding(s) observed by the nurse would relate to this diagnosis? Select all that apply. One, some, or all responses may be correct. Fainting Headache Weakness Lightheadedness Shortness of breath

38.5°C In older adults the normal temperature range is 36°C to 36.8°C orally and 36.6°C to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.

An older adult with chills arrived to the hospital. The nurse assesses the client's vital signs and determined the client has a fever. Which would be the client's rectal temperature? 1 36.0°C 2 36.8°C 3 37.2°C 4 38.5°C

A nutritional deficiency All of the signs listed are classic for a poor nutritional state lacking in basic nutrients such as vitamins and protein. A specific food allergy or medication is not described; therefore there is not enough information to assume the signs and symptoms are related to either or to noncompliance with medications.

The nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue, and bleeding gums. The nurse recognizes that these clinical manifestations are a result of which? 1 A food allergy 2 Noncompliance with medications 3 Side effects from medications 4 A nutritional deficiency

Severity of pain The primary source of information during an assessment is the client. The nurse gathers information about the client's pain from the primary source, the client. Medical records such as x-ray reports and results of blood work are secondary sources of information. The client's family caregiver is a secondary source of information.

The nurse is assessing a client after surgery. Which assessment finding would the nurse obtain from the primary source? 1 X-ray reports 2 Severity of pain 3 Results of blood work 4 Family caregiver interview

Self-perception-self-tolerance pattern The nurse is applying Gordon's self-perception-self-tolerance pattern to assess the client. This functional pattern describes the client's self-worth, emotional patterns, and body image. The value-belief pattern describes patterns of values, beliefs, spiritual practices, and goals that guide the client's choices or decisions. The role-relationship pattern describes patterns of role engagements and relationships. The cognitive-perceptual pattern describes sensory-perceptual patterns, language adequacy, memory, and decision-making ability.

The nurse is assessing a client who is undergoing chemotherapy. The nurse notes that the client is using a scarf to cover the head. The nurse asks the client about coping with the altered body image. Which functional pattern would the assessment include? 1 Value-belief pattern 2 Role-relationship pattern 3 Cognitive-perceptual pattern 4 Self-perception-self-tolerance pattern

Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.Serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. This can result in observable muscle weakness. Edema is associated with electrolyte imbalances, including sodium excess (hypernatremia). Muscle spasms and twitching are often seen in the setting of hypocalcemia. Kussmaul respiration is a breathing pattern characterized by deep and labored breaths in response to metabolic acidosis, especially diabetic ketoacidosis.

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience? 1 Visceral pain 2 Somatic pain 3 Referred pain 4 Intractable pain

A 56-year-old client who had a heart attack last week and is requesting information about exercise A client who is requesting information is indicating a readiness to learn. When the nurse is caring for a person who is coping with the diagnosis of cancer and a change in body image, the nurse would encourage the expression of feelings, not engage in teaching. People in denial are not ready to learn because they do not admit they have a problem. In addition, many adolescents believe that they are invincible. A person who is in pain is attempting to cope with a physiological need. This client is not a candidate for teaching until the pain can be lessened; pain can preoccupy the client and prevent focusing on the information being presented.

The nurse is planning to provide self-care health information to several clients. Which client would the nurse anticipate will be most motivated to learn? 1 A 55-year-old client who had a mastectomy and is very anxious about her body image 2 An 18-year-old client who smokes cigarettes and is in denial about the dangers of smoking Correct3 A 56-year-old client who had a heart attack last week and is requesting information about exercise 4 A 47-year-old client who has a long-leg cast after sustaining a broken leg and is still experiencing severe pain

Muscle weakness Serum hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. This can result in observable muscle weakness. Edema is associated with electrolyte imbalances, including sodium excess (hypernatremia). Muscle spasms and twitching are often seen in the setting of hypocalcemia. Kussmaul respiration is a breathing pattern characterized by deep and labored breaths in response to metabolic acidosis, especially diabetic ketoacidosis.

Which clinical finding would the nurse associate with hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul respirations 4 Muscle weakness

3+ The depth of pitting determines the degree of pitting edema. An indentation of 6 mm is scored to be a 3+ degree edema. An indentation of 8 mm is scored as 4+. An indentation of 4 mm is scored as 2+. An indentation of 2 mm is scored as 1+.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 4+ 3+ 2+ 1+

Correct1.Shock Correct2.Withdrawal Correct3.Acknowledgement Correct4.Acceptance Correct5.Rehabilitation When a client experiences a change in body image, the client adjusts to the condition in five phases. The initial reaction is that of shock. The client is in shock and tries to depersonalize it by discussing it as happening to someone else. As the client and family begin to recognize the reality of the change, they enter the withdrawal phase. They become anxious and refuse to discuss the subject. Then the client enters the acknowledgment phase. The client and family begin to acknowledge the condition and move through a period of grieving. By the end of the acknowledgment phase, they are ready to accept the loss and move into the acceptance phase. They realize the need for rehabilitation. During the rehabilitation phase, the client is ready to learn to use the prosthesis or change lifestyles or goals.

Which is the correct order of phases a client experiences in the event of a change in body image? 1. Acceptance 2. Shock 3. Withdrawal 4. Rehabilitation 5. Acknowledgement

Correct1.Assess the client's health status. Incorrect2.Identify the client's needs. Incorrect3.Cluster data. Incorrect4.Interpret the meaning of the data. Correct5.Look for defining characteristics. Incorrect6.Formulate nursing diagnoses. Incorrect7.Validate the data with other sources. The diagnostic reasoning process involves the use of assessment data for the client. The assessment data is obtained from the client, family, and health care resources. The nurse validates and ensures the data is accurate and uses critical thinking to interpret and analyze the data before it is classified and organized into data clusters. This organization helps the nurse identify the client's health needs. The nurse then formulates the nursing diagnoses using standard formal nursing diagnostic statements.

Which is the correct order of steps of the nursing diagnostic process? 1. Cluster data. 2. Identify the client's needs. 3. Formulate nursing diagnoses. 4. Look for defining characteristics. 5. Assess the client's health status. 6. Interpret the meaning of the data. 7. Validate the data with other sources.

Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

Which position is indicated to assess the musculoskeletal system but is contraindicated in clients with respiratory difficulties? 1 Sims position 2 Prone position 3 Supine position 4 Knee-chest position

The radial site is used for the Allen test. The popliteal pulse is used to assess status of circulation to lower leg. The status of the circulation in the lower arm and blood pressure are assessed using the brachial pulse. The femoral pulse is used to assess the character of the pulse during physiological shock or cardiac arrest when other pulses are not palpable.

Which pulse site is used for the Allen test? 1 Ulnar 2 Popliteal 3 Brachial 4 Femoral

110/65 mm Hg A 12-year-old client typically has a blood pressure of 110/65 mm Hg. A 1-year-old client would typically have a blood pressure of 95/65 mm Hg. A 6-year-old client would typically have a blood pressure of 105/65 mm Hg. A 14- to 17-year-old client has a typical blood pressure of 119/75 mm Hg.A client has relocated to a new city for work. The client is unable to continue the practice of walking for 30 minutes daily and exercising 5 days a week. Which stage of the transtheoretical model of health behavior change is the client experiencing?

Which would be a normal blood pressure of a 12-year-old client? 1 95/65 mm Hg 2 105/65 mm Hg 3 110/65 mm Hg 4 119/75 mm Hg