Health and Physical assessment week 1
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
"Can you tell me about your sleep problem from when it started until now?"
During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?
Ask the client to bring all the medications and supplements to an interview.
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use?
Cued or checklist forms
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
Decreased range of motion in right shoulder
The nurse reviews the laboratory values of a client and observes a decrease in the client's hematocrit and hemoglobin since admission. The nurse reviews the client's vital sign trend since admission and sees the BP has been decreasing as well. What is the best action of the nurse?
Develop a nursing diagnosis.
A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?
Develop a plan of care with the client.
The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?
Dorsiflexion of the foot
Shortly after a client departs the office following a routine physical, the nurse notices in her chart that the client has gained 10 lb in the past year and is now overweight. Although the client is generally healthy, the nurse realizes that if this trend continues, the overweight will begin to affect the client's health. The nurse makes a note to discuss it with the client at the next visit. Which nursing diagnosis would be most appropriate for this client?
Imbalanced nutrition: more than body requirements
In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action?
Place the completed assessment in the medical record.
The clinic nurse is preparing for a comprehensive assessment on a new client. What action(s) should the nurse take prior to conducting the assessment? Select all that apply.
Provide a comfortable, quiet environment. Ensure sufficient lighting and proper equipment are available. Provide privacy via curtain, door, or blanket. Project professionalism and build rapport.
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
To provide a record of the actual events
Which characteristics of critical thinking should a nurse employ when analyzing data collected during the physical assessment of a client? Select all that apply
Use rationale to support opinions and decisions Reflect on thoughts before reaching a conclusion Use past clinical experience to build knowledge
The nurse is interviewing a 78-year-old client for the first time. The nurse should first
assess the client's hearing acuity.
Universal precautions are primarily designed to protect the health care worker from what?
blood-borne pathogens
A client is receiving a unit of packed red blood cells (PRBC). The client develops a low-grade temperature one (1) hour after the blood transfusion was initiated. What type of assessment should the nurse perform?
focused
The nurse would use the tuning fork to assess for what?
hearing loss
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?
heart murmur
During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
hyperresonance
You should use the bell of the stethoscope when auscultating what type of sounds?
low-frequency sounds
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
perform an emergency assessment
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
physiologic status.
One disadvantage of the open-ended assessment form is that it
requires a lot of time to complete.
A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
skinfold calipers
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?
the client
stereognosis
the mental perception of depth or three-dimensionality by the senses, usually in reference to the ability to perceive the form of solid objects by touch.
How should the nurse place the ear of an adult when using the otoscope?
up and back
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."
A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?
Inspection, palpation, percussion, auscultation
A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?
Make a referral to the dietician.
A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?
Perform an emergency assessment.
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
Which of the following should be included in the documentation of subjective data in the nurse's findings from the physical examination of the head and neck in the client with acute neck pain?
The client reports worsening pain in the neck when she looks down.
Which illustrates the nurse using the technique of inspection?
The nurse detects a fruity odor of the client's breath.
If the nurse makes an error while documenting findings on a client's record, the nurse should
draw a line through the error, writing "error" and initialing.
A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?
implementation
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use?
light palpation
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
What would be the expected tone elicited by percussion of a normal lung?
resonance
The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.
seeing things as only right or wrong
A client is experiencing a relapse of a urinary tract infection. Which additional information should the nurse collect when discussing this client's present health problem?
sexual history
One characteristic of a nurse who is a critical thinker is the ability to
validate information and judgments.
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?
value-belief
During the client interview, the nurse asks specific questions such as "What were you doing when the pain started?" or "Was the pain relieved when you rested?" In what phase of the interview is the nurse involved?
working
When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician?
"I am a registered nurse caring for your client."
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
Assess the nasogastric tube for proper functioning.
A hospital is changing the format for documentation in an attempt to decrease the amount of time the nurses are spending on charting. The new type of charting will require that the nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which of the following best defines this type of charting?
Charting by exception
What is the nurse's focus while conducting a health assessment with a client? (Select all that apply.)
Completing the health history. Conducting a physical examination.
A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?
To determine any changes from the baseline data
A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?
Wellness diagnosis
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 preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?
coin or key
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram
The nurse would use what part of the hand when assessing temperature during palpation?
dorsal surface
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?
thyroid gland
While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose?
to clarify
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
validate all data before documentation of the data.
During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?
working
When charting by exception is used in a health care agency, the most important aspect of this method is what?
Identifying the standards and norms for the institution
A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next?
Implement interventions.
While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's
bone
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?
emergency
When doing an overall assessment of a client, the nurse is able to use findings for which primary purpose?
Identify in what areas the client needs the most care.
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
Evaluate outcome.
A nursing instructor is emphasizing the importance of assessment skills in nursing. In discussing the future of the nursing profession, which factors that will increase opportunities for nurses with advanced assessment skills should the instructor stress? Select all that apply.
Declining numbers of medical students due to rising costs and focus on primary care Increasing complexity of acute care Growing population of older adults with complex comorbidities Increasing impact of children and the homeless on communities
Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply.
Make sure that dress and appearance are professional Do not use facial expressions such as rolling the eyes or looking bored or disgusted Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally