Health Assessment Exam 1

A nurse is assessing the blood pressure of a client who has come to the health care facility for the first time. Which of the following is the best site for obtaining the client's blood pressure reading?

Arm

When entering a client's room, what is the nurse's first action?

Ask the client's name and birthdate.

Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When the nurse speaks with Adam alone, the client states it "would be better if he were not here." What should the nurse do next?

Assess Adam's suicide risk.

A nurse is preparing to perform a physical examination on a young man who appears anxious about the procedure. Which of the following should the nurse do to ease this client's anxiety?

Before performing each procedure, explain what it involves and its purpose.

As a nurse is assessing a client and asking her questions, the nurse notices that the client stops talking and looks up anxiously each time someone passes by in the hallway outside her hospital room. Which nursing intervention would most likely address the client's concern and promote enhanced communication in this situation?

Close the door to the client's room

The nursing student has learned that to correctly analyze data and make a proper diagnosis, the nurse must develop which of the following?

Critical thinking

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

The nurse is assessing a client's pain. Which of the following would lead the nurse to suspect that the client is experiencing pain?

Facial grimacing, leaning forward

A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care?

Maintaining the privacy and confidentiality of clients' medical records

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

Nurse

When the mental health nurse ask the client "Do you recall what month and year this is?" The nurse is assessing which part of the mental status examination?

Orientation

A nurse assesses a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong body odor. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse identify for this client?

Self-care deficit related to possible homelessness

The client states, "I cannot believe I have breast cancer. I am a good person; I don't know why God is punishing me." The nurse suspects the client is experiencing:

Spiritual distress

A student nurse assesses a blood pressure on an adult and finds it to be 140/86. What term is used for the top number (140)?

Systolic pressure

An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?

Tachycardia

When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider?

The client's physical and emotional safety

Acute pain can be differentiated from chronic pain because

acute pain is associated with a recent onset of illness or injury with a duration of less than 6 months, whereas chronic pain persists longer than 6 months.

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question?

"I just wanted to see what kind of social support you might have to help care for you during your illness."

A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries?

"Injuries like yours could have been caused by someone hurting you. Did someone hurt you?"

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry?

"Patient states pain is a 9 on a scale of 1 to 10."

A student nurse says, "I will not be able to do a good spiritual assessment, because I am not very religious." The instructor addresses this issue with which of the following statements?

"The client is the focus of the spiritual assessment."

The nurse is admitting a client to the clinic and performs a focused assessment. What makes a focused assessment different from a comprehensive assessment?

A focused assessment is more in-depth on specific issues, unlike a comprehensive assessment

Of the following measurements, which one helps to determine if a client is underweight, normal weight, or obese?

body mass index

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

head to toe

Care that considers the client's body, mind, and spirit is which type of nursing care?

holistic care

A nurse is assessing the vital signs of a client who is moaning with pain. What would be the expected findings?

increased pulse and blood pressure

A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being worst pain. What characteristic of pain is the nurse assessing?

intensity

The nurse observes unlicensed assistive personnel (UAP) at a client's bedside. Which action is UAP performing as depicted in this picture?

measuring radial pain

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's

perception of pain.

You are completing a health assessment on a new client. You note that the client has dry, dull, brittle hair and dry, flaky skin with poor turgor. What might this indicate?

poor nutritional status

During a thorough spiritual assessment, the nurse understands that the questions asked are designed to

reveal beliefs that might affect client care

A nurse is preparing to conduct an initial interview on a client from a different culture. Which of the following is important for the nurse to consider before beginning the interview?

verbal and nonverbal communication