Health Assessment Exam 1

A registered nurse assesses clients with dark skin. Which statement made by the registered nurse indicates the need for further teaching? "I should touch the skin to feel its consistency." "I should use a fluorescent light source to assess the skin color." "I should place my hand on the skin to assess the temperature." "I should look for any changes in skin color darker than surrounding skin."

"I should use a fluorescent light source to assess skin color" - natural light is best

A registered nurse teaches a nursing student about how to interview an adolescent. Which statements made by the nursing student indicate the need for further education? Select all that apply. "I should begin with less sensitive issues." "I should ask open-ended questions if possible." "I should use language that is common for adolescents." "I should make assumptions regarding his or her feelings." "I should interview an adolescent along with his or her parents."

"I should make assumptions regarding his or her feelings." and "I should interview an adolescent along with his or her parents."

A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? "Tell me about your fears regarding pain." "Analgesics will be prescribed to control the pain." "Some clients report feeling a tingling or burning sensation but not unbearable pain." "Let's make a list of the things you need to ask your healthcare provider."

"Some clients report feeling a tingling or burning sensation but not unbearable pain." - truthful answer that provides hope for the patient

When should the nurse observe the client to assess his or her level of functioning? Select all that apply.

*return demonstrations* During meal time, when preparing medication, and when administering insulin injections. (NOT when talking about pain or during the assessment interview)

The nurse is conducting a secondary survey as part of the emergency assessment. Which is the priority nursing action during the health history portion of the assessment?

Determining drug allergies (NOT noting general appearance, examining neck for stiffness, auscultating lung and heart sounds)

A client is diagnosed with a dysfunction of the eccrine gland. Which physiologic abnormality might occur in the client? Select all that apply.

Drying of surface cells, Decreased efficiency to cool the body, Decreased excretion of waste products through the skin (NOT drying of hair and decreased synthesis of Vitamin D) - Eccrine Gland (Sweat Gland) main functions - to moisturize the surface cells, cool the body by evaporation, and excrete waste products through the pores of the skin

A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion?

Exposure to Radiation - major cause of skin cancer is exposure to the sun's UV light, a form of radiation

Measure a child's head circumference for growth pattern up to what age?

From birth to 36 months of age `

Which client assessment finding should the nurse document as subjective data?

Pain rating of 5 - PAIN IS SUBJECTIVE

Decreased activity of apocrine glands may cause

Uneven skin color and dry skin

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

Unstageable

A registered nurse is teaching a nursing student how to assess for edema. Which statement made by the student indicates the need for further education? "Edema results in the separation of skin from pigmented and vascular tissue." "Pitting edema leaves an indentation on the site of application of pressure." "Trauma or impaired venous return should be suspected in clients with edema." "If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given."

"If the pressure on an edematous site leaves an indentation of 2 mm, a score of 2+ is given." - 2 mm = 1+, 4 mm = 2+, 6 mm = 3+, 8 mm = 4+

A registered nurse (RN) is performing a physical assessment of four clients with various medical conditions as shown in the chart. Which client is expected to have concavely curved nails?

A patient with iron deficiency anemia

Dorsalis Pedis Pulse

Along the top of the foot; to assess circulation in the foot

The nurse is assessing a client who arrived at the healthcare facility for an appointment. Which action by the nurse will be beneficial during the interview?

Asking the client about their current concerns

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?

Brown or black mole with red, white or blue areas

Actinic Keratosis

Clinically manifested as a flat or elevated, dry, hyperkeratotic scaly papule that appears possibly flat, rough, or verrucous

Dysplastic Nevus

Clinically manifested by an irregular border (possibly notched), variegated color of tan, brown, black, red, or pink within a single mole

Which interview technique is the nurse using when asking a client to score the pain on a scale from 0 to 10?

Closed-Ended Questioning - these types of questions specify the cause of the problem or the client's experience of the illness

A client reports diminished sensations of pain, touch, and temperature on the skin. The nurse touches the skin and finds it cool. Which skin changes should the nurse relate to the client's findings?

Decreased blood flow to the skin

A client with a history of food intolerance has abdominal pain, abdominal distention, and a feeling of fullness. The client is admitted to the hospital for diagnostic testing. What specific information should the nurse collect when performing the nursing admission history and physical?

Detailed characteristics of pain because it will help differentiate between the many different possible gastrointestinal problems

What nursing actions best promote communication when obtaining a nursing history? Select all that apply. Establishing eye contact Paraphrasing the client's message Asking "why" and "how" questions Using broad, open-ended statements Reassuring the client that there is no cause for alarm Asking questions that can be answered with a "yes" or "no"

Establishing Eye Contact, Paraphrasing the Client's Message, Using Broad, Open-Ended Statements

Posterior Tibial Pulse

Found below the medial malleolus; assess status of circulation of the foot

A client age 40 years old, has a heart rate of 40 bpm and stroke volume is increased. They are at risk for what?

Increased blood pressure. Blood pressure increases when HR is low and stroke volume is increased.

Which actions should the nurse perform while collecting subjective data from a client during a focused urinary assessment? Select all that apply. Inquire about painful urination Ask the client about changes in characteristics of urination Assess the levels of blood urea nitrogen and creatinine Palpate the abdomen for bladder distention or masses Inspect the urinary meatus for inflammation or discharge

Inquire about painful urination and ask the client about changes in characteristics of urination

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of non-intact skin

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first?

Cervical

Carotid Pulse

found along the medial edge of the sternocleidomastoid muscle of the neck; easily accessible in times of physiological shock or cardiac arrest when other sites are not palpable

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?

Incontinence and inability to move independently

Malignant Melanoma

Irregular color, surface, and border with variegated color, including red, white, blue, black, gray, and brown. Appears flat or elevated, eroded or ulcerated

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in blood pressure. The nurse would report this finding as what?

Orthostatic Hypotension

A nurse is obtaining a health history from the newly-admitted client who has chronic pain in the right knee. What should the nurse include in the pain assessment? Select all that apply.

Pain history - location, intensity, quality and Pain pattern - precipitating and alleviating factors (NOT Client's body movement when arranging papers on a bed side table, vital signs, and the clients family statement) ** Pain is SUBJECTIVE **

The nurse is assessing a client who had knee replacement surgery. Which assessment finding gathered by the nurse is an example of subjective data?

Pain level of 7/10 - PAIN IS SUBJECTIVE

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply.

Palpates for tenderness and inspects any areas of discomfort (DO NOT observe for nonverbal cues, notice if the pain is localized or radiated, noticing if the client gives nonverbal signs of pain)

Which interventions should the nurse perform while collecting subjective data from a client during a focused respiratory assessment? Select all that apply. Palpate the chest and back for masses Question the client about shortness of breath Check the hematocrit and hemoglobin values Inspect the skin and nails for integrity and color Ask the client about color and quantity of sputum

Question the client about shortness of breath and ask the client about color and quantity of sputum

Decreased Skin Turgor

Severe dehydration

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension?

Sit on the edge of the bed for 5 minutes before standing up

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for?

Skin Turgor

Basal Cell Carcinoma

Small, slowly enlarging papules with borders that are semi-translucent or pearly with overlying telangiectasia; erosion, ulceration, and depression in the center of the lesion may appear

Which strategy needs to be employed while interviewing the adolescent as a part of her health-screening?

To explain the limits of confidentiality - helps to obtain reports on physical or sexual abuse. It also helps to get others involved if the client is suicidal

A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply.

Transparent (see through), Tenting (Decreased skin turgor), Increased Wrinkles (Decreased elasticity) and Pigmented Lesions (solar lentigines i.e moles, freckles - increase in number and size) (NOT Scaly Skin - more common with psoriasis than aging)

Ulnar Pulse

Ulnar side of forearm at the wrist; to assess circulation of the hand and to perform the Allen test

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience?

Visceral - pain originates from interior organs (visceral organs, such as pancreas)

Which statement made by the nurse indicates that the client interview is coming to a close? " I have just one more question for you." "I hope you are comfortable and not in pain." "I would like to spend some time to understand your concerns." "I assure you that information I gather now will be confidential."

"I just have one more question for you."

The nurse is teaching a client about self-management to prevent dry skin. Which statement made by the client indicates the need for further teaching? "I should use nonalkaline soap for a bath." "I should apply rubbing alcohol to the skin." "I should avoid clothing that continuously rubs the skin." "I should use a room humidifier during the winter months."

"I should apply rubbing alcohol to the skin." - alcohol increases skin dryness

A nurse is taking care of a client who has chronic back pain. What nursing considerations should be made when determining the client's plan of care? Select all that apply.

Ask the patient their acceptable level of pain and administer pain medications regularly around the clock (DO NOT eliminate all activities that precipitate pain, use a different pain scale each time, or assess client's pain every 15 minutes) *Chronic - goal is to decrease pain to a tolerable level, instead of eliminating completely*

The nurse is getting a client out of bed to the chair for the first time since surgery 2 days ago. What assessment should the nurse should make first before moving the client?

Assessment of comfort and pain

Melanoma most commonly occurs?

At the place where moles or birthmarks are most evident

A nurse is performing a mental status assessment. What is being assessed when the nurse notes that the client is cooperative?

Attitude - relates to the approach or manner of the client during the interaction with the interviewer