Health Assessment Exam #1
Light palpation: __ cm depth
1
Moderate palpation: ___ cm depth
1-2
Deep palpation: ___ cm depth
2-4
A client has an oral temp of 37.2 c (99 F). The nurse interviews the client. Which of the following pieces of interview data could be an influence on this high body temp? A. the client has just run 4.82 km (3 miles) outside before coming to the interview B. the client drinks 8 glasses of water a day C. the client has a history of hypothyroidism D. the client reports having a toe infection treated with antiobiotics 3 months ago
A
A nurse is admitting a 30 yr old female client & recognizes the need to screen the client for abuse. What would the nurse do next? A. ensure a private setting B. perform a physical assessment C. obtain informed consent D. teach the client signs of abuse
A
A nurse is assessing the blood pressure of a team of healthy athletes at the health care facility. Which of the following observations can be made by the nurse & athletes by measuring the blood pressure? A. the ability of the arteries to stretch B. the thickness of the circulating blood C. the oxygen levels in the blood D. the volume of air entering the lungs
A
A nurse is preparing to assess an adult clients body temp. At which time of the day would the nurse expect to obtain the lowest body temp? A. early morning B. early afternoon C. late afternoon D. late evening
A
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? A. light palpation B. moderate palpation C. deep palpation D. bimanual palpation
A
As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgement ability in the client? A. what do you do if you have pain? B. when did you get your first job? C. when were you last hospitalized? D. how is an apple different from an orange?
A
The nurse is caring for a post-operative patient with an order for morphine sulfate 2 mg IV push every 4 hours. The patient's pain is unrelieved 30 minutes following administration of the morphine sulfate with the pain rating increasing from 7 to 10. Which action should the nurse take? A.Call the prescribing physician see about changing the pain medication. B. Instruct the patient that it is too soon for another dose of morphine. C. Wait and medicate the patient when the next dose of morphine is due. D. Administer another dose of the morphine sulfate immediately.
A
The nurse is caring for a woman being seen for possible pregnancy. When would the nurse screen for intimate partner violence? A. during the womans first prenatal visit to the clinic B. as soon as an appointment can be scheduled with the womans partner C. at a point when the women states she is comfortable with being screened D. once the woman begins her second trimester of pregnancy
A
The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image? A. "What would you change about your body, if you could?" B. "Do you gather around a table with other people for meals?" C. "How much do you exercise in one week?" D. "How many meals and snacks do you eat in one day?"
A
The nurse's assessment reveals that a client is in a low percentile for midarm muscle circumference (MAMC) and a high percentile for triceps skin fold (TSF) thickness. Which of the following would be appropriate? A. Teaching the client muscle-building exercises B. Discussing ways to increase body fat stores C. Assisting client in reducing the amount of fluid build-up D. Encouraging the use of a multivitamin supplement
A
Which of the following nutrients is most vital to life? A. Water B. Carbohydrates C. Minerals D. Vitamins
A
In the course of performing a clients physical assessment, the nurse has changed from using the diaphragm of the stethoscope to using the bell. The nurse is most likely assessing which of the following? A. Heart sounds B. Bowel sounds C. Breath sounds D. Femoral pulses
A.
Nurses provide both direct & indirect care. What is an example of indirect care? A. Participating in a client care conference B. Adjusting an IV rate C. Calculating a medication dosage D. Completing a nursing assessment
A.
The nurse conducts a health history with a client who reports having a dull headache over the past month. The client tells the nurse that using aromatherapy scents have helped manage the pain sometimes. This information belongs to which attribute of a symptom? A. treatment B. associated manifestations C. onset D. duration
A.
The nurse is assessing an older adult client at a hospice unit. The client cannot speak or communicate, but the client's daughter is there & answers all the questions as best as she can. What type of data source is the daughter? A. Secondary B. Primary C. Tertiary D. Subjective
A.
When beginning the collection of the client data base, which of the following would be most important for the nurses to do? A. Establish a trusting relationship B. Determine the client's strengths C. Identify health problems D. Make inferences
A.
When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following? A. Quote the clients words B. Summarize the clients words C. Paraphrase the clients words D. Describe the clients concerns & health goals
A.
Which describes the nurse using the technique of percussion? A. The nurse notes resonance over the individuals thorax B. The nurse detects crepitus over the individuals thorax C. The nurse notes symmetry of the individuals thorax D. The nurse detects rustling over the individuals thorax
A.
A client recovering from a motor vehicle crash sustained right rib fractures and a fractured pelvis. The nurse is reviewing the client's metabolic panel lab results and notes a blood glucose of 130 mg/dL; the client has no history of diabetes. What is the nurse's best initial action? A. Request a prescription for regular insulin. B. Ask the client if she was in pain when the labs were drawn. C. Verify the result by performing a capillary stick. D. Assess for cold, clammy skin.
B
A client with diabetes mellitus visits the health care clinic with reports of excessive thirst and excessive urination. She states her appetite has been low for the past 3 months with a 20 pound weight loss. Which nursing diagnosis should the nurse confirm based on this data? A. Fluid Volume, Excessive B. Imbalanced Nutrition CORRECT C. Activity Intolerance D. Knowledge Deficit
B
A group of students is reviewing information about general indicators for nutritional status. The students demonstrate a need for additional review when they identify which of the following as an indicator for good nutritional status? A. Flat firm abdomen B. Brittle hair C. Pink mucous membranes D. Elastic skin
B
A nurse is helping a sedentary 20-year-old female determine her dietary needs. Which of the following would be her estimated calorie needs per day? A. 1,600-1,800 B. 1,800-2,000 CORRECT C. 2,000-2,200 D. 2,200-2,400
B
A nurse needs to examine a clients hip joint, which client position would be best for this assessment? A. supine B. prone C. knee chest D. lithotomy
B
An older adult client with osteoarthritis has tearfully admitted to the nurse that she is no longer able to climb the stairs to the second floor of her house due to her knee pain. What nursing diagnosis is suggested by this client's statement? A. Ineffective coping related to knee pain B. Activity intolerance related to knee pain C. Ineffective role performance related to osteoarthritis D. Situational low self-esteem related to osteoarthritis
B
The nurse assess the amplitude of the clients radial pulses & finds it to be weak & diminished. Which of the following scores should the nurse record? A. 0 B. 1+ C. 2+ D. 3+
B
The nurse is caring for a client recovering from surgery with an open wound. The nurse should encourage this client to increase the intake of which foods? A. Leafy green vegetables and fruit. B. Meat and dairy products. C. Whole grains and nut butter. D. Citrus fruits and mixed vegetables.
B
You are the clinic nurse assessing a new patient that has come in to see a physician. The assessment data that you collect reveals that the patient is a 23 year-old female weighing 175 lb with a height of 5 ft 3 in. Her body mass index is 31. What would she be considered? A. Average weight B. Obese C. Overweight •D.Underweight
B
A client comes to the health care provider's office for a visit. The client has been seen in this office for the past 5 years & arrives today complaining of a fever & sore throat. Which type of assessment would the nurse most likely perform? A. Ongoing assessment B. Focused assessment C. Emergency assessment D. Comprehensive assessment
B.
A nurse cares for a client with lung cancer who presents rust colored aputum & a fever. The nurse performs frequent ascultation of the lung sounds to determine any changes from the baseline. What type of assessment is the nurse performing? A. Emergency B. Ongoing C. Focused D. Comprehensive
B.
A nurse is preparing to perform a genital examination of a female client. Which of the following positions should the nurse place the client in? A. Supine B. Lithotomy C. Standing D. Prone
B.
A patient is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the patient? A. Breathing B. Airway C. Cirulation D. Disability
B.
During an assessment, the nurse determines that a client sees more than one primary care provider & has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen? A. ask the client to identify which medications are taken every day B. ask the client to bring all the medications & supplements to an interviewer C. ask the caregiver whether the client is taking prescribed medications D. ask the client about the use of any over the counter medications
B.
During the interview, the client states "is today the 12th? my wife died 2 months ago today." Which of the following responses would be more appropriate? A. what was the cause of your wife's death? B. how does that make you feel right now? C. you probably must be sad D. are you feeling sad, depressed, angry, or upset?
B.
Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason? A. Determine the need for crisis intervention B. Reassess previously detected problems C. Address areas previously omitted D. Provide information for the client's record
B.
The nurse is assessing a client's lifestyle & habits. At which time should the nurse assess the client for alcohol use? A. During the review of systems B. After assessing for cigarette use C. Before assessing for vaccinations D. While completing the family history
B.
When discussing the nursing process with a group of students, which of the following statements best describes it? A. It is used primarily in acute care settings B. It is ongoing & continous C. Each step is independent of the others D. It involves independent nursing actions
B.
When performing a physical assessment on an older adult client, what should the nurse consider offering the client? A. A family member in the room B. An extra blanket C. A pillow D. Elevation of the head of the examination table
B.
Which assessment finding should the nurse document as objective data? A. Biographical information B. Body functions C. Lifestyle practices D. Personal relationships
B.
Which skill does the nurse need to obtain subjective data during the initial comprehensive assessment? A. Observation B. Empathy C. Inspection D. Sympathy
B.
A client suffering from decreased muscle strength has been diagnosed with a low Vitamin D level. The nurse should recommend that the client increase intake of which vitamin source? A. Fortified breads B. Lentils C. Sunshine D. Orange juice
C
A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following principles should guide the nurse's assessment of a client's pain? A. The client is likely experiencing less pain than he is reporting. B. The client's depression exists independently of the level of pain. C. It is likely that the client's pain rating will be influences by his emotional state. D. The degree of surgery will be the key indicator for level of pain experienced.
C
A patient is reporting pain and informs the nurse that it has become unbearable. The first thing the nurse should do is what? A. Check the patient's record for allergies. B. Check the physician's orders to see what pain medication to administer. C. Assess the site and intensity of the pain. D. Call the physician.
C
Cachexia is characterized by a highly catabolic state with accelerated muscle loss. What is the other component of cachexia? A. Anemia B. Psychological desire for attention C. Chronic inflammatory response D. Nausea and vomiting
C
Light palpation is most appropriate to assess the: A. appendix B. bladder C. inflamed areas of skin D. liver
C
One of the body's normal physiologic responses to pain is A. hypotension. B. pulse rate below 50 beats/minute. C. diaphoresis D. hypoglycemia.
C
Since the nurse is unable to obtain an average sized cuff to assess an adult patient with a large arm. The nurse uses an oversized cuff. What blood pressure reading will the nurse most likely obtain for this patient? A. correct reading B. reading will be low C. reading will be high D. reading cannot be obtained
C
To calculate the ideal body weight for a woman, the nurse allows A. 106 pounds for 5 feet of height. B. 6 pounds for each additional inch over 5 feet. C. 100 pounds for 5 feet of height. D. 80 pounds for 5 feet of height.
C
A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time? A. are both of your parents still living? B. what do you usually eat in a typical day? C. what diseases did you have as a child? D. how do you feel about having to seek health care?
C.
The nurse is focusing an interview on a patients respiratory status. Which question should the nurse ask first to begin this interview? A. do you currently have a cough? B. do you have ant difficulty producing sputum? C. describe how you breathe for me? D. do you experience any pain when you breathe?
C.
A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing? A. Cutaneous pain B. Visceral pain C. Chronic pain D. Neuropathic pain
D
A nurse is using the FLACC (Face, Legs, Activity, Cry, Consolability) scale for pediatric pain assessment to assess for pain in a 6-month-old client. Which of the following findings on this assessment tool would indicate the strongest pain in the client? A. Occasional grimace or frown B. Whimpering C. Lying quietly D. Kicking
D
After teaching a group of students about blood pressure & Korotkoffs sounds, the instructor determines that the teaching was successful when the students identify which of the following? A. phase 1 reflects the diastolic pressure B. phase IV sounds are clear & repetitive C. phase V reflects the systolic pressure D. phase II sounds appear muffled & swishing
D
Because BMI is calculated using only height and weight, the nurse knows that inaccurate findings would most likely occur in a client A. with diabetes. B. who is 182.8 cm (6 ft) tall. C. with osteoarthritis. D. who is a bodybuilder.CORRECT
D
When assessing a client's respiration, what is most important to include in the documentation? A. numerical pain rating B. position of the client C. assessment of pedal pulses D. presence of dyspnea
D
A client presents to the health care clinic with reports of sleeplessness & loss of appetite. The client tells the nurse that his wife is seriously ill in the hospital & he has not been able to visit her much because of transportation problems. Which open-ended questions should the nurse ask the client to obtain more information about his presenting symptoms? A. "when did the sleeplessness first start?" B. "are you taking any new medications?" C. "have you lost any weight this week?" D. "do you think your wife is getting better?"
D.
A client presents to the health care facility with reports of new onset of chest pain of 3 days duration. Vital signs are stable & the chest pain has subsided since the client entered the exam room. Which type of assessment is most important for the nurse to perform for this client? A. Emergency B. Focused C. Partial D. Comprehensive
D.
A nurse assessed a client with regard to nutritional habits, use of substances, education, & work and stress levels. The nurse recognizes this as what type of information? A. History of present health concern B. Personal health history C. Family health history D. Lifestyle & health practices profile
D.
A nurse is collecting data on a client's chief complaint, which is a spell of numbness & tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors? A. "how bad was the tingling & numbness?" B. "how long did the spell last?" C. "where did the numbness & tingling occur?" D. "what other symptoms occurred during the spell?
D.
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? A. bowel B. normal heart C. breath D. heart murmer
D.
The nurse is assessing the 7 attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information? A. Initial information B. Review of systems C. Health patterns D. History of present illness
D.
The nurse is preparing to assess a female client's activities related to health promotion & maintenance. Which question would provide the most objective & thorough data? A. "do you always wear your seatbelt when driving?" B. "how much beer, wine, or alchohol do you drink?" C. "do you use condoms with each sexual encounter?" D. "could you describe how you perform breast exams?"
D.
The nurse is preparing to complete a comprehensive assessment of a newly admitted client. Why is the nurse completing this type of assessment? A. addresses specific concerns B. establishes routine care needs C. assesses symptoms of one body systme D. provides a baseline for future assessments
D.
The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which piece of equipment? A. Eye goggles B. Face mask C. Cover gown D. Face shield
D.
What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation? A. application of firm pressure when using the bell B. use the diaphragm to listen to low-pitched sounds C. use the bell to detect high pitches sounds D. ensure that contact with the skin is maintained
D.
________ (greater than or equal to 3 yrs)
FACES
________ (2 months to 7 yrs)
FLACC
True or False: Painful numbness or tingling is associated with arthritic pain
False
The _______ _______ _______ & _________ ____ of 1996 regulates the security & privacy of information. Confidentiality of documentation is essential, & only information that is pertinent to the care of the patient is shared
Health Insurance Portability Accountability Act
What is a good mnemonic for completing a basic head to toe assessment?
Ill properly perform assessment
What is a good mnemonic for pain assessment?
OLDCART
True or False: When assessing pain, nurses should use scales designed for the specific population to which the patient belongs
True
Inadequately treated ______ pain can impair pulmonary function, decrease immune response, & prolong hospital stay
acute
______ pain: short duration (trauma, surgery, etc.)
acute
We use _____ part(s) of the hand when performing palpation
all
__________ Measurements -Scientific measurements of the body obtained for nutritional analysis
anthropometric
_____________ uses the stethoscope to perform; movements of air or fluid are heard in the body; need a quiet environment
auscultation
The _______ of the stethoscope is used with light skin contact to hear low frequency sounds
bell
Pain-________ substances: serotonin opiods gamma-aminobutryic acid gabaoentin (neurontin) pregablin (lyrica)
blocking
_________ pain: lasts beyond normal healing period of 3-6 months; may have no identifiable causes; (see a lot of lower back pain)
chronic
________ pain: skin layers; burning, sharp, consider a paper cute or burn from stove top
cutaneous
______ percussion involves tapping directly on the skin (sinuses)
direct
The aim of __________ _________ is complete, accurate, concise, current, factual, & organized data communicated in a timely & confidential manner to facilitate care coordination & serve as a legal document
documentation guidelines
The _____ is used to assess blood flow through an artery
doppler
_______ percussions: moderate, high pitch, moderate duration, thug quality, location in liver
dull
The nurse needs to assess the patients pain as to the location, ________, intensity, quality, aggravating & alleviating factors, pain goal, & funcctional
duration
________ refers to how long the sounds last once licited
duration
Reassessing pain can provide a means of determining the ______ of an administered pain med
efficacy
Stress response causes releases of ______, ________, & _________; they use stored energy to facilitate healing of injured tissue-increases O2 consumption, blood glucose levels, lactate, metabolism, & ketones (think fight or flight)
epinephrine, norepinephrine, cortisol
FLACC scale: F L A C C
facial expression leg movement activity crying consoled
Pain-_________ substances: substance P bradykinin glutamate
facilitating
True or False: Nurses assess a patients pain only when the patient complains
false
True or False: Use of artificial nails is safe when the nails are kept to 1/4 inch or shorter
false
When does a client's physical assessment begin?
first moment of encounter
_______ percussions: soft, high pitch, short duration, dull quality, located in bone
flat
Personal protective equipment is worn whenever there is risk for coming in contact with body ______ from the client
fluids
_________ health assessment is important to nursing because the focus is on the effects of health or illness on a patient's quality of life
functional
The _______ ______ theory posits that the body responds to a painful stimulus by either opening a neural gate to allow pain to be produced or creating a blocking effect at the synaptic junction to stop the pain
gate control
The theory of pain with the widest acceptance is the ______ ______ theory
gate control
Wear _____ when touching blood, body fluids, secretions, excretions, or contaminated items
gloves
The more seriously ill the patient, the ________the need to keep documentation current
greater
Definition of ________: state of optimal functioning or well-being with physical, social, & mental components
health
________ _________ is "gathering information about the health status of the patient, analyzing & synthesizing those data, making judgements about nursing interventions based on the finding & evaluating patient care outcomes" AACN
health assessment
The purpose of _______ _______ is to collect subjective data that may involve asking questions that are uncomfortable
health history
A health assessment includes both a ________ _______ & _______ ________
health history physical assessment
___________: pt has altered response to pain stimulus & repeated use of opiod causes their body to be more sensitive to pain; this can occur as soon as 1 month after opiod use begins
hyperalgesia
________ percussions very loud, low pitch, long duration, booming quality, location in emphysematous lungs
hyperresonant
________ percussion involves middle finger of nondominant hand over area & strike with middle finger of dominant hand
indirect
_________ is the one technique of physical assessment that is performed for every body part & body system
inspection
What does Ill Properly Perform Assessment stand for?
inspection palpation percussion auscultation
There are 4 percussion tones in the body:
intensity pitch duration quality
_________ pain: constant pain that is not curable by any known means
intractable
LOC: _______ __ ______
level of consciousness
_______ palpation is used for assessment of surface (lumps, inflammed areas, etc.)
light
________ malnutrition: 80-90% of ideal weight
mild
_______ malnutrition: 70-80% of ideal weight
moderate
_____/______ palpation is used to assess abdominal organs
moderate deep
_________ pain: results from damage to nerves; (diabetic peripheral neuropathy)
neuropathic
_________: perception of pain by sensory receptors located throughout the body (nociceptors)
nociception
If the patient is _________ the nurse can use a behavioral pain scale designed to identify pain in that particular population
nonverbal
Most commonly used pain scaled is the ________ pain intensity scale; this is the best way to validate an alert/oriented clients pain scale
numeric
Make sure your documentation reflects the ________ ________ & your professional responsibilities
nursing process
_________ is used for visualization of the interior structures of the eye
opthalmoscope
________ is used to visualize ear canal & tympanic membrane
otoscope
_____ is a common cause for clients to seek health care professional help
pain
________ _______: may see a change in vitals; this is very individualized
pain reaction
_______ _______: the level of pain someone is able to endure
pain tolerance
__________ is the use of touch to asses texture, temperature, moisture, size, shape, location, position, vibration, tenderness, pain, & edema
palpation
Pain is what the _______ says it is
patient
Health Assessment components include: _______ _______ ________ ________ ___________ _______ __ __________
patient interview physical assessment documentation interpretation of findings
_________ is when the nurse uses tapping motions with hands to produce sounds that indicated dense, fluid, or air filled spaces; dense tissue (bones); air/fluid=loud tones (lungs & hollow stomach)
percussion
_______ pain: pain that feels like its coming from a body part thats no longer there
phantom
The __________ assessment follows the history & focused interview, & includes objective data, which are observable & measurable.
physical
________ depends on how quickly the vibrations oscillates; if the frequency of the sound is fast, its high (stomach); if its slow, its low (lungs)
pitch
Adequate exposure of each body part is necessary during inspection & the nurse must maintain the client's ______ & ______ through appropriate draping
privacy dignity
________ is subjective description of the percussion sound
quality
_______ pain: pain that radiates from one place to another; consider sciatica from lumbar back down leg; MI (heart attack) causes pain in arm & jaw
radiating
Pain becomes a priority when it affects ________
recovery
________ pain: pain at a specific site & felt at different location; consider gallblader that causes generalized abdominal pain
referred
_____ _______ tests neurological responses of the depe tendons to assess for abnormalitites of central/peripheral nervous system
reflex hammer
________ percussions: loud, low pitch, long duration, hollow quality, location in healthy lungs
resonant
________ malnutrition: <70% of ideal weight
severe
_______ thickness: pts above 95th or below 5th percentile are at risk for altered nutritional status. Triceps most commonly used
skinfold
_______ pain: tissue, muscles, bones/joints, "sharp" deep pain may also be described as dull/aching; consider arthritis
somatic
Nurses use _________ precautions to reduce the transmission of pathogens during client contact
standard
Pain ________: the upper limit of tolerance to pain
threshold
4 steps in nociception: 1. ________:stimuli caused a nerve impulse; think burned finger 2. ________: signal moved from periphery, to spinal cord, & up to the brain 3. _______: impulse sent to brain identified as pain 4. _________: inhibitory
transduction transmission perception modulation
True or False: Actual patient names & other identifiers should not be used in written or oral student reports
true
True or False: Hand hygiene is the single most important element of standard precautions
true
True or False: Never document interventions before carrying them out
true
True or False: Pain is not a normal consequence of aging
true
True or False: Proper technique when using alcohol based hand gels is necessary for effectiveness
true
True or False: There are 4 basic techniques used in physical assesssment
true
True or False: You should assess pain frequently (there are specific protocols per facility)
true
True or false: The general survey includes overall appearance, hygeine, dress, skin color, body structure/development, behavior, facial expressions, level of consciousness, speech, mobility, posture, range of motion, & gait
true
True/False The nurse might expect the patient admitted with dehydration to have tachycardia.
true
_______ _______ is used to determine vibration sense in the neuromuscular system & to determine conductive vs sensorineural hearing loss in the ears
tunning fork
________ percussion: loud, high pitch, moderate duration, drumlike quality, location in gastric bubble (stomach)
tympanic
_______ pain: abdominal organs; "crampy, gnawing"; consider stomach, gall bladder, appendix, etc.
visceral
______ circumference: accumulation of abdominal fat increases risk for type II DM, HTN, cardiovascular disease
waist
Do women or men tend to have more pain?
women
