Health Assessment
The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor? You Selected:
Correct response: "A way of processing information using to formulate conclusions or diagnoses." Explanation: Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.
The nurse should perform which actions to reduce risk in the hospitalized client? (Select all that apply.)
Correct response: Inspection of surgical site wounds frequently to assess for redness, warmth, or edema. Place bed alarms in rooms of clients who are confused or demonstrate an unsteady gait. Explanation:
A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?
Correct response: Marfan syndrome Explanation: Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity, is seen in Cushing syndrome.
During a client interview, the nurse asks questions about the client's past health history. The primary purpose of asking about past health problems is to
Correct response: identify risk factors to the client and his or her significant others. Explanation: The past health history focuses on questions related to the client's personal history, from the earliest beginnings to the present. These questions elicit data related to the client's strengths and weaknesses in his or her health history. The information gained from these questions assists the nurse in identifying risk factors that stem from previous health problems. Risk factors may be to the client or significant others.
53s Report this Question A nurse is working with a client who has a history of chronic obstructive pulmonary disease (COPD). While bathing the client, the nurse senses that something is not quite right and takes the client's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?
Correct response: intuition Explanation: The nurse is acting on intuition, in this case, the feeling that something is not quite right. Scientific rationale is an explanation based on science. Knowledge is based on science and theories that the nurse learned in school. Prior history of the client is not what the nurse is acting upon in this case.
How would the nursing instructor explain the goal of guided questioning to his or her students?
Correct response: Facilitating the client's fullest communication Explanation: The main goal of guided questioning is to facilitate the client's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the client.
The nurse is formulating a wellness diagnosis for a client ready for discharge from the hospital. In order to do this, what must the nurse identify?
Correct response: Identified strengths Explanation: Identified strengths are used in formulating wellness diagnoses. Identified potential weaknesses are used in formulating risk diagnoses and abnormal findings are used in formulating actual nursing diagnoses.
A client presents to the health care facility with reports of new onset of chest pain of three days duration. Vital signs are stable and the chest pain has subsided since the client entered the exam room. Which type of assessment is most appropriate for a nurse perform for this client?
Correct response: Comprehensive Explanation: This client presents with a new problem and the nurse should perform a comprehensive assessment. Chest pain is an emergent problem but the client is has stable vital signs and no chest pain so an emergency assessment is not indicated at this time. A partial or focused assessment would not allow collection of enough data to properly complete diagnose the cause of a new problem.
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
After collecting subjective and objective data for the admission database, what is the nurse's next action?
Validate the client's identified problems Explanation: The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting.
Question 7 See full question 1m 24s Report this Question The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)
You Selected: -Use rationale to support opinions or decisions. -Acquire an adequate knowledge base that continues to build. -Be nonjudgmental and keep an open mind. Explanation: The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.
The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's
orrect response: vital signs. Explanation: It is a good idea to begin the "hands-on" physical examination by taking vital signs. This is a common, noninvasive physical assessment procedure that most clients are accustomed to.
A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.) Chapter 5
-explores other alternatives before making a decision -uses past knowledge and experience to analyze data -reserves a final opinion until further collecting data Explanation: Nurses can assess their critical thinking skills by asking themselves some of the following questions: do you reserve your final opinion until you have collected more or all of the information? Do you support your opinion with supporting data, sound rationale, and literature? Do you explore other alternatives before making a decision? Can you distinguish fact, opinion, and inference? Do you ask your client for more information or clarification when you do not understand? These are only a few questions nurses should ask when learning critical thinking skills. Disregarding the literature and sound rationale is not advisable.
How does a nurse best facilitate the nursing health assessment?
Correct response: Asking the appropriate questions Explanation: Knowing how to facilitate the nursing health assessment by asking appropriate questions to obtain more information assists the nurse to solve the mystery or create a nursing care plan.
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
Correct response: Increased pulse rate Explanation: When the stroke volume decreases, such as when blood volume is decreased because of hemorrhage, the heart rate increases to try to maintain the same cardiac output. Chapter 8
A nurse is taking a rectal temperature on an unconscious client. What reading would reflect temperature within the normal range?
Correct response: 99°F Explanation: The normal rectal temperature range is around 37°C (99°F). A rectal temperature above 100°F or at 97°F is outside the normal range. Rectal temperatures are about 0.5°C (0.8°F) higher than oral temperatures.
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?
Correct response: value-belief Explanation: The value-belief health pattern describes patterns of values, beliefs or goals that guide choices or decisions. The self-perception-self-concept pattern describes body image, feeling state, self-esteem, personal identity, and social identity. The role-relationship pattern describes patterns of role interactions and relationships including family functioning and problems, and work and neighborhood environment. The coping-stress-tolerance pattern describes general coping pattern and its effectiveness in terms of stress tolerance. Chapter 2: Collecting Subjective Data: The
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
You Selected: The blood pressure increases. Explanation: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.
A client is concerned that a blood pressure reading of 180/78 mm Hg is extremely high when the readings usually are around 130/60 mm Hg. What could have caused this elevation in blood pressure?
arm below the level of the heart Explanation: One reason for a falsely elevated blood pressure is the arm being held below the level of the heart. Reasons for a false low blood pressure include a cuff that is too large, deflating the cuff too quickly, and not placing the stethoscope over the brachial artery.
The nurse reviews data collected while completing a comprehensive assessment with a client. Which information should the nurse identify as being subjective data?
Correct response: Follows a Kosher diet Explanation: Subjective data includes information that is elicited and confirmed by the client. It cannot be measured. Objective data is that which can be measured or directly observed such as skin texture and temperature, heart rate, and hemoglobin level.
A student nurse is conducting her first client interview. The student suddenly draws a blank on what to ask the client next. What is a useful interview technique for the student to use at this point?
Correct response: Summarization Explanation: can be used at different points in the interview to structure the visit, especially at times of transition. This technique also allows the nurse to organize his or her clinical reasoning and to convey it to the client, making the relationship more collaborative. It is also a useful technique for learners when they draw a blank on what to ask the client next.
A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information?
Correct response: gastrointestinal Explanation: Because the client reports "chest pain" after eating, this information is most appropriate for the gastrointestinal system. This pain should not be documented under neurologic or musculoskeletal system. If the chest pain was not associated with eating, then it would be appropriate to document it under cardiovascular.
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. Chapter 5
Correct response: seeing things as only right or wrong Explanation: Developing expertise with making professional judgments comes with accumulation of both knowledge and experience. It is a process that develops over time and with practice. Seeing things as only right or wrong does not allow for seeing things as gray and may make you miss the bigger picture.
The nurse explains to the client that smoking has what effect on the body? Select all that apply.
Correct response: Hypertension Vasoconstriction Peripheral vascular disease Explanation: Smoking can cause vasoconstriction, hypertension and peripheral vascular disease, not vasodilation and hypotension. Chapter 8
When assessing a client's respirations, what is most important to include in the documentation?
Correct response: Presence of dyspnea Explanation: The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.
The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client? You Selected:
Correct response: Cyanotic left lower extremity Explanation: An acutely cold, cyanotic, or pulseless extremity should be reported to the healthcare provider immediately. A temperature below 39.0 Celsius, bright red bleeding, and a heart rate greater than 120 beats per minute or less than 50 beats per minute are not considered urgent findings. Reference:
The nurse is performing a health assessment on a new client. While taking the detailed history, the nurse knows to include what?
Correct response: Functional status Explanation: A detailed history includes data on all systems, psychosocial and mental health, and functional status. Data must be included information other than the client complaint. Family histories generally go back only to grandparents, not great-grandparents.
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
Correct response: 45 to 60 Explanation: The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.
A client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take?
Correct response: auscultate the heart rate for a full minute Explanation: If the radial pulse is irregular, the apical heart rate should be auscultated for a full minute. There is no need to palpate the carotid artery. Documenting that the pulse is 84 and irregular cannot be validated unless the heart rate is auscultated for a full minute. Palpating the radial pulse for a full minute will not necessarily provide the client's correct pulse rate since pauses are occurring.
The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?
Correct response: Rigid Explanation: The older client's artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy.
An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of
Correct response: decreased body metabolism. Explanation: Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.
The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should
Correct response: explain the role and purpose of the nurse. Explanation: When interacting with an anxious client provide the client with simple, organized information in a structured format and explain who you are, along with your role and purpose.
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
Correct response: "I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment.
A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?
Correct response: Anxiety. Explanation: The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.
Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?
Correct response: Ashen gray Explanation: The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.
A client has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the client's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?
Correct response: Collaborative problem Explanation: Collaborative problems are defined as "certain physiological complications that nurses monitor to detect their onset or changes in status; nurse manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complication of events.
42s Report this Question What should the nurse do prior to analyzing data collected on a client with Addison's disease? (Select all that apply) You Selected:
Correct response: Collect and organize assessment data. Validate data. Document data. Explanation: Before beginning to analyze data, make sure accurate performance of the steps of the assessment phase of the nursing process (collection and organization of assessment data, validation of data, and documentation of data) is complete. This information will have a profound effect on the conclusions that are reached in the analysis step of the nursing process.
A nurse is writing a care plan for a newly admitted client. When formulating the diagnostic statements in the care plan, what would the nurse use?
Correct response: Diagnostic reasoning Explanation: Nurses use diagnostic reasoning and critical thinking to formulate diagnostic statements. Rationale, ANA recommendations, and physical assessment skills are not part of formulating diagnostic statements. Rationale supports the nursing interventions of the nursing care plan. The American Nurses Association does not have recommendations regarding formulation of diagnostic statements for the care plan. Physical assessment skills are important in the assessment step of the nursing process, not the formulation of the diagnostic statements.
The nurse is performing vital signs during the routine assessment of an adult client who twisted his ankle during a mini-marathon. The client's pulse is 52 bpm. The nurse retakes the pulse; the finding is the same. The client tells the nurse that he has been training for 6 months for this mini-marathon. What should the nurse do in regard to this reading?
Correct response: Document the finding Explanation: A well-conditioned athlete may have a heart rate in the range of 50 to 60 bpm. It would not be appropriate to notify the physician immediately, give the client oxygen, or lower the head of the bed. Chapter 8
A few nursing students revealed to a faculty advisor that they were concerned about the effects of their program demands on their personal health practices. Follow-up with other students indicated that this was a common concern among the student group. Further assessment showed that the students expressed their belief in the importance of maintaining good health practices, but that most students had discontinued weekday efforts because of their focus on school-related stress and limited economic resources. Faculty members supported the concept of integrated health programs and were prepared to develop a program as a project. To assess the need for health promotion among the group of students, which of the following assessment methods would be most useful?
Correct response: Individual student interview and questionnaire Explanation: Key to any health promotion activity is a thorough assessment of the context and particular needs of the participants. This could be best determined by asking the students what would be more effective than a physical assessment, literature review, tour of the facility, or questionnaire of the faculty members.
A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?
Correct response: Provide simple and organized information. Explanation: The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. The nurse refers the dying client or client with spiritual concerns to a spiritual guide. The nurse should avoid expressing anxiety or becoming anxious like the client, as it would make the client more anxious.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?
Correct response: Reading is erroneously high. Explanation: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery. Chapter 8
Before delegating an assignment, the nurse should determine that which rights have been confirmed? (Select all that apply.)
Correct response: Right task Right circumstances Right person Right supervision Explanation: According to the American Nurses Association and National Council of State Boards of Nursing, the Five Rights of Delegation are: Right task; Right circumstances; Right person; Right directions and communication; Right supervision and evaluation. Reference: chapter 5
You are educating your client on taking blood pressure at home. What would be important to include in your client education?
Correct response: Routine recalibration of the device Explanation: Follow the guidelines listed, and advise your clients about how to choose the best cuff for home use. Urge them to have their home devices recalibrated routinely.
The nurse prepares to assess a client newly admitted to the care area. Which approach ensures that the data will guide the identification of appropriate interventions?
Correct response: Uses evidence-based techniques Explanation: To accomplish pertinent and comprehensive data collection the nurse uses appropriate evidence-based assessment techniques and instruments when collecting data. The ABC approach may not be necessary. Although measure vital signs can be delegated to unlicensed staff, this does not ensure that the data will guide the identification of appropriate interventions. Focusing on one system may be appropriate in specific situations however the admission assessment should include all body systems
The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is
Correct response: fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue. Explanation: The most useful format for an actual nursing diagnosis is: NANDA label (for problem) + related to (r/t) + etiology + as manifested by (AMB) + defining characteristics. Example: Fatigue r/t an increase in job demands and personal stress AMB client's statements of feeling exhausted all of the time and inability to perform usual work and home responsibilities (e.g., cooking, cleaning). Reference:
The nurse is preparing to assess an adult client in the clinic. The nurse observes that the client is wearing lightweight clothing that is worn and soiled, although the temperature is below freezing outside. The nurse anticipates that the client may be
Correct response: lacking adequate finances. Explanation: When you meet the client for the first time, observe any significant abnormalities in the client's skin color, dress, hygiene, posture and gait, physical development, body build, apparent age, and gender. If you observe abnormalities, you may need to perform an in-depth assessment of the body area that appears to be affected. Chapter 8
Which statements demonstrate the nurse's attempt to empower the client during an assessment interview? Select all that apply.
Correct response: - "Please tell me about what brought you here today." -"I'm not sure when the test will be scheduled, but I will find that out before you leave." -"Falling as you did must be a very frightening experience." Explanation: Empowering the client creates an environment that encourages the client to be more self-confident and in control of his or her own health care. Showing interest in the client, revealing limits of knowledge, and validating the client's emotional responses are all methods of sharing power with the client. Asking when the client's problem began and what factors contribute to increasing its severity are parts of assessing the characteristics of the problem.
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Correct response: Diagnosis Explanation: Diagnosis occurs when the data has been analyzed and a professional judgment occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan. Evaluation assesses whether the outcome criteria have been met.
The nurse is assessing a teenage girl newly admitted to the pediatric unit. The nurse knows that an efficient assessment framework that provides additional modesty for the client is what?
Correct response: Head to toe Explanation: The head-to-toe method is efficient and provides more modesty for clients. The body systems and functional assessment does not address the modesty issue in the question. The focused assessment is not appropriate for the newly admitted client.
The nurse is performing a follow-up assessment and interview of a 72-year-old woman with a history of congestive heart failure. The nurse asks the client, "Have you been experiencing any activity intolerance since I last saw you?" What would be a more appropriate way for the nurse to elicit this information?
Correct response: "Has this been having an effect on your ability to carry out your routines and get around your home?" Explanation: When initiating an interview, it is important to use language that is understandable and appropriate to the client. "Dyspnea," "SOB," and "activities of daily living" are potentially unclear to a client and reflect clinical language rather than clear communication.
The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?
Correct response: "Have you ever had a problem with mental or emotional illness?" Explanation: The nurse should begin by asking a non-threatening open-ended question such as "have you ever had a problem with mental or emotional illness?" Asking specifically about medication for depression assumes the client has a history of depression. Asking about talking with a psychiatrist or counseling may cause the client to become defensive. Chapter 2: Collecting Subjective Data:
A nurse is gathering biographic data from a new client who is visiting the office for the first time. Which of the following pieces of data would likely be included in the biographic section of the client's health history? Select all that apply.
Correct response: Lamar P. Thompson 1212 South Maple St., Sylvan, VA 23236 Caucasian Occupation: Brick mason Explanation: Biographic data usually include information that identifies the client, such as name, address, phone number, gender, and who provided the information—the client or significant others. The client's birth date, Social Security Number, medical record number, or similar identifying data may be included in the biographic data section. The client's culture, ethnicity, and subculture may begin to be determined by collecting data about date and place of birth; nationality or ethnicity; marital status; religious or spiritual practices; and primary and secondary languages spoken, written, and read. Gathering information about the client's educational level, occupation, and working status at this point in the health history assists the examiner to tailor questions to the client's level of understanding. The information regarding the client's mother, including the date and cause of death, would appear in the family health history section. The information on the head and neck would appear in the review of systems section.
A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition?
Correct response: Orthostatic hypotension Explanation: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.
A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement
Correct response: Stage 2 hypertension Explanation: The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.
The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? Chapter 5
Correct response: Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Explanation: Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.