Health Assessment Quiz #1
A nurse is measuring the respiratory rate of a client who has an irregular breathing pattern. For how many seconds should the nurse count the client's respirations?
60 seconds
What are the ABCDEs of melanoma?
A- asymmetry in shape B- border irregularity C- color (more than 1) D- diameter > 6 mm E- evolving, any change
__________ is the somewhat bluish color that is visible in toenails and toes.
Cyanosis
__________ is the explanation that the nurse brings to the symptoms.
Disease
________ is a nonspecific symptom with many causes including depression and hypothyroidism.
Fatigue
Stage 3 pressure ulcer
Full thickness skin loss; the ulcer has cratered into the dermis and adipose tissue may be visible.
Stage 4 pressure ulcer
Full thickness tissue loss, muscle or bone may be exposed
__________ is one of the most common complaints in clinical practice.
Headache
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
__________ refers to an abnormally low body temperature.
Hypothermia
The phase of the interviewing process that helps put the patient at ease and establish trust is called the ____________ phase.
Introduction
Stage 1 pressure ulcer
Non-blanchable redness, skin is intact
__________ is considered the fifth vital sign.
Pain
Stage 2 pressure ulcer
Partial thickness skin loss; skin is not intact, may present as a blister or open sore
What should you be concerned about when finding a pressure ulcer that looks like a deep bruise?
Possible deep tissue injury
__________ varies according to the patient's memory, trust, and mood.
Reliability
What is an important diagnostic consideration regarding pressure ulcers?
Removing necrotic tissue before staging; it can obscure the true depth of the wound
Regarding pressure ulcers, what clinical finding cannot be relied upon necessarily in assessing severity?
Skin color alterations; blanching is not always apparent with darker skin tones
__________ precautions apply to all patients in all settings.
Standard
What best describes a pressure ulcer that has dead tissue obscuring it like a scab?
Unstageable; the depth cannot be determined
What included in personal protective equipment? Select all that apply. a. Mouth, nose, eye protection b. Gloves c. Gown d. Cleaning processes e. Special linen
a, b, and c
Which interventions should a nurse use to collect the subjective data from a patient? Select all that apply. a. Listen carefully to the patient's description of problem b. Maintain a quiet environment when interviewing c. Provide help if the patient's unable to express themselves d. Maintain the client's privacy and ensure confidentiality
a, b, and d
At which location would a nurse palpate a client's submental lymph nodes? a. Behind the tip of the mandible b. Area behind the ears c. At the angle of the mandible d. Posterior base of the skull
a. Behind the tip of the mandible; the tonsillar nodes are located at the angle of the mandible
Universal precautions are primarily designed to protect the health care worker from what? a. Blood-borne pathogens b. Musculoskeletal injuries c. Respiratory diseases d. STDs
a. Blood-borne pathogens
Why should the nurse ask the patient if there have been any new moles or changes in existing moles? a. Changes in existing moles or the development of new moles may indicate melanoma b. Transition from pustules to moles can indicate psoriasis c. The appearance of new moles is a sign of vitamin D deficiency. d. Excessive eccrine sweat gland production can cause the emergence of a new mole.
a. Changes in existing moles or the development of new moles may indicate melanoma
During the examination of an adult patient, it is very important to a. Control your nonverbal communication. b. Share everything you see. c. Have a a chaperone in the room. d. Ask the patient to remain silent at all times.
a. Control your nonverbal communication.
A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating? a. Disinfect the stethoscope before touching the client b. Make sure the stethoscope is placed directly on the client's skin so that there is complete contact with the skin surface c. Put on a personal protection gown d. Disinfect the stethoscope after touching the client
a. Disinfect the stethoscope before touching the client
When assessing a client, the first skill used is inspection. What purpose does inspection serve? a. Gathering information b. Feeling abnormalities c. Observing modesty d. Identifying internal abnormalities
a. Gathering information
A nurse is preparing to physically examine a client. The nurse recognizes that it is best to begin the objective data collection with which procedure? a. Measure the client's vital signs, height, and weight. b. Allow the client to undress and put on a gown. c. Auscultate all necessary body systems to prevent disturbing any organs. d. Begin at the head and move in a systematic approach
a. Measure the client's vital signs, height, and weight.; It is important to begin the assessment with less intrusive procedures to build trust. The client does not need to undress for these.
To assess for skin turgor the nurse uses this technique a. Pinch the skin on the sternum and observe its return to the original shape. b. Palpate the skin on the sternum to determine its flexibility c. Palpate the skin around the umbilicus to assess for intactness. d. Pinch the skin on the abdomen and observe for color changes
a. Pinch the skin on the sternum and observe its return to the original shape.
When assessing a client's pulse, the nurse should be alert to which of the following characteristics? a. Rate, rhythm, amplitude and contour, and elasticity. b. Pain, temperature, amplitude and contour, and elasticity. c. Rate rhythm, temperature, rigidity, color, and elasticity. d. Tenderness, moistness, contour, elasticity, pressure.
a. Rate, rhythm, amplitude and contour, and elasticity.
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 client's words b. summarize the client's words c. paraphrase the client's words d. describe the client's concerns and health goals
a. quote the client's words
Shared practices and rituals used to express one's faith can be called a. religion b. denomination c. philosophy d. spirituality
a. religion
For which of the following diseases should you obtain family history? a. sickle-cell anemia b. influenza c. chickenpox d. measles
a. sickle-cell anemia (genetic component)
The nurse is going to take a blood pressure on a client who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse? a. take the blood pressure in the right arm b. take the blood pressure in the left thigh c. take the blood pressure in the left arm d. take the blood pressure in the right thigh
a. take the blood pressure in the right arm
A stage II pressure ulcer involves the epidermis, dermis, or both. a. true b. false
a. true
Acne vulgaris is the most common cutaneous disorder in the United States. a. true b. false
a. true
An oral temperature is not recommended when the patient is unconscious, restless, or unable to close their mouth. a. true b. false
a. true
Asking parents about their approach to discipline is a routine part of well-child care. a. true b. false
a. true
Communication that does not involve speech provides important clues to feelings and emotions. a. true b. false
a. true
Hirsutism occurs in some women with polycystic ovary syndrome. a. true b. false
a. true
Hyperthyroidism produces heat intolerance and weight loss. a. true b. false
a. true
Left-handed students are encouraged to adopt right-sided positioning. a. true b. false
a. true
Macrocephaly is an anomaly characterized by a large head in proportion to the body and an underdeveloped brain. a. true b. false
a. true
Night sweats occur in tuberculosis and malignancy. a. true b. false
a. true
The chief cause of hypothermia is exposure to cold. a. true b. false
a. true
The skin is the largest and heaviest organ of the body. a. true b. false
a. true
Hair, nails, and sebaceous and sweat glands are considered _________ of the skin.
appendages
The __________ gap is a silent interval that may be present between the systolic and the diastolic pressure.
auscultatory
To adhere to standard precautions, the nurse should remember to do which? Select all that apply. a. When a gown is required, reuse gown when reinitiating contact with the same client. b. Remove any personal protective equipment (PPE) before leaving client's room. c. Wear gloves for each client contact. d. Perform hand hygiene before and after direct client contact.
b and d; Gloves are only necessary when providing direct client care or cleaning. Gowns should never be reused.
A nurse is assessing a 49-year-old client who questions the nurse's need to know about sunburns he experienced as a child. How should the nurse best explain the rationale for this subjective assessment? a. "This is one of the assessments we use to determine whether your parents took good care of your skin when you were young." b. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life." c. "When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you're older." d. Repeated sunburns in childhood may explain the presence of some of your moles.
b. "Having bad sunburns when you're a child puts you at risk for skin cancer later in life."
Which of the following statements would you make in response to a male, teenage patient who is complaining that you are taking too long to complete your assessment? a. " I have to figure out what's wrong with you. " b. "I have to obtain enough information so that I can help you." c. " I have to decide what kind of treatment to give you." d. "I have to help you feel better."
b. "I have to obtain enough information so that I can help you."
The nurse is working with a patient on how to manage their hypertension. The patient states that they are taking recommended from within. How should the nurse best respond? a. "Medications should not be mixed. You will need to chose how you will be treated." b. "Let's talk with your physician to see how we can incorporate these into your plan of care." c. "Herbal remedies have not been tested. They should never be used." d. "Unless the FDA approved herbal treatment, we cannot be sure if the contents are safe."
b. "Let's talk with your physician to see how we can incorporate these into your plan of care."
What of the following would be considered an abnormal assessment finding? a. A patient's skin is warm to the touch. b. A patient's tongue is covered with a white-yellowish coating. c. A patient's hair is thick in texture and light brown in color. d. A patient's nails display a 160 degree shape/curvature
b. A patient's tongue is covered with a white-yellowish coating.
The nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment finding? a. Administer a dose of nitroglycerin. b. Auscultate the client's apical pulse. c. Reposition the client in a side-lying position. d. Palpate the client's ulnar pulse.
b. Auscultate the client's apical pulse.
Assessing a patient's skin turgor is done to assess which clinical finding? a. Edema b. Dehydration c. Vitiligo d. Scleroderma
b. Dehydration
When a nurse concentrates on just gathering information about the patient's problem, he or she is completing a a. Comprehensive health assessment b. Focused assessment c. Follow-up history d. Emergency history
b. Focused assessment
A client presents to the health care clinic with reports of new onset of generalized hair loss for the past two months. The client denies the use of any new shampoos, or other hair care products; no new medications. The nurse should ask the client questions related to the onset of which disease process? a. Diabetes mellitus b. Hypothyroidism c. Crohn's disease d. Liver disease
b. Hypothyroidism
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? a. Migraine b. Meningitis c. Measles d. Cervical fracture
b. Meningitis
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? a. Nephrotic syndrome b. Parkinson's disease c. Cushing's syndrome d. Myxedema
b. Parkinson's disease
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? a. Reading is erroneously low. b. Reading is erroneously high. c. Pressure on the cuff would be painful. d. It will be difficult to pump up the bladder
b. Reading is erroneously high.
A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision? a. Ophthalmoscope b. Snellen chart c. Rosenbaum pocket screener d. Cover card
b. Snellen chart
The nurse is caring for a newly admitted adult patient. When performing the general survey on this patient, the nurse knows that accurate measurements provide critical information about what? a. Safety b. State of health c. Growth patterns d. Past surgeries
b. State of health
The nurse is conducting a general survey of a client new to the clinic. In what part of the survey would the nurse assess the hair distribution on the client's body? a. When assessing the range of motion b. When assessing the skin c. When assessing the posture d. When assessing the body structure and development
b. When assessing the skin
One of the body's normal physiologic responses to pain is a. pulse rate below 50 beats/minute. b. diaphoresis. c. hypotension. d. hypoglycemia.
b. diaphoresis.
A false high blood pressure reading can be obtained when the blood pressure cuff is too large (wide) on a pediatric patient. a. true b. false
b. false
Bacterial decompensation of eccrine sweat is responsible for adult body odor. a. true b. false
b. false
Jaundice occurs in hypothyroidism. a. true b. false
b. false
Pain related to tissue damage is referred to as neuropathic pain. a. true b. false
b. false
Tender lymph nodes suggest malignancy. a. true b. false
b. false
Fine hair accompanies hypothyroidism. a. true b. false
b. false; hypothyroidism is associated with course hair
The nurse assesses a bed-bound older adult client in the client's home. While assessing the client's buttocks, the nurse observes that an area of the skin is broken. The wound is shallow and dry, and there is no bruising. The nurse should document the client's pressure ulcer as a. stage I b. stage II c. stage III d. stage IV
b. stage II
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to: a. cough deeply. b. swallow a small sip of water. c. inhale deeply. d. flex the neck to each side.
b. swallow a small sip of water.
The nurse has finished the physical examination. What should the nurse do immediately after finishing? (Mark all that apply.) a. Identify needed laboratory tests b. Share findings with physician c. Give your general impressions d. Tell the patient what to expect next
c and d
An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern? a. "These areas need to be cleansed daily and covered with a dry gauze bandage." b. "I will report these to the health care provider so that medication can be prescribed." c. "These are considered a normal age-related change in the skin." d. "It means you have skin cancer and need to have them removed."
c. "These are considered a normal age-related change in the skin."
A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes? a. 4 b. 1 c. 2 d. 3
c. 2
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The client describes the pain as sharp, stabbing, and at times very intense. This is a description of which type of pain? a. Cutaneous b. Chronic c. Acute d. Phantom
c. Acute
A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm, is described as a: a. Linear lesion b. Clustered lesion c. Annular lesion d. Gyrate
c. Annular lesion
A new nurse on the long-term care unit is learning how to assess a client's risk for skin breakdown. What would be the most likely instrument this nurse would use? a. Head-to-toe assessment b. Norton scale c. Braden scale d. Newton scale
c. Braden scale
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? a. Congruency, induration, size, turgor b. Delineation, integrity, shape, color c. Consistency, delineation, mobility, tenderness d. Configuration, discreteness, temperature, color
c. Consistency, delineation, mobility, tenderness
What is the most common type of hyperthyroidism? a. Moon face b. Thyroid cancer c. Graves' disease d. Cushing's syndrome
c. Graves' disease
A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? a. Cluster b. Tension c. Migraine d. Analgesic rebound
c. Migraine
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? a. Temporal arteritis b. Tension headache c. Migraine headache d. Bell's palsy
c. Migraine headache
The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first? a. Give PRN blood pressure medications b. Document the findings c. Retake the blood pressure d. Notify the physician immediately
c. Retake the blood pressure
An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse? a. The client has asthma b. The client has COPD c. The client has chronic hypoxia d. The client has melanoma
c. The client has chronic hypoxia
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? a. Its relation to the cricoid cartilage b. The curve on its inferior edge c. The notch on its superior edge d. Its position just below the mandible
c. The notch on its superior edge
Before calling a patient back to an examination room, the nurse quickly observes the patient in the waiting room from head to toe. Which of the following is the best rationale for this action? a. To check the patient for skin lesions the patient may not be aware of. b. To overhear the patient's conversation with a family member. c. To see the patient's before the patient assumes a social face or behavior. d. To determine whether the nurse recognizes the patient from a previous visit.
c. To see the patient's before the patient assumes a social face or behavior.
A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? a. When palpating the texture of the client's skin b. When palpating the client's hair c. When palpating lesions on the client's skin d. When palpating the client's nail beds for texture and capillary refill
c. When palpating lesions on the client's skin
A nurse cares for a client with a stage II pressure ulcer on the right hip. The nurse anticipates finding what type of appearance to the skin over this area? a. unbroken but red in color b. ulceration resembling a crater c. broken with the presence of a blister d. exposure of subq tissue and muscle
c. broken with the presence of a blister
During a comprehensive assessment, the primary technique used by the nurse throughout the examination is a. percussion. b. auscultation. c. inspection. d. palpation.
c. inspection.
While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting a. an immune disorder resulting in low platelet count. b. hypothermia that occurs before an infectious process. c. normal changes that occur with the aging process. d. a metabolic disorder resulting in circulatory changes.
c. normal changes that occur with the aging process.
The increased adrenal ___________ production of Cushing syndrome produces a round or "moon" face with red cheeks.
cortisol
When can general inspection begin? a. During the examiner's preparation to meet the patient. b. When the patient is completely exposed. c. After height and weight have been taken d. As soon as the examiner first sees the patient.
d. As soon as the examiner first sees the patient.
The nurse is caring for a 4-year old client with abdominal pain. The most appropriate pain assessment tool would be the: a. Visual Analog Scale b. Numeric Pain Intensity Scale c. Combined Thermometer Scale d. FACES Pain Scale
d. FACES Pain Scale
A patient complains of aching all over his body. The patient's health record indicates that he is otherwise healthy, with his baseline vital signs all well within normal limits. The nurse is assessing him for pain. Which of the following objective findings would most tend to indicate pain? a. Muscles appear relaxed b. Respiratory rate of 16 breaths per minute c. Blood pressure of 114/65 d. Heart rate of 110 beats per minute
d. Heart rate of 110 beats per minute
A nurse needs to obtain a pulse on a client. Which physical assessment technique should the nurse use? a. Bimanual palpation b. Moderate palpation c. Deep palpation d. Light palpation
d. Light palpation; Moderate and bimanual palpations are used to note the size, consistency and mobility of structures. Deep palpation is used to feel deep organs or structures covered by muscles.
Which of the following is a component of the general survey? a. Patient's breath sounds b. Patient's oral temperature c. Patient's blood pressure d. Patient's state of hygiene
d. Patient's state of hygiene
A client tells the clinic nurse that his feet and lower legs turn a blue color. On assessment, the nurse notes that the client's oxygenation level is within normal levels. The nurse knows that the blue color the client described is caused by what? a. Reynaud disease b. Central cyanosis c. Neurofibromatosis d. Peripheral cyanosis
d. Peripheral cyanosis
It would be most important for the nurse to include the fingernails in a basic assessment for the client with which type of condition? a. Neurological b. Musculoskeletal c. Integumentary d. Respiratory
d. Respiratory; changes in the color of the nails indicate a problem with oxygen
A nurse inspects a client's skin and notices several flat, brown color change areas on the forearms. What is the proper term for documentation of this finding by the nurse? a. nodule b. papule c. vesicle d. macule
d. macule
When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition? a. Dry skin b. Easy bruising c. Fungal infections d. sun exposure
d. sun exposure
The increased __________ hormone of acromegaly produces enlargement of both bone and soft tissues.
growth
A localized systolic or continuous bruit may be heard with __________.
hyperthyroidism
Nonpitting edema reflects a condition in which serum proteins have accumulated in the __________ space with the water and coagulated.
interstitial
Melanoma arises from the pigment-producing __________.
melanocytes
The physical examination is a process to obtain __________ data from the patient.
objective
The __________ enables visibility of the eardrum and the external ear canal.
otoscope
Fever or __________ refers to an elevated body temperature.
pyrexia
A _________ is a thin flake of dead exfoliated epidermis.
scale
Occipital nodes are located at the base of the __________.
skull
__________ indicates how closely a given observation agrees with the best possible measure of reality.
validity
A nurse is calculating the BMI for a client who weights 150 lbs and is 5 ft 4 in. The nurse is using the BMI formula for funds and inches, BMI = weight (lb)/height (in)^2 x 703. What is the client's BMI?
25.7
How many generations should you collect medical history about?
3 (grandparents, parents, and siblings)
Therapeutic communication involves which of the following? (select all that apply) a. touch b. open-ended questions c. sharing your own personal experiences with the client d. if the client speaks another language than the nurse, finding someone in the facility that speaks their language
a and b
During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply. a. To help identify those diseases for which the client may be at risk b. To provide counseling and health teaching in high-risk areas c. To identify genetic family trends for which the client is at risk d. To elicit negative family history e. To help the client feel at ease and not worry about being sick
a, b and c
Which of the following actions by the nurse are examples of infection control? (select all that apply) a. hand washing with soap and water for 15 seconds b. using an alcohol-based rub when hands are not visibly soiled c. using an alcohol pad to wipe the diaphragm of the stethoscope between clients d. wearing artificial nails e. wearing sterile gloves when opening gauze dressing packages
a, b, an c
As a nurse assessing the endocrine and hematologic systems, it is important to ask the client about what? Select all that apply. a. excessive bruising b. swelling of the lower extremities c. changes in body hair d. explained weight loss or gain e. intolerance to cold
a, c, and e
Which of the following factors are included in health literacy? (select all that apply) a. basic reading skills b. basic writing skills c. competency using numbers d. understanding how to use a library e. ability to follow verbal instructions f. ability to use a computer
a, c, and e
Place the steps in the correct order to record information when using the GTPAL format. a. number of pregnancies b. current number of living children c. number of term deliveries d. number of preterm deliveries e. number of voluntary or involuntary abortions
a, c, d, e, b GTPAL stands for gravid, term births, preterm births, abortions and living children.
Match the ethical principle to the appropriate definition: a. fidelity b. nonmaleficence c. beneficence d. justice e. autonomy 1. allowing a client to make informed decisions 2. promoting best interests of a client 3. keeping a promise to a client 4. avoiding harm to all clients 5. fair treatment of all clients
a-3 b-4 c-2 d-5 e-1
A nurse is completing a comprehensive assessment of a client who has been referred to the clinic. Which of the following would be most appropriate for the nurse to ask when beginning to assess the client's spirituality? a. "What gives you hope or peace?" b. "Do you believe in God?" c. "What religion are you?" d. "Would you like to speak to a chaplain?
a. "What gives you hope or peace?"
A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what? a. Arthritic changes of the cervical spine b. Bacterial thyroiditis c. Cranial damage d. Muscle tension
a. Arthritic changes of the cervical spine
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching? a. Encourage the use of safety equipment b. Encourage proper nutrition to promote healing c. Encourage the client to take a safety course d. Teach proper posture, bending, and lifting
a. Encourage the use of safety equipment
The nurse recognizes that an example of subjective data would include: a. a pain rating of 7 b. 100 cc of emesis c. scratching d. 2-inch scar right lower abdomen
a. a pain rating of 7
Select the action the PN participates in with the nursing process. a. assist the RN with collecting data from the client b. perform a comprehensive assessment on the client c. develop the client care plan using your best judgement d. analyze the objective data from the client
a. assist the RN with collecting data from the client
A client comes to the emergency department wanting to be examined for the symptom of chest pain. While listening to the client describe his symptom in more detail, the nurse says "Go on," then later "Mm-hmmm." This is an example of which of the following skilled interviewing techniques? a. continuers b. echoing c. nonverbal communication d. empathetic response
a. continuers
While gathering data for the family history portion of the health history, what would you ask about? a. coronary artery disease b. low bone density c. liver disease d. injuries
a. coronary artery disease
Diagnosis has a nursing focus and is based on real or potential health problems or human response. a. true b. false
a. true
Good observations or tests have a sensitivity of more than 90% and help rule out disease because there are few false negatives. a. true b. false
a. true
Objective data is information gathered from the physical assessment and the laboratory tests. a. true b. false
a. true
Reliability is also known as precision. a. true b. false
a. true
The Health Insurance Portability and Accountability Act (HIPAA) sets standards for disclosure for both institutions and providers when sharing patient information. a. true b. false
a. true
The cardinal techniques of examination include inspection, palpation, percussion, and auscultation. a. true b. false
a. true
The nurse should make every attempt to quote the patient's own words when documenting in the patient's record. a. true b. false
a. true
The preferred method of hand decontamination is with an alcohol-based hand rub. a. true b. false
a. true
Two or more affirmative answers to the CAGE questionnaire suggest alcohol misuse. a. true b. false
a. true
Universal precautions are a set of guidelines designed to prevent transmission of HIV. a. true b. false
a. true
When abuse is suspected, it is important to spend part of the encounter alone with the patient. a. true b. false
a. true
When interacting with a person with impaired vision, it is important to use words rather than postures or gestures. a. true b. false
a. true
The cardinal techniques of examination will always be used in the same order with all systems with the exception of the __________.
abdomen
Underlying all the techniques of skilled interviewing is the habit of __________ __________.
active listening
Which of the following are research-validated reasons to conduct a health history using an interpreter? (Select all that apply) a. to increase the self-esteem of the client b. to increase the accuracy of the communication c. to decrease the cost of care d. to increase the client's satisfaction with care
b and d
Which of the following are tools used with auscultation? (select all that apply) a. dorsal sides of hands b. stethoscope c. penlight d. doppler e. tape measure
b and d
A nurse is assessing a client's behavior during the initial survey. Which of the following does the nurse include in this assessment? (select all that apply) a. client's level of education b. client's clothing c. client's speech d. client's occupation e. client's hobbies
b and c
A nurse is taking a rectal temperature on a client. Which of the following actions does the nurse perform? (select all that apply) a. selects the blue probe b. lubricates the probe cover c. asks the client to lie in prone position d. inserts the probe into the rectum 1 to 1.5 inches e. cleans the probe with warm soapy water after use
b and d
Place each step of the nursing process in the correct order. a. analysis b. assessment c. implementation d. planning e. evaluation
b, a, d, c, e
In the closing phase of the interview process, the nurse analyzes the data collected for what priority reason? a. Establish a baseline from which to start interviewing the family b. Identifying the primary problems or patterns of concern c. Communicate information to the physician d. Communicate information to the physician
b. Identifying the primary problems or patterns of concern
A nurse is collecting data during a review of systems and asks the client how many pillow are required to sleep comfortably at night. The questions involves assessment of which of the following systems? a. musculoskeletal b. cardiovascular c. neurological d. endocrine
b. cardiovascular (can provide information regarding cardiac conditions such as heart failure)
Important points are summarized during the working phase of the interview process. a. true b. false
b. false
Questioning during the interview process should proceed from specific to general. a. true b. false
b. false
The first step to conducting a physical examination is to prepare the environment. a. true b. false
b. false
The focal point of the diagnosis phase is based on the nurse's concerns, issues, and needs. a. true b. false
b. false
When interviewing a client with a language barrier, it is best to use a family member to help interpret so the client has a level of comfort with the process. a. true b. false
b. false
When obtaining a mental health history, ask closed-ended questions initially. a. true b. false
b. false
A client comes to the community clinic seeking help for acute low back pain. Which type of assessment should the nurse complete for this client? a. follow-up b. focused c. emergency d. comprehensive
b. focused
Which of the following is the first action during the physical assessment of the client? a. asking the client about any allergies b. inspecting the client c. palpating any areas of tenderness the client identifies d. auscultating for breath sounds, bowel sounds and heart sounds
b. inspecting the client
A client says that food is not important and meals are not enjoyable. Where should the nurse document this information? a. past medical history b. nutrition health pattern c. history of present illness d. GI review of systems
b. nutrition health pattern
Which aspect of life is assessed using the FICA approach? a. sexual history b. spirituality c. activities of daily living d. sleep patterns
b. spirituality (FICA stands for faith, influence, community, address)
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? a. to summarize the conversation b. to clarify c. to restate what the client has said d. to promote objectivity
b. to clarify
Which of the following is a purpose of obtaining a health history? a. to document objective data b. to establish a baseline of the client's health status c. to provide documentation about the nurse's opinion of the client's health status d. to have an unstructured conversation with the client
b. to establish a baseline of the client's health status
The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? a. valid data b. too many or too few data c. reliable data d. cues available to support the diagnosis
b. too many or too few data; other pitfalls would be invalid data, unreliable data, or not enough cues to support diagnosis
A nurse is measuring the oxygen saturation of a client who has cyanosis of the extremities. Using a pulse oximeter, where does the nurse place the sensor probe? (select all that apply) a. forefinger b. thumb c. forehead d. bridge of nose e. earlobe f. great toe
c, d, and e
Place the steps in the correct order to conduct a review of systems. a. nose b. neck c. head d. ears e. mouth f. eyes
c, f, d, a, e, b (head-to-toe approach)
Which of the following is a closed-ended question? a. "Can you tell me about the work that you do" b. "How are you managing your stress" c. "What time do you usually get up in the morning" d. "Describe the symptoms you're having"
c. "What time do you usually get up in the morning"
Upon entering an exam room, the client states, "Well! I was getting ready to leave. My schedule is very busy and I don't have time to waste waiting until you have the time to see me!" Which response by the nurse would be most appropriate? a. "Would you like to report your complaints to someone with power?" b. "Our schedule is very busy also. We got to you as soon as we could." c. "You're certainly justified in being upset, but I am ready to begin your exam now." d. "No one is forcing you to be here, and you are free to leave at any time."
c. "You're certainly justified in being upset, but I am ready to begin your exam now."; It is important to acknowledge the client's feelings.
A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover? a. Respect for nature and use of masks and sand paintings b. Prayers to God and saints for spiritual reparations for sins c. A focus on maintaining balance between yin and yang d. Use of herbs, roots, talismans, and amulets
c. A focus on maintaining balance between yin and yang
The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step? a. Opinions and comments are not relevant in making accurate interpretations of data. b. The nurse must be an expert in her field in order to interpret data accurately. c. Diagnostic reasoning skills are required to interpret data accurately. d. Final opinions or judgements must be made rapidly.
c. Diagnostic reasoning skills are required to interpret data accurately.
The nurse is setting an outcome with the client experiencing social isolation. Which goal would be appropriate? a. The client will express feelings of connectedness with God. b. The client will attend a church event every week. c. The client will initiate interaction with others. d. The client will express meaning and purpose in life.
c. The client will initiate interaction with others.
A nurse assesses a client with regard to nutritional habits, use of substances, education, and work and stress levels. The nurse recognizes this as what type of information? a. personal health history b. history of present health concern c. lifestyle and health practices profile d. family health history
c. lifestyle and health practices profile
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information? a. chief complaint b. history of present illness c. personal health history d. review of systems
c. personal health history
The client is being interviewed upon arrival in the Emergency Department. When collecting subjective data from the client, the nurse is obtaining what other type of data from the client? a. secondary b. objective c. primary d. tertiary
c. primary; secondary data comes from charts or the client's family
The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes the main points of what the client has just said. What type of communication is the nurse using? a. elaboration b. silence c. reflection d. restatement
c. reflection
A nurse is reviewing the vital signs for a client who was admitted with shortness of breath. The nurse notes the client's respiratory rate is 24/min. The nurse should use which of the following terms when documenting this finding? a. hypoventilation b. apnea c. tachypnea d. cheyne-strokes respirations e. labored
c. tachypnea
A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client? a. mild confusion b. presence of lethargy c. unable to feel his leg d. bleeding profusely from the wound
c. unable to feel his leg
Which of the following techniques is used with palpation? a. palpate the tender areas before the other areas b. use short, quick taps with palpation c. use the palmar side of the hands or the pads of the fingers d. use the stethoscope during palpation
c. use the palmar side of the hands or the pads of the fingers
A nurse is assessing a client who is admitted with abdominal pain. The client reports that the pain is "in the stomach and is a crampy, dull ache." Which type of pain should the nurse identify this client is experiencing? a. neuropathic b. somatic c. visceral d. referred
c. visceral (pain related to large internal organs)
The __________ __________ is the symptom(s) or concern(s) causing the patient to seek care.
chief complaint
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize? a. making clinical inferences b. identifying potential health problems c. determining the client's strengths d. establishing a trusting relationship
d. establishing a trusting relationship
A nurse is performing an initial survey on a client and calculates a BMI of 31 kg/m^2. The nurse classifies this client in which of the following weight ranges? a. underweight b. normal weight c. overweight d. obese
d. obese (BMI > 30)
Place the steps for communication with members of the health care team in the correct order. a. provide information regarding the background situation b. provide information regarding the current situation c. provide suggestions that may be helpful to the situation d. identify the member by name and title e. repeat the orders back that are given to you by the provider f. give the most recent set of vital signs to the team member
d, b, a, f, c, e (remember ISBARR)
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? a. "Do you ever find yourself SOB when you're carrying out your daily routines?" b. "Has your heart failure been causing you any dyspnea lately?" c. "Has your congestive heart failure been affecting your activities of daily living recently?" d. "Has this been having an effect on your ability to carry out your routines and get around your home?"
d. "Has this been having an effect on your ability to carry out your routines and get around your home?" Using language such as "SOB, dyspnea, and activities of daily living" are potentially unclear as they reflect clinical language
A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response? a. "Tell the client that insurance will not pay for observation." b. "Call the healthcare provider to change the admitting diagnosis." c. "Refuse to admit the client without a proper medical diagnosis." d. "It's acceptable for a client to be admitted for observation."
d. "It's acceptable for a client to be admitted for observation."
A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as judgmental? a. "How would you describe your feelings about getting older?" b. "How often do your adult children typically visit you?" c. "Your husband's death must have been very difficult for you." d. "You must quit smoking because it affects others, not only you."
d. "You must quit smoking because it affects others, not only you."
The nurse is preparing a client with pancreatic cancer for surgery, during which the client is going to have a Whipple procedure. The client says she is Catholic but never really went to church or prayed much. the client is crying and very frightened. What is the most appropriate action the nurse can do for the client before she goes to surgery? a. Leave the client so she can reflect on her life b. Consult the physician for a sedative medication c. Give the client something for anxiety d. Ask the client if she would like to see a priest
d. Ask the client if she would like to see a priest
A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is: a. validation b. evaluation c. implementation d. analyze the data
d. analyze the data
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information? a. onset b. location c. duration d. characteristic
d. characteristic
A nurse is performing an initial assessment on a client's skin. Which of the following observations will require further assessment of the client's circulation? a. skin is warm to touch b. skin is dry c. freckles are noted on face d. cyanosis is noted on fingers
d. cyanosis is noted on fingers
Which of the following is considered an unexpected finding for a 40-year-old client's pulse? a. brisk pulse strength of +2 b. equal time space between each pulsation c. pulse rate of 95/min d. stronger radial pulse on left compared to right
d. stronger radial pulse on left compared to right (pulse should be equal bilateral)
The disk at the end of the stethoscope is the bell and ________.
diaphragm
_________ is a continuing process and determines if the goals/outcomes have been attained.
evaluation
A follow-up history is a form of ___________ assessment.
focused
What does ISBARR, the acronym for effective communication between members of the health team, stand for?
identify, situation, background, assessment, recommendation, read back orders
__________ can be defined as how the patient experiences all aspects of the disease.
illness
The single most important rule is to be __________.
nonjudgemental
The _________ __________ is a broad systematic framework that supplies a methodical base applicable to the practice of nursing.
nursing process
Interviewing patients requires __________.
planning
__________ is charting the best course to achieve the patient's optimal wellness and comfort.
planning
Cholesterol testing and mammograms are examples of _________ tests.
screening
Symptoms are also known as __________ data.
subjective