Health assessment

What are some critical thinking criteria for clinical judgments?

- keep an open mind - reflect on thoughts - use past clinical experiences - be aware of interactions and influences of others - be aware of the influences of the environment

The nurse develops a plan of care for a newly admitted client. The nurse revises the plan of care when which of the following occurs

- new symptoms develop - client refuses treatment - symptoms worsen with interventions

What are the 3 assessment forms for documentation?

1. Initial assessment 2. Frequent or ongoing 3. Focused or speciality

A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client

Adequate lighting

The nurse is caring for a client exhibiting slurred speech after suffering from a cerebrovascular accident. The nurse is unable to completely understand the client. What is the nurse's best action?

Ask the client to repeat the statement or question.

Markedly dismissed emotional expression

Blunted

What does COLDSPA spell out?

Character Onset Location Duration Severity Pattern Associated factors

Head and Neck Assessment

Check for size, shape, symmetry, lumps, positions, and masses on the neck and head area

What intervention would be most helpful when conducting an interview with a client who has stated, "I'm a little hard of hearing"?

Closing the door may help to limit background noise

Mildly diminished range of intensity of emotional withdrawal

Constricted

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

Deep palpating

Normal, steady

Euthymic

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

Evaluation

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

Severely reduced emotional expressiveness

Flat

Learning about the effects of the illness does what for the nurse and the client

Gives them the opportunity to create a complete and congruent picture of the problem

Steps to Make a Clinical Judgment From Assessment Data

Identify —> Cluster —> Draw —> identify —> validate —> document

Emotional response that are not keeping with the situation or are incompatible with expressed thoughts or wishes

Inappropriate

Which of the following techniques are used in a physical assessment? Select all that apply. Inspection Palpation Auscultation Questioning Subjectivity

Inspection Palpation Auscultation

Irregular and severe mood swings

Labile

tonsillar nodes

Lymph nodes at the back of the jaw (angle of the mandible)

narrative description is an _________-ended question

Open

A client admitted to the hospital with status asthmaticus suddenly develops the following signs and symptoms: increased heart rate (105 bpm), increased respiratory rate (24/min), O2 saturation 90% on 100% nonrebreather mask, and sudden absence of wheezing. What action should the nurse take?

Perform an emergency assessment

The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?

Sensory abilities

What are the types of headaches?

Sinus Cluster Tension Migraine Tumor related

A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment?

To determine any changes from the baseline data

True/False: Tell me about your pain" is an example of an open-ended question.

True

How do you validate when talking to a patient?

Validate what the receiver has heard by questioning or asking the receiver to summarize or read back what you have written down

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

acromegaly

abnormal enlargement of the extremities

A client 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 client

airway

Posterior cervical lymph nodes

behind the sternomastoid muscle

This type of assessment includes a health history and physical assessment

comprehensive

deep cervical lymph nodes

deep under the sternomastoid muscle

Data Analysis

diagnostic or clinical reasoning phase

occipital nodes

felt at the base of the skull

submandibular lymph nodes

gland located underneath the neck

preauricular nodes

in front of the ear

postauricular nodes

lymph nodes behind the ear

submental lymph nodes

lymph nodes beneath the chin

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

superficial cervical lymph nodes

overlying the sternomastoid muscle

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?

Assess the nasogastric tube for proper functioning

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time?

Ongoing

When should the nurse perform hand hygiene? Select all that apply. When hands are visibly soiled After removing gloves After providing mouth care After reconciling the client's medications After taking the blood pressure of a client with intact skin

When hands are visibly soiled After removing gloves After providing mouth care After taking the blood pressure of a client with intact skin

You should use the bell of the stethoscope when auscultating what type of sounds?

low frequency sounds

An older adult client had hip replacement surgery 2 days ago. The nurse enters the client's room and encourages the client to use the incentive spirometer ten times every hour. What is this action an example of?

nursing intervention

When the nurse places one hand flat on the body surface and uses the fist of the other hand to strike the back of the hand flat on the body surface, the nurse is using

blunt percussion

supraclavicular nodes

located just above and behind the clavicle, at the sternomastoid muscle

While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is

"How do you manage your stress?"

Nonverbal communication is a very important aspect in nurse-client relationships. What can the nurse do to help gain trust in clients? Select all that apply A. Make sure that dress and appearance are professional B. Do not use facial expressions such as rolling the eyes or looking bored or disgusted C. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally D. Laugh a lot, which puts the client at ease E. Do not look the client in the eye

A. Make sure that dress and appearance are professional B. Do not use facial expressions such as rolling the eyes or looking bored or disgusted C. Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally

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

The nurse would use what part of the hand when assessing temperature during palpation

dorsal surface

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?

to clarify