Health Assessment

Which of the following objective data does the nurse need to investigate further?

Blood pressure reading of 167/102

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess apical pulse for a full minute

Which of the following terms is most important to include in the health history of an 88-year-old female patient?

Daily activities

Choose the correct order to perform the assessment skills

Inspection, Palpation, Percussion, Auscultation

A client presents to the clinic with a complaint of sinus pressure for several days. During the review of systems, the nurse questions the client about his neck and he denies any pain, tenderness, swelling, limits to movement, or history of a goiter. The nurse documents this as:

Neck-denies pain, limited ROM, lumps or swelling, enlarged or tender nodes, and goiter

During an interview, the nurse states, "You came today because you are having pain in your leg" Tell me more about this pain. Which verbal skill is being used by this nurse?

Open-ended question

The nurse documents which of the following as an abnormal finding from the general survey?

The client has a a flat affect and answers questions with as few words as possible The clients dress is clean, fits the body, and is appropriate to the weather and occasion. Client walks smoothly with a symmetric arm swing The exposed skin is even in tone and intact

A nurse identified all of these findings when assessing a client. Which one is an example of subjective data?

The client reports having frequent episodes of anxiety The client does not make eye contact The client is guarding her abdomen

Select all the reasons that pain-rating scales are used in most facilities today.

They provide a baseline intensity evaluation of the pain. They allow nurses and providers to track changes in pain They facilitate ease of documentation

Which of the following are abnormal findings of the general survey?

Unkempt grooming Odors of the body or breath The use of medical equipment