Introduction to Health Assessment Test
A nurse in the emergency department has received report on a child who has a laceration to the right calf. Which of the following steps of the nursing process should the nurse perform first?
Assessment
A nurse has performed pre-operative care on a client and is transferring the client to the surgical holding area when the client states, "I have changed my mind; I do not want to have this surgery." Which of the following ethical principles is the client using?
Autonomy
A nurse is preparing to perform a physical examination on a client. Which of the following interventions should the nurse perform to ensure client privacy?
Do not expose any more of the client's body than required at a time.
A nurse is preparing to irrigate a client's leg wound. Which of the following pieces of personal protective equipment should the nurse wear while performing this task? (Select all that apply.)
Goggles Gown Gloves
A nurse is assisting a client with ambulating around the nurses' station. Which of the following steps of the nursing process is the nurse performing?
Implementation
A nurse has just received report on a newly admitted client who reports abdominal tenderness in the lower right quadrant. Which of the following is the first step the nurse should perform during the abdominal assessment?
Inspection
A nurse is performing a pre-admission assessment on a client and employs the use of nonverbal and verbal communication. Which of the following actions demonstrates the use of a nonverbal communication technique by the nurse?
Maintain a fair distance between self and client.
A nurse is performing a physical assessment of a client who has reported abdominal tenderness. Which of the following actions should the nurse take?
Palpate the tender areas of the abdomen last.
A nurse is preparing to assess a newly admitted client. Which of the following pieces of equipment does the nurse need to begin the inspection part of the physical examination? (Select all that apply.)
Penlight Tape measure Tongue depressor
A nurse is caring for a client who is crying and appears upset after receiving news that they will need to have a surgical procedure. Which of the following actions should the nurse take to display empathy towards the client?
Put themselves in the client's situation to understand the client's anxiety.
A nurse is completing documentation in a client's medical record. Which of the following actions should the nurse take?
Record the client's most recent assessment results.
A nurse has just received report on a newly admitted client who speaks a different language than the nurse. Which of the following actions should the nurse take to assist with effective communication with the client during the initial assessment process?
Request assistance from an interpreter during the assessment.
A nurse is preparing to perform palpation on a client during a physical assessment. Which of the following findings is the nurse assessing during palpation?
Skin temperature, moisture, and abnormalities
A nurse is performing auscultation during a client's physical assessment. Which of the following tools should the nurse use for this part of the assessment?
Stethoscope
A nurse is performing an assessment on a client. The client states, "I have a dry cough every morning when I wake up." Which of the following is the type of data the nurse is collecting?
Subjective