Lab Manual Questions-Health Assessment

a 90 year old pt is crying and states to the nurse "ive had such a wasted life" the most appropriate response from the nurse would be

"you are feeling like you have has a wasted life..?"

during a comprehensive assessment of an adult client the nurse can best hear high pitched sounds by using a stethoscope with a

1 and 1/2 inch diaphragm

developmental tasks correspond to biophysical maturity and societal expectations

Erikson's theory

the result of a nursing assessment is the

Formulation of nursing diagnoses

id, ego, and superego

Freud's theory

viewed justice or fairness as the goal of moral judgement

Kohlberg's theory

which of the following statements best describes Sigmund Freud's view of human behavior

a person is generally not aware of the underlying reasons for his behavior

creation of a new schema or the modification of an old one

accommodation

the nurse is beginning a health history interview with an adult client who expresses anger at the nurse the best approach for dealing with an angry client is for the nurse to

allow the client to ventilate his or her feelings

before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the purpose of the assessment is to

arrive at conclusions about the client's health

the nurse is interviewing a 78 year old client for the first time the nurse should first

assess the client's hearing activity

adaptive process whereby information is incorporated into an already existing schema

assimilation

the nurse is preparing to meet a client in the clinic for the first time. after reviewing the client's record, the nurse should

avoid premature judgments about the client

during a client interview the nurse uses nonverbal expressions appropriately when the nurse

avoids excessive eye contact with the client

Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)

bell of stethoscope

an adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infections. to detect tenderness over the client's kidneys the nurse should instruct the client that he or she will be performing

blunt percussion

when the nurse places one hand flat on the body surface and used the fist of the other hand to strike the back of the hand flat on the body surface the nurse is using

blunt percussion

while percussing an adult client during a physical examination the nurse can expect to hear flatness over the client's

bone

To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next,

check for the presence of defining characteristics

which of the following statements correctly discuss jean piagets theory of cognitive development

cognitive development occurs as a result of the persons organization and adaptation to the perceived environment

problem that requires the attention or assistance of other health care professionals

collaborative problem

When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed

comprehensive

begins to think and reason logically about objects in the environment

concrete operational

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous

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 palpation

the person who has attained kohlbergs conventional level of moral development is best described as

desiring to avoid disapproval from others and be considered a respectful helpful person

which of the following statements is true regarding developmental theories

developmental theory often reflects the culture life experiences of the theorist

larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds

diaphragm of stethoscope

Part of the examiner's hand used to feel for temperature

dorsal surface of hand

while examining a client the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand

the nurse is interviewing a client in the clinic for the first time. when the client tells the nurse that he smokes "about two pack of cigarettes a day" the nurse should

encourage the client to quit smoking

assessing whether outcome criteria have been met and revising the plan of care if necessary

evaluation

to alleviate a clients anxiety during a comprehensive assessment, the nurse should

explain each procedure being performed and the reason for the procedure

the nurse is preparing to interview an adult client for the first time the nurse observes that the client appears to be very anxious the nurse should

explain the role and purpose of the nurse

the nurse is planning to interview a client who is being treated for depression when the nurse enters the examination room the client is sitting on the table with shoulders slumped the nurse should plan to approach the client by

expressing interest in a neutral matter

part of examiner's hand used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus

fingerpads

an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern

focused or problem-oriented assessment

the person who is able to correctly calculate algebraic equations has most likely attained which piagetian stage of cognitive development

formal operational

the nurse completes her interview or a 39 year old female client who seems happily married with four healthy children who are doing very well in school and who works part time as a college professor the nurse would be able to conclude that this client is in which of the following psychosocial developmental stages

generativity

while interviewing an adult client about the clients stress levels and coping responses an appropriate question by the nurse is

how do you manage your stress

During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit

hyperresonance

during a client interview the nurse asks questions about the clients past health history the primary purpose of asking about past health problems is to

identify risk factors to the client and his or her significant other

carrying out the plan of care

implementation

the nurse has interviewed a hispanic client with limited english skills for the first time. the nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. the nurse should

indicate acceptance of the client's cultural differences

the most commonly used method of percussion is

indirect percussion

during a comprehensive assessment, the primary technique used by the nurse throughout the examination is

inspection

for a nurse ot be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality the nurse should have

knowledge of his or her own thoughts and feelings about these issues

back lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum

lithotomy position

while interviewing a client for the first time the nurse is using a standardized nursing history form the nurse should

maintain eye contact while asking the questions from the form

generativity versus stagnation

middle adult

lawrence kohlberg based his theory of moral development on the premise that

moral development is determined in part by decisions that challenge the person

collection of subjective and objective data

nursing assessment

analysis of subjective and objective data to make a professional nursing judgement

nursing diagnoses

clinical judgement about individual, family, or community responses to actual or potential health problems and life processes

nursing diagnosis

findings directly observed or indirectly observed through measurements

objective data

during an interview, the nurse collects both subjective and objective data from an adult client, subjective data would include the client's

perception of pain

while performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using

percussion

a medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the clients

physiologic status

growth and development of intellectual structures

piaget's theory

developing a plan of nursing care and outcome criteria

planning

a 50 year old pt tells the nurse that she enjoys babysitting her grandchildren while their parents are attending night classes at the local college she also shares that on many days she volunteers at a neighborhood food bank. erikson would most likely place this pt as

positively resolving a sense of generativity versus stagnation

ability to make a mental representation for something not present using language

preoperational

client lies on abdomen with head turned to side; may be used to assess back and mobility of hip joint

prone position

the nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits during the interview process the nurse should plan to

provide structure and set limits with the client

during the interview of an adult client the nurse should

provide the client with information as questions arise

Sigmund Freud postulated that

puberty allows sexual impulses to reappear

the depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of

rapid advance in biomedical knowledge and technology

physiologic complications that nurses monitor to detect ehir onset or changes in status

referral problem

during an interview with an adult client for the first time the nurse can clarify the client's statement by

rephrasing the client's statements

while interviewing an adult client about her nutrition habits the nurse should

review the ChooseMyPlate information with the client

to prepare for the assessment of a client visiting a neighborhood health care clinic the nurse should first

review the client's health care record

thoughts are demonstrated by physical manipulation of objects/stimuli

sensorimotor

side-lying position used during the rectal examination

sims' position

position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities

sitting position

position used to examine male genitalia and to assess gait, posture, and balance

standing position

sensations or symptoms that can be verified only by the client

subjective data

back lying position used for examination of the abdomen, this position allows easy access for palpation and peripheral pulses

supine position

The client frequently chews his nail to the point that his fingers are bleeding. when questioned about this he has attacked people who question him about his nail biting and bit them. Freud would interpret this as which of the following

the id is controlling this patients behavior

each of erik erikson's central developmental tasks is composed of opposing viewpoints erikson thus theorized taht

the person must accomplish a healthy balance between these opposing viewpoints in order to progress to the next psychosocial stage

which of the following statements is true regarding piagets concept of transductive thinking

transductive thinking can be used by formal operational thinkers

Part of the examiner's hand used to feel for vibration, thrills, or fremitus

ulnar surface or palm of hand

while performing a physical examination on an older adult the nurse should plan to

use minimal position changes

the nurse is interviewing a client in the clinic for the first time. the client appears to have a very limited vocabulary. the nurse should plan to

use very basic lay terminology

during an interview with an adult client the nurse can keep the interview from going off course by

using closed-ended questions

Before beginning a physical assessment for a client, the nurse should first

wash both hands with soap and water

during an interview between a nurse and a client the nurse and the client collaborate to identify problems and goals this occurs during the phase of the interview termed

working