N3030 Exam 1 PrepU
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
"Can you tell me about your sleep problem from when it started until now?"
Which of the following data entries follows the recommended guidelines for documenting data?
"Following oxygen administration, vital signs returned to baseline."
The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data?
"I have pain across my entire forehead."
A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?
"I'm going to assess the client now so that I can begin formulating the care plan."
Which actions might cause the nurse to obtain a blood pressure (BP) reading that is artificially high? Select all that apply.
-deflating the BP cuff too slowly -using a BP cuff that is too small or narrow -positioning the arm below the level of the heart
The nurse explains to the client that smoking has what effect on the body? Select all that apply.
-hypertension -vasoconstriction -peripheral vascular disease
A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?
45-60
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?
A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight
A nurse is interviewing an adult client who had a miscarriage 3 weeks ago. The woman is crying and is having difficulty talking. The nurse moves closer and places a hand on the woman's hand. What type of communication is this?
Active Listening
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 (remember ABCs)
The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?
Allen Test
A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition?
Ankle-brachial index (ABI)
The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?
Arterial Occlusion
Which lung sound possesses the following characteristics? Expiration is longer than inspiration; the sound is louder and higher in pitch with a short silence between inspiration and expiration.
Bronchial
During the physical assessment of a client, a nurse observes that the client tends to lean forward, using the arms to support the upper body. The nurse recognizes this as a sign of what disease process?
COPD
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Cheyne-Stokes
During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?
Diabetes
The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?
Evaluate changes in respiratory pattern and rate.
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
A nurse is collecting subjective data from a client as part of the assessment process. Which behavior is most appropriate for the nurse to display in this situation?
Explaining the reason for taking down notes
A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?
Facial Expression
To function adequately, the nurse knows that the heart valves need to open simultaneously. (T/F)
False
When interviewing, the nurse should logically move from specific to open-ended questions. (T/F)
False
The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client?
Focused
The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?
Funnel Chest
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?
Head-to-Toe
When doing an overall assessment of a client, the nurse is able to utilize findings and do what?
Identify in what areas the client needs the most care
A client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, and a deep, wet cough. A nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, and inability to cough up secretions. Which nursing diagnosis can be confirmed with this data?
Ineffective Airway Clearance
Which is true of a third heart sound (S3)?
It is caused by rapid deceleration of blood against the ventricular wall.
Which of the following statements is true of the role of inspection in the physical examination?
It is often the source of the most physical signs.
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
Limiting abbreviations to those approved for use by the institution
A nurse is distracted during her assessment of a client and does not take as thorough or as accurate notes as usual. Her supervisor, who is familiar with the client, reads the client's chart and questions the nurse. The supervisor should point out to the nurse that which of the following errors is most likely to occur due to the nurse's lapse?
Making incorrect nursing judgments or diagnoses
The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?
Measure the client's heart rate and blood pressure while supine then within 3 minutes of standing.
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
The client has a murmur. This is what type of data?
Objective Data
A nurse is assessing a client for possible dehydration. Which of the following should the nurse do?
Observe for a decrease in jugular venous pressure
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
In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?
Palpitation
When assessing the extremities of a client reporting leg cramping, the nurse notes muscle atrophy. What does the nurse suspect is the cause?
Peripheral arterial disease
The nurse obtains a flat sound when percussing the right lower lobe of a client. What does this assessment finding indicate to the nurse?
Pleural effusion
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary Prevention
A client is admitted to the health care facility with new onset of abdominal pain. The client becomes angry with the nurse when questions about personal information are asked. How should the nurse proceed with the interview?
Remain in control and allow the client to vent feelings
Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?
Severe sepsis
When assessing the breath sounds of a newly admitted client, the nurse notes increased transmission of voice sounds over the right lung. What would this indicate to the nurse?
The lung has become airless
The nurse on the cardiac unit is caring for a client who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this client, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein?
They more than double the risk of cardiac disease.
The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?
Upon meeting the client and family members
During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?
Venous insufficiency
An adult client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible
angina
The client is experiencing septic shock. What assessment finding would the nurse expect to find?
capillary refill greater than 2 seconds
The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the
competence of the saphenous vein valves.
The nurse should immediately notify the healthcare provider if which assessment finding is obtained on a hospitalized client?
cyanotic left lower extremity
During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?
decreased cardiac output
The nurse is unable to palpate a client's left popliteal artery. Which artery should be assessed to determine the presence of blood flow in the left leg?
femoral
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 is referred to as a(n)
focused or problem-oriented assessment.
A client reports experiencing chest pain after eating. Which category within the review of systems should the nurse document this information?
gastrointestinal
An adult client tells the nurse that his father died of a massive coronary attack at the age of 65. The nurse should explain to the client that one of the risk factors for coronary heart disease is
high serum level of low-density lipoproteins.
An older adult client with COPD has come to the clinic for a routine follow-up visit. The nurse escorts the client to an examination room and measures vital signs. The nurse would expect the client's vital signs to be what?
higher than normal
Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?
increased pulse rate
The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?
inflammation of parietal pleura
The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?
intermittent claudication
A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?
less than 90 degrees
The nurse aide reports to the nurse that an older adult client has abnormal vital signs. What is important to remember in this type of situation?
normal readings vary according to age
A 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/partial
While performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
percussion
What color of sputum would support the diagnosis of heart failure?
pink
During the interview of an adult client, the nurse should
provide the client with information as questions arise.
What information concerning a client's respirations should the nurse record after completing a general physical assessment?
rate, rhythm, and depth of respirations taken for a full minute
A nursing instructor is talking about nonverbal communication with the nursing class. The instructor explains that facial expressions should be what?
relaxed
During an interview with an adult client for the first time, the nurse can clarify the client's statements by
rephrasing the client's statements.
A client has engorged jugular veins. What should this finding suggest to the nurse?
right atrial pressure
A nurse has completed assessment of a client and is now validating the information gathered and reviewing goals with the client. Which phase of the interview process is this?
summary
A nurse assesses a client who reports the onset of a severe headache. During which phase of the nursing interview should the nurse ask the client about the history of the present health concern and the reasons for seeking care?
working
A nurse is assessing the cognitive function of a 13-year-old boy who is in the hospital following a head injury sustained while playing football. The boy acts annoyed with the assessment questions and asks how often he will have to answer them. The nurse should respond with which of the following?
"I'm sorry, but assessment is ongoing and continuous."
A nurse collects data about a client's family health history. Which family member's health problems should the nurse include when documenting this information in the database?
As many maternal and paternal relatives as the client can recall
A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?
Ask the other nurse to read back what first nurse reported
Using both verbal and nonverbal clues given by the client, what is the nurse constantly doing?
Assessing
The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible
Chronic Bronchitis
A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?
Chronic obstructive lung disease
What is responsible for the inspiratory splitting of S2?
Closure of aortic then pulmonic valves
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?
Coin or key
A nurse conducts an initial comprehensive assessment for a client admitted with a fever of unknown origin. Which area of assessment is primarily the nurse's responsibility?
Collect subjective and objective data related to overall function.
A nurse is assessing a client with acute asthma. Which adventitious breath sound should the nurse expect to hear in this client?
Sibilant wheezes heard primarily during expiration but may also be heard on inspiration
Which of the following occurs in respiratory distress?
Skin between the ribs moves inward with inspiration.
A client recovering from abdominal surgery is complaining of pain. The nurse realizes that the client is most likely experiencing which type of pain?
Somatic
A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form?
Specialty Area Assessment Form
Which describes the nurse using the technique of palpation?
The nurse notes increased warmth surrounding an abdominal incision.
After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data?
To communicate effectively with other health care team members
A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment?
To establish a database against which subsequent assessments can be measured
On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?
Trendelenburg test
It is recommended that a left-handed examiner adopt a right-sided position. (T/F)
True
Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?
Unequal expansion of the chest
The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?
Venous insufficiency
The nurse begins a client assessment by conducting a general survey that focuses on objective observations. What is the primary purpose for collecting this sort of information first?
assists the nurse in formulating appropriate subjective questioning
While assessing an older adult client, the nurse detects a bruit over the carotid artery. The nurse should explain to the client that a bruit is
associated with occlusive arterial disease.
While palpating the apex, left sternal border, and base in an adult client, the nurse detects a thrill. The nurse should further assess the client for
cardiac murmur
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 client presents to the health care facility with a 2-week history of persistent dry, hacky cough, chest tightness, and shortness of breath with activity. The client admits to a 1-pack-per-day history of cigarette smoking for 20 years. The nurse observes a respiratory rate of 16 breaths per minute, easy and regular. Which nursing diagnosis should the nurse confirm based on this assessment data?
impaired gas exchange
A client has an enlarged area on the lower leg. Which technique should the nurse expect to use to assess this body area?
palpation
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 assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible
pneumonia
The anterior chest area that overlies the heart and great vessels is called the
precordium
The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct?
right cervical node
A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a client. The nurse should be aware of what risk when using this assessment technique?
risk for injury
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.