Prep U (ch 1,2,3)
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?"
A nurse is discussing with a client the client's personal health history. Which of the following would be an appropriate question to ask at this time?
"What diseases did you have as a child?"
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 who is new to the facility has a recent history of chronic pain that is attributed to fibromyalgia. The nurse has reviewed the available health records and suspects that pain management will be a major focus of nursing care. How can the nurse best validate this assumption?
Ask the client about the most recent experiences of pain.
The nurse is preparing to conduct an interview with a hospitalized client. What nursing intervention can best ensure a confidential and comfortable environment for the client?
Asking permission to draw the client's privacy curtain.
How does a nurse best facilitate the nursing health assessment?
Asking the appropriate questions
The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?
Conduct a brief review of the client's charts.
A nurse completes an initial assessment and discusses findings with the client. What is the next best action of the nurse?
Develop a plan of care with the client.
The nurse is conducting a physical examination of a client who is lying down. Which is the most appropriate for the nurse to assess while the client is in this position?
Dorsiflexion of the foot
The nurse is preparing for a physical examination of a client. What should the nurse do first?
Hand hygiene
The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?
Hyperresonant
A nurse has assessed a client who was admitted to the medical unit to treat acute complications of type 1 diabetes. During the assessment, the client admitted that his blood sugar monitoring when he is at home is "a bit sporadic." How should the nurse best respond to this assessment finding?
Identify a nursing diagnosis of Ineffective Health Maintenance.
A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?
Personal Health History
The nurse is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?
Reduce all environmental noise.
A nurse is preparing to perform a physical examination of an obese client who is beginning a diet and exercise program. The physician would like to establish a baseline percent body fat measurement for the client so that the client's progress in reducing body fat can be tracked over time. Which piece of equipment should the nurse anticipate needing for this purpose?
Skinfold calipers
An elderly client with Parkinson's disease and his wife, who appears to be much younger than he, are being interviewed by the nurse to update the client's health history. The nurse also has the client's electronic health record on her tablet computer. Earlier in the day, the nurse had spoken with the client's primary care physician, who had relayed some concerns to the nurse regarding the progression of the client's disease. Which source of biographic information should the nurse view as primary?
The client
A client who only speaks Spanish is admitted to the unit. The client's sister, who speaks English, is in the room when the English-speaking nurse starts the admission assessment. Why would it be inappropriate to use the sister as an interpreter for this client?
The client may not want the sister to know their private information
The nurse is utilizing the Health Belief Model in the care of a client whose type 1 diabetes is inadequately controlled. When implementing this model, the nurse should begin by assessing which of the following?
The client's motivation for change
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
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. Do not look the client in the eye Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally Make sure that dress and appearance are professional Laugh a lot, which puts the client at ease Do not use facial expressions such as rolling the eyes or looking bored or disgusted
Use gestures intentionally to illustrate points, especially for clients who cannot communicate verbally Make sure that dress and appearance are professional Do not use facial expressions such as rolling the eyes or looking bored or disgusted
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 NG tube for proper functioning
The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular
breasts, the chest and thorax, the cardiovascular system, the groin, hips, and knees, and then the shins and ankles.
During an assessment the client says "I've been having bad pain in my left leg for a week." In which section should the nurse document this information?
chief complaint
A nurse is preparing to perform a test for stereognosis in a client. Which piece of equipment should the nurse use?
coin or key
Consider the nurse's role in the health assessment of a client. What action will the nurse perform initially when admitting a client to a long-term care facility?
collecting information regarding the client's health status
A client reports the health status of living parents, siblings, and deceased grandparents. What should the nurse do with this information?
create a genogram
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 _____ palpations
deep
A nurse is preparing to obtain subjective data during the initial comprehensive assessment from an older client who recently underwent amputation of her lower leg. Which skill will the nurse most need to perform this assessment?
empathy
A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?
heart murmurs
When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply. "Do you have any fears about the headaches you experience?" "Can you tell me when the headaches first began?" "Do the headaches negatively impact your day-to-day life?" "What do you do to make the headaches go away?" "Do you have any idea concerning why you are experiencing these headaches?"
"Do you have any idea concerning why you are experiencing these headaches?" "Do the headaches negatively impact your day-to-day life?" "Do you have any fears about the headaches you experience?"
A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?
"What is your major health concern at this time?"
The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?
Complete the forgotten portion of the exam out of sequence.
Several hours into a shift, the nurse working on a medical-surgical unit observes a change in the client's mental status. Which action should the nurse take first?
Conduct a focused assessment.
A nurse is examining a child who is suspected of having bronchitis and is preparing to auscultate his chest with a stethoscope. Which of the following actions would demonstrate the correct technique for this procedure?
Ensuring that contact with the skin is maintained
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client's data, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
Evaluate outcome.
A group of nurses are reviewing information about the potential opportunities for nurses who have advanced assessment skills. When discussing phenomena that have contributed to these increased opportunities, what should the nurses identify?
Expansion of health care networks
A nurse analyzes the data obtained from an initial assessment of a new client: weight gain of 15 lbs in 3 months, intolerance to cold, constipation, and lethargy. The nurse determines the client may have hypothyroidism and develops several nursing diagnoses with interventions to address the client concerns. Which action should the nurse take next?
Implement interventions.
The nurse is reviewing a new client's chart prior to the initial interview. The chart reveals the client has a visual impairment. What actions should the nurse take to ensure a successful interview?
Knock and announce self before entering the client's room.
What physical assessment technique should a nurse use to obtain a pulse on a client?
Light palpation
A nurse is preparing to perform a genital examination of a female client. Which position should the nurse place the client in?
Lithotomy
Which action should a nurse implement when assessing a nonnative client to facilitate collection of subjective data?
Maintain a professional distance during assessment.
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 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
The nurse is providing care to a newly admitted client with a long history of chronic obstructive pulmonary disease (COPD). According to the client's chart, the client has been taking several inhalers to manage their respiratory condition. The nurse enters the room with the prescribed inhalers to administer them. What action should the nurse take next?
Validate that the client understands how to use the inhalers.
The nurse is caring for the client who is receiving heparin. The nurse plans to:
Wear clean gloves when administering heparin to the client
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
diagnosis
While examining a client, the nurse plans to palpate temperature of the skin by using the
dorsal surface of the hand
A client returns to the unit after a thyroidectomy. On entering the client's room, the nurse observes the client having difficulty breathing due to swelling in the neck. What type of assessment should the nurse perform at this time?
emergency
The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg, O2 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?
evaluate an outcome
Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next?
evaluation
An older client cannot recall the date of a surgical procedure but the adult daughter interjects with the exact date because it occurred a week before her wedding. How should the nurse document this information?
last surgery date validated by adult daughter
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
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's _____________
physiological status
What would be the expected tone elicited by percussion of a normal lung?
resonance
The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority?
significantly impaired hearing
How should the nurse place the ear of an adult when using the otoscope?
up and back
The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?
use as a drape
A client is asked to describe "something that brings the most hope." Which functional health pattern is the nurse assessing?
value-belief
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