Health Assessment Review questions ch. 1,2,3,11,4,5,6,13,14,15,16,17,22

  1. A patient is having side effects from a medication. The nurse calls the provider to request a change to the medication order. The nurse is functioning as an/a



    C. Advocate
  2. Nurses advocate for underserved populations to reduce health disparities. This promotes



    C. Social justice
  3. Nurses belong to the ANA as part of their



    D. Ongoing professional responsibility
  4. The purpose of health assessment is to



    A. Obtain subjective and objective data
  5. The nurse documents the following information in a patient's chart: "cough and deep breathe every hour while awake." This is an example of



    D. Nursing interventions
  6. The nurse provides teaching about smoking cessation to a 20-year-old man. The nurse assesses that the patient is concerned because his father died from lung cancer. Which theory would the nurse most likely use when providing teaching to this patient?



    A. Health belief model
  7. Which of the following processes is the most important when providing nursing care to an ill patient?



    A. Using critical thinking
  8. A patient is admitted to a hospital for surgery for colon cancer. What type of assessment is the nurse most likely to perform upon admission?



    A. Comprehensive
  9. Which of the following are components of a comprehensive health assessment?



    A. Examination of Body systems
  10. The nurse conducts the health history based upon the patient's responses to the medical diagnosis. This type of framework is based on the



    B. Functional framework
  11. Nonverbal communication skills include



    A. facial expression and body position
  12. The nurse talks with the patient and asks, "So tell me more about the chest pain that you had." This is an example of



    B. Encouraging elaboratoin
  13. When the patient says, "I'm so angry that I have to have surgery," the nurse says, "you sound very frustrated." This is an example of



    B. refelction
  14. The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the



    C. Working phase
  15. When working with a medical interpreter, the nurse knows that it is best to



    D. Look directly at the patient
  16. When interviewing adolescents, the nurse recognizes that



    C. Privacy may be especially important
  17. The patient is crying after being given a diagnosis with a poor prognosis. The best response from the nurse is



    C. "I'll stay with you." (and gets a tissue)
  18. An older adult says, "How come you're asking me so many questions?" The best response from the nurse is



    A. "Are you getting tired? I can come back later."
  19. When the nurse asks the patient during a health history about mental health problems, the patient responds by saying, "Don't you tell me I'm crazy!" The best response by the nurse is



    B. "Tell me more about what you mean by that."
  20. The mother of an infant with severe asthma is extremely anxious. The nurse is treating the patient in the emergency room. When collecting the history, the best response of the nurse is



    A. "You seem worried, but I need to ask a few questions."
  21. A patient says that she is having throbbing pain that she rates as 6 o a 10-point scale. This is referred to as



    B. Subjective primary data
  22. The patient is having crushing chest pain that he rates as 8 on a 10-point scale. His blood pressure is 80/62. The nurse performs which type of assessment?



    D. Emergency
  23. As part of the past health history, the nurse collects the following data:



    D. Patient had breast cancer in 2007; treated with chemotherapy
  24. When gathering the family history, the nurse draws a genogram, using



    C. Lines between parents to show marriage.
  25. The history of present illness includes an assessment of



    D. location, intensity,duration, description, aggravating and alleviating factors, functional impairment, and pain goa
  26. The nurse asks, "What are the most important things to you in life?" to assess the function pattern related to



    D. values
  27. To assess self-perception, the nurse asks



    D. How would you describe yourself
  28. When the nurse asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking, he or she is assessing



    B. ADLs
  29. The nurse assessing the child focuses the health history on



    A. birth history, immunizations, growth and development
  30. The nurse performs patient teaching after assessing that the nutritional history reveals a patient generally consumes a high-fat, high-calirie diet. This critical thinking



    C. uses subjective data to analyze findings and intervene
  31. National standards for Culturally and Linguistically Appropriate Services in Health Care mandate that the standards



    C. be upheld in every health care setting
  32. CAM therapies used instead of conventional treatments to restore health are often termed



    A. alternative
  33. The social context influences the patterns of health and illness for individuals, communities, and societies. An example is



    C. Assessment of focus groups in multiple location
  34. The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to



    D. Provide a picture of the individual's culture-based health care needs
  35. With transcultural assessment, the nurse must



    C. Determine which questions to ask
  36. A shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world is defined as



    C. culture
  37. Even when daily prayers or other religious practices are not a part of a patient's life routine, they often take central position during life transitions, such as loss of a loved one, accident, or serious illness. A related nursing diagnosis might be



    A. spiritual distress
  38. It is important to identify similarities and differences among the cultural beliefs of the patient, health care agency, and the nurse to



    D. avoid making assumptions
  39. Seeking understanding of one's culturally base health care practices is essential to nursing because each culture has its own traditional values and beliefs about health and illness that



    B. may affect patients' adherence to treatments
  40. What is the nurse's best response when a Muslim patient has a basin of water on his bedside stand that he does not want emptied?



    C. Support and accommodate his preference
  41. Which of the following interventions is most important to prevent nosocomial infections?



    C. Hand hygiene
  42. Standard precautions



    D. are used on every patient, because many infections are unknown
  43. Latex allergies



    D. are more common in nurses and frequently hospitalized patients.
  44. Which of the following is an appropriate use of gloves? Gloves are



    B. worn during anticipated contact with body secretions
  45. Which of the following is an example of inspection?



    A. Skin pink
  46. The patient is complaining of abdominal pain. What technique is used to form an overall impression?



    B. Light palpation
  47. Tympany is a percussion sound commonly located in the



    A. abdomen
  48. The nurse auscultates which organs as part of the admitting assesment?



    B. Heart, lungs and abdomen
  49. What technique facilitates accurate auscultation?



    A. the chestpiece of the stethoscope is sealed against the skin
  50. When assessing the child, the nurse makes the following adaption to the usual techniques:



    B. A pediatric stethoscope provides better contact
  51. Which of the following are advantages of the electronic medical record? Select all that apply



    A. Nurses can enter data by checking boxes and adding free full text
  52. Which of the following are high-risk assessments for liability? Select all that apply.
    A. Failure to document completely
    B. Inadequate admission assessment
    C. Charting in advance
    D. Bunch charting at the end of the shift
    • All of the above
    • failure to doc completely, inadequate admission assessment, charting in advance, bunch charting at the end of the shift.
  53. Which of the following is the purpose of auditing charting?



    C. To determine if staff members are providing and documenting standards of care
  54. Which of the following are acceptable under the Hippa Privacy Rule?



    C. Communicate report with the next nurse during change of shift
  55. Which of the following is the proper technique for correcting written documentation?



    B. Draw a single line through the error and initial
  56. What do the different formats of progress notes have in common?



    A. All use the nursing process in some form to show nursing thinkin
  57. What are some strategies for effective handoffs during change-of-shift report?



    A. Allow an opportunity to ask and answer questions
  58. In the SBAR reporting format, which of the following would be an example of data found in the assessment?



    D. Mr. Imami's lungs sounds are decreased
  59. Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on



    D. a focused assessment flow sheet
  60. Your patient with a humerus fracture is stating pain of 15 on a 10-point scale. His hand is pale, cool, and swollen. His pain medication is ineffective, and he is at risk for compartment syndrome. What action will the nurse take first?



    D. Contact the primary provider and document the findings now
  61. Mr. Holmes has come to the clinic for a well-patient visit. When assessing his vital signs, the nurse palpates an irregular heart rate. The nurse must then auscultate for a full minute at the apical pulse site. Locate the apical pulse on the diagram below.
    The apical pulse is close to the left nipple
  62. What are the four characteristics of a pulse?
    Rate, rhythm, force(amplitude ), elasticity
  63. An unconscious 20-year-old woman arrives at the hospital after drinking large quantities of alcohol. Her vital signs are T 98.2 0F, po; P 58; R 9; BP 100/64. What conclusion would a nurse make about this patient's respiratory status?



    D. The patient is experiencing bradypnea
  64. The patient's radial pulse is weak and thready. The nurse would document the finding as



    C. 1+/4+
  65. The nurse is preparing to assess the vital signs of a 62-year-old woman following hip surgery. When the nurse arrives, the patient is sitting in her chair having just finished breakfast. What is the appropriate nursing action?



    A. Wait 20 to 30 minutes and then take vital sign
  66. The postoperative vital signs of a 47-year-old man with a ruptured appendix are BP 112/68, pulse 56, R 8, T 37.6 C temporally. The patient is pale and confused, with minimal urine output. The nurse should



    A. notify the clinician
  67. The pulse pressure for a patient with a BP of 144/86 is



    A. 58
  68. The nurse is caring for an elderly confused patient. In assessing temperature, the nurse will obtain the reading using



    B. A tympanic thermometer
  69. PThe nurse notes an irregular radial pulse in a patient. Further assessment includes assessing



    C. apical pulse
  70. Which action will result in an accurate BP reading? Select all that apply.
    A. Applying the center of the bladder of the cuff directly over the brachial artery
    B. Raising the arm to the level of the heart
    C. Using the bell to assess the BP
    D. Pumping the cuff 60 mm Hg above the estimated BP
    • A. Applying the center of the bladder of the cuff directly over the brachial artery
    • B. Raising the arm to the level of the heart
    • C. Using the bell to assess the BP
  71. The nurse is admitting a 75-year-old man with a 50-year history of smoking one pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is



    C. clubbing
  72. All of the following skin lesions are papular except



    D. herpes zoster
  73. The ABCDs of melanoma identification include all of the following except



    B. B (birthmark): recently changed in appearance
  74. A nurse observes a skin lesion with a well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion?



    D. Patch
  75. When assessing hydration in an infant, the nurse would



    B. Pinch a fold of skin on the abdomen and observe for recoil to normal
  76. A fari-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. What would the nurse teach the patient?



    • D. All of the above.
    • Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer
    • Apply a sunscreen or sunblock at least 15 to 30 minutes prior to sun exposure
    • Avoid sun exposure between 10am and 4pm to reduce UVA and UVB exposure
  77. An 8-year-old patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow ulcerated surface; some have scabbed over. The nurse suspects which of the following infectious illnesses?



    D. Varicella
  78. A 24-year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the large patch. What is the correct terminology for the distribution patter of these smaller lesions?



    D. Satellite
  79. A 22-year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 1 inch in diameter. It is not tender, redened, or seeping any drainage. What is the term used to describe this secondary skin lesion?



    D. Keloid
  80. An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation?



    D. Thinning of the skin
  81. A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?



    D. Pustule
  82. While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?



    D. Document this finding as normal
  83. The lymph nodes that lie superficial to the mastoid bone are the



    A. Posterior auricular node
  84. Which of the following descriptions is most consistent with a patient who has hypothyroidism?



    A. Slightly obese female with periorbital edema and a flat facial expression, who complains of constipation, deceased appetite and fatigue
  85. Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected nodes would be



    A. Firm but movable and tender
  86. While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of



    A. dehydration
  87. The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient



    D. turn his or her head against resistance
  88. Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach?



    A. pelase look straight ahead and tilt your head slightly down and to one side.
  89. While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?



    D. Recognize that a palpable node in this region is a dangerous indication of metastatic cancer that requires further evaluation
  90. While reviewing laboratory values for thyroid function on an adult patient, the nurse sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of



    B. hypothyroidism
  91. A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve?



    A. Cranial nerve VII
  92. Which of the following patients would require the most emergent nursing care?



    D. A 20-year-old man with sudden visual loss after playing football
  93. Which of the following teaching points would the nurse emphasize related to eye health?



    C. Always wear eye protection for occupational exposures
  94. Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field?



    B. Floater
  95. When working with an older adult, what would the nurse emphasize as increased risks for the patient?



    A. Glaucoma and cataracts
  96. A school nurse is performing annual vision screening for seventh grade students. Which of the following charts would the nurse most likely be using?



    B. Snellen's chart
  97. Which of the following scores for distance vision indicates the patient with the poorest vision?



    C. 20/100
  98. The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of the loss in the ability of the eye to



    A. accommodate
  99. Peripheral vision is elevated by the nurse using



    A. confrontation test
  100. The cranial nerves involved with eye movement include



    D. III, IV, and VI
  101. The nurse assesses the response of the eye to light and documents normal findings as



    B. PERRLA
  102. The function of the ear is for



    B. Hearing and equilibrium
  103. The inner ear



    A. provides the body with proprioception
  104. Cues of hearing loss include which of the following?
    Choose all that are correct
    A. Using a loud or monotonous voice
    B. Asking to repeat questions
    C. Concentrating on lip movement
    D. Leaning forward to hear
    • A. Using a loud or monotonous voice
    • B. Asking to repeat questions
    • C. Concentrating on lip movement
    • D. Leaning forward to hear
  105. Risk factors for hearing loss include which of the following? Choose all that are correct.



    • A. Frequent ear infection
    • C. Exposure to smoke
  106. Tinnitus is described as



    C. ringing in the ear
  107. Which of the following patients is most likely to have hearing loss?



    B. Caucasian man older than 70 years
  108. Which of the following differentiates the RN assessment from the APRN assessment?



    D. Otoscopic assessment
  109. A nursing diagnosis appropriate for a patient with ear problems includes



    D. disturbed sensory perception
  110. An outcome that is appropriate for a patient with hearing impairment is



    D. Patient explains plan to accommodate hearing impariment
  111. Which of the following are appropriate interventions for the patient who is at risk for ear infection? Select all that apply
    A. Be current on immunizations
    B. Avoid second hand smoke
    C. Clean only external ear
    D. Have audiogram yearly
    • A. Be current on immunizations
    • B. Avoid second hand smoke
    • C. Clean only external ear
  112. Which of the following is part of the upper gastrointestinal tract?



    B. Throat
  113. The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding is which of the following?



    D. Kesselbach plexu
  114. The nurse knows that the floor of the mouth is highly vascular so it is a good location for which of the following?



    D. Absorption of sublingual medications
  115. Acute airway obstruction is a situation that should be



    D. quickly assessed and treated
  116. Risk factors for nose, sinus, mouth, and throat problems include,



    C. topical decongestant use, smoking, and allergie
  117. The nurse has assesssed the nose and documents normal findings as



    C. nose symmetrical and midline
  118. The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following?



    D. C. albicans
  119. An adolescent and male presents with complaints of nose bleeds. The nurse would further assess for



    C. nasal trauma
  120. The nurse assess the child with purulent unilateral nasa discharge. The nurse knows that the most likely causative factor is



    D. foreign body in nose
  121. During routine physical examination of a 20-year-old woman, the nurse notes a septal perforation. This finding may be significant for which of the following causes?



    D. Illicit drug use
  122. When performing an abdominal assessment, what is the correct sequence?



    D. Inspection, auscultation, percussion, palpation
  123. A patient reports a long history of changes in bowel pattern. Which is the BEST questions to determine normal bowel habit?



    A. What was your bowel pattern before you noticed the change?
  124. When palpating the abdomen, the nurse notices a mass in the LUQ lateral to the MCL. Which organ is involved?



    C. Spleen
  125. What percussion sounds is heart over most of the abdomen



    C. Tympany
  126. A patient with a history of kidney stones presents with complains of pain, hematuria, and nausea with vomiting. What assessment technique will illicit kidney pain?



    B. Fist percussion for CVA tenderness
  127. When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as a bruit of which of the following?



    A. Right iliac artery
  128. A patient with a history of cirrhosis tells the nurse that his or her abdomen seems to be getting larger and that he or she has gained 20 lb in the last 6 months. How will the nurse determine whether the abdominal enlargement is from accumulation of fluid or fat from the weight gain?



    C. Percuss the abdomen with the patient in different positions
  129. A patient with a protuberant abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?



    A. Murphy's sig
  130. Which assessment technique would best confirm splenic enlargement?



    B. Percussion to estimate the size of the spleen and gentle palpation
  131. The documenting a finding in the region over the stomach and above the umbilicus, the nurse would identify the region as



    A. epigastric
Author
lansmith
ID
92929
Card Set
Health Assessment Review questions ch. 1,2,3,11,4,5,6,13,14,15,16,17,22
Description
Review questions
Updated