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
Nurses advocate for underserved populations to reduce health disparities. This promotes
C. Social justice
Nurses belong to the ANA as part of their
D. Ongoing professional responsibility
The purpose of health assessment is to
A. Obtain subjective and objective data
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
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
Which of the following processes is the most important when providing nursing care to an ill patient?
A. Using critical thinking
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
Which of the following are components of a comprehensive health assessment?
A. Examination of Body systems
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
Nonverbal communication skills include
A. facial expression and body position
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
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
The nurse is gathering the health history data before performing the physical assessment. This phase of the interview process is the
C. Working phase
When working with a medical interpreter, the nurse knows that it is best to
D. Look directly at the patient
When interviewing adolescents, the nurse recognizes that
C. Privacy may be especially important
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)
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."
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."
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."
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
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
As part of the past health history, the nurse collects the following data:
D. Patient had breast cancer in 2007; treated with chemotherapy
When gathering the family history, the nurse draws a genogram, using
C. Lines between parents to show marriage.
The history of present illness includes an assessment of
D. location, intensity,duration, description, aggravating and alleviating factors, functional impairment, and pain goa
The nurse asks, "What are the most important things to you in life?" to assess the function pattern related to
D. values
To assess self-perception, the nurse asks
D. How would you describe yourself
When the nurse asks about feeding, bathing, toileting, dressing, grooming, mobility, home maintenance, shopping, and cooking, he or she is assessing
B. ADLs
The nurse assessing the child focuses the health history on
A. birth history, immunizations, growth and development
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
National standards for Culturally and Linguistically Appropriate Services in Health Care mandate that the standards
C. be upheld in every health care setting
CAM therapies used instead of conventional treatments to restore health are often termed
A. alternative
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
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
With transcultural assessment, the nurse must
C. Determine which questions to ask
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
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
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
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
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
Which of the following interventions is most important to prevent nosocomial infections?
C. Hand hygiene
Standard precautions
D. are used on every patient, because many infections are unknown
Latex allergies
D. are more common in nurses and frequently hospitalized patients.
Which of the following is an appropriate use of gloves? Gloves are
B. worn during anticipated contact with body secretions
Which of the following is an example of inspection?
A. Skin pink
The patient is complaining of abdominal pain. What technique is used to form an overall impression?
B. Light palpation
Tympany is a percussion sound commonly located in the
A. abdomen
The nurse auscultates which organs as part of the admitting assesment?
B. Heart, lungs and abdomen
What technique facilitates accurate auscultation?
A. the chestpiece of the stethoscope is sealed against the skin
When assessing the child, the nurse makes the following adaption to the usual techniques:
B. A pediatric stethoscope provides better contact
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
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.
Which of the following is the purpose of auditing charting?
C. To determine if staff members are providing and documenting standards of care
Which of the following are acceptable under the Hippa Privacy Rule?
C. Communicate report with the next nurse during change of shift
Which of the following is the proper technique for correcting written documentation?
B. Draw a single line through the error and initial
What do the different formats of progress notes have in common?
A. All use the nursing process in some form to show nursing thinkin
What are some strategies for effective handoffs during change-of-shift report?
A. Allow an opportunity to ask and answer questions
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
Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on
D. a focused assessment flow sheet
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
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
What are the four characteristics of a pulse?
Rate, rhythm, force(amplitude ), elasticity
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
The patient's radial pulse is weak and thready. The nurse would document the finding as
C. 1+/4+
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
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
The pulse pressure for a patient with a BP of 144/86 is
A. 58
The nurse is caring for an elderly confused patient. In assessing temperature, the nurse will obtain the reading using
B. A tympanic thermometer
PThe nurse notes an irregular radial pulse in a patient. Further assessment includes assessing
C. apical pulse
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
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
All of the following skin lesions are papular except
D. herpes zoster
The ABCDs of melanoma identification include all of the following except
B. B (birthmark): recently changed in appearance
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
When assessing hydration in an infant, the nurse would
B. Pinch a fold of skin on the abdomen and observe for recoil to normal
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
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
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
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
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
A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?
D. Pustule
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
The lymph nodes that lie superficial to the mastoid bone are the
A. Posterior auricular node
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
Physical examination of a patient reveals an enlarged tonsilar node. Acutely infected nodes would be
A. Firm but movable and tender
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
The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient
D. turn his or her head against resistance
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.
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
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
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
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
Which of the following teaching points would the nurse emphasize related to eye health?
C. Always wear eye protection for occupational exposures
Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field?
B. Floater
When working with an older adult, what would the nurse emphasize as increased risks for the patient?
A. Glaucoma and cataracts
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
Which of the following scores for distance vision indicates the patient with the poorest vision?
C. 20/100
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
Peripheral vision is elevated by the nurse using
A. confrontation test
The cranial nerves involved with eye movement include
D. III, IV, and VI
The nurse assesses the response of the eye to light and documents normal findings as
B. PERRLA
The function of the ear is for
B. Hearing and equilibrium
The inner ear
A. provides the body with proprioception
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
Risk factors for hearing loss include which of the following? Choose all that are correct.
A. Frequent ear infection
C. Exposure to smoke
Tinnitus is described as
C. ringing in the ear
Which of the following patients is most likely to have hearing loss?
B. Caucasian man older than 70 years
Which of the following differentiates the RN assessment from the APRN assessment?
D. Otoscopic assessment
A nursing diagnosis appropriate for a patient with ear problems includes
D. disturbed sensory perception
An outcome that is appropriate for a patient with hearing impairment is
D. Patient explains plan to accommodate hearing impariment
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
Which of the following is part of the upper gastrointestinal tract?
B. Throat
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
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
Acute airway obstruction is a situation that should be
D. quickly assessed and treated
Risk factors for nose, sinus, mouth, and throat problems include,
C. topical decongestant use, smoking, and allergie
The nurse has assesssed the nose and documents normal findings as
C. nose symmetrical and midline
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
An adolescent and male presents with complaints of nose bleeds. The nurse would further assess for
C. nasal trauma
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
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
When performing an abdominal assessment, what is the correct sequence?
D. Inspection, auscultation, percussion, palpation
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?
When palpating the abdomen, the nurse notices a mass in the LUQ lateral to the MCL. Which organ is involved?
C. Spleen
What percussion sounds is heart over most of the abdomen
C. Tympany
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
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
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
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
Which assessment technique would best confirm splenic enlargement?
B. Percussion to estimate the size of the spleen and gentle palpation
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