3035 Exam Flashcards
A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the “P”?
“How does it feel?”
“What makes it worse?”
“When did it start?”
“How would you rate your pain?”
Correct! - “What makes it worse?”
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?”
“Did you bring all your medications with you?”
“Are you generally fairly healthy?”
“Do you have adequate health insurance coverage?”
Correct - “What is your major health concern at this time?”
To alleviate a client’s anxiety during a comprehensive assessment, the nurse should do which of the following?
Begin with intrusive procedures first to get them completed quickly
Ask the client to sign a consent for the physical exam
Explain each procedure being performed and the reason for the procedure
Remain in the exam room while the client changes into a gown
Correct! - Explain each procedure being performed and the reason for the procedure
A nurse is interviewing a client in the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Limiting all facial expressions
Sitting across the room from the client
Using a moderate amount of eye contact
Standing while the client is seated
Correct! - Using a moderate amount of eye contact
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?
Collaborate with the client to identify problems.
Explain the purpose of the interview.
Obtain family health history data.
Determine the client’s vital signs.
Correct! - Explain the purpose of the interview.
The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this component of assessment?
“I have a brother with leukemia and a sister with hypertension.”
“My mom’s still alive, but my dad died 10 years ago of heart failure.”
“I have been having some pain when I urinate for the last several days.”
“I had surgery 5 years ago to repair an inguinal hernia.”
Correct! - “I had surgery 5 years ago to repair an inguinal hernia.”
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client’s complaint?
Document “unable to assess client’s discomfort”.
Restate the question using simpler terms.
Provide a laundry list of descriptive words.
Ignore the complaint for now and return to it later in the assessment.
Correct! - Provide a laundry list of descriptive words.
A nurse is interpreting and validating the information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?
Summary
Closing
Introductory
Working
Correct! - Working
A client comes to the health care provider’s office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Comprehensive assessment
Focused assessment
Ongoing assessment
Emergency assessment
Correct! - Focused assessment
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?
The client’s ability to see and hear
The client’s judgment and insight
The client’s general intelligence
The presence of any phobias
Correct - The client’s ability to see and hear
A nurse is providing feedback to a colleague after observing the colleague’s interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?
“Are you allergic to any medications?”
“What is your typical day like?”
“Describe what you eat in a normal day.”
“Tell me about your relationship with your children.”
Correct - “Are you allergic to any medications?”
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
Determining the client’s strengths
Making clinical inferences
Identifying potential health problems
Correct - Establishing a trusting relationship
A client has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as biased?
“Your husband’s death must have been very difficult for you.”
“How often do your adult children typically visit you?”
“How would you describe your feelings about getting older?”
“You know you should quit smoking because it affects others, right?”
Correct! “You know you should quit smoking because it affects others, right?”
The nurse has completed the review of systems component of the client’s health history. Which finding should the nurse document under the review of systems?
“Menstruation began at age 13”
“High school diploma plus 2 years of college”
“Lungs clear to auscultation bilaterally”
“Caregiver reliable source of information”
Correct - “Menstruation began at age 13”
As part of a mental status assessment, the nurse asks the client how they would respond if they found a wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status?
Abstract reasoning
Constructional ability
Concentration
Judgment
Correct! - Judgment
The nurse asks a client to recall five words after 5, 10, and 30 minutes. Which of the following is the nurse assessing?
Client’s memory of new information
Client’s thought process and perceptions
Client’s recent memory
Client’s concentration
Correct - Client’s memory of new information
The nurse is performing hourly assessments of the client’s level of consciousness. During the assessment, the client remains unresponsive after multiple attempts of the nurse calling their name. Which of the following would the nurse perform next?
Gently shake the client’s shoulders.
Call the rapid response team
Press down on one of the client’s nail beds.
Rub the client’s sternum with the knuckles.
Correct - Gently shake the client’s shoulders.
During the interview of a client, the client states to the nurse, “I am just so overwhelmed with everything in my life right now. I think it would be better for everyone if I just wasn’t around anymore.” What statement by the nurse would be most appropriate?
“Everyone gets overwhelmed at times. I’m sure things will get better.”
“Have you been thinking about killing yourself?”
“I’m sure things aren’t that bad. Have you tried medications for your depression?”
“You should try looking at the bright side of things.”
Correct! - “Have you been thinking about killing yourself?”
The nurse is assessing the orientation of a client. The nurse understands which of the following is typically the last level of orientation to be lost?
Situation
Place
Time
Person
Correct! - Person
The nurse is evaluating a client using the Glasgow Coma Scale (GCS). Which of the following components would not be used during this evaluation?
Pupillary response
Eye opening response
Verbal response
Motor response
Correct - Pupillary response
The nurse is preparing to obtain information about a client’s mental and psychological status. Which of the following actions would the nurse take first?
Check the client’s level of consciousness for any changes.
Explain the purpose of the exam and the types of questions that will be asked.
Perform a neurologic examination to determine any deficits.
Question the patient about their usual lifestyle and behaviors.
Correct Answer - Explain the purpose of the exam and the types of questions that will be asked.
The nurse is beginning the initial assessment of a 92-year-old client admitted from the long-term care facility. The client does not seem to be responding to the nurse’s questions or following her movements. What is the appropriate next action by the nurse?
Document “unable to assess client”.
Check the client’s vision and hearing before proceeding with the assessment.
Skip the subjective data collection and proceed to the physical assessment.
Defer the assessment until the client is more responsive.
Correct! - Check the client’s vision and hearing before proceeding with the assessment.
The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the following assessments by the nurse would be consistent with this posturing?
Extended elbows and pronated wrists
Dorsiflexion of the feet
Flexion of the elbows
Externally rotated thighs
Correct! - Flexion of the elbows
The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask?
“Can you tell me what you have eaten in the last 24 hours?”
“How are an apple and orange the same?”
“When did you get your first job?”
“Can you draw the face of a clock for me?”
Correct! - “How are an apple and orange the same?”
What four questions might you ask to determine if your client is alert and oriented x 4?
Type your four questions in the text box below.
Can you tell me your name?
Where are we at right now?
What is the year?
Why are you being seen today?
The nurse is assessing a client admitted to the unit with pleuritis. Which of the following sounds would the nurse expect to hear on auscultation?
Bubbling, moist sounds during early inspiration
Low-pitched, snoring sounds during expiration
Sound like rolling hair between the finger
Low-pitched grating sound on inspiration and expiration
Correct! - Low-pitched grating sound on inspiration and expiration
When auscultating the left carotid artery, the nurse notes a blowing, swishing sound. What does the nurse suspect is the cause of this finding?
Decreased cardiac output
Turbulent blood flow through a vessel
Increased venous pressure
Right ventricular failure
Correct! - Turbulent blood flow through a vessel
The nurse is assessing a 79-year-old client’s posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?
Slight kyphosis
Asymmetrical chest expansion
Audible wheeze
Inaudible posterior lung sounds
Correct - Slight kyphosis
During the assessment of a client with a heart murmur, the nurse places the palm of their hand on the client’s precordium and feels a moderate vibration. The nurse would document this finding as which of the following?
Fremitus
Within normal limits
Thrill
Bruit
Correct! - Thrill
A client is diagnosed with pulmonary edema, and the nurse is performing a rapid assessment prior to treatment. The nurse would be most concerned about what assessment finding related to the client’s sputum?
Pink and frothy
White or cream-colored
Brown-tinged
Yellowish and foul-smelling
Correct! - Pink and frothy
The clinical faculty is reviewing heart sounds with the student nurse. Which of the following would indicate understanding of the S1 heart sound by the student nurse?
S1 is the beginning of diastole
S1 is the closure of the atrioventricular valves
S1 indicates valve stenosis
S1 is the closure of the semilunar valves
Correct! - S1 is the closure of the atrioventricular valves
A nurse assesses a client’s capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next?
Reassess after applying warm compresses.
Recheck in 5 minutes after elevating the arm.
Document this finding as normal.
Refer the client for medical follow-up.
Correct! - Document this finding as normal.
The nurse is assessing a client admitted with exacerbation of his congestive heart failure (CHF). Which of the following would be consistent with this diagnosis?
Jugular venous distention with the client positioned greater than 45 degrees
Increased cardiac output
Jugular veins visible with the client positioned supine
Increased urination during the day
Correct - Jugular venous distention with the client positioned greater than 45 degrees
The nurse is assessing the apices of the client’s lungs. The nurse should locate them at which position?
At about the tenth rib
Near the level of the eighth rib
At the level of the diaphragm
Slightly above the clavicle
Correct! - Slightly above the clavicle
The hospitalized client complains of pain in the right calf. The nurse notices red streaks along the leg and it is warm and swollen. The nurse would anticipate which of the following diagnoses?
Venous insufficiency
Deep vein thrombosis
Systemic infection
Arterial insufficiency
Correct! - Deep vein thrombosis
The emergency department nurse is assessing a client who was hit by a car while on his bike. The nurse notes the client has irregular respirations of varying depth and rate followed by periods of apnea. The nurse would document the respirations as which of the following?
Kussmaul respirations
Hyperventilation
Biot’s respirations
Cheyne-Stokes respirations
Correct! - Biot’s respirations
The nurse assesses a client’s carotid pulse and finds it to be of normal amplitude. The nurse would document this as which of the following?
2+
4+
1+
3+
Correct - 2+
The nurse is using COLDSPA to assess a client’s history of chest pain. Which question best addresses “A” in the assessment model?
“Would you describe your chest pain as being acute, or is it chronic?”
“In your experience, what kinds of activities tend to cause your chest pain?”
“Does your pain radiate to another location?”
“Do you have any other symptoms with your chest pain, such as nausea?”
Correct! - “Do you have any other symptoms with your chest pain, such as nausea?”
The nurse is auscultating the lung sounds of a client with asthma and notes sibilant wheezes during expiration. The nurse understands the cause of the wheezes to be which of the following?
Air passing through secretions in the bronchi and trachea
Air passing through constricted passages
Inflamed parietal and visceral pleura rubbing together
Air suddenly opening small air passages coated with exudate
Correct! - Air passing through constricted passages
While inspecting the lower extremities of a client, the nurse observes an ulcer. What would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.
Circular in shape Client reports severe pain Deep Irregular border Leg edema
Correct! - Circular in shape
Correct! - Client reports severe pain
Correct! - Deep
The clinical faculty is observing a student nurse perform auscultation of breath sounds. Which of the following demonstrates correct technique by the student nurse?
Listens as the client inhales and then goes to the next site during exhalation
Listens to the right lung first and then proceeds to the left lung
Listens to at least one full inspiration and expiration at each site
Listens laterally to three locations on the left and two locations on the right.
Correct! - Listens to at least one full inspiration and expiration at each site
Upon entering the examination room, the nurse observes that the client is leaning forward with his arms supporting his body weight. The nurse would suspect the presence of which condition?
Chronic obstructive pulmonary disease
Pneumonia
Pleural effusion
Heart failure
Correct - Chronic obstructive pulmonary disease
The nurse is unable to palpate the dorsalis pedis pulse on a client. Which action should the nurse take next?
Call the physician for further follow-up
Document “absence of dorsalis pedis pulse” in the medical record
Use a Doppler device to locate the pulse
Auscultate the anatomic area with a stethoscope
Correct! - Use a Doppler device to locate the pulse
The nurse notes unequal chest expansion during inspection of the client’s chest. Which of the following does the nurse expect as the cause of this finding?
Bulging of the intercostal spaces is present
Part of the lung is obstructed or collapsed
The client has chronic obstructive pulmonary disease (COPD)
Accessory muscles are used to augment respiratory effort
Correct! - Part of the lung is obstructed or collapsed
During the assessment of a client with a chest tube, the nurse notes crepitus around the insertion site. The nurse recognizes which of the following as the cause of the crepitus?
Fluid or pus in the lungs
Air leaking into the subcutaneous tissues
Infection at the insertion site
Consolidation of the lung
Correct! - Air leaking into the subcutaneous tissues
When auscultating a client’s breath sounds, the nurse notes a high, harsh sound with short inspiration and long expiration over the trachea. The nurse understands these sounds to be which of the following?
Bronchovesicular breath sounds
Adventitious breath sounds
Bronchial breath sounds
Vesicular breath sounds
Correct! - Bronchial breath sounds
The nurse is preparing to assess a client’s lungs by auscultation. The nurse demonstrates correct use of the stethoscope for auscultating high-pitched sounds in the lungs when they do which of the following?
Listens over the client’s gown to provide for privacy
Uses the bell of the stethoscope
Uses both the bell and the diaphragm
Uses the diaphragm of the stethoscope
Correct! - Uses the diaphragm of the stethoscope
The nurse is preparing to assess a client’s carotid arteries. Which nursing action would be most appropriate?
Palpate the arteries before auscultating them.
Palpate each artery individually to compare.
Use the diaphragm of the stethoscope.
Ask the client to breathe in and out deeply.
Correct! - Palpate each artery individually to compare.
A nurse is obtaining a client’s radial pulse. Which action demonstrates correct technique for this assessment?
Use of the thumb and index finger applied to obliterate the wrist area along the thumb side
Application of the bell of the stethoscope to the antecubital area of the upper extremity
Application of firm pressure on the wrist area along the side of the fifth digit
Use of two fingerpads lightly applied to wrist area along the thumb side
Correct! - Use of two fingerpads lightly applied to wrist area along the thumb side
The nurse is auscultating the apical pulse on a healthy adult client. Which of the follow would indicate correct placement of the stethoscope by the nurse?
Second intercostal space, right sternal border
Third intercostal space, left sternal border
Fifth intercostal space, left midclavicular line
Second intercostal space, left sternal border
Correct! - Fifth intercostal space, left midclavicular line
The nurse is assessing the client’s temporomandibular joint (TMJ). Which of the following findings by the nurse would be documented as normal?
Swelling around the joint space
Clicking when the mouth opens
Popping and grating sounds
Tenderness on palpation
Correct! Clicking when the mouth opens
A client shows the nurse a “bump” on his neck. The nurse observes a palpable, raised, solid, 0.3 cm by 0.2 cm lesion. The nurse would document the presence of which of the following?
Pustule
Macule
Nodule
Papule
Correct! - Papule
The nurse notes that a client’s capillary refill is 5 seconds. What should this finding indicate to the nurse?
A normal finding
Hypoxia
Infection of the nailbed
Vitamin deficiency
Correct! - Hypoxia
A client tells the nurse that she is having a hard time bringing her hand to her mouth during meals. To assess the client’s range of motion in the elbow, the nurse would have the client demonstrate which of the following?
Circumduction
Internal rotation
Abduction
Flexion
Correct! - Flexion
The nurse asks a client to bring his hands together behind his lower back with his elbows flexed. Which range of motion movement is the nurse assessing?
External rotation
Abduction
Adduction
Internal rotation
Correct! - Internal rotation
The nurse is caring for an African American client admitted to the unit for cirrhosis of the liver. Which of the following areas would the nurse inspect to determine if the client has jaundice?
Eyes
Legs
Ears
Face
Correct - Eyes
During a skin assessment, an adult client asks the nurse, “Why do you need to know about sunburns I had as a kid?” Which of the following is the best response by the nurse?
“Having bad sunburns as a child puts you at risk for skin cancer later in life.”
“When you burn your skin as a child, it makes your skin more sensitive and slower to heal when you’re older.”
“Repeated sunburns in childhood may explain the presence of some of your moles.”
“This is one of the assessments we use to determine how well you took care of your skin when you were young.”
Correct - “Having bad sunburns as a child puts you at risk for skin cancer later in life.”
Assessment of a client’s nails reveals the presence of Beau’s lines. The nurse interprets this finding as suggestive of which of the following?
Vitamin B deficiency
Prolonged oxygen deficiency
Acute illness
Psoriasis
Correct! - Acute illness
The nurse is checking an elderly client for signs of dehydration. Which of the following would be a correct action by the nurse when assessing the client’s skin turgor?
The nurse pinches the skin on the back of the client’s hand.
The nurse pinches the skin on the client’s forearm.
The nurse pinches the skin over the client’s clavicle.
The nurse pinches the skin on the back of the client’s upper arm.
Correct! - The nurse pinches the skin over the client’s clavicle.
The nurse is caring for a client with eczema and extremely dry skin. The nurse notes deep linear cracks to the client’s heels. The nurse would document the assessment findings as which of the following?
Erosion
Fissure
Ulcer
Scar
Correct! - Fissure