course point Q&A Flashcards
What type of assessment includes a health history and physical assessment?
comprehensive
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
nurse
A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?
objective
What is the primary purpose of health assessment?
To gather information about the health status of the client
The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient’s hospital stay. Before the physical examination, the nurse should first
take a complete health history
A student nurse is learning to document an initial assessment. What would the instructor tell the student that accurate documentation of this specific assessment best provides?
A baseline for comparison with future findings
After teaching a group of student about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phases as most important?
Assessment
During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is
primary prevention
As part of a class assignment, each student is to ask another student questions to determine that student’s critical thinking skills. Which of the following responses would reflect that the student has some critical thinking skills?
“I try to think about alternatives before making a decision.”
The nurse recognizes the following to be a necessary component of performing an accurate assessment.(Select all that apply.)
Validation of data
Documentation of data
Collection and organization of data
The nursing student demonstrates a need for further teaching when she states which of the following?
Patients do not need to understand their problems.
The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?
nursing intervention nursing rationale data organization nursing diagnosis
nursing diagnosis
The nurse identifies the UAP recorded the client’s blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?
Reassess blood pressure
One characteristic of a nurse who is a critical thinker is the ability to
validate information and judgments.
The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?
Ask the client for opinions and willingness to proceed with the interventions.
The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.
seeing things as only right or wrong
The nurse is asking the patient about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?
To identify diseases for which the patient may be at risk
The nurse is performing a health history on a patient with mild chest pain who came to the Emergency Department. When asked about his allergies, the patient states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a patient states an allergy?
What type of reaction did the patient experience?
The nurse is taking a health history on a newly admitted patient. When the nurse asks, “How would you describe yourself?” the nurse is assessing which of the following?
self-perception/self-concept
The student nurse is studying therapeutic communication and realizes that it is an important aspect of collecting a health history. When gathering information about the patient’s current illness, the student nurse understands that she should use which technique?
Asking open-ended questions
A genogram is developed to visually show what?
Family health patterns
The nursing instructor is explaining to students the difference between the language used when a nurse talks to the client and the language used when documenting in the medical record. What would the instructor tell the students about documenting in the medical record?
Use medical terminology when documenting in the medical record
During the comprehensive health assessment, the nurse asks several questions relating to the client’s family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.
To identify genetic family trends for which the client is at risk
To help identify those diseases for which the client may be at risk
To provide counseling and health teaching in high-risk areas
The nurse is assessing the seven attributes of a client’s symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?
History of present illness
A comprehensive health history includes which components? Select all that apply.
Past health history
Reason for seeking care
History of present illness
The nurse would document driving with car seatbelt fastened, bicycling with properly-fitted helmet, and installing a smoke detector in a vacation home in the client’s health history under which of the following?
Personal and social history
The nursing instructor explains that sometimes a nurse uses a mnemonic, such as OLDCARTS, as the nurse completes the assessment. What is the purpose of the mnemonic?
To remember the elements that are important to assess with a symptom
Jason, a 41-year-old electrician, presents to the clinic for evaluation of shortness of breath, which occurs with exertion and improves with rest. The shortness of breath has been occurring for several months. Initially, it happened only a few times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than 12 times a day. The shortness of breath lasts for fewer than 5 minutes at a time. The client has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?
Severity
How should the nurse document a patient’s chief complaint of right hip pain for the comprehensive health history?
“I have pain in my right hip when I walk.”
A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the
focused assessment
The review of systems component of the health history is best described as which of the following?
A focus on symptoms related to each of the different body systems
As a nurse is assessing a client and asking her questions, the nurse notices that the client stops talking and looks up anxiously each time someone passes by in the hallway outside her hospital room. Which nursing intervention would most likely address the client’s concern and promote enhanced communication in this situation?
Close the door to the client’s room
To alleviate a client’s anxiety during a comprehensive assessment, the nurse should
explain each procedure being performed and the reason for the procedure.
An instructor is describing the four basic physical examination techniques and their sequence. The instructor determines that the teaching was successful when the students identify which technique as always being done first?
Inspection
Which action by a nurse is appropriate before beginning a physical examination of a client?
Wash hands before examination in the examination room
What tool does the nurse use to auscultate the client’s abdomen?
Stethoscope
practiceA nursing student will soon be graduating and beginning a new job at a local health clinic. The nursing student is excited about the new career but also anxious about performing physical assessments of actual clients. Which of the following would be the best way for this student to gain confidence in assessment skills?
Practice performing a physical examination on a classmate, friend, or relative.
Which of the following would be most important for the nurse to do immediately before beginning the physical exam?
Collect necessary equipment essential to the exam.
A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?
Color
A nurse, who suffers from a respiratory infection, is preparing to perform a shift assessment on a client when she feels the urge to cough. What is the nurse’s best action?
Cough into the inner aspect of the elbow.
While performing a physical examination on an older adult, the nurse should plan to
use minimal position changes.
The nurse is preparing to perform a physical examination on a female client who has been transferred to the medical unit from the emergency department. The nurse should begin the collection of objective data with which of the following examinations?
Vital signs
A nurse is preparing to assess a client’s abdomen. Which client position would be best for this assessment?
Supine
A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this?
Otoscope
The nurse is applying standard precautions by performing which of the following?
Wears gloves to palpate the tongue and buccal membranes
A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?
Inspection, palpation, percussion, auscultation
What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?
Ensure that contact with the skin is maintained
Which of the following is a component of the general survey?
Patient’s state of hygiene
Inspection, palpation, percussion, auscultation
