course point Q&A

Question 1

What type of assessment includes a health history and physical assessment?

Answer 1

comprehensive

Question 2

Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?

Answer 2

nurse

Question 3

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?

Answer 3

objective

Question 4

What is the primary purpose of health assessment?

Answer 4

To gather information about the health status of the client

Question 5

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

Answer 5

take a complete health history

Question 6

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?

Answer 6

A baseline for comparison with future findings

Question 7

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?

Answer 7

Assessment

Question 8

During a health class, the nurse is emphasizing exercise and healthy eating. The level of prevention being utilized by the nurse is

Answer 8

primary prevention

Question 9

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?

Answer 9

“I try to think about alternatives before making a decision.”

Question 10

The nurse recognizes the following to be a necessary component of performing an accurate assessment.(Select all that apply.)

Answer 10

Validation of data
Documentation of data
Collection and organization of data

Question 11

The nursing student demonstrates a need for further teaching when she states which of the following?

Answer 11

Patients do not need to understand their problems.

Question 12

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

Answer 12

nursing diagnosis

Question 13

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?

Answer 13

Reassess blood pressure

Question 14

One characteristic of a nurse who is a critical thinker is the ability to

Answer 14

validate information and judgments.

Question 15

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?

Answer 15

Ask the client for opinions and willingness to proceed with the interventions.

Question 16

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.

Answer 16

seeing things as only right or wrong

Question 17

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?

Answer 17

To identify diseases for which the patient may be at risk

Question 18

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?

Answer 18

What type of reaction did the patient experience?

Question 19

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?

Answer 19

self-perception/self-concept

Question 20

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?

Answer 20

Asking open-ended questions

Question 21

A genogram is developed to visually show what?

Answer 21

Family health patterns

Question 22

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?

Answer 22

Use medical terminology when documenting in the medical record

Question 23

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.

Answer 23

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

Question 24

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?

Answer 24

History of present illness

Question 25

A comprehensive health history includes which components? Select all that apply.

Answer 25

Past health history
Reason for seeking care
History of present illness

Question 26

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?

Answer 26

Personal and social history

Question 27

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?

Answer 27

To remember the elements that are important to assess with a symptom

Question 28

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?

Answer 28

Severity

Question 29

How should the nurse document a patient’s chief complaint of right hip pain for the comprehensive health history?

Answer 29

“I have pain in my right hip when I walk.”

Question 30

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

Answer 30

focused assessment

Question 31

The review of systems component of the health history is best described as which of the following?

Answer 31

A focus on symptoms related to each of the different body systems

Question 32

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?

Answer 32

Close the door to the client’s room

Question 33

To alleviate a client’s anxiety during a comprehensive assessment, the nurse should

Answer 33

explain each procedure being performed and the reason for the procedure.

Question 34

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?

Answer 34

Inspection

Question 35

Which action by a nurse is appropriate before beginning a physical examination of a client?

Answer 35

Wash hands before examination in the examination room

Question 36

What tool does the nurse use to auscultate the client’s abdomen?

Answer 36

Stethoscope

Question 37

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?

Answer 37

Practice performing a physical examination on a classmate, friend, or relative.

Question 38

Which of the following would be most important for the nurse to do immediately before beginning the physical exam?

Answer 38

Collect necessary equipment essential to the exam.

Question 39

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?

Answer 39

Color

Question 40

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?

Answer 40

Cough into the inner aspect of the elbow.

Question 41

While performing a physical examination on an older adult, the nurse should plan to

Answer 41

use minimal position changes.

Question 42

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?

Answer 42

Vital signs

Question 43

A nurse is preparing to assess a client’s abdomen. Which client position would be best for this assessment?

Answer 43

Supine

Question 44

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?

Answer 44

Otoscope

Question 45

The nurse is applying standard precautions by performing which of the following?

Answer 45

Wears gloves to palpate the tongue and buccal membranes

Question 46

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?

Answer 46

Inspection, palpation, percussion, auscultation

Question 47

What action by a nurse demonstrates the correct technique when using a stethoscope for auscultation?

Answer 47

Ensure that contact with the skin is maintained

Question 48

Which of the following is a component of the general survey?

Answer 48

Patient’s state of hygiene

Inspection, palpation, percussion, auscultation