Health Assessment Test 1

The nurse is assessing a client’s temperature with a temporal artery thermometer. Which step ensures an accurate reading?

acclimate device to room temp for 30 minutes

The nurse is assessing pain in a child aged 4 years. Which pain scales are appropriate for this?

Wong-Baker FACES and/or Oucher Scale

The nurse observes a client with Cheyne-Stokes respirations. Which description best explains this pattern?

alternating periods of deep, rapid breathing followed by apnea

The nurse measures a client’s blood pressure as 148/92 mm Hg. According to American College of Cardiology/American Heart Association guidelines, how should this be classified?

Stage 2 hypertension

The nurse is assessing respirations. The client appears anxious, with a rate of 28 breaths per minute. Which term best describes this finding?

Tachypnea

The nurse enters the client’s room to begin the general survey. Which observation would be considered an expected finding?

symmetrical facial features and relaxed expression

The nurse notes that a client’s stated age is 55, but the client appears closer to 70. Which factor should the nurse consider as a possible cause?

chronic illness and prolonged sun exposure

The nurse prepares to take a client’s blood pressure. Which action will result in a falsely low reading?

arm positioned above heart level

While assessing a client’s pulse, the nurse notes a pulse volume of “+1/4.” How should this be interpreted?

weak or thready pulse

The nurse is assessing an older client with suspected orthostatic hypotension. What findings would support this diagnosis? (3)

drop is systolic BP greater than 30 mm Hg when standing, report of dizziness when rising, syncope upon standing

The nurse assesses a client’s apical and radial pulses simultaneously and finds a difference of 8 beats per minute. What does this indicate?

pulse deficit

During the general survey, the nurse notices a strong musty-sweet odor on a client’s breath. Which condition should the nurse suspect?

liver failure with portal hypertension

The nurse is reviewing physiologic factors that can increase heart rate. What are they? (4)

hyperthyroidism, fever, pain, anxiety

The nurse prepares to percuss the client’s thorax during a respiratory exam. Which finding is expected over healthy lung tissue?

resonance, low-pitched and hollow

The nurse prepares to begin a physical examination of a client who appears nervous. Which action will be most effective to reduce the client’s anxiety and promote cooperation?

explain the purpose of the exam and what the client can expect

The nurse instructs a client on preparing for a physical exam. Which statement indicates the client requires further teaching?

“I should eat a large meal right before the exam so I don’t get hungry?.”

The nurse plans to palpate the abdomen of a client with suspected appendicitis. Which principle should guide the nurse’s technique?

warm hands and explain each step before palpating

The nurse is palpating the thyroid gland during a neck assessment. Which technique ensures accurate findings?

stand behind the client and use finger pads to palpate gently while the client swallows

During a head-to-toe assessment, the nurse notes that a client grimaces when the stethoscope touches their chest. Which nursing action is best?

warm the stethoscope before continuing with the exam

The nurse reviews the “golden rules” for physical examination. What principles are emphasized in these rules? (3)

always compare right and left sides for symmetry, perform the exam systematically in the same order each time, stand on the right side of the client whenever possible

The nurse is teaching a group of students about techniques for palpation. What are they? (4)

the dorsum of the hand is best for detecting temperature, the ulnar surface is useful for assessing vibrations such as fremitus, finger pads provide the most sensitive discrimination for texture and masses, the ulnar aspect of the closed fist is best for direct fist percussion

The nurse prepares a room for a comprehensive physical examination. Which action demonstrates best practice?

provide adequate lighting and a warm, private space

A nurse percusses over a client’s left lower lobe and hears a dull, high-pitched sound where resonance is expected. What is the most likely interpretation?

consolidation from pneumonia

A client asks the nurse, “Why do you listen with different sides of the stethoscope?” Which response by the nurse is correct?

“The diaphragm is used for high-pitch sounds, and the bell is used for low-pitched sounds.”

The nurse auscultates the abdomen of a client who has not eaten for 12 hours. Which finding is expected?

hypoactive bowel sounds occurring every 5-15 seconds

The nurse reviews infection control measures with a client undergoing assessment. Which are included in Standard Precautions? (3)

performing hand hygiene before and after client contact, using PPE as appropriate, disinfecting equipment between clients

The nursing is explaining infection control measures to a client family, these include: gowns, gloves, and surgical mask. Which transmission-based precaution is being implemented?

droplet

The nurse is obtaining a health history from a new client. Which approach best ensures that the information gathered about the chief complaint is complete and accurate?

use a systematic format such as OLD CARTS or PQRST to explore the complaint

During a health history interview, a client reports feeling “dizzy” but cannot describe the sensation further. What should the nurse do first?

ask the client to clarify what “dizzy” means to them

The nurse asks a client, “What does this pain mean to you? How is it affecting your daily activities?” These questions assess which characteristic of the chief complaint?

meaning and impact

A client reports sharp chest pain that occurs only when climbing stairs. Which characteristic of the chief complaint does this best represent?

setting

Which considerations should the nurse include to ensure a respectful and effective health history interview? (3)

document client’s sexual orientation, ask about history of substance use, inform the client about the duration of the health history

The nurse is documenting a health history and notes: “Client reports burning pain in epigastric area, rated 6/10, occurring after meals.” Which part of the chief complaint is most clearly described in this entry?

quality

The nurse is gathering information for a family health history. Which items are essential to include? (3)

age and current health status of immediate family, causes of death in immediate family members, genetic diseases present in the family

The nurse is asking a client about their abdominal pain and says, “What makes it better or worse?” This question addresses which element of the chief complaint?

aggravating and alleviating factors

Which element is included when documenting the date and time of a health history in the medical record? (2)

exact calendar date of the interview, time the interview began

When gathering a past health history, which items should the nurse include? (3)

all prior surgeries and their outcomes, complete list of current and past medications, history of communicable diseases

The nurse is assessing a client’s chief complaint of abdominal pain. The client states, “It starts near my belly button and sometimes moves toward my right side.” Which characteristic of the chief complaint is the nurse documenting?

radiation

A nurse is interviewing a client who reports shortness of breath and wheezing. The nurse asks, “Do you have any chest tightness or coughing with this?” This question addresses which characteristic of the chief complaint?

associated manifestations

Define critical thinking.

the skill of using logic and reasoning to identify the strengths and weaknesses of alternative health-care solutions, conclusions, or approaches to clinical or practice problems

Define clinical reasoning.

The application of critical thinking in a clinical situation, and the ability to understand the relevance of evidence and scientific knowledge as it applies to a client

Define clinical judgement.

An iterative process that uses nursing knowledge to observe and assess situations, identify client priorities, and generate the best evidence-based solutions to deliver safe care

What are the 6 components of critical thinking?

interpretation, analysis, inference, explanation, evaluation, self-regulation

Define interpretation as regarding to critical thinking.

Nurses must be able to uncover underlying concerns and decode clients’ real reasons for seeking care

Define analysis as regarding to critical thinking.

Identifying inconsistencies in a client's story and understanding why they exist, which helps nurses recognize key themes or issues that may not be immediately obvious

Define inference as regarding to critical thinking.

A higher-level skill that involves drawing conclusions from stated information and underlying assumptions

Define explanation as regarding to critical thinking.

Providing rationale based on evidence to justify conclusions

Define evaluation as regarding to critical thinking.

Implementing an intervention, reassessing outcomes, and deciding if the care provided resolved the problem

Define self-regulation as regarding to critical thinking.

Reflection on one’s own thinking process and how personal biases may have affected care

What are the 9 universal intellectual standards (UIS) for critical thinking?

clarity, accuracy, precision, relevance, depth, breadth, logic, significance, fairness

Define breadth as regarding to UIS.

Consider multiple perspectives or sources of information, including input from family or significant others if appropriate

What are the 6 aspects of the nursing process per the ANA?

assessment, diagnosis, outcomes identification, planning, implementation, evaluation

What is the assessment aspect of the nursing process?

systematic data collection related to the clients health status including health history, physical examination findings, and diagnostic/lab data

What is the diagnosis aspect of the nursing process?

analyzing data to identify actual or potential health problems to then select a nursing diagnosis

What are the 3 types of nursing diagnoses?

problem-focused, health promotion, and risk

What is the outcomes identification aspect of the nursing process?

broad client goals are set which then turn into client outcomes which are specific and measurable

What is the planning aspect of the nursing process?

consisting of three types: prioritization, intervention selection, and EBP

What is the implementation aspect of the nursing process?

executing interventions chosen during planning stage, a dynamic process with continuous interactions

What is the evaluation aspect of the nursing process?

done in collaboration with client, seeing if outcomes were met and adjusting as needed

What are the 6 aspects of the nursing clinical judgement measurement model (NCJMM)?

recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes

What is SBAR?

the standardized verbal communication or hand-off method; situation, background, assessment, recommendation

What are the 3 most common methods of written documentation?

CBE (charting by exception), SOAP (subjective, objective, analysis, plan), and PIE (problem, intervention, evaluation)

What are the 3 stages of the client interview?

1. Joining stage

2. Working stage

3. Termination stage

What are factors that influence the client interview? (6)

approach, environment, confidentiality/HIPAA, note taking, time/length/duration, self-awareness

What are factors that affect communication during the client interview? (4)

listening, nonverbal cues, distance, personal space

What are the 4 effective communication techniques for client interviews?

open-ended questions, closed questions, facilitating, using silence

What are communication facilitators?

ensuring privacy, allocating adequate time, maintaining comfortable eye level, using plain language, demonstrating nonjudgmental attitude, using professional interpreters as needed

What are communication hindrances?

environmental noise, interruptions, acute pain, fatigue, severe anxiety, language barriers, medical jargon, rushed pace, personal bias or judgement

What are the 8 ways to give listening responses during the client interview?

making observations, restating, reflecting, clarifying, interpreting, sequencing, encouraging comparisons, summarizing, silence

What are the 8 ways to give action responses during the client interview?

focusing, exploring, presenting reality, confronting, informing, collaborating, limit setting, normalizing

What are the 6 nontherapeutic communication techniques for the client interview?

requesting an explanation, probing, offering false reassurance, giving approval/disapproval, defending, advising

What are the 7 problematic questioning techniques for the client interview?

leading questions, interrupting, neglecting to ask pertinent questions, talkativeness, multiple questions at once, medical jargon, authoritative

What are the 4 types of health history?

complete, episodic, interval/follow-up, emergency

Define complete health history.

comprehensive history of client’s past and present health status, usually obtained during initial visit to establish a baseline

Define episodic health history

specific to the client’s reason for seeking care

Define interval or follow-up health history.

builds on previous visit and documents recovery (or nonrecovery) from illness

Define emergency health history.

only gathering information that is required immediately to treat emergency needs

What are the 5 aspects of the complete health history?

date, biographical data, source/reliability of information, client profile, chief complaint

Define C.O.L.D. C.A.R.T.S.

chief complaint, onset, location, duration, character, aggravating/relieving, timing, severity

What are the 10 aspects of past health history?

medical history, surgical history, allergies (all), medications (prescription, OTC, vitamins, supplements), communicable diseases, injuries/accidents, differing abilities, blood transfusions, childhood illnesses, immunizations

What are the 3 aspects of family health history?

health status of immediate blood relatives, identifying familial disease/genogram, determining need for screening(s)

What are the 18 aspects of social history?

alcohol use, tobacco use, recreational drug use, vaping, intimate partner violence, sexual practices, travel history, work environment, home environment, hobbies, stress, education, economic status, military service, religion, ethnic background, roles/relationships, characteristic patterns of daily living/ADLs

What are the pillars of legally defensible documentation (FACT)?

factual (objective, quotes), accurate (measurements, times, correct terms), complete, timely

What are the best practices and legal guardrails regarding documentation?

avoid subjective judgement, direct client quotes, adhering to HIPAA

What are the 3 types of transmission-based precautions?

contact, droplet, airborne

Define contact precautions.

used for infections that can be spread directly from person to person (ex: MRSE, impetigo, scabies, varicella-zoster virus)

Define droplet precautions.

used for infections that are spread when microorganisms are deposited on susceptible body parts via respiratory secretions (ex: rhinovirus, adenovirus, group A strep)

Define airborne precautions.

used for infections that spread through air currents and inhalation (ex: measles, varicella, TB)

What are factors that should be established regarding the physical examination environment?

privacy and modesty, lighting, room temp, acoustics and noise control, ergonomics and safety

What are the 4 physical examination techniques for objective data collection?

inspection, palpation, percussion, auscultation

Define inspection as regarding to physical examination techniques.

using the senses of vision and smell to assess client

Define palpation as regarding to physical examination techniques.

therapeutic touch to elicit information, can be light or deep

Define percussion as regarding to physical examination techniques.

striking one object against another to evaluate underlying structures to cause vibrations that produce sound, analyzed using: intensity, duration, pitch, quality, location

Define auscultation as regarding to physical examination techniques.

actively listening to body organs, can be direct (unaided ear) or indirect (using stethoscope)

What are the aspects of general survey?

physical presence and psychological presence

What are the factors for assessing distress?

triage immediately for cardiopulmonary distress (nasal flaring, tripod, cyanosis), acute pain (grimacing, guarding), or emotional agitation

What are the 5 components of vitals?

respiration, pulse, temperature, blood pressure, pain

What is included in the respiratory assessment when collecting vital signs?

count respiration rate which checking pulse, normal is 12-20 for adults, counting over 1 minute time

Define tachypnea.

greater than 20 breaths per minute; common causes include hypoxia, metabolic acidosis, fever, stress/anxiety, stimulants

Define bradypnea.

less than 12 breaths per minute; common causes include head injury, meds, alcohol