Health Assessment

In the mental status examination, the nurse asks a client, “What would you do if you fell and were not able to get back up?” Which client ability is the nurse assessing?

Judgment

A student nurse completes skin and nail assessments for multiple older adult clients. The student nurse identifies which finding as normal?

Wrinkled, dry skin

Thinning of scalp hair

The nurse completes an assessment of an adult client. Which finding indicated to the nurse a possible problem with fluid volume deficit?

Increased hematocrit

The nurse prepares to discharge a client diagnosed with a myocardial infarction (MI). The client will participate in a planned cardiac rehabilitation program. Which instruction does the nurse include in the client’s discharge teaching?

Do physical activities gradually and rest as needed

Follow a low-sodium diet

Continue taking prescribed medications

Report chest pain to the health care provider (HCP)

The nurse enters an adult client’s room and finds the client pale, cool, and unresponsive. The nurse attempts to rouse the client by gently pushing on the chest. Which assessment by the nurse is the priority?

inspect for chest rise and fall

The nurse teaches a class on health promotion activities to older adults at an assisted living facility. The nurse understands what a benefit of weight reduction is.

Decreased risk of developing type 2 diabetes mellitus

Decreased risk of hypertension and stroke

Decreased risk of developing heart disease

The nurse performs health assessments on clients at a clinic. During the interview, the nurse asks a client about an advance directive. Which client statement indicates understanding about a health care proxy?

I asked my adult child to make health care decision for me if I cannot make them for myself

The nurse performs wound care for an older adult client with a venous leg ulcer. Which action is necessary during wound care? (Select all)

Assess wound for healing

Apply dressing as prescribed

Evaluate size and depth of wound

Cleanse wound bed as needed

The nurse teaches the student nurse about the prevention of intravenous (IV) opioid-induced respiratory depression. Which statement by the student nurse requires further teaching?

If sedation is noted, the priority is to notify the health care provider

The nurse on the medical-surgical unit prepares to administer medications to clients. Which client does the nurse assess first?

A client diagnose with heart failure (HF) who is prescribed intravenous (IV) furosemide 40 mg every 12 hours

The nurse provides care for an older adult client diagnosed with cardiovascular disease and hypertension. Which assessment finding does the nurse report immediately to the health care provider?

Redness, warmth, swelling of the calf

When performing a physical assessment, the nurse observes a client’s eye moving involuntarily and rapidly from side to side. Which term does the nurse use to document this observation?

Nystagmus

The nurse treats clients at an urgent care clinic. Which client does the nurse see first?

A client who reports chest heaviness and arm pain

After completing the data collection process of a client’s health history interview, which action does the nurse take first?

summarize the highlights of the interview and permit the client to add or clarify information

The nurse enters a client’s room and finds the client leaning over the bedside table, using accessory muscles, and breathing rapidly. Which assessment finding most concern the nurse?

stridor

Which action does the nurse take when communicating with a client diagnosed with presbycusis?

converses in a well-lit, quiet room

The nurse cares for an adult client diagnosed with gastrointestinal bleeding. The nurse understand which finding is consistent with the compensated stage of shock?

BP 110/70 mmHg

R 24 breath/minute

Respiratory alkalosis

The Informatics nurse prepares an educational session on a new electronic health record (EHR) system. Which benefit of using a computerized documentation system does the nurse include in the session?

enhanced communication between health care providers

clients can communicate electronically with health care providers

diagnostic test results can be viewed in real time

improved client care within a health care facility

a potential source for research

The nurse completes a cardiovascular assessment on a client. The nurse recalls which pulse characteristic is assessed?

Rate

Rhythm

Quality

The nurse teaches a group of nursing students about the physiological effects of stress. Which statements by a student indicate further teaching is needed?

Long-term stress causes minimal effects on the body

The nurse cares for a client newly diagnosed with heart failure as a result of left ventricular hypertrophy. Which assessment is the priority?

auscultating bilateral lung sounds

The nurse in the outpatient clinic receives a phone call from a client reporting a rash. Which action does the nurse take first?

determine if the client is taking any new medications

The nurse admits a client who reports alcohol abuse. Which information obtained during admission indicates to the nurse that this client is at risk for delirium tremens (DTs)?

reports consuming a “six-pack of beer daily”

The nurse provides care to a client who has undergone a lumbar puncture. Which assessment finding does the nurse report to the healthcare provider?

nausea and vomiting

severe headache

increased lethargy

The nurse provides care for a client diagnosed with hypertension. The nurse understands which risk factor most likely contributed to that diagnosis?

the client has a high daily sodium intake

Which statement describes the correct procedure for the nurse to use to examine the fundus of a client’s eye?

examine the pupils with an ophthalmoscope

The nurse performs a neurological assessment on a client. Which action does the nurse take to test the client’s gag reflex?

touches the back of the pharynx with a cotton-tipped applicator

When auscultating a client’s breath sounds, the nurse knows that rhonchi will have which characteristics?

continuous, low-pitches, coarse sounds or vibrations best heard on expiration

The nurse in a clinic is testing a child’s urine for specific gravity, color, and clarity. Which laboratory results does the nurse expect if the urine is normal?

specific gravity 1.020, yellow, clear

To assess a client’s popliteal pulse, the nurse palpates in which location?

the region in the back on the knee

A client’s visual acuity is tested with a Snellen chart and reported to be 20/60. The nurse knows the number 60 indicates which measurement?

The distance at which the client with normal vision can read the chart

The nurse assesses the cardiac status of a client and identifies an increased pulse pressure. The nurse recalls which definition when providing education regarding this phenomenon?

the difference between systolic and diastolic blood pressure readings

The nurse provides care for a client who is diagnosed with a pleural effusion of the left lower lobe. Which sound does the nurse expect to hear when percussing this area of the client’s lung?

Dullness

The nurse places a pulse oximetry probe on a client newly admitted for evaluation of a seizure disorder. The client asks the nurse, “Why do I have to have this thing on me?” Which response does the nurse provide?

It measure the amount of oxygen circulating in your blood

While assessing the pulse oximetry of an adult client, the nurse has difficulty obtaining a reading using the fingertip of a client’s hand. Which factor could contribute to this difficulty?

The client has dark color nail polish on all fingernails

The clinic nurse performs a neurological assessment on a new client. When the right leg is tapped for the patellar reflex, there is no movement. Which action does the nurse take first?

taps the tendon again while the client is pulling against interlaced, locked fingers

The nurse performs a physical assessment of several adult clients, and is most concerned about which set of vital signs?

BP 80/50 mmHg, P128 beat/min, R 28 breaths/min

The nurse begins an initial health interview with a client and collects demographic data. Which is the next focal area of assessment?

Reason for seeking health care now

The nurse prepares to assess a client’s ears and hearing. The nurse gather which piece of equipment?

a tuning fork

an otoscope

After receiving the hand-off shift report, the nurse assesses a client who has Cheyne-Stokes respirations. Which statement describes the breathing pattern the nurse expects to see?

gradual increase in depth of respirations, followed by a gradual decrease in depth, then a period of apnea

The nurse auscultates the lung fields of a client with a diagnosis of heart failure and identifies crackles in the lower left lung field. Which is the best description of crackles?

intermittent non-musical brief clicking sound commonly heard on inspiration

The nurse performs an abdominal assessment on a client. Which is the correct order of a physical examination?

inspection, auscultation, percussion, and palpation

The nurse conducts a physical assessment on a client with a diagnosis of myocardial infarction and assesses the apical pulse. Which finding demonstrates bradycardia?

44 beats/minute

The nurse assesses a client for tactile fremitus during a physical examination. Which part of the hand does the nurse use to perform the assessment?

ulnar and palmar surface of the hand

The nurse cares for a healthy adult client. Which daily urinary output is expected?

1,500 mL

The nurse in the clinic tests the pH of a child’s urine. The nurse expects which result?

pH 6.9

The nurse identifies which location as the correct area to assess the apical pulse?

fifth intercostal space at the left midclavicular line

When assessing the abdomen of a client, the nurse places the client in which position?

supine position with knees flexed