Health Assessment Quiz 1

A nurse begins an assessment by collecting information that the patient personally reports, such as how the patient feels and what symptoms they are experiencing. Which type of data is the nurse collecting?

Subjective data

During an assessment, the nurse records a patient's blood pressure as 138/84 mmHg and observes swelling of the patient's lower extremities. Which statement best describes these findings?

Both findings are objective data

A nurse is preparing to examine a patient who needs to lie flat on their back with their face upward. Which position should the nurse use?

Supine

A patient is positioned lying on their back with their legs raised and supported in stirrups. Which position is the nurse using?

Lithotomy

The nurse needs the patient lying on their stomach with the posterior surface of the body accessible. Which position is most appropriate?

Prone

A nurse positions a patient on their side with their legs slightly bent. Which position is being described?

Lateral recumbent

During a physical assessment, the nurse visually examines the patient for abnormalities such as swelling or other visible changes. Which assessment technique is being used?

Inspection

A nurse uses their fingers and hands to feel a patient's body during an assessment. Which technique is being performed?

Palpation

The nurse taps on the patient's body to cause vibrations that can help assess underlying tissues. Which technique is this?

Percussion

A nurse uses a stethoscope to listen to sounds produced within the patient's body. Which technique is being used?

Auscultation

A nurse compares one side of the patient's body with the other to determine whether the structures appear similar. Which concept is the nurse assessing?

Symmetry

Which situation best represents a surgical wound?

A clean, closed incision created during a surgical procedure

A nurse is reviewing the chain of infection. Which action is most effective for breaking the chain of infection?

Performing proper hand hygiene

A nurse is caring for a patient with an infection and prepares to use precautions designed to protect both the patient and healthcare personnel. Which concept is most directly related to this intervention?

Transmission-based precautions

A patient arrives for care and explains the reason they are seeking healthcare. Which portion of the health history is the nurse addressing?

Chief concern

During the health history, the nurse asks the patient what they expect will happen during the healthcare encounter. Which part of the health history is this?

Patient expectations

A nurse is conducting a patient interview and intentionally works to establish a relationship with the patient. Which of the following is one of the 4 Cs?

Connection

Which group correctly identifies the 4 Cs of interview skills?

Concern, connection, communication, collaboration

A nurse is obtaining a patient's health history. The patient's son offers to translate because the nurse and patient do not share a common language. Which issue should the nurse recognize as requiring appropriate consideration?

Communication during the health history

A nurse is caring for a patient with end-stage HIV. Which type of precautions should guide the nurse's approach according to the material?

Standard precautions

A nurse is preparing to perform hand hygiene with soap and water in a healthcare setting. What should they do?

Washing hands appropriately with soap and water

The nurse removes gloves after caring for a patient and prepares for the next patient encounter. Which action is most consistent with the infection-prevention material?

Perform appropriate hand hygiene

A nurse is assessing a patient and wants to obtain information directly from what the patient says they are experiencing. Which approach is most appropriate?

Collect subjective information during the health history

A nurse is preparing to perform a physical examination. Which sequence contains only techniques specifically identified in the lab guide?

Inspection, palpation, percussion, auscultation

A nurse recognizes that a patient's assessment requires privacy before beginning the examination. Which nursing action best reflects the environmental preparation emphasized in the lab guide?

Provide appropriate privacy before the examination

A nurse notices that a patient's vital signs have changed gradually over several days. Why is trending vital signs specifically important according to the lab guide?

It allows the nurse to identify trends over several hours or days

A nurse is reviewing the factors that can affect vital signs in older adults. Which topic should the nurse specifically review because it is listed as a critical-thinking question?

Factors affecting vital signs of older adults

The nurse is reviewing fever care. Which topic is explicitly included in the lab guide?

Seven nursing interventions for febrile patients

A nurse is preparing to complete the vital-sign assessment. Which set contains only vital signs specifically identified in the guide?

Temperature, pulse, respirations, blood pressure, oxygen saturation

A nurse obtains a patient's radial pulse and then needs to assess another type of pulse specifically listed in the lab guide. Which should the nurse assess?

Apical pulse

A nurse is assessing a patient's breathing. Which vital-sign assessment is being performed?

Respiratory assessment

The nurse places a pulse oximeter on a patient's finger. What is the nurse attempting to measure?

Oxygen saturation

A patient has very cold fingers when the nurse attempts to obtain a pulse-oximeter reading. Which interpretation is most consistent with the lab guide?

Cold fingers may produce an inaccurate reading

A nurse obtains a vital-sign reading that is "way out of the norm." Which issue does the lab guide specifically direct the nurse to consider?

What to do first after obtaining an abnormal reading

A patient has just consumed ice water. The nurse plans to obtain an oral temperature. Which consideration from the lab guide is most important?

The nurse should consider the appropriate waiting period after drinking

A patient is currently drinking coffee when the nurse prepares to obtain an oral temperature. Which statement is most appropriate based strictly on the lab guide?

The nurse should consider the waiting period after drinking before obtaining the oral temperature

Which device is specifically associated with measuring blood pressure?

Sphygmomanometer

A nurse is deciding which portion of a stethoscope to use during an assessment. Which two parts are specifically identified in the guide?

Bell and diaphragm

Which pair represents the two pressures specifically identified when discussing blood pressure?

Systolic and diastolic

A patient's blood pressure is being assessed. Which finding represents the pressure that occurs during the systolic portion of blood pressure?

Systolic pressure

A nurse is reviewing the patient's blood pressure terminology. Which term refers to elevated blood pressure according to the guide?

Hypertension

Which term refers to low blood pressure?

Hypotension

A patient experiences a blood-pressure change associated with changing position. Which term is specifically included in the lab guide?

Postural hypotension

A patient is experiencing an abnormal decrease in blood pressure related to position and is included separately in the guide. Which term is included?

Orthostatic hypotension

A patient is described as having an elevated body temperature. Which term from the guide could describe this condition?

Hyperthermia

A patient is experiencing an abnormally low body temperature. Which term should the nurse recognize?

Hypothermia

A patient is sweating excessively during an assessment. Which term from the lab guide describes this finding?

Diaphoresis

A nurse documents that a patient has stopped breathing. Which term corresponds to this finding?

Apnea

A patient is experiencing a lack of adequate oxygen in the blood. Which term is specifically included in the guide?

Hypoxemia

A patient reports pain that began recently following an injury. Which pain classification is specifically included in the guide?

Acute pain

A patient reports pain that has continued over an extended period. Which classification should the nurse recognize?

Persistent/chronic pain

The nurse begins a pain assessment using PQRST. Which assessment framework is the nurse using?

Pain Assessment PQRST

The nurse wants to identify information about a patient's pain using the PQRST framework listed in the guide. Which action is appropriate?

Use the PQRST pain-assessment framework

A nurse performs a complete assessment of a patient's skin-related structures. Which areas should be included?

Skin, hair, nails, and scalp

A nurse is assessing a patient's skin integrity. Which finding would require the nurse to recognize that the patient's skin condition has changed from normal?

An altered skin condition

A nurse is assessing a patient's wound. Which information should be included in the nurse's documentation according to the lab guide?

Wound assessment findings

A patient has an abdominal incision and is obese. The nurse observes a bulge over the abdomen and determines that the intestinal tract has pushed through the abdominal incision. Which complication is represented by this scenario?

Evisceration

Which term from the lab guide is specifically associated with the intestinal tract pushing through an abdominal incision?

Evisceration

A nurse notes a small amount of shadow drainage on a dressing. Which term is the nurse being asked to recognize in the lab guide?

Shadowing

A wound assessment requires the nurse to document characteristics of the wound. Which action needs to be documented?

Document the wound assessment

A nurse is assessing a patient's skin and notices that hair over an extremity is reduced. Which concept does the lab guide specifically ask the nurse to consider?

What reduced hair over an extremity can indicate

Which term describes loss of hair?

Alopecia

A nurse is assessing a wound and notices tissue that has a dry, dark appearance. Which term from the lab guide should the nurse recognize as a wound-assessment term?

Eschar

A nurse is assessing a wound and observes a drainage material. Which general term for wound drainage is specifically listed?

Exudate

A nurse is assessing a wound and observes drainage that is specifically described as pus-like. Which term from the guide corresponds to this type of drainage?

Purulent

A nurse observes drainage containing blood. Which term is c?

Sanguineous

A nurse documents drainage containing both serous and bloody characteristics. Which term from the lab guide should the nurse recognize?

Serosanguineous

A nurse is assessing the tissue surrounding a wound and is concerned about a firm area. Which term from the guide relates to this assessment?

Induration

A nurse is assessing whether a patient's skin returns appropriately after being gently assessed for elasticity. Which term from the guide is relevant?

Turgor

A nurse observes a wound in which the edges are no longer together. Which wound-related term is correct?

Dehiscence

A nurse observes that the edges of a wound are together. Which term specifically listed in the guide relates to this description?

Approximated

A patient has a wound caused by a scraping injury. Which term is specifically included in the lab guide?

Abrasion

A patient has a wound caused by a penetrating object.

Puncture

A nurse observes a wound caused by a tearing injury. Which term from the guide should the nurse recognize?

Laceration

A nurse is assessing the patient's skin for areas of redness. Which term is specifically included in the lab guide?

Erythema

A nurse observes a yellow discoloration of the patient's skin.

Jaundice

A nurse observes a bluish discoloration of the skin. Which term from the guide corresponds to this finding?

Cyanosis

A patient appears unusually pale. What is the correct term?

Pallor

A nurse observes small pinpoint areas on a patient's skin. Which term is specifically listed in the lab guide?

Petechiae

A nurse observes swelling in a patient's tissue. Which term is correct?

Edema

A patient's skin appears unusually thin. Which term included in the lab guide should the nurse recognize?

Atrophy

A nurse observes excessive sweating. Which term from the guide describes this finding?

Diaphoretic

The nurse is assessing the patient's skin for possible carcinoma. Which assessment framework should be used?

ABCDE

A nurse is assessing a patient for pressure-injury development. Which assessment tool should be used?

Braden Scale

The nurse is asked what the Braden Scale predicts. Which response stays within the content of the uploaded guide?

It is a scale associated with pressure-injury development

What are the pressure injury categories?

Stage 1, Stage 2, Stage 3, Stage 4, deep tissue injury, unstageable wound

A nurse is completing the pressure-injury portion of the lab guide. Which action is specifically included among the skills/topics?

Assessment for pressure-injury development

A nurse is caring for a patient with a wound and prepares to change the dressing. Which skill should be used?

Applying dry and moist dressings

A nurse is preparing to care for a patient's pressure injury. Which skill is specifically identified?

Treating pressure injuries and wounds

Which finding is specifically represented by the term "maceration"

The nurse should recognize it as a wound/skin assessment term