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NUR2092 Health Assessment /
Health Assessment - Exam 1
A patient is admitted to the medical-surgical unit with a diagnosis of hypertension. The nurse is using the nursing process to develop the plan of care. Which steps should the nurse incorporate? A. Assessment, treatment, planning, evaluation, discharge, follow-up B. Admission, assessment, diagnosis, treatment, discharge planning C. Admission, diagnosis, treatment, evaluation, discharge planning D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation - ANSWER D. Assessment, diagnosis, outcome identification, planning, implementation, evaluation The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nurse must analyze and interpret these data before initiating a plan of care. The nurse is incorporating the principles of the quality and safety competencies from the Institute of Medicine (IOM) recommendations into the health assessment of a patient in the long-term care setting. What principles should the nurse consider? Select all that apply: A. Use evidence to support interventions. B. Evaluate the plan of care. C. Use a step-by-step approach to problem solving.
D. Use technologies and informatics in delivering care. E. Place the patient at the center of care. F. Include other disciplines in the plan of care. - ANSWER A, D, E, F Use Evidence to support interventions Use technologies and informatics in delivering care Place the patient at the center of care Include other disciplines in care The Institute of Medicine identified five core competencies as essential for health care professionals to demonstrate how to respond effectively to patient care needs: provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvements, and use informatics. The student nurse is preparing to assess a patient in the hospital clinical setting. Which components best describe the concept of health assessment? Select all that apply: A. Collection of objective data B. Collection of subjective data C. Collection of data and identification of nursing diagnosis D. Planning and evaluation of data E. Analysis of data F. Physical exam G. Documentation of data - ANSWER A, B, F, G Collection of objective data Collection of subjective data Physical exam Documentation of Data
examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility. A patient complains of a cough for 4 days unrelieved with position changes. The nurse interprets this as a symptom and documents the finding under ____________on the patient's chart. A. The nursing care plan B. Assessment C. History D. Vital signs - ANSWER C. History A symptom is something described by the patient and considered subjective; therefore it would be documented under "History." The nurse is administering an influenza (flu) shot to a patient in a retail health setting. Of which level of prevention is this an example? A. Primary B. Secondary C. Post secondary D. Tertiary - ANSWER A. Primary Prevention Vaccinations protect from disease and are considered primary prevention.
A patient tells the nurse that he has had a headache and nausea for 3 days. Which type of assessment should the nurse perform? A. Focused assessment B. Episodic follow-up assessment C. Shift assessment D. Comprehensive health assessment - ANSWER A. focused assessment The type of health assessment performed by the nurse is also driven by patient need. A focused assessment involves a history and examination that are limited to a specific problem or complaint. The nurse is conducting a data analysis on objective information obtained during the health history. What should be included? Select all that apply A. Vital signs B. Pain assessment C. Review of symptoms D. Surgical history E. Social history F. Heart murmur - ANSWER A. Vital signs F. Heart murmur Pain assessment, review of symptoms, surgical history, and social history are considered subjective data. The _______ refers to the circumstances or situations related to the health care delivery. This may be related to the setting or environment; it might relate to
During an interview the nurse learns that a patient has a 5-year history of hypertension. Which health promotion intervention is most appropriate at this time? A. Teaching the patient how to relieve stress to prevent hypertension B. Monitoring and minimizing the progression of hypertension C. Establishing a screening schedule for detection of hypertension D. Advising the patient on the benefits of exercise to lower blood pressure - ANSWER C. Establishing a screening schedule for detection of hypertension A patient reports painful urination for 2 days. The urine is pink tinged and cloudy. What type of data does this information represent? A. Subjective data B. Objective data C. Subjective and objective data D. Secondary source data - ANSWER C. Subjective and objective data Which process does the clustering of data facilitate? A. Analyzing data B. Collecting data C. Implementing nursing care
D. Evaluating nursing care - ANSWER D. Evaluating nursing care During an interview an elderly patient tells the nurse that she has periodic problems keeping her balance. The nurse asks her what she is doing when the episodes occur. Which area of the symptom analysis is the nurse pursuing with this question? A. Severity B. Frequency C Aggravating factors D. Location - ANSWER 3. Aggravating factors The nurse is conducting an interview. During an interview, the primary type of data being collected is: A. Subjective data B. Objective data C. Secondary data D. Recent data - ANSWER A. Subjective Data Subjective data is what the patient tells you.
B. Maintaining privacy C. Asking open-ended questions D. Conducting a fast, efficient interview E. Obtaining answer to questions in advance F. Asking closed-ended questions G. Asking how the patient is feeling today - ANSWER B, C, G Maintaining privacy Asking open ended questions Asking how the patient is feeling today Numerous factors affect the interview and the communication process, including the physical setting, nurses behaviors, the type of questions asked and how they are asked. In addition, the personality and behavior of patients, how they are feeling at the time of the interview, and the nature of information being discussed or problem being confronted may affect the data revealed. The nurse is conducting an interview with a patient who is mentally challenged. The nurse knows that ____________ assessment is the preferred method for this interview. A. Comprehensive B. Focused C. Family D. Health risk - ANSWER B. Focused Conducting an interview with a patient in physical or emotional distress is difficult. In such case, use a focused assessment to limit the number and nature of questions to those absolutely necessary for the given situation, and save additional questions for a later time.
In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the __________________________. A. History of present illness B. Biographic data C. Present health status D. Review of symptoms - ANSWER C. History of present illness This may be a problem or a routine health care issue. The nurse needs to assess an adolescent patient's risk for sexually transmitted diseases. What technique shows the most sensitivity? A. "Statistics show that teens between the ages of 14 and 20 are at high risk for sexually transmitted diseases. Would you more like information?" B. "What do you rate your risk of sexually transmitted disease?" C. Ask the parent, "Have you talked to your teen about sexually transmitted diseases?" D. "Many young people have questions regarding sexually transmitted diseases. What questions do you have?" - ANSWER D. "Many young people have questions regarding sexually transmitted diseases. What questions do you have?" When asking questions about sensitive issues, the nurse explains that there are personal or sensitive questions to ask. Another technique is referred to as
This process can be used with any complaint a patient may have. The nurse is preparing to assess a patient in the hospital setting. What should the nurse do first? A. Don gloves B. Wear a mask C. Don goggles D. Wash hands - ANSWER D. Wash hands Hand hygiene is considered to be the single most important action to reduce transmission of infection and is considered an essential element of standard precautions. The nurse is assessing a superficial mass on a patient skin surface. Which part of the hand is used to palpate a superficial mass in the skin? A. The fingertips B. The heel of the hand C. The dorsal surface of the hand D. The ulnar surface of the hand - ANSWER A. the fingertips The fingertips are the most sensitive part of the hand and are used for superficial palpation.
The nurse is percussing the liver of an obese patient. Which percussion finding would be expected? A. Tones with a booming quality B. An enhanced tone quality C. A higher pitch tone than in patients of a normal weight D. A reduced intensity of tone - ANSWER D. A reduced intensity of tone The thickness of tissue can impair vibrations, causing quieter percussion tones The nurse should use a(n) _________to auscultate the chest and abdomen. A. Doppler B. Stethoscope C. Audiometer D. Transilluminator - ANSWER B. Stethoscope A stethoscope assists in the identification of internal sounds. The nurse is palpating the abdomen of a patient. How deep should the hands press while performing deep palpation? A. 1 cm B. 2 cm C. 4 cm D. 8 cm - ANSWER C. 4 cm Deep palpation is done with one or two hands to a depth of 1.6 inches or 4 cm
Which are considered basic techniques for physical assessment? Select all that apply: A. Palpation B. Medication reconciliation C. Inspection D. Auscultation E. History of present illness F. Percussion - ANSWER A. Palpation C. Inspection D. Auscultation F. Percussion Data for physical assessment are collected using four basic assessment techniques: inspection, palpation, percussion, and auscultation The nurse suspects that a patient has a fungal infection of the skin. Which instrument helps confirm this suspicion? A. Wood's lamp B. Otoscope C. Sniff test D. Slit lamp - ANSWER A. woods lamp A Wood's lamp is used to detect fungal infections of the skin. Lesions of the skin appear as a fluorescent yellow-green or blue-green color.
The nurse is obtaining a pulse oximeter reading on an adult patient. Where is the probe of a pulse oximeter placed? A. In the mouth or under the arm B. On the ear C. On the tip of a finger or toe or on an ear lobe D. In the rectum - ANSWER C. On the tip of a finger or toe or on an ear lobe It is important to know how to attach the probe. The nurse is percussing a patient's abdomen. What sound will the nurse most likely percuss? A. Resonance B. Dullness C. Tympany D. Flatness - ANSWER C. Tympany Tympany is normally heard over the abdomen The nurse is percussing a patient's Lungs. What sound will the nurse most likely percuss? A. Resonance B. Dullness C. Tympany
The nurse is taking a patient's oral temperature. How should the nurse perform the procedure? The thermometer should be placed: A. Under the tongue next to the frenulum of lower lip B. Under the tongue in the posterior sublingual pocket C. Between the tongue and the hard palate D. Along the outer aspect of the lower molars and against the cheek - ANSWER B. Under the tongue in the posterior sublingual pocket Placing the thermometer under the tongue in the posterior sublingual pocket provides the most accurate temperature. The nurse is counting an infant's respirations. Which technique is correct? A. Watch the chest rise and fall. B. Watch the abdomen for movement. C. Place a hand across the infant's chest. D. Use a stethoscope to listen to the breath sounds. - ANSWER B. Watch the abdomen for movement. Watch the infant's abdomen for movement because the infant's respirations are normally more diaphragmatic than thoracic. The nurse is auscultating the lungs to listen for breath sounds. What sounds will indicate that the nurse is auscultating correctly?
A. The nurse will hear the diffusion of air and carbon dioxide. B. The nurse will hear the air move in and out of the lungs. C. The nurse will hear a "lub/dub" sound. D. The nurse will hear gurgling noises. - ANSWER B. The nurse will hear the air move in and out of the lungs. If the stethoscope is placed over the lung fields, the nurse should hear air moving in and out of the lungs. The nurse knows that the _______ blood vessels should be used to assess an adult's blood pressure. A. Carotid artery B. Brachial vein C. Brachial artery D. Radial artery - ANSWER C. Brachial artery The brachial artery is found near the antecubital space. An adult patient is being assessed in the outpatient clinic secondary to a recent weight loss. Why is the weight of an adult patient measured routinely during a physical assessment? A. It allows assessment of body fat content. B. A change in body weight can be indicative of health problems.
