Assessment I
Assessment II
Assessment III
Health Assessment Key Terms I
Health Assessment Key Terms II
100

The nurse is preparing to assess the remote memory of a client who has a diagnosis of early stage Alzheimer disease. Which question would be most appropriate for the nurse to use?

  • “Can you tell me what you have eaten in the last 24 hours?”
  • “When did you get your first job?”
  • “What did you do last evening?”
  • “How are an apple and orange the same?”
  • “Can you tell me what you have eaten in the last 24 hours?”
  • “When did you get your first job?”
  • “What did you do last evening?”
  • “How are an apple and orange the same?”
100

When preparing to obtain information about a client's mental and psychosocial status, what would the nurse do first?

  • Question the patient about their usual lifestyle and behaviors.
  • Perform a neurologic examination to determine any deficits.
  • Check the client's level of consciousness for changes.
  • Explain the purpose of the exam and types of questions.
  • Question the patient about their usual lifestyle and behaviors.
  • Perform a neurologic examination to determine any deficits.
  • Check the client's level of consciousness for changes.
  • Explain the purpose of the exam and types of questions.
100

A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. What would lead the nurse to suspect that the client has Alzheimer disease? Select all that apply.

  • “He repeats the same story, word for word, over and over again.”
  • “He took a fall when he was replacing a light bulb last month.”
  • “I have to balance the checkbook now because he just won't do it.”
  • “If I don't tell him when to shower, he won't and will fight me on it.”
  • “He got lost walking to the pharmacy around the corner the other day.”
  • “He repeats the same story, word for word, over and over again.”
  • “He took a fall when he was replacing a light bulb last month.”
  • “I have to balance the checkbook now because he just won't do it.”
  • “If I don't tell him when to shower, he won't and will fight me on it.”
  • “He got lost walking to the pharmacy around the corner the other day.”
100

Redness of the skin

Erythema: redness of the skin

100

Paleness of the skin

Pallor: paleness of the skin

200

When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free flow of thought and the woman's ability to follow directions. What would the nurse do first?

  • Use a Geriatric Depression Scale.
  • Refer for further medical evaluation.
  • Assess the client's vision and hearing.
  • Refer the client to social services for home assistance.
  • Use a Geriatric Depression Scale.
  • Refer for further medical evaluation.
  • Assess the client's vision and hearing.
  • Refer the client to social services for home assistance.
200

The nurse begins the physical examination of a newly admitted client by assessing the client's mental status. What is the nurse's best rationale for performing the mental status exam early in the assessment?

  • The client will be less anxious, providing the nurse with more accurate and reliable data.
  • The exam can provide clues about the validity of the client's responses now and throughout.
  • The exam provides data about mental health problems that the client may be afraid to report.
  • The client's fears about having a serious illness may be alleviated by the results of the exam.
  • The client will be less anxious, providing the nurse with more accurate and reliable data.
  • The exam can provide clues about the validity of the client's responses now and throughout.
  • The exam provides data about mental health problems that the client may be afraid to report.
  • The client's fears about having a serious illness may be alleviated by the results of the exam.
200

A nurse is assessing a client who is exhibiting decorticate posturing. What would the nurse observe?

  • Extended upper extremities
  • Internally rotated lower extremities
  • Pronated forearms
  • Flexed hands at the side of the body
  • Extended upper extremities
  • Internally rotated lower extremities
  • Pronated forearms
  • Flexed hands at the side of the body
200

Method of examining by feeling a part of the body with the fingers or hand

Palpation: method of examining by feeling a part of the body with the fingers or hand

200

Abnormal breath sound heard over the lungs

Adventitious breath sounds: abnormal breath sound heard over the lungs

300

The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. What would be the nurse's priority assessment at this time?

  • Asking whether the client often feels cold
  • Assessing the client's developmental level
  • Reviewing the client's culture for possible influence
  • Observing the client's overall hygiene
  • Asking whether the client often feels cold
  • Assessing the client's developmental level
  • Reviewing the client's culture for possible influence
  • Observing the client's overall hygiene
300

Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?

  • Obtunded
  • Stupor
  • Coma
  • Lethargy
  • Obtunded
  • Stupor
  • Coma
  • Lethargy
300

The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would interpret this to indicate that the client is experiencing:

  • Confusion
  • Anxiety
  • Powerlessness
  • Restlessness
  • Confusion
  • Anxiety
  • Powerlessness
  • Restlessness
300

Physical examination of all body systems in a systematic manner as part of the nursing assessment

Review of systems: physical examination of all body systems in a systematic manner as part of the nursing assessment

300

Purposeful and systematic observation

Inspection: purposeful and systematic observation

400

A nurse assesses a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong body odor. The client mentions that she was evicted from her apartment 2 weeks ago. Which nursing diagnosis would the nurse identify for this client?

  • Caregiver role strain related to fatigue
  • Impaired skin integrity related to neurologic deficits
  • Deficient fluid volume related to possible urinary tract infection
  • Self-care deficit related to possible homelessness
  • Caregiver role strain related to fatigue
  • Impaired skin integrity related to neurologic deficits
  • Deficient fluid volume related to possible urinary tract infection
  • Self-care deficit related to possible homelessness
400

The nurse is assessing a client using the Glasgow Coma Scale following an acute hypoglycemic episode and obtains a score of 14. The nurse interprets this as indicating which of the following?

  • Deep coma
  • Coma
  • Obtunded
  • Alert and oriented
  • Deep coma
  • Coma
  • Obtunded
  • Alert and oriented
400

A nurse asks a client the following question: “What do you do if you have pain?” The nurse is assessing what aspect of cognitive function?

  • Orientation
  • Judgment
  • Abstract reasoning
  • Memory
  • Orientation
  • Judgment
  • Abstract reasoning
  • Memory
400

Tension of the skin determined by its hydration

Turgor: tension of the skin determined by its hydration

400

Accumulation of fluid in extracellular spaces

Edema: accumulation of fluid in extracellular spaces

500

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principle would guide the nurse's assessment of the client's mental status?

  • The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing.
  • The nurse should first explain to the couple that senility is expected among adults over age 80.
  • The nurse must differentiate between age-related changes and the signs and symptoms of dementia.
  • The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary.
  • The nurse must modify the cognitive assessment to exclude assessments requiring reading or writing.
  • The nurse should first explain to the couple that senility is expected among adults over age 80.
  • The nurse must differentiate between age-related changes and the signs and symptoms of dementia.
  • The nurse must explain that the results of the assessment will be used to determine if admission to long-term care is necessary.
500

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability?

  • Gently shake the client's right shoulder and then his left shoulder.
  • Rub the client's sternum with the knuckles.
  • Speak to the client clearly from a close distance.
  • Press down on one of the client's nail beds.
  • Gently shake the client's right shoulder and then his left shoulder.
  • Rub the client's sternum with the knuckles.
  • Speak to the client clearly from a close distance.
  • Press down on one of the client's nail beds.
500

A 21-year-old client has been admitted to the emergency department following an accident that is suspected of being a suicide attempt. When assessing the client's perceptions, what question should the nurse ask the client?

  • “How would you describe your health these days?”
  • “Are you able to smell and taste as well as you've been able to in the past?”
  • “If you found a stamped envelope on the street, what would you do?”
  • “Can you tell me the circumstances surrounding your accident?”
  • “How would you describe your health these days?”
  • “Are you able to smell and taste as well as you've been able to in the past?”
  • “If you found a stamped envelope on the street, what would you do?”
  • “Can you tell me the circumstances surrounding your accident?”
500

The nurse is assessing an older adult client's mental status. Consistently, the client pauses after the nurse poses a question, but then the client provides a response that is correct or appropriate. How should the nurse best interpret this characteristic of the client?

  • Slight delays in mental processing are normal in older adults.
  • The client may be trying to anticipate the nurse's desired response.
  • The client is displaying a sign of early Alzheimer disease.
  • The client may be experiencing an early sign of delirium.
  • Slight delays in mental processing are normal in older adults.
  • The client may be trying to anticipate the nurse's desired response.
  • The client is displaying a sign of early Alzheimer disease.
  • The client may be experiencing an early sign of delirium.
500

Normal sound of respirations heard on auscultation over peripheral lung areas

Vesicular breath sounds: Normal sound of respirations heard on auscultation over peripheral lung areas

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