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In which situation would it be most appropriate to perform a comprehensive health history assessment on a client?
A client is being seen for complaints of fatigue
A client is seeking care for a broken arm
A client needs an adjustment on his asthma medications
A client is being seen for a follow-up appointment after surgery
What is...A client is being seen for complaints of fatigue
When listening to a client’s heart sounds during auscultation, which sounds would most likely be heard using the bell of the stethoscope?
S1
S2
S3
High-frequency murmurs
What is...S3 (low-frequency)
A nurse needs to assess posterior lung sounds in a client. In which position would it be most appropriate to place this client?
Dorsal recumbent
High Fowler's
Semi-Fowler's
Sims' position
What is...High Fowler's
The nurse is performing an assessment of a client’s abdomen. Upon palpation, the nurse feels an abnormal lump in the left upper quadrant that is extremely painful for the client. The nurse is likely palpating which of the following?
Inflamed spleen
Enlarged liver
Inflamed appendix
Bilious gallbladder
What is...Inflamed Spleen
The nurse is performing an initial assessment on a new client in the clinic. Which of the following elements would be included as part of the general survey? Select all that apply.
Complaints of abdominal pain
Height and weight
Cooperative behavior
Prescription medication for heart failure
Clean appearance
What are...
Complaints of abdominal pain
Height and weight
Cooperative behavior
A nurse is performing an initial assessment on a client who is being admitted to the hospital for exacerbation of heart failure. During the client interview, the nurse wants to assess the client’s background and health history. Which of the following are examples of leading questions that the nurse should avoid? Select all that apply.
Do you have a history of heart disease?
Where are you working right now?
You feel pretty good right now, right?
You don’t miss doses of your medication, do you?
Who do you live with?
What are...
You feel pretty good right now, right?
You don’t miss doses of your medication, do you?
The nurse is caring for a client who arrives at the emergency department after falling down multiple times. Upon initial assessment, the client states, “I am so dizzy I can’t stay standing up.” What is the nurse’s first priority?
Vital signs
Get an EKG
Draw blood
Full neurological exam
What is...Vital signs
While at a routine clinic appointment, the nurse notes a client with lung cancer is breathing heavily, wearing dirty clothes and looking disheveled. The client has lost 15 pounds since the last visit. Which of the following statements by the nurse therapeutically assesses the client’s functional capacity? Select all that apply.
"Tell me more about your support system at home “
“Have you noticed that you are shorter of breath lately?”
“I am going to arrange for someone to come to your home to wash your clothes”
“I am going to contact the social worker since you can’t afford to purchase food”
“Can you tell me how you are doing at home managing your daily activities?”
What is...
"Tell me more about your support system at home “
“Have you noticed that you are shorter of breath lately?”
“Can you tell me how you are doing at home managing your daily activities?”
A nurse is palpating a client’s abdomen to check for an aortic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding?
The ball of the hand
The dorsal of the hand
The palmar surface
The pads of the fingers
What is...The pads of the fingers
You’re performing a head-to-toe assessment on a patient admitted with abdominal pain. During inspection of the abdomen, you note the abdominal contour to be round and distended with no masses or lesions present. The patient reports that their last bowel movement was one hour ago, and the stool was loose. In addition, the patient states that the abdominal pain is located below the umbilicus and is sharp in quality. After inspection of the abdomen, you will:
Perform light palpation on the abdomen, followed by deep palpation.
Percuss the abdomen.
Auscultate for bowel sounds by starting in the right lower quadrant.
Palpate for bruits and rebound tenderness.
What is...Auscultate for bowel sounds by starting in the right lower quadrant.
A nurse is a preceptor for a nurse who just graduated from nursing school. When caring for a patient, the new graduate nurse begins to explain to the patient the purpose of completing a physical assessment. Which of the following statements made by the new graduate nurse requires the preceptor to intervene?
"I will use the information from my assessment to figure out if your antihypertensive medication is working effectively. “
"Nursing assessment data are used only to provide information about the effectiveness of your medical care. “
"Nurses use data from their patient's physical assessment to determine a patient's educational needs. “
Information gained from physical assessment helps nurses better understand their patients' emotional needs."
What is..."Nursing assessment data are used only to provide information about the effectiveness of your medical care. “
Having misplaced his stethoscope, a nurse borrows a colleague's stethoscope. He next enters the patient's room and identifies himself, washes his hands with soap, and states the purpose of his visit. He performs proper identification of the patient before he auscultates her lungs. Which critical health assessment step was not performed?
Running warm water over stethoscope for patient comfort
Cleaning stethoscope with Betadine
Using alcohol-based hand disinfectant
Cleaning stethoscope with alcohol
What is...Cleaning stethoscope with alcohol
Which is the best examination position for a complete geriatric physical examination on a weak patient with bilateral basilar pneumonia?
Prone position
Sim’s position
Supine position
Lateral recumbent
What is...Supine position
During an annual gynecological examination, a college student discusses her upcoming college break at a tropical location. After the student receives an oral contraceptive prescription, the nurse identifies the importance of skin cancer prevention education by discussing which evidence-based prevention health topic?
Applying water-based sunscreen only before swimming
Using tanning bed daily for 7 days before college break trip
Applying broad-spectrum sunscreen of SPF 5
Taking extra precautions in the sun secondary to the prescription
What is...Taking extra precautions in the sun secondary to the prescription