Exam 34: Assessment

The nurse is preparing to conduct a physical examination of a client's head and neck area. The client is paralyzed from the neck down. Which action by the nurse is appropriate when conducting the physical assessment of this area?

The nurse is conducting a physical assessment of a middle-aged female client during an annual exam. What should the nurse assess that is particularly relevant to this age group? Select all that apply.

The nurse is conducting a health history as part of a nursing assessment. The client says to the nurse, "I am allergic to penicillin." Which assessment question would best help the nurse learn more about the client's allergy?

The nurse is assessing an older adult client who experienced a myocardial infarction (MI)a few months ago. The client states, "I don't feel like doing much. I feel okay physically, but I just don't want to be around anyone." Based on this data, which tool should the nurse use to further assess the client?

A client is complaining of pain in the lower-left quadrant of his abdomen. The nurse prepares to auscultate the lower abdomen and notes that the client has a great deal of hair there. Which action by the nurse is appropriate prior to auscultating the client's abdomen?

The nurse is conducting a physical assessment of a middle-aged client upon admission to the cardiovascular care unit for cardiopulmonary problems. Which position is likely to be contraindicated for this client?

Data that are detectable by an observer or can be measured or tested against an accepted standard are known as

The nurse is preparing to examine a toddler's ear canals with an otoscope. Which actions by the nurse are appropriate? Select all that apply.

The nurse in the clinic is assessing an adult client who has signs and symptoms of heart failure. Which of the following lifestyle habits would be useful for the nurse to assess before developing the client teaching plan?

The nurse is assessing an older adult client who is confused. The client is accompanied by his adult son. Who can the nurse employ as a primary source of data when assessing this client?

The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate?

For which client would the Denver II tool not be an appropriate choice for the nurse to use during a well-child assessment?

The nurse is caring for a new older adult client who speaks a foreign language and who does not speak English. Which action by the nurse is appropriate when conducting the health history portion of the assessment?

The nurse is preparing to assess a client who is experiencing difficulty breathing. Before palpating the client's abdomen, which nursing action is appropriate?

Which of the following sounds would not be detected during percussion of a healthy client?

A nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span. Which statements should the educator include in the teaching session? Select all that apply.

What is one possible conclusion the nurse could draw after assessing a client with the Braden Scale?

A nurse is reviewing the medical record for a school-age client prior to a scheduled health maintenance visit. Which data from the record indicates that the client is overweight?

An adult client and her spouse are seen in an urgent care clinic. The client presents with a temperature of 102°F, complains of nausea, and has experienced vomiting and diarrhea for 12 hours. The nurse notes that the client's mucous membranes are pale and dry and suspects that the client is dehydrated. Which action by the nurse is the most appropriate?