Deck 34: Assessment

Question 1

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?

A)Ask the spouse for more information.
B)Assess for pedal edema.
C)Assess skin turgor.
D)Repeat the temperature measurement.

Answer 1

Assess skin turgor.

Question 2

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

A)A male client
B)A client aged 7 or older
C)A female client
D)A client aged 6 or younger

Answer 2

A client aged 7 or older

Question 3

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.

A)"Auscultate the chest while the client is sleeping to obtain the most accurate assessment of the heart."
B)"Use standard precautions during the history and physical examination process."
C)"Perform invasive procedures like pharyngeal and otic exams at the end of the assessment."
D)"Use age-appropriate terminology for explaining procedures and actions."
E)"Use the assessment process to teach about exam procedures and findings."

Answer 3

"Use standard precautions during the history and physical examination process."
"Use age-appropriate terminology for explaining procedures and actions."
"Use the assessment process to teach about exam procedures and findings."

Question 4

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?

A)Supporting the client during the examination
B)Placing the client in an armless regular chair
C)Placing the client in Sims position
D)Placing the client in supine position

Question 5

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

A)The client is at risk for falls.
B)The client is at risk for pressure ulcers.
C)The client is at risk for malnutrition.
D)The client may be unable to complete activities of daily living.

Question 6

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

A)subjective data or symptoms.
B)objective data or symptoms.
C)subjective data or signs.
D)objective data or signs.

Question 7

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?

A)The client himself
B)The client's adult son
C)A nurse who cares for the client at the retirement home
D)The client's primary healthcare provider

Question 8

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?

A)Seat the client and extend each knee until the client alerts the nurse of severe pain.
B)Seat the client and extend each knee until the client alerts the nurse of any pain whatsoever.
C)Place the client prone and gently lift the entire right leg,followed by the entire left leg.
D)Have the client stand and extend each knee as far as it will go.

Question 9

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)Get-Up-and-Go Test
B)Barthel Index of Activities of Daily Living
C)Geriatric Depression Scale
D)Short Portable Mental Status tool

Question 10

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?

A)Moistening the abdominal hair
B)Documenting that the client has hirsutism
C)Cutting the client's hair over the entire abdomen
D)Discontinuing the use of auscultation and palpating the abdomen only

Question 11

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?

A)Body mass index (BMI)>85th percentile
B)BMI >95th percentile
C)25% increase in weight in a 6-month period
D)35% increase in weight in a 6-month period

Question 12

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?

A)Sitting with back unsupported
B)Supine (horizontal recumbent)
C)Dorsal recumbent (back-lying)
D)Sims (side-lying)

Question 13

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.

A)Having the child sit on the examination table
B)Having the child play with the equipment
C)Having the child sit on the parent's lap
D)Telling the child the examination will not hurt
E)Asking the child to tilt the head

Question 14

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?

A)The client's occupation
B)The client's diet
C)The client's usual sleep schedule
D)The client's marital status

Question 15

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?

A)Speaking in a loud tone when addressing the client
B)Providing the client with educational materials that are written in English
C)Asking the client's adult son to translate during the assessment
D)Having a medical translator available during the health history

Question 16

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.

A)Speech and language
B)Body development and growth
C)Sleeping patterns
D)Ability to carry out activities of daily living (ADLs)
E)Body mass index (BMI)measurement

Question 17

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?

A)"Where did you experience the reaction?"
B)"What type of reaction occurred?"
C)"How long did your symptoms last?"
D)"Do any other family members have this same allergy?"

Question 18

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

A)Administering 10 L of oxygen to the client
B)Having the client remain upright
C)Placing the client in a modified Sims position
D)Asking the client to bend over a table

Question 19

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

A)Tympany
B)Hyperresonance
C)Dullness
D)Flatness