Deck 34: Assessment

Question 1

The nurse is conducting a health history during the nursing assessment.The client states to the nurse,"I am allergic to penicillin." Which assessment question is most appropriate to 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?"

Answer 1

"What type of reaction occurred?"

Question 2

The nurse is preparing to assess a client who has chronic obstructive pulmonary disease (COPD).The client is currently experiencing difficulty breathing.Before palpating the client's abdomen,which action is appropriate by the nurse?

A) Administering 6 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

Answer 2

Having the client remain upright

Question 3

An adult client and 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.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) Administer IV fluids.

Answer 3

Assess skin turgor.

Question 4

The nurse is conducting a physical assessment of a middle-age 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 5

An older Spanish-speaking adult client who recently moved to a new city makes an appointment for a routine annual assessment with a new primary care provider.Which action by the nurse is appropriate when conducting the health history?

A) Speaking in a loud tone when addressing the client.
B) Providing the client with educational material 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 6

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 the knee until the client alerts the nurse of severe pain.
B) Seat the client and instruct to alert the nurse of any pain.
C) Place the client prone and gently lift the entire leg.
D) Have the client stand and extend the knee as far as it will go.

Question 7

The nurse is conducting a physical assessment for a middle-age adult female client during an annual exam.When discussing the importance of diet and exercise,which with the nurse include in the teaching session? Select all that apply.

A) Increasing caloric intake
B) Decreasing the intake of grains, fruits, and vegetables
C) Increasing fat and cholesterol intake
D) Encouraging adequate calcium intake
E) Engaging in regular physical activity

Question 8

The nurse is conducting an assessment for an older adult client who experienced a myocardial infarction (MI)a few months ago.The clients states,"I just don't feel like doing much.I feel ok 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 9

The nurse is examining a client with congestive heart failure (CHF)who is prescribed propranolol and furosemide.The client complains of fatigue and an inability to finish tasks.Which conclusion by the nurse is the most appropriate?

A) The medication needs adjustment.
B) The client has not been exercising.
C) The client is experiencing normal findings for the disease process.
D) The client should be hospitalized.

Question 10

The nurse preparing to assess a toddler-age client ears.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 11

A client is complaining of pain in the lower-left quadrant of the abdomen.The nurse prepares to percuss the abdomen and notes that the client has a great deal of hair on the lower abdomen.Which action by the nurse is appropriate prior to percussing 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 percussion, palpate the abdomen only.

Question 12

The nurse is preparing to conduct a physical examination of a client's head and neck area.The client is in a wheelchair due to a C3-C4 spine injury.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 a Sims position
D) Placing the client in a supine during the examination

Question 13

The 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 will 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."

Question 14

The nurse in the clinic is assessing an adult client who has 2+ ankle edema,crackles throughout the lung fields,and dyspnea on exertion.Which will the nurse inquire about prior to initiating the client's teaching plan?

A) The client's family history.
B) The client's diet.
C) The number of children the client has.
D) The client's marital status.

Question 15

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

A) A BMI of > 85th percentile.
B) A BMI of > 95th percentile.
C) A 25 percentage point increase in weight in 6 months is categorized as being overweight, regardless of the baseline (e.g., 6 month's previous) percentile.
D) A 35 percentage points in 6 months is categorized as being overweight, regardless of the baseline (e.g., 6 month's previous) percentile.

Question 16

The nurse is conducting an assessment on an older adult client who is confused.The client is accompanied to the appointment with an adult child.When collecting data,who can provide primary sources of data during the assessment?

A) The confused older adult client.
B) The client's adult child.
C) The nurse who cares for the client at the retirement home.
D) The primary healthcare provider.