Deck 2: Health Assessment

Question 1

Which principles of assessment does the nurse use when working with hospitalized clients? (Select all that apply.)

A) Assess each client at the beginning of each shift.
B) Base the frequency of assessment on client condition.
C) Begin with the most seriously ill client.
D) Record findings as they are assessed, not later.
E) Wait for physician orders to determine the frequency of assessments.

Answer 1

Assess each client at the beginning of each shift.
Base the frequency of assessment on client condition.
Begin with the most seriously ill client.
Record findings as they are assessed, not later.

Question 2

A client is brought to the emergency department in serious condition and needs an operation within the next hour. Which of the following principles does the nurse use to guide the health history? (Select all that apply.)

A) Assess the client's current health status.
B) Collect data pertinent to the immediate problem.
C) Strive to collect only pertinent data while being thorough.
D) Update the database when the client's condition allows.
E) Use a systematic approach to gather the client's entire health history.

Answer 2

Assess the client's current health status.
Collect data pertinent to the immediate problem.
Strive to collect only pertinent data while being thorough.
Update the database when the client's condition allows.

Question 3

The nurse collecting data on a client's social history asks questions regarding the client's (select all that apply)

A) exposure to communicable diseases.
B) home life.
C) immunization history.
D) lifestyle.
E) social roles.

Answer 3

exposure to communicable diseases.
home life.
lifestyle.
social roles.

Question 4

1.Match each item to the correct description below.
Place the following physical assessment techniques in their usual order during a physical exam.

Palpation

A) 1
B) 2
C) 3
D) 4

Question 5

1.Match each item to the correct description below.
Place the following physical assessment techniques in their usual order during a physical exam.

Auscultation

A) 1
B) 2
C) 3
D) 4

Question 6

To assess precipitating factors, the nurse interviewer would ask

A) "Do you remember the first time you had this problem?"
B) "How many times has the problem been related to activity?"
C) "What measures relieve this problem for you?"
D) "What were you doing when you first noticed the problem?"

Question 7

1.Match each item to the correct description below.
Place the following physical assessment techniques in their usual order during a physical exam.

Inspection

A) 1
B) 2
C) 3
D) 4

Question 8

A client is being admitted to the hospital and the nurse has the client's electronic record, including past medical history. What should the nurse do with this information?

A) Copy the information from the electronic database to the admission database.
B) Not use it because it is preferred to ask clients about past history at each encounter.
C) Save time and skip this part of the history-taking because the record is electronic.
D) Verify with the client that the list is current, complete, and correct.

Question 9

A nurse is collecting a health history from a client and feels the client is not reliable. One recommended way to verify some of the client data is to

A) ask the client the same questions but in a different manner.
B) confront the client with your suspicions.
C) find and question a secondary source.
D) have another nurse try to get data from the client

Question 10

Because the psychosocial assessment includes many more personal aspects of the client's history, the most significant variable that may affect the quality and usefulness of the collected data is the

A) nurse's ability to establish a therapeutic relationship.
B) nurse's difficulty in differentiating normal from abnormal.
C) reluctance of most clients to share information with health care providers.
D) value the client places on the health interview.

Question 11

1.Match each item to the correct description below.
Place the following physical assessment techniques in their usual order during a physical exam.

Percussion

A) 1
B) 2
C) 3
D) 4

Question 12

In the preparation of a nursing care plan relative to the client's mental status, the least helpful data would be those resulting from

A) client's overall response to the interview.
B) formal psychological tests.
C) notation of appropriateness of affect.
D) observation of nonverbal behavior.

Question 13

A client had surgery yesterday and is complaining of pain. The best action by the nurse is to

A) ask the patient which pain medication she/he took last.
B) do a complete assessment of the pain.
C) prepare to administer the ordered pain medication.
D) record the client's complaints thoroughly and get the pain medication.

Question 14

The nurse is collecting a health history on a middle-aged African American male. The nurse asks about past blood pressure screening because the incidence of hypertension is higher in this ethnic group than in others. This is an example of

A) a generalization based on the nurse's limited experience with African Americans.
B) bias, and the nurse should not question the client about blood pressure screening.
C) stereotyping the client based on the client's ethnic/racial group.
D) using valid research data to focus questions on the client's specific risks.