Flashcards in 3035 Exam Deck (150)
A client has presented for care with complaints of persistent lower back pain. When using the mnemonic COLDSPA, which question should the nurse use to evaluate the “P”?
"How does it feel?"
"What makes it worse?"
"When did it start?”
"How would you rate your pain?"
Correct! - "What makes it worse?"
A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?
“What is your major health concern at this time?”
“Did you bring all your medications with you?”
“Are you generally fairly healthy?”
“Do you have adequate health insurance coverage?”
Correct - “What is your major health concern at this time?”
To alleviate a client’s anxiety during a comprehensive assessment, the nurse should do which of the following?
Begin with intrusive procedures first to get them completed quickly
Ask the client to sign a consent for the physical exam
Explain each procedure being performed and the reason for the procedure
Remain in the exam room while the client changes into a gown
Correct! - Explain each procedure being performed and the reason for the procedure
A nurse is interviewing a client in the campus medical clinic. Which nonverbal behavior should the nurse adopt to best facilitate communication during this phase of assessment?
Limiting all facial expressions
Sitting across the room from the client
Using a moderate amount of eye contact
Standing while the client is seated
Correct! - Using a moderate amount of eye contact
A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?
Collaborate with the client to identify problems.
Explain the purpose of the interview.
Obtain family health history data.
Determine the client's vital signs.
Correct! - Explain the purpose of the interview.
The nurse is obtaining information about a client's past health history. Which client statement would best reflect this component of assessment?
“I have a brother with leukemia and a sister with hypertension.”
“My mom's still alive, but my dad died 10 years ago of heart failure.”
“I have been having some pain when I urinate for the last several days.”
“I had surgery 5 years ago to repair an inguinal hernia.”
Correct! - “I had surgery 5 years ago to repair an inguinal hernia.”
A client has presented to the emergency department and is having difficulty describing her vague sensation of physical discomfort and unease. How can the nurse best elicit meaningful assessment data about the nature of the client's complaint?
Document “unable to assess client’s discomfort".
Restate the question using simpler terms.
Provide a laundry list of descriptive words.
Ignore the complaint for now and return to it later in the assessment.
Correct! - Provide a laundry list of descriptive words.
A nurse is interpreting and validating the information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview?
Correct! - Working
A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
Correct! - Focused assessment
The nurse is preparing to assess the mental status of a 90-year-old client who is being admitted to the hospital from a long-term care facility. Which of the following should the nurse assess first?
The client's ability to see and hear
The client's judgment and insight
The client's general intelligence
The presence of any phobias
Correct - The client's ability to see and hear
A nurse is providing feedback to a colleague after observing the colleague's interview of a newly admitted client. Which of the following would the nurse identify as an example of a closed-ended question or statement?
“Are you allergic to any medications?”
“What is your typical day like?”
“Describe what you eat in a normal day.”
“Tell me about your relationship with your children.”
Correct - “Are you allergic to any medications?”
A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize?
Establishing a trusting relationship
Determining the client's strengths
Making clinical inferences
Identifying potential health problems
Correct - Establishing a trusting relationship
A client has been admitted to the hospital for a vaginal hysterectomy, and the nurse is collecting subjective data prior to surgery. Which statement by the nurse could be construed as biased?
“Your husband's death must have been very difficult for you.”
“How often do your adult children typically visit you?”
“How would you describe your feelings about getting older?”
“You know you should quit smoking because it affects others, right?"
Correct! “You know you should quit smoking because it affects others, right?"
The nurse has completed the review of systems component of the client's health history. Which finding should the nurse document under the review of systems?
“Menstruation began at age 13”
“High school diploma plus 2 years of college”
“Lungs clear to auscultation bilaterally”
“Caregiver reliable source of information”
Correct - “Menstruation began at age 13”
As part of a mental status assessment, the nurse asks the client how they would respond if they found a wallet lying on the sidewalk. This will allow the nurse to assess which domain of mental status?
Correct! - Judgment
The nurse asks a client to recall five words after 5, 10, and 30 minutes. Which of the following is the nurse assessing?
Client's memory of new information
Client's thought process and perceptions
Client's recent memory
Correct - Client's memory of new information
The nurse is performing hourly assessments of the client’s level of consciousness. During the assessment, the client remains unresponsive after multiple attempts of the nurse calling their name. Which of the following would the nurse perform next?
Gently shake the client’s shoulders.
Call the rapid response team
Press down on one of the client’s nail beds.
Rub the client’s sternum with the knuckles.
Correct - Gently shake the client’s shoulders.
During the interview of a client, the client states to the nurse, "I am just so overwhelmed with everything in my life right now. I think it would be better for everyone if I just wasn't around anymore." What statement by the nurse would be most appropriate?
"Everyone gets overwhelmed at times. I'm sure things will get better."
"Have you been thinking about killing yourself?"
"I'm sure things aren't that bad. Have you tried medications for your depression?"
"You should try looking at the bright side of things."
Correct! - "Have you been thinking about killing yourself?"
The nurse is assessing the orientation of a client. The nurse understands which of the following is typically the last level of orientation to be lost?
Correct! - Person
The nurse is evaluating a client using the Glasgow Coma Scale (GCS). Which of the following components would not be used during this evaluation?
Eye opening response
Correct - Pupillary response
The nurse is preparing to obtain information about a client’s mental and psychological status. Which of the following actions would the nurse take first?
Check the client’s level of consciousness for any changes.
Explain the purpose of the exam and the types of questions that will be asked.
Perform a neurologic examination to determine any deficits.
Question the patient about their usual lifestyle and behaviors.
Correct Answer - Explain the purpose of the exam and the types of questions that will be asked.
The nurse is beginning the initial assessment of a 92-year-old client admitted from the long-term care facility. The client does not seem to be responding to the nurse's questions or following her movements. What is the appropriate next action by the nurse?
Document "unable to assess client".
Check the client's vision and hearing before proceeding with the assessment.
Skip the subjective data collection and proceed to the physical assessment.
Defer the assessment until the client is more responsive.
Correct! - Check the client's vision and hearing before proceeding with the assessment.
The nurse notes decorticate posturing in a client following a traumatic brain injury. Which of the following assessments by the nurse would be consistent with this posturing?
Extended elbows and pronated wrists
Dorsiflexion of the feet
Flexion of the elbows
Externally rotated thighs
Correct! - Flexion of the elbows
The nurse is preparing to assess the abstract reasoning of a client who has a diagnosis of early stage Alzheimer disease. Which of the following questions would be most appropriate for the nurse to ask?
“Can you tell me what you have eaten in the last 24 hours?”
“How are an apple and orange the same?”
“When did you get your first job?”
“Can you draw the face of a clock for me?”
Correct! - “How are an apple and orange the same?”
What four questions might you ask to determine if your client is alert and oriented x 4?
Type your four questions in the text box below.
Can you tell me your name?
Where are we at right now?
What is the year?
Why are you being seen today?
The nurse is assessing a client admitted to the unit with pleuritis. Which of the following sounds would the nurse expect to hear on auscultation?
Bubbling, moist sounds during early inspiration
Low-pitched, snoring sounds during expiration
Sound like rolling hair between the finger
Low-pitched grating sound on inspiration and expiration
Correct! - Low-pitched grating sound on inspiration and expiration
When auscultating the left carotid artery, the nurse notes a blowing, swishing sound. What does the nurse suspect is the cause of this finding?
Decreased cardiac output
Turbulent blood flow through a vessel
Increased venous pressure
Right ventricular failure
Correct! - Turbulent blood flow through a vessel
The nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. The nurse should attribute what assessment finding to age-related changes?
Asymmetrical chest expansion
Inaudible posterior lung sounds
Correct - Slight kyphosis
During the assessment of a client with a heart murmur, the nurse places the palm of their hand on the client’s precordium and feels a moderate vibration. The nurse would document this finding as which of the following?
Within normal limits
Correct! - Thrill