Assessments Flashcards
(91 cards)
The best example of Holistic data collection by a nurse?
- blood pressure
- nutritional intake
- Assessing for depression
- how conditions affect family gatherings
When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
comprehensive
A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client?
AIRWAY
REMEMBER THE MNEMONIC: A, B, C, D, E
~~~~~~~
A-Airway
~~~
B-Breathing
C-Circulation
D-Disability
E-Exposure.
A student nurse is learning to document an initial assessment. What would the
instructors tell the student that accurate documentation of this specific assessment best provides?
A baseline for comparison with future findings
Accurate documentation provides a baseline so that changes are noted between assessments.
Which is an “ABCDE” characteristic of malignant melanoma?
A: asymmetrical B: borders (irregular) C: color (variations) D: diameter (exceeding 1/8 to 1/4 of an inch) E: elevated.
An important function of the skin?
Synthesis of vitamin D
What is the expected moisture and texture of the skin of a client with hypothyroidism?
Dry and rough
The nurse notes that a client’s nails are greater than a 160-degree angle. What should the nurse assess as a priority for this client?
pulse oximetry
A nail angle greater than 160 degrees indicates clubbing which is caused by chronic hypoxia.
The preceptor of the student nurse is explaining the assessment that is considered the most organized for gathering comprehensive physical data. What assessment is the preceptor talking about?
Head-to-toe
A head-to-toe or comprehensive assessment is the most organized system for gathering comprehensive physical data.
What will be the nurse’s initial role when conducting a health assessment with a client reporting abdominal pain?
Collecting data regarding the nature of the pain
What is one of the broad goals within nursing?
To treat human responses
A nurse recommends that a client come back once every 3 months in the coming year to have his cholesterol checked, to make sure he is maintaining a healthy level. Which type of assessment is the nurse proposing?
Ongoing or partial
The client has a murmur. This is what type of data?
Objective
What is Objective data?
data that is measurable
What is Subjective data?
what the client states, feels or senses.
The RN is implementing which level of intervention when administering immunizations at a pediatric clinic?
Primary
(Primary prevention involves strategies aimed at preventing problems. Immunizations, health teaching, safety precautions, and nutrition counseling are examples.)
What are one-way nurses use critical thinking in regard to the nursing process?
Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions
Which type of question is asked first by the nurse in order to attain a full description of the client’s symptoms and to generate and test diagnostic hypotheses?
open-ended questions to encourage the client to tell his or her story
Learning about the effects of the illness does what for the nurse and the client?
Gives them the opportunity to create a complete and congruent picture of the problem
In interviewing a client about substance use, a nurse asks her whether she takes any herbal supplements. Which of the following is the best rationale for asking this question?
Some herbal supplements may interact with prescribed medications.
A nurse is performing percussion on a client’s back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?
Resonance
(Resonance is a loud, low-pitched, hollow sound normally percussed over an area that is part air and part solid, which is expected over normal lung fields.)
During palpation of a client’s organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing
deep palpation
(Deep palpation depresses the surface between 2.5 and 5 cm (1 and 2 inches).
During the physical examination of your client, you auscultate the sound of the client’s breathing. What area of the client are you assessing?
Lungs
To assess the client’s breathing sounds, the nurse auscultates the lungs using the stethoscope.
The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position?
Balance