Self Assessment Qs from Canvas Flashcards
Prior to beginning a physical examination of a client, the nurse should carry out which activities? (Select all that apply)
Group of answer choices
Wash hands
Provide for privacy of the client
Obtain a healthcare provider’s order
Explain the procedure to the client
Position the client comfortably
wash hands, provide privacy, explain procedure to client, position the client comfortably
The student nurse enters a client’s room and conducts a general survey. Which of the following is an appropriate finding during a general survey?
Group of answer choices
Pulse is present and palpable bilaterally
Client appears calm
Lungs are clear to auscultation
Respirations are 16
client appears calm
As the student nurse prepares to conduct a nutritional assessment, the student is reminded that the nutritional assessment includes which of the following? (Select all that apply)
Group of answer choices
Height
Weight
Body mass index
Symmetric expansion of the lungs
Respirations
height, weight, body mass index
In an effort to provide a comfortable environment for a client during a physical assessment, the nurse should take which action?
Group of answer choices
Drape the client prior to beginning the examination
Urge the client to have all abnormal findings treated promptly
Avoid wearing gloves when assessing an open wound
Obtain a signed consent to perform a physical assessment
Drape the client prior to beginning the examination
The student nurse has taken a client’s vital signs. Which of the following shows proper documentation of vital signs?
Group of answer choices
Temperature 98.6, pulse 80, respirations 16, hemoglobin 20
Temperature 98.6, pulse 80, respirations 16, blood pressure 120/80
Temperature 98.6, pulses palpable bilaterally, lungs clear to auscultation
Temperature 98.6, pulse 80, respirations 16, skin is warm to touch
Temperature 98.6, pulse 80, respirations 16, blood pressure 120/80
What questions are appropriate for eliciting information regarding functional activities of daily living (ADL’s)? (Select all that apply)
Group of answer choices
Are you able to walk up and down stairs in your house?
Are you able to pay your bills and manage your accounts?
Can you cut up foods and bring them to your mouth?
Are you able to organize your day around housework effectively?
Can you get you self on and off the toilet in your house?
Are you able to walk up and down stairs in your house?
Can you cut up foods and bring them to your mouth?
Can you get you self on and off the toilet in your house?
The student nurse has completed a health assessment on her client and needs to document the findings. Which statement represents objective data?
Group of answer choices
Eats three meals a day.
Denies headaches.
Respirations are 14
Chest pain
Respirations are 14
The student nurse completed teaching a client about diabetes. What step should the nurse take next?
Group of answer choices
Thank him for his time and leave the room.
Check for the client’s understanding and acceptance of the information.
Discuss how his stay has been so far.
Elevate his legs on a pillow.
Check for the client’s understanding and acceptance of the information.
A client states she is concerned about her MRI results. The nurse replies that she should not worry. What type of response did the nurse provide?
Group of answer choices
Empathy
Facilitation
Using professional jargon
Providing false assurance or reassurance
Providing false assurance or reassurance
A client exhibits signs of heightened anxiety. Which response by the nurse is most likely to reduce the client’s anxiety?
Group of answer choices
“Everything will be fine. Don’t worry.”
“Read this manual and then ask me any questions you may have.”
“Why don’t you listen to the radio?”
“Let’s talk about what is bothering you.”
“Let’s talk about what is bothering you.”
What should every childbearing woman be asked during the physical exam?
Group of answer choices
What is the average age of menopause in the family?
Is there a history of tubal ligation
The date of the last menstrual period
Any past medical or surgical history
The date of the last menstrual period
Using the Snellen eye chart, the student nurse assesses the client’s visual acuity at 20/25. How should the student nurse explain this result to the client?
Group of answer choices
“You can read at 25 feet what most people can read at 20 feet.”
“Your left eye can see the chart at 20 feet and your right eye can see at 25 feet.”
“You can read at 20 feet what most people can read at 25 feet.”
“You can read the chart perfectly with both eyes.”
“You can read at 20 feet what most people can read at 25 feet.”
The numerator indicates the distance the client is standing from the chart. The denominator is the distance at which a normal eye could read the line. This measurement is vision on both eyes simultaneously. 20/20 vision is considered perfect vision.
During an assessment of the external ocular structures, the nurse should inspect which structures? (Select all that apply)
Group of answer choices
Pinna
Pupillary reaction to light
Eyebrows
Ocular fundus
eyebrows
*The pinna is a part of the ear. The pupillary reaction to light is an objective finding. The ocular fundus is an internal surface of the retina.
The nurse will assess a client’s nose for patency by performing which action?
Group of answer choices
Occlude right naris and ask the client to breathe through the left naris and then repeat the procedure by occluding the left naris.
Occlude one naris and ask the client to state if there is pain and then repeat the procedure on the other side
Palpate each naris one at a time for tenderness and swelling
Asking the client if the nares are patent
Occlude right naris and ask the client to breathe through the left naris and then repeat the procedure by occluding the left naris.
*One side must be occluded to assess the patency of the other side. Patency is not determined by the presence of pain. Assessing for tenderness and swelling through palpation does not determine if the nares is patent. Asking a client if his or her nares are patent would be subjective data and the nurse is obtaining objective data.
When inspecting the tongue of an adult client, the nurse expects to find which of the following as considered a normal characteristic of the tongue?
Group of answer choices
Bright red and shiny
Thick white coating
Pink and even
Deep vertical fissures
Pink and even
*A tongue that is bright red and shiny is indicative of atrophic glossitis. A thick white coating is indicative of a candidiasis infection. Deep vertical fissures is indicative of dehydration.
