Chapter 8--Health Assessment

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Chapter 8--Health Assessment MULTIPLE CHOICE 1. A client is brought to the emergency department with injuries sustained from a motor vehicle accident. The nurse will conduct which of the follow ... ing types of health assessments? 1. Focused 2. Comprehensive 3. Emergency 4. Follow-up PTS: 1 DIF: Apply REF: Types of Assessment 2. The nurse is collecting data for a comprehensive assessment. Data that can be seen, heard, or felt by someone other than the person experiencing them are called: 1. primary. 2. objective. 3. subjective. 4. secondary. PTS: 1 DIF: Understand REF: Types of Data 3. A recently admitted client answers all health assessment questions clearly and provides the necessary information. The nurse realizes that this assessment data is considered: 1. primary. 2. objective. 3. subjective. 4. secondary. PTS: 1 DIF: Analyze REF: Sources of Data 4. A client is complaining of a headache and an upset stomach. The nurse realizes that this type of data is: 1. primary. 2. objective. 3. subjective. 4. secondary. PTS: 1 DIF: Analyze REF: Types of Data 5. The nurse is beginning the introductory portion of the health interview process. This part of the assessment is considered the: 1. orientation phase. 2. initiation phase. 3. working phase. 4. closure phase. ANS: 1 PTS: 1 DIF: Understand REF: Phases of the Interview Process 6. The nurse completes a comprehensive health assessment with a client. This assessment is completed so that when future assessments are made they can be: 1. incorporated into the initial assessment. 2. considered a new baseline. 3. compared to the initial assessment. 4. disregarded. PTS: 1 DIF: Analyze REF: Comprehensive Assessment 7. The nurse is assessing a client for a cardiac thrill. To best assess this thrill, the nurse should do which of the following? 1. Use the ulnar surface of the hand. 2. Use the dorsal aspect of the hand. 3. Use the fingertips. 4. Use a stethoscope. PTS: 1 DIF: Apply REF: Nursing Strategy: Parts of Hand Used for Palpation 8. The nurse is using percussion to assess a client’s lung region. Which of the following would be considered a normal assessment finding? 1. Flatness 2. Dullness 3. Tympany 4. Resonance PTS: 1 DIF: Analyze REF: Table 8-1 Characteristics of Percussion Sounds 9. A 17-year-old male client tells the nurse that he hopes he stops growing since he is already over 6 feet tall. Which of the following should the nurse respond to this client? 1. “You have reached your full adult stature by age 17.” 2. “You have until age 21 to reach your full adult height.” 3. “You won’t reach your full height until age 25.” 4. “You have reached your full height and will begin to lose height every year.” PTS: 1 DIF: Apply REF: Variations Related to Health Assessment Practices: Adult 10. The nurse is assessing a week-old male client. Which of the following will the nurse assess as a common variation because of the client’s gender? 1. Physiologically more mature 2. More motor activity 3. Responsive to tactile stimulation 4. Smaller in size PTS: 1 DIF: Apply REF: Physical Variations Related to Gender 11. The nurse desires to provide care according to the American Nurses Association Code of Ethics. Which of the following is the primary ethical responsibility of the nurse when providing client care? 1. To do no harm 2. To do good 3. Protect the clients’ right to make their own decisions 4. To tell the truth PTS: 1 DIF: Analyze REF: Ethical Considerations Related to Data Collection; Table 8-2 Overview of Ethical Principles 12. While completing an assessment, the nurse learns that the client has been a victim of domestic violence with multiple bruises and a possible fractured arm. Which of the following should the nurse do with this information? 1. Document the assessment findings in the client’s medical record. 2. Report the findings of domestic violence to the appropriate regulatory agency. 3. Document the assessment findings and have the client moved to a private room. 4. Notify the physician. PTS: 1 DIF: Apply REF: Confidentiality 13. The fetus of a pregnant client is diagnosed with a genetic defect that can be corrected immediately upon birth. The nurse realizes that this newborn will benefit from which of the following genetic advancements? 1. Eugenics 2. Genetic engineering 3. Euthenics 4. Genetic testing PTS: 1 DIF: Analyze REF: Genetic Screening and Counseling 14. During the health history, a client tells the nurse that she is allergic to penicillin. In which area of the history should the nurse document this information? 1. Management of health 2. Activities of daily living 3. Psychosocial history 4. Demographic information PTS: 1 DIF: Apply REF: Box 8-1 Elements of Health History MULTIPLE RESPONSE 1. The nurse is assessing a client’s activities of daily living. Which of the following will be included in this nurse’s assessment? (Select all that apply.) 1. Nutrition 2. Elimination 3. Sleep 4. Self-identity 5. Cognition 6. Values PTS: 1 DIF: Apply REF: Box 8-1 Elements of Health History 2. A client has just learned of a diagnosis of type 2 diabetes mellitus. The client is anxious about the diagnosis. Which of the following should the nurse assess regarding this client’s ability to cope with the new problem? (Select all that apply.) 1. “How do you typically handle problems in your life?” 2. “What helps you when you feel tense?” 3. “Are you still actively employed?” 4. “Who do you talk with when you have a problem?” 5. “Do you take drugs or alcohol when stressed?” 6. “Who is your health insurance carrier?” PTS: 1 DIF: Apply REF: Patient Playbook: Coping with Problems 3. The nurse is assessing a 10-month-old client. Which of the following should be the nurse’s focus during this assessment? (Select all that apply.) 1. Respiratory volume 2. Safety 3. Heart size 4. Prevention of infection 5. Developmental milestones 6. Musculoskeletal system development PTS: 1 DIF: Apply REF: Variations Related to Health Assessment Practices: Infant 4. The nurse routinely cares for non-English-speaking clients. Which of the following must the nurse do to develop cultural competence? (Select all that apply.) 1. Learn a foreign language. 2. Identify own cultural beliefs related to health and health care. 3. Engage in cross-cultural interactions with people from diverse cultural backgrounds. 4. Become knowledgeable about the predominant cultural groups within one’s own geographic area. 5. Relocate to another country to learn the culture. 6. Become skilled at cultural data assessments. PTS: 1 DIF: Apply REF: Culture 5. The nurse is preparing to conduct a client interview. Which of the following behaviors should the nurse use when conducting this interview? (Select all that apply.) 1. Do not impose personal beliefs onto the client. 2. Listen to verbal and nonverbal cues. 3. Focus on the client. 4. Maintain eye contact according to cultural variation. 5. Allow for silence. 6. Keep the client on track and prevent rambling. PTS: 1 DIF: Apply REF: Nursing Strategy: Prepare Yourself for the Patient Interview [Show More]

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