Final Exam Health Assessment Q& A. Latest 2022. 100 % Approved pass Rate

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What is the primary function of the health care team? - Ans-The health care team meets to collaborate on patients and decide the best overall care. This occurs throughout the lifespan, from the incept... ion of life until death What are nurses able to detect through the health assessment? - Ans-Through the health assessment nurses are able to detect areas in need of health adjustments. A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and the temperature of the extremities. What is the purpose of this ongoing or partial assessment? - Ans-Ongoing or partial assessments help to determine any major changes from the baseline data. When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed - Ans-An initial comprehensive assessment involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination. As a nurse becomes more proficient and comfortable in his or her role, what increases? - Ans-As the nurse becomes more proficient and comfortable in his or her role, the accountability does not decrease, but the knowledge base and expertise increase to foster confidence. Why is the nurse always reassessing the patient for changes? - Ans-The nurse or detective is always reassessing the patient or case for changes in order to achieve the best results. Each relies on both the science and art of his or her respective profession. During the interview of an adult client, the nurse should a) provide the client with information as questions arise. b) complete the interview as quickly as possible. c) read each question carefully from the history form. d) use leading questions for valid responses. - Ans-a) provide the client with information as questions arise. The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by - Ans-expressing interest in a neutral manner How many steps can you climb before you get short of breath?" is an example of what kind of question? - Ans-A question that elicits a graded response What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking? - Ans-Suggest methods and provide resources to assist with smoking cessation While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is - Ans-To investigate the amount of stress clients perceive they are under and how they cope with it, ask questions that address what events cause stress for the client and how they usually respond. In addition, find out what the client does to relieve stress and whether these behaviors or activities can be construed as adaptive or maladaptive The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should - Ans-If you are interviewing a client who smokes, avoid lecturing condescendingly about the dangers of smoking. Also, avoid telling the client that he or she is foolish and avoid projecting an attitude of disgust. This will only harm the nurse-client relationship and will do nothing to improve the client's health. The client is, no doubt, already aware of the dangers of smoking. Forcing guilt on him is unhelpful. Accept the client, be understanding of the habit, and work together to improve the client's health. This does not mean you should not encourage the client to quit; it means that how you approach the situation makes a difference. Let the client know you understand that it is hard to quit smoking, support efforts to quit, and offer suggestions on the latest methods available to help kick the smoking habit. A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client? - Ans-The nurse should provide simple and organized information to reassure the client about the procedure and its expected outcomes. The nurse approaches the aggressive, not anxious, client in an in-control manner. Learning about the effects of the illness does what for the nurse and the patient? - Ans-Learning about the effects of the illness gives the nurse and the patient the opportunity to create a complete and congruent picture of the problem. During a comprehensive assessment of the lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit - Ans-Hyper-resonance is a sound heard when percussing over the lungs of a client with emphysema. Emphysema: a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness. A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision? - Ans-Snellen Chart A nurse must examine the rectum of a woman who has complained of bleeding from the anus and pain on defecating. Which of the following positions would be most appropriate for the client? - Ans-The knee-chest position is useful for examining the rectum. In this position, the client kneels on the examination table with the weight of the body supported by the chest and knees A nurse needs to measure the degree of flexion and extension that a student athlete has available at his knee joint 6 weeks after orthopedic surgery. Which of the following pieces of equipment would be best for the nurse to use? - Ans-A goniometer is a device used for measuring the degree of flexion and extension available at a joint. A nurse is performing percussion over the area of a client's stomach. The nurse should anticipate hearing which type of sound? - Ans-The stomach is air filled, and the normal sound heard over an area that is air filled is tympany. This is a very loud, high-pitched, drumlike sound. A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client? - Ans-Adequate lighting is most important for the physical examination of the client with scabies. Sunlight (when available) would be preferable; however, even a portable lamp or a good overhead light is sufficient for illuminating the skin and for viewing shadows and contours. While percussing an adult client during a physical examination, the nurse can expect to hear flatness over the client's - Ans-bone- dense tissue Universal precautions are primarily designed to protect the health care worker from what? - Ans-Blood borne pathogens Equipment used in conducting a physical examination includes a 2 × 2 gauze pad. What is this used for? - Ans-2 × 2 gauze pads are used during tongue examination. A nurse, new to the hospital, is attending orientation with the nurse educator. The educator is discussing the use of deep palpation when assessing a patient. The nurse should be aware of what risk when using this assessment technique? - Ans-Risk for injury When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: - Ans-In addition to avoiding abbreviations that are prohibited by the Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal? - Ans-Nurses perform all these functions for clients. Nevertheless, the best way to provide safe client care is to continually communicate with all members of the health care team. A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call? - Ans-Ask the other nurse to read back what first nurse reported A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? - Ans-The client record serves as a legal document recording the client's health status and any care the client receives. The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should - Ans-Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data. A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? - Ans-The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. [Show More]

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