Health Assessment Exam 1

An instructor is describing a comprehensive nursing health assessment to a group of students. The instructor determines that the teaching was successful when the students identify which of the following as the overall purpose?
A) Collect accurate data
B) Assist the physician
C) Validate previous data
D) Make a clinical judgment
d
Which individual typically would be responsible for collecting the subjective data on a client during the initial comprehensive assessment?
A) Physician
B) Nurse
C) Secretary
D) Technician
b
When discussing the nursing process with a group of students, which of the following statements best describes it?
A) Each step is independent of the others.
B) It is ongoing and continuous.
C) It is used primarily in acute care settings.
D) It involves independent nursing actions.
b
Before meeting the client and performing a comprehensive health assessment, which of the following would be most important for the nurse to do?
A) Review the client’s medical record.
B) Obtain basic biographic data.
C) Consult essential resources.
D) Validate information with the client.
a
Which of the following client situations would the nurse interpret as requiring an emergency assessment?
A) A client with severe sunburn
B) A client needing an employment physical
C) A client who took a drug overdose
D) A client who wants a pregnancy test
c
In comparison with the physician’s medical exam, the comprehensive health assessment performed by the nurse focuses on which aspect?
A) Current physiologic status
B) Effect of health on lifestyle
C) Past medical history
D) Motivation for compliance
b
After teaching a group of students about the phases of the nursing process, the instructor determines that the teaching was successful when the students identify which phase as most important?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
a
Following completion of the comprehensive health assessment, the nurse periodically performs a partial assessment primarily for which reason?
A) Reassess previously detected problems
B) Provide information for the client’s record
C) Address areas previously omitted
D) Determine the need for crisis intervention
a
The nurse is working in an ambulatory care clinic. Which client would the nurse determine to be in most need of an emergency assessment?
A) A 14-year-old girl who is crying because she thinks she is pregnant
B) A 35-year-old man with chest pain and diaphoresis for 1 hour
C) A 3-year-old child with fever, rash, and sore throat
D) A 20-year-old man with a 3-inch shallow laceration on his leg
b
A nurse has completed gathering some basic data about a client and then reflects on personal feelings about the client. The nurse does this primarily to accomplish which of the following?
A) Determine if pertinent data has been omitted
B) Identify the need for referral
C) Avoid biases and judgments
D) Construct a plan of care
c
The nurse is collecting data from a client. Which of the following best reflects objective data?
A) Religion
B) Occupation
C) Appearance
D) Age
c
Which of the following would the nurse implement in response to a collaborative problem?
A) Encouraging oral fluids
B) Providing bedtime protein snack
C) Assisting with personal hygiene
D) Taking blood glucose twice daily
d
The nurse is analyzing the data obtained from the following clients. Which client would the nurse expect to facilitate a referral?
A) An 80-year-old client who lives with her daughter
B) A 50-year-old client newly diagnosed with diabetes
C) A 3-year-old child with an acute ear infection
D) A teenager seeking information about contraception
b
An instructor is reviewing the evolution of the nurse’s role in health assessment. The instructor determines that the teaching was successful when the students identify which of the following as the major method used by nurses early on to perform assessment?
A) Natural senses
B) Biomedical knowledge
C) Technology
D) Critical pathways
a
When describing the expansion of the depth and scope of nursing assessment over the past several decades, which of the following would be identified as being the primary force?
A) Documentation
B) Informatics
C) Diversification
D) Technology
d
A group of students is reviewing information about the potential opportunities for nurses with advanced assessment skills. The students demonstrate that they understand the information when they identify which of the following as helping to promote this role?
A) Expansion of health care networks
B) Decrease in client participation in care
C) Restraints in the cost of medical care
D) Broadening of the base of biomedical data
a
During an in-service presentation, the presenter stresses the importance of accurate and thorough documentation for which reason?
A) Guarantee a continual assessment process.
B) Identify abnormal data.
C) Assure valid conclusions from analyzed data.
D) Allow for drawing inferences and identifying problems.
c
When performing the steps of the assessment phase of the nursing process, which of the following would the nurse do first?
A) Collect objective data
B) Validate the data
C) Collect subjective data
D) Document the data
c
A nurse is gathering subjective data. Which of the following would the nurse be most likely to assess?
A) Feelings of happiness
B) Posture
C) Mood
D) Behavior
a
When describing a focused assessment to a group of students, which of the following would the instructor include?
A) It is done before the physical exam.
B) It replaces the comprehensive data base.
C) It assesses a particular client problem.
D) It is done after gathering subjective data.
c
The nurse is reviewing a client’s health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.
A) “I feel so tired sometimes”
B) Weight—145 lb
C) Lungs clear to auscultation
D) Client complains of a headache
E) “My father died of a heart attack”
F) Pupils equal, round, and reactive to light
a d e
The activities below reflect the steps of the nursing process. Place the activities in their proper sequence from first to last.
A) Identifying outcomes
B) Determining client’s nursing problem
C) Collecting information about the client
D) Determining outcome achievement
E) Carrying out interventions
a b c d e
After explaining the skills used to gather subjective and objective data, the instructor determines that additional teaching is needed when the students identify which of the following as a skill necessary for collecting subjective data?
A) Inspection
B) Therapeutic communication
C) Interviewing
D) Active listening
a
The nurse is performing a health assessment on client. Which of the following would be most important for the nurse to do?
A) Focus the assessment on the client as an individual
B) Interpret the information about the client in context
C) Rely primarily on the client’s statements
D) Gather information from a variety of sources
b
A client comes to the health care provider’s office for a visit. The client has been seen in this office for the past five years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform?
A) Comprehensive assessment
B) Ongoing assessment
C) Focused assessment
D) Emergency assessment
c
When beginning the collection of the client data base, which of the following would be most important for the nurse to do?
A) Establish a trusting relationship
B) Determine the client’s strengths
C) Identify health problems
D) Make inferences
a
A nurse is interpreting and validating information from the client. The nurse is in which phase of the interview?
A) Introductory
B) Working
C) Summary
D) Closing
b
Which statement by the nurse could be construed as judgmental?
A) “How often do your adult children visit?”
B) “Your husband’s death must have been difficult for you.”
C) “You must quit smoking because it is offensive to others.”
D) “How do you feel about getting older?”
c
A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication?
A) Standing while the client is seated
B) Using a moderate amount of eye contact
C) Sitting across the room from the client
D) Minimizing facial expressions
b
After teaching a group of students about verbal communication techniques, the instructor determines that the teaching was successful when the students identify which of the following as an example of a closed-ended question/statement?
A) “What is your relationship with your children?”
B) “Tell me what you eat in a normal day.”
C) “Are you allergic to any medications?”
D) “What is your typical day like?”
c
A client is having difficulty describing a chief complaint of chest pain. Which action by the nurse would be most appropriate?
A) Ignore the complaint for now and return to it later.
B) Provide a laundry list of descriptive words.
C) Restate the question using simple terms.
D) Wait in silence until the client can determine the correct words.
b
A client asks “Can I take the herb, ginkgo biloba, with my other medications?” What action would be best if the nurse is unsure of the answer?
A) Promise to find out the information for the client.
B) Ignore the question by changing the subject.
C) Tell the client to only take prescribed medication.
D) Encourage the client to ask the pharmacist.
a
The nurse is preparing to assess the mental status of an older adult client. Which of the following would the nurse need to assess first?
A) Sensory abilities
B) General intelligence
C) Severe phobias
D) Irrational cognition
a
When interviewing a Hispanic client, the nurse enlists the assistance of a “culture broker,” based on the understanding that this person’s primary function is to:
A) Interpret the language and culture.
B) Evaluate the client’s health practices.
C) Teach the client about health care.
D) Make the client feel comfortable and safe.
a
Upon entering an exam room, the client states, “Well! I was getting ready to leave. My schedule is very busy and I don’t have time to waste waiting until you have the time to see me!” Which response by the nurse would be most appropriate?
A) “Our schedule is very busy also. We got to you as soon as we could.”
B) “No one is holding you captive, you are free to leave at any time.”
C) “Would you like to speak to the office manager about your complaint?”
D) “You seem very angry. I am ready to begin your exam now.”
d
When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?
A) Completes the client’s health record.
B) Assures a trusting interpersonal relationship.
C) Evaluates the seriousness of the client’s risk factors.
D) Provides a focus for the physical exam.
d
Which of the following questions would be most important for the nurse to ask first when obtaining the health history?
A) “Do you have adequate health insurance coverage?”
B) “Are you generally fairly healthy?”
C) “What is your major health concern at this time?”
D) “Did you bring all your medications with you?”
c
When using the mnemonic COLDSPA, which question would be most appropriate to use to evaluate the “P”?
A) “What makes it worse?”
B) “When did it start?”
C) “How does it feel?”
D) “What does it look like?”
a
After teaching a group of students about the review of systems component of the health history, the instructor determines that the teaching was successful when the students identify which data as an example?
A) “High school diploma plus 2 years of college”
B) “Caregiver reliable source of information”
C) “Menarche at age thirteen”
D) “Lungs clear to auscultation bilaterally”
c
A new graduate nurse asks another more experienced nurse about the best way to assess a client’s dietary habits. Which suggestion would be most appropriate?
A) Ask the client to explain the food pyramid.
B) Obtain a 24-hour diet recall.
C) Ask about the contents of one meal.
D) Determine how often the client eats.
b
The nurse is assessing the client’s activity and exercise level. Which client statement would indicate to the nurse that the client is getting the recommended amount of exercise?
A) “I walk on the treadmill once or twice a week.”
B) “I play basketball with a team each week.”
C) “I go to an aerobics class for 1 hour three times a week.”
D) “I swim for 30 minutes each Saturday morning.”
c
Which method would be most appropriate to determine a client’s medication and substance use?
A) Ask the client to identify which medications he or she is taking every day.
B) Ask the client to bring all the medications and supplements to the interview.
C) Ask the caregiver whether the client is taking the prescribed medications.
D) Ask the client whether he or she takes any over-the-counter medications.
b
The nurse is preparing to assess a female client’s activities related to health promotion and maintenance. Which question would provide the most objective and thorough data?
A) “Do you always wear your seatbelt when driving?”
B) “How much beer, wine, or alcohol do you drink?”
C) “Do you use condoms with each sexual encounter?”
D) “Could you describe how you perform self-breast exams?”
d
A nurse is creating a genogram for a client’s family health history. The nurse would use which of the following to denote the client’s female relatives?
A) Circle
B) Square
C) Triangle
D) Rectangle
a
The nurse is in the introductory phase of the client interview. Which of the following activities would be appropriate?
A) Collaborating with the client to identify problems
B) Explaining the purpose of the interview
C) Determining the client’s reason for seeking care
D) Obtaining family health history data
b
A client states, “My wife died two months ago today.” Which of the following responses would be most appropriate?
A) “What did she die of?”
B) “How does that make you feel?”
C) “You probably must be sad.”
D) “Are you feeling sad, depressed, angry, or upset?”
b
The nurse is using the mnemonic, COLDSPA, to assess a client’s complaint of abdominal pain. The nurse asks the patient to rate the pain on a scale of 0 to 10. The nurse is assessing which aspect of the complaint?
A) Character
B) Onset
C) Severity
D) Pattern
c
The nurse is obtaining information about a client’s past health history. Which client statement would best reflect this aspect?
A) “My mom’s still alive but my dad died 10 years ago of heart failure.”
B) “I have a brother with leukemia and a sister with hypertension.”
C) “I had surgery 5 years ago to repair an inguinal hernia.”
D) “I have been having some pain when I urinate for the last several days.”
c
A group of students is reviewing for a quiz on verbal and nonverbal communication. The students demonstrate a need for additional studying when they identify which of the following as an example of nonverbal communication?
A) Attitude
B) Silence
C) Laundry list
D) Facial expression
c
Selected sections of a health history are listed below. Place them in the correct sequence, beginning with the section that is obtained first.
A) Family health history
B) Reason for seeking care
C) Biographic data
D) Review of body systems
E) History of present concern
F) Past health history
a b c d e f
The nurse is completing a review of systems for a client. Which of the following information would the nurse document related to the client’s musculoskeletal system? Select all that apply.
A) Joint stiffness
B) Rhinorrhea
C) Shortness of breath
D) Chest pain
E) Muscle strength
F) Swelling
a e f
Which of the following would be most important for the nurse to do immediately before beginning the physical exam?
A) Practice interviewing skills.
B) Construct the client’s family genogram.
C) Establish the client’s reliability as historian.
D) Collect necessary equipment essential to the exam.
d
The nurse is implementing actions to help reduce a client’s anxiety during the physical exam. Which of the following would be most appropriate?
A) Ensuring client’s privacy by providing an examination gown
B) Providing a comfortable, warm room temperature
C) Arranging exam equipment on a bedside tray table
D) Explaining why standard precautions are being used
a
The nurse is applying standard precautions by performing which of the following?
A) Washes the hands between examination of each body part
B) Discards in the trash can the safety pin that was used to assess sensory perception
C) Wears gloves to palpate the tongue and buccal membranes
D) Wears gown, gloves, and mask during the physical exam
c
The nurse is using a Wood’s light for a client complaining of itching, burning, and peeling of the skin between the toes. The nurse is assessing for which of the following?
A) Parasitic infection
B) Fungal infection
C) Bacterial infection
D) Allergic reaction
d
For which of the following would it be most appropriate for a nurse to use a centimeter-scale ruler for measurement?
A) Mid-arm circumference
B) Client’s height
C) Skin lesion size
D) Pupillary size
c
The nurse is preparing to assess a client’s near vision. Which of the following would be most appropriate for the nurse to use?
A) Newspaper
B) Snellen chart
C) Ophthalmoscope
D) Penlight
a
After performing an anal exam for prostate enlargement/tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?
A) Parasites
B) Blood
C) Bacteria
D) Fungus
b
The nurse is examining an older adult client and using a goniometer. Which of the following would the nurse be assessing?
A) Extremity edema
B) Joint flexion/extension
C) Two-point discrimination
D) Vibratory sensation
b
A female client is told that she needs a pelvic exam and Papanicolaou (Pap) smear. She says “No! I will not let you do that to me!” Which response by the nurse would be most appropriate?
A) Respect the client’s wishes and omit the pelvic exam.
B) Tell the client that she needs to have the Pap smear to check for cancer.
C) Ask the client if she would like someone else to do the exam.
D) Proceed with the pelvic exam even if the client protests.
a
The nurse is preparing to perform a physical examination on a client. The nurse would begin with which of the following examinations?
A) Head and neck
B) Lymph glands
C) Breast exam
D) Vital signs
d
The nurse is to collect a throat culture from a client. The nurse demonstrates the best adherence to standard precautions by using which of the following?
A) Eye goggles
B) Face mask
C) Cover gown
D) Face shield
d
When performing a physical examination of an older adult client, which of the following would be most appropriate?
A) Omit intrusive parts of the exam.
B) Try to minimize position changes.
C) Allow client to remain dressed.
D) Dim the room light.
b
The nurse is preparing to assess a client’s peripheral pulses. The nurse would place the client in which position?
A) Sitting
B) Supine
C) Sims
D) Prone
b
When assessing the temperature of the feet of an older client with diabetes, the nurse would use which part of the hand to obtain the most accurate information?
A) Finger pad surface
B) Palmar hand surface
C) Dorsal hand surface
D) Ulnar hand surface
c
An instructor is explaining the technique for deep palpation, describing it as which of the following?
A) Using one hand and depressing the skin 1 centimeter
B) Using the dominant hand to depress the skin one-half to three-quarters of an inch
C) Using both hands to depress the skin one-half of an inch
D) Using both hands to depress the skin 1 to 2 inches
d
Which technique would be best for the nurse to use to evaluate kidney tenderness in a client complaining of dysuria and back pain?
A) Light palpation
B) Indirect percussion
C) Moderate palpation
D) Blunt percussion
d
The nurse is using the bell of a stethoscope to assess which of the following?
A) Heart murmurs
B) Bowel sounds
C) Breath sounds
D) Femoral pulses
a
An instructor is teaching a student about the proper use of a stethoscope. The instructor determines the need for additional teaching when the student states which of the following?
A) Plastic tubing should be longer than 3 feet.
B) The bell is used after using the diaphragm.
C) When using the bell, push on it lightly.
D) A diaphragm picks up low-pitched sounds.
c
A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following?
A) Auscultation can be performed through clothing.
B) The diaphragm should be held firmly against the body part.
C) The bell of the stethoscope can detect bowel sounds.
D) The binaurals connect the tubing to the chest piece.
b
The nurse demonstrates the proper technique for light palpation by which of the following?
A) Depressing the skin 1 to 2 centimeters with the dominant hand
B) Feeling the surface structures using a circular motion
C) Placing the nondominant hand on top of the dominant hand
D) Using one hand to apply pressure and the other hand to feel the structure
b
The nurse is preparing to examine an older adult client. Which of the following would be most appropriate for the nurse to do during the examination?
A) Complete the examination as quickly as possible.
B) Speak clearly and slowly when explaining a procedure.
C) Begin the examination with auscultation instead of inspection.
D) Maintain the supine position for each part of the examination.
b
The nurse places a client complaining of back pain in the dorsal recumbent position. Which area would the nurse be least likely to assess with the client in this position?
A) Chest
B) Head
C) Peripheral pulses
D) Abdomen
d
The nurse is gathering the necessary equipment in preparation for examining a client’s ears. The nurse will be checking bone and air conduction of sound. Which of the following would the nurse obtain?
A) Penlight
B) Tongue depressor
C) Tuning fork
D) Otoscope
c
The nurse is evaluating the setting for a client’s physical examination. The nurse ensures that the setting has which of the following? Select all that apply.
A) Adequate lighting
B) Cool room temperature
C) Quiet surroundings
D) Soft chair or table
E) Table for equipment
F) Door or curtain
a c e f
The nurse is using the fingerpads of the hand to palpate a body part. Which of the following would the nurse be able to detect?
A) Temperature
B) Vibrations
C) Crepitus
D) Fremitus
c
An instructor is describing the four basic physical examination techniques and their sequence. The instructor determines that the teaching was successful when the students identify which technique as always being done first?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
a
The nurse is percussing the area over the lungs and hears a loud, low pitched, hollow sound. The nurse documents this finding as which of the following?
A) Flatness
B) Resonance
C) Tympany
D) Dullness
b
Which of the following would be most important to ensure accurate data when gathering client information?
A) Documenting the data
B) Validating the data
C) Identifying client support systems
D) Determining client needs
b
A nurse obtains the following information from a client. Which statement would the nurse need to validate?
A) “I’ve recently lost 20 pounds.”
B) “I feel very weak and tired.”
C) “I’ve had two cesarean deliveries.”
D) “I am generally healthy and happy.”
a
A client who had a mastectomy is being discharged home. The client lives alone. Which data would be most important to validate for this client?
A) If the client has transportation for follow-up appointments
B) If the client usually functions independently
C) What support systems are in place to assist the client
D) If the client has a religious belief regarding illness
c
When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?
A) Health care institutions have established policies regarding documentation.
B) Incorrect conclusions may be made without documentation of initial data.
C) It satisfies legal standards established by health care organizations and institutions.
D) It becomes the foundation for the entire nursing process.
d
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?
A) Subjective data and objective data
B) Interpretation and inference
C) Observation and inspection
D) Data and results
a
The nurse is explaining the role of documenting the initial and ongoing assessment data base. Which of the following would the nurse emphasize as major reason?
A) Reduce fragmentation of care
B) Minimize incorrect conclusions from data
C) Promote communication between disciplines
D) Facilitate achievement of professional standards
c
A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
A) Evaluation
B) Implementation
C) Planning
D) Analysis.
d
Which of the following statements best reflects appropriate documentation?
A) “Client depressed because of fear of breast biopsy”
B) “Client with lower back pain”
C) “Client unkempt appearance, avoids eye contact”
D) “Client has clear lung sounds in right and left lungs”
c
A nurse is working in a health care facility that using charting by exception. Which of the following would the nurse expect to document?
A) Liver palpation normal
B) No tenderness on palpation
C) Bowel sounds normoactive
D) Aching, burning pain in lower back
d
The instructor is describing the various types of initial assessment documentation forms. The instructor determines that the teaching was successful when the students identify which form helping to standardize data collection?
A) Open-ended
B) Integrated cued checklist
C) Cued/checklist
D) Nursing minimum data set
c
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
A) A screening tool that assesses specific risks
B) An integrated cued checklist
C) An abbreviated admission data sheet
D) An assessment flow chart
d
A nurse is using a cardiovascular assessment documentation form. The nurse understands that this is an example of which type of form?
A) A focused area assessment form
B) An ongoing assessment form
C) A frequent assessment form
D) An initial assessment form
a
A nurse is explaining the facility’s open-ended form for documentation to a group of new nursing employees. Which of the following would the nurse give as the primary reason for using this form?
A) Prevents missed questions
B) Combines assessment data with nursing diagnosis
C) Individualizes information
D) Meets needs of multiple data users
c
A nurse is starting a new job at a long-term care facility. Which initial assessment documentation form would the nurse most likely expect to use?
A) Nursing minimum data set
B) Cued or checklist forms
C) Integrated cued checklist
D) Open-ended forms
a
When performing an assessment, which of the following would be most helpful in validating a client’s chief complaint?
A) Objective data
B) A genogram
C) Past health history
D) Family history data
a
The nurse obtains the following information. The nurse would need to validate the data for which client?
A) A new mother who says she is tired
B) A client who is laughing and talking with a temperature of 104°F
C) A young girl with a small right lower quadrant scar who reports she had an appendectomy
D) A man who has been a diabetic for 25 years
b
Which method of validation would be most appropriate when the nurse is unsure if a murmur is heard when assessing heart sounds?
A) Verify with another health care professional.
B) Recheck through reassessment.
C) Compare objective data with subjective data.
D) Clarify data with the client.
a
A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse include as the purpose of this type of documentation?
A) It helps cluster data
B) It provides lines for comments.
C) It includes specialized data
D) It standardizes data collection.
a
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
A) It provides a chronologic source of client assessment data.
B) It creates a data base for care that was not rendered to the client.
C) It replaces the client acuity classification system.
D) It directly formulates the nursing diagnoses.
a
The nurse compares subjective data and objective data to achieve which of the following?
A) Formulation of nursing diagnoses
B) Identification of missing data
C) Determination of documentation form to use
D) Validation of data
d
A nurse is preparing an in-service education program for a group of staff nurses about documentation, including documentation of assessment data. The nurse demonstrates understanding of the significance of documentation by including a discussion of which of the following as playing a role in this area? Select all that apply.
A) Joint Commission
B) State nurse practice act
C) Medicare
D) Local city government
E) Institutional agency
a b c e
A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation?
A) Client appears upset about upcoming surgery.
B) Client was interviewed about previous history of hypertension
C) Skin pale, warm, and dry without evidence of lesions
D) Client’s oral intake is satisfactory
c
A nurse is using a nursing minimum data set to document assessment information. The nurse most likely would be working in which setting?
A) Acute care facility
B) Long-term care facility
C) Urgent care center
D) Health clinic
b
While gathering a nursing history about a client’s previous hospitalizations and surgeries, the nurse finds out that this is the client’s first hospitalization and that he hasn’t had any surgeries. The nurse would document which of the following?
A) Client denies prior hospitalizations and surgeries
B) Client has not been hospitalized before nor has he had any surgery
C) Client answered no to previous hospitalizations or surgery
D) Negative for past hospitalizations
a
An instructor is describing various ways that a nurse can validate data to a group of nursing students. The instructor determines that additional teaching is necessary when the students identify which of the following as a reliable method?
A) Repeating the assessment
B) Asking additional questions
C) Having the client repeat what was said
D) Checking findings with another health care professional
c
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?
A) Open-ended form
B) Focused assessment form
C) Frequent assessment form
D) Ongoing assessment form
b
A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following?
A) “Documentation helps support reimbursement but gives little epidemiologic data.”
B) “Documentation provides a permanent legal record of care given and not given.”
C) “Documentation is a viable means of communication but is repetitious.”
D) “Documentation helps determine client education needs but not staff mix.”
b
A nurse has completed data analysis. Which of the following would the nurse identify first as the result?
A) Outcome evaluation
B) Nursing diagnosis
C) Interventions
D) Plan of care
b
A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?
A) Abnormal data must be identified.
B) It ends a decision about a nursing diagnosis.
C) It requires diagnostic reasoning skills.
D) Conclusions must be documented.
c
After teaching a group of students about critical thinking, the instructor determines that the teaching was successful when the students identify which of the following about critical thinking?
A) It avoids interaction with others.
B) It does not include past experiences.
C) It is based primarily on getting correct information.
D) It involves reflections on thoughts before reaching conclusions.
d
Before analyzing collected data, which of the following would the nurse need to complete first?
A) Validate collected data
B) Formulate a nursing diagnosis
C) Make inferences about the data
D) Identify client strengths
a
A nurse is preparing to identify abnormal data and strengths of a client. Which of the following would be most important for the nurse to have?
A) Knowledge about anatomy and physiology
B) Awareness of the client’s symptoms
C) Inferences about the client
D) Knowledge about the referral process
a
A nurse is formulating a risk nursing diagnosis. Which piece of data would be most useful?
A) Patchy hair loss, primarily occipital
B) Loss of job resulting from illness
C) Pain in joints, especially in the morning
D) Effect of illness on social activity in the community
d
When the client is in a state of harmony and balance, which of the following most likely would be appropriate?
A) Actual nursing diagnosis
B) Risk nursing diagnosis
C) Collaborative problem
D) Wellness nursing diagnosis
d
A nurse determines that a client’s data indicate the need for medical and nursing interventions. The nurse would identify which of the following?
A) Actual nursing diagnosis
B) Referral
C) Risk nursing diagnosis
D) Collaborative problem
d
After analyzing the data clusters, and hypothesizing a diagnosis, which of the following would the nurse do next?
A) Document conclusions
B) Identify abnormal data.
C) Check defining characteristics
D) Formulate nursing diagnoses.
c
A nurse determines that the cue clusters meet the defining characteristics. Which of the following would the nurse do next?
A) Explain the client’s problem to the client.
B) Verify it with the client and with other health care professionals.
C) Validate the diagnosis with the physician.
D) Work with the client to begin planning interventions.
b
Which of the following best reflects accurate documentation of a risk nursing diagnosis?
A) Risk for fatigue related to increased job demands as manifested by feelings of exhaustion and frequent naps
B) Risk for infection as manifested by lack of client knowledge of wound care
C) Risk for violence related to history of overt, aggressive acts
D) Risk for altered respiratory function related to environmental allergens as manifested by asthma
c
A nurse is preparing to document conclusions after analyzing data and includes information about related factors. The nurse is formulating which of the following?
A) Risk nursing diagnosis
B) Actual nursing diagnosis
C) Collaborative problem
D) Problem for referral
b
Which of the following would be included as the primary purpose of assessing a client’s health status?
A) Analyze subjective and objective data
B) Confirm or rule out a diagnosis
C) Formulate a nursing diagnosis
D) Check for the presence of defining characteristics
a
The nurse is writing down thoughts about each cue cluster. The nurse is involved in which step of the diagnostic reasoning process?
A) Step One: Identify Abnormal Data and Strengths
B) Step Two: Cluster Data
C) Step Three: Draw Inferences
D) Step Four: Propose Possible Nursing Diagnoses
c
A nurse is determining whether the data for a client support a potential nursing diagnosis. The nurse is most likely engaged in which step in the diagnostic reasoning process?
A) Step Three: Draw Inferences
B) Step Four: Propose Possible Nursing Diagnoses
C) Step Five: Check for Defining Characteristics
D) Step Six: Confirm or Rule Out Diagnoses
d
An instructor is describing the steps of the diagnostic reasoning process to a group of students. The instructor is accurate when describing step Two, Clustering Data as involving which of the following?:
A) Hypothesizing of any potentially applicable wellness diagnoses, risk diagnoses, and actual diagnoses
B) Documentation of all professional judgments along with any data that support those judgments
C) The looking at of the identified abnormal findings and strengths for cues that are related
D) Evaluation of both subjective and objective data to identify strengths and abnormal findings
c
A group of students is reviewing information about the diagnostic reasoning process. The students demonstrate understanding of the process when they identify it as consisting of how many steps?
A) 4
B) 5
C) 6
D) 7
d
A student asks an instructor for suggestions on how to best to develop expertise in using diagnostic reasoning skills to arrive at the correct conclusions. Which of the following suggestions would be most appropriate?
A) “You need to cluster the data correctly.”
B) “This skill comes with accumulating experience.”
C) “Be systematic in documenting the data.”
D) “Try to apply your knowledge at each opportunity.”
b
Which of the following would be most important for a nurse when developing critical thinking skills?
A) Quick decision making
B) Reliance on current situation
C) Maintenance of an open mind
D) Static knowledge base
c
After teaching a group of students about the second phase of the nursing process, the instructor determines that additional teaching is needed when the students identify which of the following as a component?
A) Organizing data
B) Clustering data
C) Formulating a medical diagnosis
D) Generating hypotheses
c
As part of a class assignment, each student is to ask another student questions to determine that student’s critical thinking skills. Which of the following responses would reflect that the student has some critical thinking skills?
A) “I have a good background so I’m hardly ever wrong.”
B) “I try to think about alternatives before making a decision.”
C) “I don’t need a lot of information to make a decision.”
D) “I rely on the present situation without worrying about the past.”
b
The following are listed on a client’s medical record. Which of the following would the nurse identify as a collaborative problem?
A) Temperature—99.6o F
B) Impaired skin integrity related to immobility as manifested by 1 cm ulcer on ankle
C) PC: Hemorrhage
D) Client rates pain as 3 out of 10
a
The following are selected steps of the diagnostic reasoning process. Place them in the proper sequence from first to last.
A) Check for defining characteristics
B) Draw inferences
C) Propose possible nursing diagnoses
D) Identify abnormal data and strengths
E) Cluster data
a b c d e
When describing the diagnostic reasoning process, which of the following terms would least likely apply?
A) Randomized
B) Rational
C) Intelligent
D) Self-directed
a
After completing the diagnostic reasoning process, the nurse documents a wellness diagnosis. Which of the following would the nurse have most likely identified?
A) Potential weaknesses
B) Strengths
C) Abnormal findings
D) Potential complication
b
After teaching a group of students about the pitfalls of diagnostic reasoning, the instructor determines a need for additional teaching when the students identify which of the following as a pitfall?
A) View of things as either right or wrong
B) Overemphasis on details
C) Inclusion of valid data
D) Clustering of unrelated cues
c
The nurse is preparing to assess a client’s remote memory. Which question would be most appropriate for the nurse to use?
A) “Can you tell me what you have eaten in the last 24 hours?”
B) “When did you get your first job?”
C) “What did you do last evening?”
D) “How are an apple and orange the same?”
b
When assessing the mental status of a 67-year-old woman, the nurse detects some difficulty with free-flow of thought and following directions. Which of the following would the nurse do first?
A) Use a Geriatric Depression Scale.
B) Refer for further medical evaluation.
C) Assess the client’s vision and hearing.
D) Refer the client to social services for home assistance.
c
The nurse performs a Mini-Mental Status Exam on a client. The total score is 22. Which of the following would be most appropriate for the nurse to do next?
A) Refer for further evaluation.
B) Evaluate benefits versus risks of a mental health label.
C) Assess further for dementia.
D) Document this as a normal score.
a
The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which of the following would be the priority assessment at this time?
A) Asking whether the client often feels cold
B) Assessing the client’s developmental level
C) Reviewing the client’s culture for possible influence
D) Observing the client’s overall hygiene
a
A nurse is working in a clinic in a poverty-stricken neighborhood and sees a female adult client who states that she has a urinary tract infection. The nurse notes that the client is unkempt, wearing stained clothing, and has a strong foul body odor. The client mentions that she was evicted from her apartment two weeks ago. Which nursing diagnosis would the nurse most likely identify for this client?
A) Caregiver role strain related to fatigue
B) Impaired skin integrity related to neurological deficits
C) Deficient fluid volume related to possible urinary tract infection
D) Self-care deficit related to possible homelessness
d
An instructor is describing psychosocial development to a group of students. Which of the following would the instructor include when describing this concept? Select all that apply.
A) Spiritual beliefs
B) Cognitive function
C) Emotional stability
D) Self-concept
E) Coping-stress patterns
F) Thought patterns
a d e
A group of students is reviewing material about mental and psychosocial status in preparation for an examination. The students demonstrate understanding of the topic when they identify which of the following as a major system affecting a client’s status?
A) Respiratory
B) Neurological
C) Cardiovascular
D) Renal
b
The nurse begins the physical examination of a client by assessing the client’s mental status. The nurse does this primarily based on which rationale?
A) The client will be less anxious early, providing the nurse with more accurate and reliable data.
B) The exam can provide clues about the validity of the client’s responses now and throughout.
C) The exam provides data about mental health problems that the client may be afraid to report.
D) The client’s fears about having a serious illness may be alleviated by the results of the exam.
b
The nurse asks a client to explain the saying, “people in glass houses shouldn’t throw stones.” Which of the following is the nurse assessing?
A) Remote memory
B) Abstract reasoning
C) Judgment
D) Concentration
b
Assessment of a client reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client’s level of consciousness as which of the following?
A) Obtunded
B) Stupor
C) Coma
D) Lethargy
c
A group of students is reviewing material about assessing mental status. The students demonstrated understanding of the material when they identify which of the following as a cognitive ability to be assessed?
A) Orientation
B) Posture
C) Speech
D) Thought processes
a
The nurse is assessing a client using the Glasgow Coma Scale and obtains a score of 14. The nurse interprets this as indicating which of the following?
A) Deep coma
B) Coma
C) Obtunded
D) Alert and oriented
d
A woman brings her 69-year-old husband to the clinic for an evaluation because he has become increasingly forgetful. Which of the following would lead the nurse to suspect that the client has Alzheimer’s disease? Select all that apply.
A) “He repeats the same story, word for word, over and over again.”
B) “He’s good at and enjoys doing the minor repairs in the home.”
C) “I have to balance the checkbook now because he just won’t do it.”
D) “If I don’t tell him when to shower, he won’t and will fight me on it.”
E) “He got lost walking to the pharmacy around the corner the other day.”
a c d e
As part of a mental status assessment, the nurse asks a client to draw the face of a clock. The nurse is assessing which of the following?
A) Concentration and orientation
B) Perceptions and thought processes
C) Visual perceptual and constructional ability
D) Expressions and feelings
c
The nurse is assessing the psychosocial development of a middle-aged client. Which question would be most appropriate for the nurse to ask?
A) “Do you have a close relationship with a partner?”
B) “Are you able to solve problems that arise now that you are independent?”
C) “Do you find pleasure in your current work or profession?
D) “Are you able to cope with the physical changes that are happening?”
c
A nurse is assessing a client exhibiting decorticate posturing. Which of the following would the nurse observe?
A) Extended upper extremities
B) Internally rotated lower extremities
C) Pronated forearms
D) Flexed hands at the side of the body
b
The nurse observes a client’s entire body posture to be stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is:
A) Relaxed
B) Anxious
C) Feeling powerless
D) Restless
b
A nurse is reviewing a depression questionnaire completed by a client. Which of the following would the nurse interpret as being suggestive of depression?
A) “Occasionally I feel like my attention wanders.”
B) “I haven’t noticed any change in my appetite.”
C) “It usually takes me over an hour to fall asleep.”
D) “I might wake up once during the night but not often.”
c
When assessing the speech of an older adult client, which of the following would the nurse expect to find?
A) Repetitive
B) Rapid
C) Moderately paced
D) Loud tone
c
A nurse completes a Geriatric Depression Scale for an older adult client. The nurse determines that the client is not depressed by which score?
A) 9
B) 14
C) 20
D) 25
a
A nursing instructor is teaching a group of students about assessing a client’s orientation. The instructor determines that the teaching was successful when the students state that the ability to identify which of the following usually is lost first?
A) Time
B) Self
C) Place
D) Family members
a
A nurse asks a client the following question: “What do you do if you have pain?” The nurse is assessing which of the following?
A) Orientation
B) Judgment
C) Abstract reasoning
D) Memory
b
After teaching a class about Erikson’s development stages, the instructor determines that the students have understood the information when they identify which of the following as the basic task associated with the older adult?
A) Generativity
B) Identity
C) Ego-integrity
D) Intimacy
c
When preparing to obtain information about a client’s mental and psychosocial status, which of the following would the nurse need to do first?
A) Question the patient about his or her usual lifestyle and behaviors.
B) Perform a neurological examination to determine any deficits.
C) Check the client’s level of consciousness for changes.
D) Explain the purpose of the exam and types of questions.
d
A nurse is preparing to assess a client’s mental status using the Mini-Mental State Examination. The nurse would need to complete additional assessment of which of the following?
A) Orientation
B) Memory
C) Thought processes
D) Speech
c
When explaining the basis of pain, which of the following would the nurse include? Select all that apply.
A) Physiologic
B) Psychological
C) Cutaneous
D) Somatic
E) Visceral
a b
A group of students is reviewing information about pain transmission and the fibers involved. The students demonstrate understanding when they state that A-delta fibers transmit pain that is felt as which of the following?
A) Burning
B) Throbbing
C) Sharp
D) Aching
c
A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following would the nurse need to keep in mind when assessing the client’s pain?
A) The client is likely experiencing less pain than he is reporting.
B) The depression will have minimal impact on the client’s level of pain.
C) It is likely that the client’s pain rating will be less than what he is feeling.
D) The degree of surgery will be the key indicator for level of pain experienced.
c
A client is diagnosed with chronic non-malignant pain. The nurse understands that this client has experienced this pain for at least how many months?
A) 3
B) 6
C) 9
D) 12
b
A nurse is presenting an in-service program to a group of nurses who will be working on an oncology unit. Which of the following would the nurse include when describing cancer pain?
A) Its basis is chronic neuropathy.
B) It is caused by a specific recent trauma.
C) It appears in the first month after cancer develops.
D) It is caused by compressed peripheral nerves.
d
Which of the following would the nurse use as the primary assessment for a client’s pain?
A) The client’s spiritual view of the pain
B) Current pain therapies used
C) The client’s report of the pain
D) Psychosocial questions related to perceptions
c
The nurse is using the Verbal Descriptor Scale to assess a client’s pain. This scale rates pain using which of the following?
A) Facial expressions
B) 0 to 10 numeric scale
C) 0 to 10 visual analog scale
D) Ranges from no pain to worst possible pain
d
The nurse collects vital signs on a client with pain. Which of the following would indicate to the nurse that the client is experiencing pain?
A) Respiratory rate of 18 breaths/min
B) Temperature of 99.1°F
C) Heart rate of 110 bpm
D) Blood pressure of 120/70 mmHg
c
Based on analysis of assessment data from a client with pain, the nurse writes a wellness diagnosis. Which of the following would be most appropriate?
A) Readiness for enhanced spiritual well-being related to coping with prolonged physical pain
B) Risk for activity intolerance related to chronic pain and immobility
C) Bathing self-care deficit related to severe pain
D) Chronic pain related to chronic inflammatory process of rheumatoid arthritis
a
A nurse is preparing to document a collaborative problem for a client with pain. Which of the following would be most appropriate?
A) “Impaired physical mobility related to chronic pain”
B) “Risk for powerlessness related to chronic pain”
C) “Readiness for enhanced comfort level”
D) “PC: peripheral nerve compression”
d
The nurse is assessing a client who is experiencing a great deal of pain. Which assessment data would be considered normal under those circumstances?
A) Decreased heart rate
B) Hypoglycemia
C) Increased urinary output
D) Decreased gastric motility
d
A client rates his pain as 9 on a scale of 1 to 10. The nurse would expect to assess which of the following?
A) Constricted pupils
B) Hypotension
C) Increased serum glucose
D) Flaccid muscles
c
Which question would be most appropriate to ask a client when the goal is to identify precipitating factors that might have exacerbated the pain?”
A) “What were you doing when the pain first stated?
B) “Do concurrent symptoms accompany the pain?”
C) “When did the pain start?”
D) “Is the pain continuous or intermittent?”
a
A client asks why the nurse is asking how the client’s family experiences and tolerates pain. Which of the following would be the most appropriate response by the nurse?
A) “It is just a way for me to more fully understand you and your upbringing.”
B) “It helps me to direct interventions toward your cultural history.”
C) “It helps me to determine how the family understands and perceives pain.”
D) “It will allow me to see if you are more likely to react to pain in a negative manner.”
c
When assessing pain in a older adult client who is alert and oriented, which assessment tool would be most appropriate to use?
A) Numerical rating scale
B) Faces Pain Scale-Revised
C) FLACC Scale
D) Graphic rating scale
a
The nurse is observing a client’s posture and facial expression for evidence of pain. Which of the following would most likely lead the nurse to suspect that the client may be experiencing pain?
A) Attentive listening
B) Slumped posture
C) Eye contact
D) Periodic position changes
b
After describing the pathophysiology of pain, an instructor determines that the students have understood the teaching when they identify which of the following as being responsible for transmitting the sensations to the central nervous system?
A) Transduction
B) Modulation
C) Nociceptors
D) Cytokines
c
A client who has fractured an arm is complaining of pain. The nurse determines that this type of pain is most likely which of the following?
A) Cutaneous
B) Visceral
C) Deep somatic
D) Radiating
c
The nurse is assessing the client’s perception of pain and its intensity and quality. Which dimension is the nurse evaluating?
A) Physical
B) Sensory
C) Behavioral
D) Cognitive
b
When attempting to assess a client’s pain, which of the following would the nurse obtain first?
A) Observe behaviors in the client
B) Obtain a client self-report
C) Search for possible causes of pain
D) Ask family members about the client’s pain
b
The nurse is preparing a presentation about cancer pain for a group of caregivers of clients with cancer. Which of the following would the nurse expect to include in the description of this type of pain?
A) Cancer pain is usually acute severe pain.
B) Clients often experience brief severe pain despite medication.
C) Surgery is the primary cause of pain secondary to cancer.
D) Cancer pain is typically treated aggressively.
b
When assessing a client of Asian American background, which of the following would the nurse need to keep in mind?
A) Pain is a challenge to be fought.
B) Pain helps to achieve higher spirituality.
C) Pain must be endured to prepare for reincarnation.
D) Pain is an inevitable event that must be endured.
b
Which of the following questions would be most appropriate for a nurse to ask when assessing the cognitive dimension of pain?
A) “Where is the pain located?”
B) “How does the pain affect your mood?”
C) “What do you think is causing your pain?”
D) “How would you rate your pain from 1 to 10?”
c
A group of students is reviewing information about pain and pain assessment in preparation for an examination. Which of the following statements indicates the need for additional study?
A) “Open-ended questions are most helpful in eliciting information about pain.”
B) “Client’s facial expressions during an interview can provide clues to possible pain.”
C) “Clients may believe that acknowledging pain shows that they are weak.”
D) “Clients who are sleeping usually aren’t experiencing pain.”
d
A nursing instructor is describing the transduction of pain. Which of the following would the instructor explain as being released by the nociceptors leading to vasodilation?
A) Cytokines
B) Substance P
C) Neuropeptides
D) Histamine
b
When the nurse is inspecting a client’s fingers, a client asks how fingerprints are formed. When deciding on an answer, the nurse recalls that the fingerprints are formed in which skin layer?
A) Epidermal
B) Sebaceous
C) Subcutaneous
D) Dermal
d
When examining a fair-skinned white woman with red hair and freckled skin, the nurse should focus health education on measures related to which condition?
A) Dry skin
B) Easy bruising
C) Fungal infections
D) Sun exposure
d
During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?
A) Nail beds
B) Sclera
C) Palms
D) Oral mucosa
d
A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the exam, the nurse notices areas of hyperpigmentation around the neck and in the axillae. Which of the following would the nurse do next?
A) Document the benign findings.
B) Perform a random blood sugar test.
C) Ask the client about a family history of cancer.
D) Refer the client for medical follow-up.
b
An older adult female client is concerned because her skin is very dry. She asks the nurse why she has dry skin now when she never had dry skin before. The nurse responds to the client based on the understanding that dry skin is normal with aging due to a decrease of what?
A) Squamous cells
B) Sweat glands
C) Subcutaneous tissue
D) Sebum production
d
A female client is noted to have excessive hair on her face and chest. The nurse plans further evaluation of which body system?
A) Endocrine
B) Neurologic
C) Cardiovascular
D) Genitourinary
a
A client’s fingernails are noted to be very thin and concave. The nurse knows the client needs medical follow-up for further assessment of which condition?
A) Diabetes mellitus
B) Iron deficiency anemia
C) Vitamin deficiency
D) Peripheral vascular disease
b
For which client condition would the nurse most likely expect a capillary refill time longer than 2 seconds?
A) Inflammatory bowel disease
B) Multiple sclerosis
C) Malignant melanoma
D) Peripheral vascular disease
d
When asked to assess an area of broken skin on an older adult client in a long-term care facility, the nurse notes a break in the skin erythema and a small amount of serosanguineous drainage over the sacrum. The area appears blister-like The nurse would interpret this finding as indicating which stage of pressure ulcer?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
b
An adolescent shows the nurse a “bump” on his neck. The nurse observes a raised, erythematous, solid 0.3-cm by 0.2-cm mass. The nurse would document this finding as which of the following?
A) Macule
B) Papule
C) Nodule
D) Pustule
b
The nurse inspects the skin of an older adult client and notes thick, rough skin over the elbows. The nurse would document this finding as which of the following?
A) Crust
B) Lichenification
C) Atrophy
D) Erosion
b
The nurse notes a large keloid on the pierced ear of an adolescent. The client asks what caused this finding. Which of the following would the nurse incorporate into the response as the most likely cause?
A) Continuous trauma
B) Excessive collagen formation
C) Decreased subcutaneous tissue
D) Inadequate circulation
b
While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse documents this finding as which of the following?
A) Purpura
B) Petechiae
C) Ecchymosis
D) Cherry angioma
b
A male construction worker asks the nurse if the mole on his arm is skin cancer. During assessment using the mnemonic ABCDE, which finding would the nurse identify as being suspicious of melanoma?
A) Solid, dark brown color
B) Asymmetric, irregular borders
C) Diameter of 3 mm
D) Flat with silvery scales
b
A client reports that he might have shingles. Which type of lesion would the nurse most likely assess?
A) Papule
B) Vesicle
C) Bulla
D) Crust
b
The nurse notes multiple elevated masses with irregular transient borders that are superficial, raised, and erythematous in a client who complains of an “itching rash.” Which question would be most important for the nurse to ask?
A) “Are you allergic to foods, medications, or other substances?”
B) “Does anyone else in your family have a rash like this?”
C) “Have you ever had a rash like this before?”
D) “What have you been doing to control the itching?”
a
A client’s history reveals that he has been taking oral steroid therapy for several years for treatment of an autoimmune disorder. The nurse would expect to assess the client’s skin as which of the following?
A) Thick
B) Thin
C) Pale
D) Flushed
b
An older adult male client states that he has trouble cutting his toenails because they are hard and thick, and the nurse notes that they are very long and unkempt. Which system would be most important for the nurse to assess?
A) Integumentary
B) Digestive
C) Neurologic
D) Circulatory
d
A group of students are reviewing the structure and function of the skin in preparation for a test on the material. The students demonstrated understanding when they identify which layer as the outermost layer of the epidermis?
A) Stratum corneum
B) Stratum lucidum
C) Stratum granulosum
D) Stratum germinativum
a
Assessment of a client’s nails reveals a brownish-black discoloration and crumbling of the nail plate. The nurse suspects which of the following?
A) Fungal infection
B) Bacterial infection
C) Yeast infection
D) Trauma
b
The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following?
A) Cherry angioma
B) Cutaneous horn
C) Seborrheic keratosis
D) Pressure ulcer
d
The health history of a female client who comes to the clinic for a routine examination reveals a family history of keloids. The client asks the nurse about ear piercing. “Our daughter wants to get her ears pierced and we’re wondering if there is a best age to do it.” The nurse would suggest that the client have the daughter’s ears pierced before which age?
A) 5 years
B) 7 years
C) 9 years
D) 11 years
d
When preparing to examine a client’s skin, which of the following would be most important for the nurse to do?
A) Ensure that the room is warm to prevent chilling
B) Wear gloves when preparing to inspect the skin and nails
C) Expose only the body part that is being examined
D) Have the client remove clothing from the upper body
c
A nurse is providing a client with instructions on how to perform self-examination of the skin. The nurse would encourage the client to perform this examination at which frequency?
A) Monthly
B) Bimonthly
C) Quarterly
D) Yearly
a
A nurse is preparing to assess the skin of a client. The nurse performs the following steps. Place these steps in the sequence that the nurse would perform them, from first to last.
A) Inspect the scalp and hair.
B) Inspect skin color and temperature.
C) Inspect for skin lesions.
D) Palpate the skin for texture and moistness.
E) Note the condition of the nail beds.
F) Check capillary refill.
a b c d e
After teaching a group of students about the structure and function of the skin, the instructor determines that the teaching was successful when the students identify which of the following as responsible for variations in skin color?
A) Sebaceous glands
B) Keratin
C) Melanin
D) Eccrine glands
c
Which of the following findings related to hair would the nurse most likely assess in an older adult female client?
A) Thick elastic scalp hair
B) Terminal hair growth on chin
C) Increased pubic hair
D) Copper-red color
b
A group of students is reviewing information about common skin variations. The students demonstrate the need for additional review when they identify which of the following as an example?
A) Cutaneous tags
B) Striae
C) Vitiligo
D) Fissure
d
Assessment of a client’s skin reveals several individual and distinct 2-mm lesions on the client’s back. The nurse would document the configuration as which of the following?
A) Discrete
B) Linear
C) Annular
D) Confluent
a
Assessment of a client’s nails reveals Beau’s lines. The nurse interprets this finding as indicating which of the following?
A) Oxygen deficiency
B) Acute illness
C) Psoriasis
D) Trauma
b
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