A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of
... [Show More] illness?
"My life is really out of balance."
2. A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.)
Be open to people who are different
Have a curiosity about people.
Become culturally competent.
Which statement is accurate about assessing the spleen?
It must be enlarged at least three times normal size for it to be palpable.
What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope?
Posterior chest below the 3rd intercostalspace.
The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition?
Place the bell on the 5th intercostal space, left midclavicular line.
The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition?
2nd intercostal space along the right sternal border.
The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing?
The client works in a daycare setting that has had a scabies outbreak.
A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client?
Level of consciousness.
A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation?
Use of vitamin and iron supplements.
The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation?
There is no sign of associated infection.
The client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps?
Swelling anterior to the ear lobe on one side of the face.
A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client?
Swelling of the left arm and non-pitting edema.
What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment?
Ask the client specifically about any leakage of urine.
A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client?
Have you experienced sudden weight loss?
A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client?
Family history of colon cancer on mother's side. Correct
Which information should the nurse obtain to identify the client's self-perception of health status?
Health history.
During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document?
Cataracts
While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition?
Fibroadenoma.
Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure?
Ankles.
Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp toexamine a client's skin lesions?
Fungal infection
The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire?
Have you ever felt guilty about your drinking?
A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure?
Lying
The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest?
The left leg remains on the table.
An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status?
The skin immediately returns to normal position.
The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client?
barrel chest
The nurse performs a series of cranial nerve tests on a client with a head injury. Which test should the nurse use to assess damage to the first cranial nerve?
Occlude one nostril and have the client identify various odors.
Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury?
Glasgow Coma Scale
A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation?
Change in consistency
While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client?
12
Which question should the nurse ask in order to test a client's remote memory?
What is your date of birth?
A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing?
Pleural friction rub.
The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain?
Knee joint evaluation
A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client?
You have benign fibroid tumors, a common occurrence in women your age.
The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use?
Press the tongue down one side at a time with a tongue depressor.
A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake?
24-hour dietary recall
The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status?
audiometry
The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.)
Diminished hair on legs
Skin cool to touch
Which findings can the nurse determine by palpating a client's skin? (Select all that apply.)
Diaphoresis.
Scaling.
The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response?
The client is treating the nurse with respect.
A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.)
Use simple sentences during the examination.
Reduce environmental detractors during the examination.
Ask questions one at a time to decrease confusion.
The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis?
Phlegm production and wheezing.
A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use?
Face the client so the client can see the RN's mouth
Check if the client's hearing aides are working properly
Reduce environmental noise surrounding the client
Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter?
Maintain eye contact with the client while listening to the translation.
The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen?
Percuss the splenic area as the client takes a deep breath
The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly?
Use a bouncing motion to tap the middle finger placed within boundaries of the liver.
When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses?
Only one side of the mouth moves when smiling.
A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide?
"What effect do you think your use of alcohol may have on you?"
When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented?
Abnormal.
During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding?
Abnormal findings
The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions?
Request that the mother leave the exam room.
While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate?
"Short-term memory is intact." [Show Less]