Holistic Assessment Exam Comprehensive Questions and Answers 2024.
A nurse is assessing a patient for possible fluid overload. Which
... [Show More] assessment
finding is most consistent with this diagnosis
-Boggy eyeball
-Moist, plump tongue
-Distended neck veins w/ head elevated at 45 degrees
-venous filling of 3 second - ANSWER Distended neck veins w/ head elevated at
45 degrees
The nurse is preparing to perform a physical examination on a female patient who
has been transferred to the medical unit from the emergency department. The
nurse should begin the collection of objective data with which examination?
-Head and neck examination.
-Palpation of lymph nodes.
-Vital signs.
-Breast examination - ANSWER -Vital signs.
The nurse is assessing an older adult patient's mental status. Consistently, the
patient pauses after the nurse poses a question, but then provides a response that
is correct or appropriate. How should the nurse best interpret this characteristic
of the patient?
-The patient is displaying a sign of early Alzheimer disease.
-Slight delays in mental processing are normal in older adults.
-The patient may be trying to anticipate the nurse's desired response.
-The patient may be experiencing an early sign of delirium. - ANSWER -Slight
delays in mental processing are normal in older adults.
Holistic Assessment Exam Comprehensive
Questions and Answers 2024
After teaching a group of students about the external and internal structures of
the eye, the instructor determines that the teaching was successful when the
students identify which of the following as external structures? SELECT ALL THAT
APPLY
-Lacrimal apparatus
-Conjunctiva
-Lens
-Iris
-Sclera
-Caruncle - ANSWER -conjunctiva
-lens
-iris
The nurse has completed the comprehensive health assessment of a patient who
has been admitted for the treatment of community-acquired pneumonia.
Following the completion of this assessment, the nurse periodically performs a
partial assessment primarily for which reason?
-Provide information for the client's record.
-Address areas previously omitted.
-To determine the need for crisis intervention.
-To reassess previously detected problems. - ANSWER -To reassess previously
detected problems.
A nurse is reviewing the four basic physical examination techniques and their
sequence prior to receiving a new patient from post-anesthetic recovery. The
nurse should plan to perform which technique first?
-Inspection
-Palpation
-Percussion
-Auscultation - ANSWER -Inspection
The nurse collects vital signs on a hospital patient who has recently been
experiencing pain. Which finding would indicate the patient is currently
experiencing pain?
-Respiratory rate of 18 breaths/min.
-Temperature of 37.3°C (99.1°F).
-Heart rate of 110 beats/min.
-Blood pressure of 115/65 mm Hg - ANSWER -Heart rate of 110 beats/min.
The nurse has identified abnormal findings when reviewing a young adult
patient's health history. Within Kohlberg theory of moral development, what
behavioral characteristic is the nurse most likely to observe?
-The patient is easily manipulated by others.
-The patient is unable to weigh options when presented with a dilemma.
-The patient has difficulty trusting others.
-The patient makes decisions without considering the impact on others. - ANSWER
-The patient makes decisions without considering the impact on others.
The nurse is percussing the area over the patient's lungs and hears a loud,
low-pitched, hollow sound. The nurse documents this finding as which of the
following?
-Tympany
-Dullness
-Flatness
-Resonance - ANSWER -Resonance
A nurse has received a report on a patient who will soon be admitted to the
medical unit from the emergency department. When preparing for the assessment
phase of the nursing process, what should the nurse do first?
-Validate important data.
-Collect subjective data.
-Document the data.
-Collect objective data. - ANSWER -Collect subjective data.
During a Weber test, the patient reports lateralization of sound to the good ear.
The nurse interprets this as which the following?
-The poor ear is receiving sound vibrations by air.
-The good ear cannot receive sound vibrations.
-There is a sensorineural hearing impairment.
-There is a dysfunction of the middle ear. - ANSWER -There is a sensorineural
hearing impairment.
The nurse is preparing to test a patient's eyes for accommodation. The nurse
would have the patient focus on an object in which sequence for this test?
-Near, then far
-Lateral, then near
-Lateral, then far
-Far, then near - ANSWER -Far, then near. [Show Less]