Question 1

The nurse is conducting a health history during the nursing assessment.The client states to the nurse,"I am allergic to penicillin." Which assessment question is most appropriate to learn more about the client's allergy?

Accepted Answer

A) The nurse should ask the client to expand about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important but the priority is determining the type of reaction the client experienced. Asking if any other family members have the same allergy will not provide the nurse with useful information.
B) The nurse should ask the client to expand about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important but the priority is determining the type of reaction the client experienced. Asking if any other family members have the same allergy will not provide the nurse with useful information.
C) The nurse should ask the client to expand about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important but the priority is determining the type of reaction the client experienced. Asking if any other family members have the same allergy will not provide the nurse with useful information.
D) The nurse should ask the client to expand about the type of reaction that occurred when the penicillin was administered. The location of the reaction and how long the symptoms lasted are important but the priority is determining the type of reaction the client experienced. Asking if any other family members have the same allergy will not provide the nurse with useful information.

Question 2

The nurse is preparing to assess a client who has chronic obstructive pulmonary disease (COPD).The client is currently experiencing difficulty breathing.Before palpating the client's abdomen,which action is appropriate by the nurse?

Accepted Answer

A) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client's ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD
B) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client's ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD
C) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client's ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD
D) Abdomen palpation is usually done in the supine position, but the client with COPD would not tolerate the position well. The nurse should position the client with the head elevated to the point of comfortable breathing to perform the assessment. Having the client lie in the modified Sims position could compromise the client's ability to breathe effectively. A client with COPD who is experiencing dyspnea would not be asked to bend over the table. Administering an additional 6 L of oxygen is an excessive amount of oxygen to give someone with COPD

Question 3

An adult client and spouse are seen in an urgent care clinic.The client presents with a temperature of 102°F,complains of nausea,and has experienced vomiting and diarrhea for 12 hours.The nurse notes that the client's mucous membranes are pale and dry.Which action by the nurse is the most appropriate?

Accepted Answer

A) A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.
B) A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.
C) A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.
D) A client who presents with hyperthermia, vomiting, diarrhea, and pale dry mucous membranes requires assessment for dehydration. An appropriate action by the nurse is to assess the client's skin turgor, which can provide more support that the client is dehydrated and requires further intervention. Pedal edema would indicate fluid volume overload and not dehydration. Asking the spouse for more information will not provide adequate support for the treatment of dehydration. The nurse must further assess the client prior to administering IV fluids.

Question 4

The nurse is conducting a physical assessment of a middle-age client upon admission to the cardiovascular care unit for cardiopulmonary problems.Which position is likely to be contraindicated for this client?

Accepted Answer

A) Placing clients with cardiopulmonary problems in the dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is more likely to be contraindicated because of the increased physiologic stress that this position places on the body. The other positions noted-sitting (whether with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)-are typically better tolerated by clients with cardiopulmonary illness than the dorsal recumbent position.
B) Placing clients with cardiopulmonary problems in the dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is more likely to be contraindicated because of the increased physiologic stress that this position places on the body. The other positions noted-sitting (whether with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)-are typically better tolerated by clients with cardiopulmonary illness than the dorsal recumbent position.
C) Placing clients with cardiopulmonary problems in the dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is more likely to be contraindicated because of the increased physiologic stress that this position places on the body. The other positions noted-sitting (whether with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)-are typically better tolerated by clients with cardiopulmonary illness than the dorsal recumbent position.
D) Placing clients with cardiopulmonary problems in the dorsal recumbent position (back-lying with knees flexed and hips externally rotated) is more likely to be contraindicated because of the increased physiologic stress that this position places on the body. The other positions noted-sitting (whether with back supported or unsupported), supine (horizontal recumbent), and side-lying (Sims)-are typically better tolerated by clients with cardiopulmonary illness than the dorsal recumbent position.

Question 5

An older Spanish-speaking adult client who recently moved to a new city makes an appointment for a routine annual assessment with a new primary care provider.Which action by the nurse is appropriate when conducting the health history?

Accepted Answer

A) A client who is Spanish-speaking will require a medical translator to be available during the health history portion of the nursing assessment. While the nurse may need to increase the volume of speech due to client's age, this is not an appropriate action until it is determined that the client is hard of hearing. Educational material should be provided to the client in the native language. Asking a family member to translate during an assessment can violate the client's privacy.
B) A client who is Spanish-speaking will require a medical translator to be available during the health history portion of the nursing assessment. While the nurse may need to increase the volume of speech due to client's age, this is not an appropriate action until it is determined that the client is hard of hearing. Educational material should be provided to the client in the native language. Asking a family member to translate during an assessment can violate the client's privacy.
C) A client who is Spanish-speaking will require a medical translator to be available during the health history portion of the nursing assessment. While the nurse may need to increase the volume of speech due to client's age, this is not an appropriate action until it is determined that the client is hard of hearing. Educational material should be provided to the client in the native language. Asking a family member to translate during an assessment can violate the client's privacy.
D) A client who is Spanish-speaking will require a medical translator to be available during the health history portion of the nursing assessment. While the nurse may need to increase the volume of speech due to client's age, this is not an appropriate action until it is determined that the client is hard of hearing. Educational material should be provided to the client in the native language. Asking a family member to translate during an assessment can violate the client's privacy.

Question 6

The nurse is assessing an older adult client during a routine health maintenance visit.To assess the client's range of motion of the knees,which action by the nurse is appropriate?

Accepted Answer

A) To assess the range of motion of the knees the client should be placed in a sitting position. The nurse will instruct the client to alert the nurse at the first sign of discomfort when checking range of motion of the knee. Seating the client is appropriate, but the knee is not forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of the hips. The client will not be asked to stand when assessing range of motion of the knees.
B) To assess the range of motion of the knees the client should be placed in a sitting position. The nurse will instruct the client to alert the nurse at the first sign of discomfort when checking range of motion of the knee. Seating the client is appropriate, but the knee is not forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of the hips. The client will not be asked to stand when assessing range of motion of the knees.
C) To assess the range of motion of the knees the client should be placed in a sitting position. The nurse will instruct the client to alert the nurse at the first sign of discomfort when checking range of motion of the knee. Seating the client is appropriate, but the knee is not forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of the hips. The client will not be asked to stand when assessing range of motion of the knees.
D) To assess the range of motion of the knees the client should be placed in a sitting position. The nurse will instruct the client to alert the nurse at the first sign of discomfort when checking range of motion of the knee. Seating the client is appropriate, but the knee is not forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of the hips. The client will not be asked to stand when assessing range of motion of the knees.

Question 7

The nurse is conducting a physical assessment for a middle-age adult female client during an annual exam.When discussing the importance of diet and exercise,which with the nurse include in the teaching session? Select all that apply.

Accepted Answer

A) Counseling for the middle-aged client includes the importance of limiting fat and cholesterol intake, encouraging adequate calcium intake for females, and engaging in regular physical activity. The client should be counseled to maintain caloric balance and increase the intake of grains, fruits, and vegetables.
B) Counseling for the middle-aged client includes the importance of limiting fat and cholesterol intake, encouraging adequate calcium intake for females, and engaging in regular physical activity. The client should be counseled to maintain caloric balance and increase the intake of grains, fruits, and vegetables.
C) Counseling for the middle-aged client includes the importance of limiting fat and cholesterol intake, encouraging adequate calcium intake for females, and engaging in regular physical activity. The client should be counseled to maintain caloric balance and increase the intake of grains, fruits, and vegetables.
D) Counseling for the middle-aged client includes the importance of limiting fat and cholesterol intake, encouraging adequate calcium intake for females, and engaging in regular physical activity. The client should be counseled to maintain caloric balance and increase the intake of grains, fruits, and vegetables.
E) Counseling for the middle-aged client includes the importance of limiting fat and cholesterol intake, encouraging adequate calcium intake for females, and engaging in regular physical activity. The client should be counseled to maintain caloric balance and increase the intake of grains, fruits, and vegetables.

Question 8

The nurse is conducting an assessment for an older adult client who experienced a myocardial infarction (MI)a few months ago.The clients states,"I just don't feel like doing much.I feel ok physically but I just don't want to be around anyone." Based on this data,which tool should the nurse use to further assess the client?

Accepted Answer

A) The most appropriate tool for the nurse to use in further assessing the client is the Geriatric Depression Scale. This instrument is designed to assess low mood and diminished self-esteem as well as loss of interest in activities that are normally enjoyed, and because the client experienced a myocardial infarction 6 months previously, the nurse should be aware that depression following such a major illness is not uncommon. The other instruments measure other factors that are relevant to the functioning of older adult client, but do not appear to be indicated at this time given the historical data presented.
B) The most appropriate tool for the nurse to use in further assessing the client is the Geriatric Depression Scale. This instrument is designed to assess low mood and diminished self-esteem as well as loss of interest in activities that are normally enjoyed, and because the client experienced a myocardial infarction 6 months previously, the nurse should be aware that depression following such a major illness is not uncommon. The other instruments measure other factors that are relevant to the functioning of older adult client, but do not appear to be indicated at this time given the historical data presented.
C) The most appropriate tool for the nurse to use in further assessing the client is the Geriatric Depression Scale. This instrument is designed to assess low mood and diminished self-esteem as well as loss of interest in activities that are normally enjoyed, and because the client experienced a myocardial infarction 6 months previously, the nurse should be aware that depression following such a major illness is not uncommon. The other instruments measure other factors that are relevant to the functioning of older adult client, but do not appear to be indicated at this time given the historical data presented.
D) The most appropriate tool for the nurse to use in further assessing the client is the Geriatric Depression Scale. This instrument is designed to assess low mood and diminished self-esteem as well as loss of interest in activities that are normally enjoyed, and because the client experienced a myocardial infarction 6 months previously, the nurse should be aware that depression following such a major illness is not uncommon. The other instruments measure other factors that are relevant to the functioning of older adult client, but do not appear to be indicated at this time given the historical data presented.

Question 9

The nurse is examining a client with congestive heart failure (CHF)who is prescribed propranolol and furosemide.The client complains of fatigue and an inability to finish tasks.Which conclusion by the nurse is the most appropriate?

Accepted Answer

A) CHF and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with CHF. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.
B) CHF and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with CHF. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.
C) CHF and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with CHF. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.
D) CHF and the drugs prescribed for it cause the client to be fatigued. Although this would be considered abnormal in most clients, it is expected in the client with CHF. The client does not need to be hospitalized for fatigue. Fatigue is not an indication that the medication needs adjusting. A lack of exercise would not cause the client to experience fatigue severe enough to prevent the completion of tasks.

Question 10

The nurse preparing to assess a toddler-age client ears.Which actions by the nurse are appropriate? Select all that apply.

Accepted Answer

A) The best way to get the child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, and to have the child sit on the parent's lap. Tilting the head does not gain the child's cooperation. Most children of this age need to see for themselves that the procedure will not hurt. Simply telling the child will not work.
B) The best way to get the child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, and to have the child sit on the parent's lap. Tilting the head does not gain the child's cooperation. Most children of this age need to see for themselves that the procedure will not hurt. Simply telling the child will not work.
C) The best way to get the child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, and to have the child sit on the parent's lap. Tilting the head does not gain the child's cooperation. Most children of this age need to see for themselves that the procedure will not hurt. Simply telling the child will not work.
D) The best way to get the child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, and to have the child sit on the parent's lap. Tilting the head does not gain the child's cooperation. Most children of this age need to see for themselves that the procedure will not hurt. Simply telling the child will not work.
E) The best way to get the child of this age to cooperate is to let the child play with the equipment and perhaps use the equipment on a doll, and to have the child sit on the parent's lap. Tilting the head does not gain the child's cooperation. Most children of this age need to see for themselves that the procedure will not hurt. Simply telling the child will not work.

Question 11

A client is complaining of pain in the lower-left quadrant of the abdomen.The nurse prepares to percuss the abdomen and notes that the client has a great deal of hair on the lower abdomen.Which action by the nurse is appropriate prior to percussing the client's abdomen?

Accepted Answer

A) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.
B) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.
C) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.
D) If the client has excess body hair, the nurse should dampen the hair so that it lies flat against the abdomen to enhance sound transmission. The nurse would not shave the client's hair for percussion. The client complains of abdominal pain, and percussion would be part of a thorough examination to determine the cause. Hirsutism includes excess hair all over the entire body.

Question 12

The nurse is preparing to conduct a physical examination of a client's head and neck area.The client is in a wheelchair due to a C3-C4 spine injury.Which action by the nurse is appropriate when conducting the physical assessment of this area?

Accepted Answer

A) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.
B) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.
C) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.
D) The client with a C3-C4 spine injury is not able to support the body. When considering positioning, the nurse recognizes that the client will need to be supported during the procedure. Placing the client supine will not allow the nurse full view of the client during observation. This client would not be able to sit in an armless chair, which has no support. The Sims position would not allow the nurse to observe the client adequately.

Question 13

The nurse educator is providing information to a group of nursing students regarding appropriate assessment techniques that can be applied across the life span.Which statements will the educator include in the teaching session? Select all that apply.

Accepted Answer

A) Using standard precautions, age-appropriate terminology, and the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducing a cardiovascular assessment during sleep is appropriate for some pediatric clients, but would be considered as an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for the pediatric client but is not necessary for the adult client.
B) Using standard precautions, age-appropriate terminology, and the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducing a cardiovascular assessment during sleep is appropriate for some pediatric clients, but would be considered as an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for the pediatric client but is not necessary for the adult client.
C) Using standard precautions, age-appropriate terminology, and the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducing a cardiovascular assessment during sleep is appropriate for some pediatric clients, but would be considered as an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for the pediatric client but is not necessary for the adult client.
D) Using standard precautions, age-appropriate terminology, and the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducing a cardiovascular assessment during sleep is appropriate for some pediatric clients, but would be considered as an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for the pediatric client but is not necessary for the adult client.
E) Using standard precautions, age-appropriate terminology, and the examination to provide teaching are all actions that the nurse can implement across the life span when assessing clients. Conducing a cardiovascular assessment during sleep is appropriate for some pediatric clients, but would be considered as an intrusion or violation of privacy by older pediatric and adult clients. Performing invasive procedures at the end of the assessment is appropriate for the pediatric client but is not necessary for the adult client.

Question 14

The nurse in the clinic is assessing an adult client who has 2+ ankle edema,crackles throughout the lung fields,and dyspnea on exertion.Which will the nurse inquire about prior to initiating the client's teaching plan?

Accepted Answer

A) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client's lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client's current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client's current lifestyle.
B) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client's lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client's current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client's current lifestyle.
C) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client's lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client's current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client's current lifestyle.
D) The nurse realizes the client may be experiencing heart failure and asks the client questions aimed at obtaining the client's lifestyle habits that can contribute to the heart failure, such as smoking and dietary habits. Gathering psychosocial information such as marriage and children is important, but in this case the nurse focuses on the client's current problem and teaching needs. Family history is also an important part of data gathering, but does not address the client's current lifestyle.

Question 15

The nurse is reviewing the medical record for a school-age client prior to a scheduled health maintenance visit.Which data indicates the client is overweight?

Accepted Answer

A) A child with a BMI greater than 85% is considered overweight. A child with a BMI greater than 95% is considered obese. Percentage of weight gain in a 6 month period regardless of baseline is not used to determine whether a client overweight or obese.
B) A child with a BMI greater than 85% is considered overweight. A child with a BMI greater than 95% is considered obese. Percentage of weight gain in a 6 month period regardless of baseline is not used to determine whether a client overweight or obese.
C) A child with a BMI greater than 85% is considered overweight. A child with a BMI greater than 95% is considered obese. Percentage of weight gain in a 6 month period regardless of baseline is not used to determine whether a client overweight or obese.
D) A child with a BMI greater than 85% is considered overweight. A child with a BMI greater than 95% is considered obese. Percentage of weight gain in a 6 month period regardless of baseline is not used to determine whether a client overweight or obese.

Question 16

The nurse is conducting an assessment on an older adult client who is confused.The client is accompanied to the appointment with an adult child.When collecting data,who can provide primary sources of data during the assessment?

Accepted Answer

A) The client is the only person who is considered a primary source of data. Data obtained from family members, other support people, health professionals, records, reports, laboratory and diagnostic reports, and any other information gleaned from sources other than the client himself or herself are considered secondary data sources.
B) The client is the only person who is considered a primary source of data. Data obtained from family members, other support people, health professionals, records, reports, laboratory and diagnostic reports, and any other information gleaned from sources other than the client himself or herself are considered secondary data sources.
C) The client is the only person who is considered a primary source of data. Data obtained from family members, other support people, health professionals, records, reports, laboratory and diagnostic reports, and any other information gleaned from sources other than the client himself or herself are considered secondary data sources.
D) The client is the only person who is considered a primary source of data. Data obtained from family members, other support people, health professionals, records, reports, laboratory and diagnostic reports, and any other information gleaned from sources other than the client himself or herself are considered secondary data sources.

Quiz 34: Assessment