Nurs 114 Exam 1 (prepU) Questions with detailed correct answers all correct

To clarify (making sure the client has been taught and no further teaching is/is not necessary) - correct answers While interviewing a client, the nurse asks, "What happens when you have low blood glucose?" This type of response to the client is used for what purpose? Using a moderate amount of eye contact (nonverbal communication- not too much or too little ey contact) - correct answers A nurse is interviewing a client. Which nonverbal behavior by the nurse would best facilitate communication? Establishing a trusting relationship (interpersonal part of nursing competencies) - correct answers A nurse is preparing to assess a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? "What is your major health concern at this time?" (making sure to prioritize the pt needs first) - correct answers A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history? Speak clearly Use simple terms Show respect avoid jargon use simple terms (geriatric patients require accommodations, it is helpful to assess the pt records first, in case there is some info to know before seeing them) - correct answers An older client arrives for an appointment in the community clinic. Which approach should the nurse use when communicating with this client? Select all that apply. Elevated LDL (objective data is very important for new patients, as no prior relationship/rapport has been est with them, use objective data that can be proven) - correct answers You are seeing a client for the first time and there are no medical records, select the objective data from the list below The nurse detects gurgling throughout the abdomen. (auscultation can be done on the abdomen, back, chest, bronchial area ) - correct answers Which describes the nurse using the technique of auscultation? To determine whether a structure is filled with air or fluid or is a solid structure. (this is percussion) - correct answers While performing the physical examination of a client, a nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment? Fungal infection. ( in nails, fungal infections are common and will cause nails to look yellow) - correct answers The nurse is using a Wood's light for a client who has complaints of itching, burning, and peeling of the skin between his toes. The nurse is assessing for what etiology of the client's symptoms? Gloves Gown Mouth, nose, eye protection - correct answers What included in personal protective equipment? Select all that apply. Lungs - correct answers During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing? Inspection (nurse must be consistently inspecting for changes) - correct answers During a comprehensive assessment, the primary technique used by the nurse throughout the examination is Fingers pads (using another part of hand could cause to feel own pulse of be too heavy a touch to feel pt pulse) - correct answers When assessing pulses, the nurse would use which part of the hand for palpation? Hearing loss (tuning forks used in Rinnes test for hearing loss) - correct answers The nurse would use the tuning fork to assess for what? "They make sure that any microorganisms on my hands do not touch your skin." (the real reason is to protect ourselves from the patient but cannot state that.) - correct answers A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client? Alcohol based rub (70% isopropyl alcohol is most effective in permeating bacterial cell walls because of pressure exerted between alcohol molecules and water molecules at that specific ratio) - correct answers The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what? Inspection, palpation, percussion, auscultation. - correct answers A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client? gloves, mask , gown, eye goggles - correct answers A nurse will be performing a complete physical examination of a man who has emphysema with a chronic productive cough, including an assessment of his oral cavity. Which pieces of personal protective equipment should the nurse wear? Blood borne pathogens (standard protocol is to perform proper hand hygiene and use gloves- in the case nurse comes in contact with blood borne pathogens that are not droplet, contact or airborne- so no need for masks, gown, goggles, etc) - correct answers Universal precautions are primarily designed to protect the health care worker from what? inspection, palpation, auscultation - correct answers Which of the following techniques are used in a physical assessment? Select all that apply. Wash hands. Obtain and check needed equipment. Identify ways to ensure client privacy. (standard protocol) - correct answers Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply.) adequate lighting (adequate lighting especially important for skin assessments- keep in mind special circumstances needed for specific assessments) - correct answers A client with scabies visits the health care facility for a follow up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client? balance - correct answers The client is in a standing position. Which of the following can the nurse most effectively assess with the client in this position? Snellen chart - correct answers A client with an inability to read billboards while driving arrives at the health care facility for an eye examination. Which piece of equipment should the nurse use to check the client's distant vision? Dorsal surface (palmar surface might be warm and give wrong feeling) - correct answers The nurse would use what part of the hand when assessing temperature during palpation? Heart murmurs (the bell is used for abnormal , low pitch and S3/S4 sounds) - correct answers A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds? Collecting data regarding the nature of the pain (PQRST- provocation, quality, radiation, severity, time) - correct answers What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? Measuring the remaining tread on a car tire to determine whether it is time to replace it. - correct answers Which of the following is the best example of assessment in everyday life? Identify in what areas the client needs the most care. (whole idea of a nursing assessment, to see in what ways the patient needs nursing care) - correct answers When doing an overall assessment of a client, the nurse is able to utilize findings and do what? Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings. (holistic approach looks at the whole person- physiological, psychological, emotional, spiritual, socioeconomic factors of the WHOLE person) - correct answers Which of the following is the best example of holistic data collection by a nurse? Body functions (can be directly proven) - correct answers Which assessment finding should the nurse document as objective data? To determine any changes from the baseline data. (as pt status can change quickly especially with known risk factors) - correct answers A nurse provides care for a client with impaired respiratory function. The nurse frequently assesses the client's skin color and temperature of the extremities. What is the purpose of this ongoing or partial assessment? Appearance - correct answers The nurse is collecting data from a client who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. Which of the following would the nurse categorize as objective data? Evaluation (constantly evaluating the result of the plan of care- prescribed medication) - correct answers A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment? airway - correct answers A client is brought to the emergency department by ambulance after a motor vehicle accident. What would be given the highest priority by the staff triaging the client? Using reputable health-education strategies to reduce risk behaviors - correct answers To enhance personal health practices, the most fundamental and effective approach to individual client assessment would be: Up and back - correct answers How should the nurse place the ear of an adult when using the otoscope? A healthy environment - correct answers When assisting a client with health promotion, what must the nurse also nurture? Strength of a reflex - correct answers What is used to gauge central and peripheral nervous system disorders? Significantly impaired hearing - correct answers The nurse has completed a health assessment on an older adult client being seen at a neighborhood clinic. What client-specific information should the nurse identify as being a priority? "I'm going to assess the client now so that I can begin formulating the care plan." (prioritizing the patient needs) - correct answers A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment? Performing a focused assessment on a client who is complaining of shortness of breath. (critically thinking of the most urgent issue) - correct answers The nurse is exhibiting critical thinking in which client care situation? "Nurses focus on the diagnosis of actual human responses to disease or life events." (nurses focus more on the response of the illness or diagnosis and how to care as a result of the response, rather than the diagnosis itself) - correct answers A client asks why the nurse and health care provider seem to be asking the same questions and performing the same examination. What should the nurse explain as being the difference between the two assessments?