Holistic Assessment Exam Questions With 100% Correct Solutions.

Holistic Assessment Exam Questions With 100% Correct Solutions. A nurse is assessing a patient for possible fluid overload. Which 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 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 -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. -Slight delays in mental processing are normal in older adults. 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 -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. -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 -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 -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. -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 -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. -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. -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 -Far, then near An infant was removed from her home by social services because of the dangerous and neglectful conditions that existed. According to Erikson, failure of the infant to resolve the central crisis of infancy may lead to what personality characteristics later in life? -Suspicion and fear. -Dependency and relational entanglement. -Aggression and antagonism. -Depression and introversion. -Suspicion and fear. Assessment of a patient who has suffered a recent stroke 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? -Obtunded -Coma -Stupor -Lethargy -Coma A nurse is preparing to assess a patient who is new to the clinic. When beginning the collection of the patient database, which of the following actions should the nurse prioritize? -Identifying potential health problems. -Determining the patient's strengths. -Establishing a trusting relationship. -Making clinical inferences. -Establishing a trusting relationship. A patient has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause? -Inner ear problem -Otosclerosis -Perforated eardrum -Otitis Media -Inner ear problem The nurse is collecting data from a patient who has recently been diagnosed with type 1 diabetes and who will begin an educational program. The nurse is collecting subjective and objective data. What would the nurse categorize as objective data? -Family history -Appearance -History of present health concern -Occupation -Appearance Assessment of a client reveals a history of insulin-dependent diabetes mellitus, weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. What nursing diagnosis would be priority? -Potential complication: hypertension. -Powerlessness related to diabetes self-care and management. -Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination. -Imbalanced nutrition: more than body requirements related to diabetes -Risk for imbalanced fluid volume related to inadequate oral intake and frequent urination. When assessing the ear, which finding would be cause for concern? -Red, flaky cerumen -Darwin tubercle -Tender tragus -Pearly gray tympanic membrane -Tender tragus Which test would be most appropriate for the nurse to perform when assessing eye muscle strength and cranial nerve function? -Eye positions test -Vision fields test -Corneal light reflex test -Cover test -Eye positions test During a health history, a patient reports complaints of headaches. What would lead the nurse to suspect that the patient is experiencing cluster headaches? -Additional complaint of sensitivity to light. -Throbbing and severe pain. -Pain radiating from eye to temporal region. -Report of ringing in the ears prior to headache. -Pain radiating from eye to temporal region. A nurse utilizes the Alcohol Use Disorders Identification Test (AUDIT) as part of the standard admission protocol. After obtaining a score of 9 from a recently admitted patient, the nurse should recognize the possibility of which of the following? -Imminent liver disease. -Alcoholism. -Acute pancreatitis. -Hazardous and harmful alcohol use. -Hazardous and harmful alcohol use. When talking to a patient before starting the physical exam, the nurse notes that the patient repeatedly tilts her head to one side with the left ear facing the RN. Which of the following would the nurse examine first? -Mental Status -Thyroid Gland -Lymph Nodes -Hearing Acuity -Hearing Acuity A school nurse who provides care in a middle school works exclusively with adolescents. According to Erikson's theory of psychosocial development, what task will underlie much of the students' behavior? -Appraising religious dogma. -Establishing a personal identity. -Evaluating the merits of their parents' beliefs. -Exerting influence over others. -Establishing a personal identity. 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. How would the nurse document this finding? -Macule -Nodule -Papule -Pustule -Papule A nurse examines an older adult patient. Which of the following would the nurse document as a normal finding? -Episcleritis -Ectropion -Exophthalmos -Chalazion -Ectropion The nurse has been applying the nursing process in the care of an adult patient who is being treated for acute pancreatitis. Place the nurse's actions in their proper sequence from first to last. Determining outcome achievement. Identifying outcomes. Determining the patient's nursing problem. Carrying out interventions. Collecting information about the patient. Collecting information about the patient. Determining the patient's nursing problem. Identifying outcomes. Carrying out interventions. Determining outcome achievement The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which patient would the nurse determine to be in most need of an emergency assessment? -A 14-year-old girl who is crying because she thinks she is pregnant. -A 3-year-old child with fever, rash, and sore throat. -A 20-year-old man with a 3-in shallow laceration on his leg. -A 45-year-old man with chest pain and diaphoresis for 1 hour. -A 45-year-old man with chest pain and diaphoresis for 1 hour. A nurse is appraising a colleague's assessment technique as part of a continuing education initiative. The nurse demonstrates the proper technique for light palpation by performing which action? -Placing the non-dominant hand on top of the dominant hand for improved sensation. -Feeling the surface structures using a circular motion. -Depressing the skin 1 to 2 inches with the dominant hand. -Using one hand to apply pressure and the other hand to feel the structure -Feeling the surface structures using a circular motio Assessment of a client's skin reveals several individual and distinct 2-mm lesions on the patient's back. The nurse would document the configuration as which of the following? -Confluent -Linear -Annular -Discrete -Discrete The nurse is completing the general survey of a patient and determines that his temperature is 102°F. What would the nurse also expect to find? -Weak, thready pulse. -Heart rate greater than 100 beats/min. -Diastolic blood pressure 10 mm Hg greater than normal. -Respiratory rate between 12 and 20 breaths/min. -Heart rate greater than 100 beats/min. When assessing pain in an older adult patient who is alert and oriented, which assessment tool would be most appropriate to use? -Faces Pain Scale-Revised -FLACC Scale -Graphic Rating Scale -Numeric Rating Scale -Numeric Rating Scale A nurse is reviewing a colleague's documentation of a patient assessment. The nurse reads that the patient's radial pulse was 2+. How should the nurse interpret this assessment finding? -The patient's radial pulse occluded with moderate pressure. -The patient's radial pulse could not be manually occluded. -The patient's radial pulse occluded with very firm pressure. -The patient's radial pulse occluded easily. -The patient's radial pulse occluded with moderate pressure. A nurse has completed the general survey of a patient who has been transferred to the unit. The information gathered during the general survey primarily provides the nurse with which of the following? SELECT ALL THAT APPLY. -An indication of the level of physical distress experienced by the patient. -Clues about the overall health of the patient. -A direct link to the patient's medical diagnosis. -Indications about normal variations in the status of body systems. -Data relating to the patient's level of social support. -An indication of the level of physical distress experienced by the patient. -Clues about the overall health of the patient. -Indications about normal variations in the status of body systems.