CHAPTER 26 HEALTH ASSESSMENT ACTUAL
QUESTIONS AND VERIFIED ANSWERS
UponAenteringAtheAclient'sAroomAatAtheAbeginningAofAaAshiftAandAthroughoutAtheAshift,AtheAnurseAa
ssessesAtheAclient.AThe
nurseAconsidersAtheAclient'sAplanAofAcareAandAresponseAtoAnursingAinterventionsAduringAtheAassess
ments.AWhatAtypeAofA1.AassessmentAisAtheAnurseAperforming?
A)AOngoingApartialAassessment
B)AComprehensiveAassessment
C)AFocusedAassessment
D)AEmergencyAassessmentA-ACORRECTAANSWER-Ans:AA
Feedback:
AnAongoingApartialAassessmentAisAconductedAatAregularAintervalsAduringAcareAofAtheAclientAandAco
ncentratesAonAidentifiedAhealthAproblemsAandAtheAeffectivenessAofAinterventions.AAAcomprehensi
veAassessmentAincludesAaAhealthAhistoryAandAcompleteAphysicalAexaminationAandAisAusuallyAcond
uctedAwhenAaAclientAfirstAentersAaAhealthAcareAsetting.AAAfocusedAassessmentAisAconductedAtoAass
essAaAspecificAproblem.AAnAemergencyAassessmentAisAaAtypeAofArapidAfocusedAassessmentAconduc
tedAtoAdetermineAaApotentiallyAfatalAsituation.
AnAolderAadultAasksAtheAnurseAaboutAtheAappearanceAofAflatAbrownAageAspotsAonAtheAhands.AAfter
AexaminingAtheAclient's
hands,AtheAnurseArecognizesAtheseAskinAcharacteristicsAasAaAcommonAskinAvariationAinAtheAolderAa
dultAandAdocumentsAtheA2.AvariationsAasAwhichAofAtheAfollowing?
A)ASenileAlentigines
B)ALanugo
C)ASenileAkeratosis
D)ACherryAangiomasA-ACORRECTAANSWER-Ans:AA
Feedback:
, SenileAlentiginesAareAflat,AbrownAageAspots,AsenileAkeratosisAareAraised,AdarkAareas,AandAcherryAan
giomasAareAsmall,AroundAredAspots.AAllAareAcommonAskinAvariationsAinAtheAolderAadult.ALanugoAisA
aAfineAdownyAhairAthatAappearsAonAtheAnewbornAforAtheAfirstAtwoAweeksAofAlife.
TheAnurseAisAperformingAanAassessmentAonAanAinfant.AWhichAfindingAisAconsideredAanAabnormalAc
ardiovascularAassessmentA3.AthatAshouldAbeAdocumentedAandAreportedAtoAtheAphysician?
A)ADecreasedAheartArate
B)AVisibleApulsationAthroughAaAthinAchestAwall
C)ASinusAdysrhythmiaAthatAincreasesAwithAinspirationAandAdecreasesAwithAexpirationA
D)APresenceAofAanASAheartAsoundA-ACORRECTAANSWER-Ans:AA
Feedback:
InfantsAandAchildrenAshouldAhaveAaAmoreArapidAheartArate,AinsteadAofAaAdecreasedAheartArate,Aunti
lAaboutAageA8Ayears.ACommonAcardiovascularAfindingsAincludeAvisibleApulsationAifAtheAchestAwallAis
Athin,AsinusAdysrhythmiaA(theArateAincreasesAwithAinspirationAandAdecreasesAwithAexpiration),Aand
AtheApresenceAofAanASAheartAsound.
TheAnurseAisAconductingAanAassessmentAonAtheAintegumentaryAsystemAofAaAclientAageA74Ayears.AW
hichAofAtheAfollowingA4.AfindingsAshouldAtheAnurseAdocumentAasAanAanomalyAthatAmayAwarrantAfol
low-up?
A)ATheAclientAstatesAthatAaAmoleAonAhisAforeheadAhasAbecomeAlargerAinArecentAmonths.
B)ADecreasedAskinAturgorAisAevidentAwhenAtheAskinAisAfoldedAandAthenAreleased.
C)ASmall,Around,AredAspotsAareApresentAonAtheAclient'sAforearmsAbilaterally.
D)AThereAareAsomeAraised,AbrownAareasAonAtheAbacksAofAtheAclient'sAhands.A-ACORRECTAANSWER-
Ans:AA
Feedback:
ChangesAinAtheAsizeAorAappearanceAofAaAmoleAalwaysArequireAfurtherAassessmentAandAfollow-
upAdueAtoAtheirAassociationAwithAskinAcancer.ADecreasedAskinAturgorAisAanAexpectedAfindingAinAold
erAadults,AasAareAdiffuseAredAspotsA(cherryAangioma)AandAraised,AdarkAareasA(senileAlentigines).
AsAaAcomponentAofAaAheadAtoAtoeAassessment,AtheAnurseAisApreparingAtoAassessAconvergenceAofAt
heAclient'sAeyes.AHowA5.AshouldAtheAnurseAconductAthisAassessment?
A)AAskAtheAclientAtoAfollowAherAfingerAasAsheAslowlyAmovesAitAtowardsAtheAclient'sAnose.
QUESTIONS AND VERIFIED ANSWERS
UponAenteringAtheAclient'sAroomAatAtheAbeginningAofAaAshiftAandAthroughoutAtheAshift,AtheAnurseAa
ssessesAtheAclient.AThe
nurseAconsidersAtheAclient'sAplanAofAcareAandAresponseAtoAnursingAinterventionsAduringAtheAassess
ments.AWhatAtypeAofA1.AassessmentAisAtheAnurseAperforming?
A)AOngoingApartialAassessment
B)AComprehensiveAassessment
C)AFocusedAassessment
D)AEmergencyAassessmentA-ACORRECTAANSWER-Ans:AA
Feedback:
AnAongoingApartialAassessmentAisAconductedAatAregularAintervalsAduringAcareAofAtheAclientAandAco
ncentratesAonAidentifiedAhealthAproblemsAandAtheAeffectivenessAofAinterventions.AAAcomprehensi
veAassessmentAincludesAaAhealthAhistoryAandAcompleteAphysicalAexaminationAandAisAusuallyAcond
uctedAwhenAaAclientAfirstAentersAaAhealthAcareAsetting.AAAfocusedAassessmentAisAconductedAtoAass
essAaAspecificAproblem.AAnAemergencyAassessmentAisAaAtypeAofArapidAfocusedAassessmentAconduc
tedAtoAdetermineAaApotentiallyAfatalAsituation.
AnAolderAadultAasksAtheAnurseAaboutAtheAappearanceAofAflatAbrownAageAspotsAonAtheAhands.AAfter
AexaminingAtheAclient's
hands,AtheAnurseArecognizesAtheseAskinAcharacteristicsAasAaAcommonAskinAvariationAinAtheAolderAa
dultAandAdocumentsAtheA2.AvariationsAasAwhichAofAtheAfollowing?
A)ASenileAlentigines
B)ALanugo
C)ASenileAkeratosis
D)ACherryAangiomasA-ACORRECTAANSWER-Ans:AA
Feedback:
, SenileAlentiginesAareAflat,AbrownAageAspots,AsenileAkeratosisAareAraised,AdarkAareas,AandAcherryAan
giomasAareAsmall,AroundAredAspots.AAllAareAcommonAskinAvariationsAinAtheAolderAadult.ALanugoAisA
aAfineAdownyAhairAthatAappearsAonAtheAnewbornAforAtheAfirstAtwoAweeksAofAlife.
TheAnurseAisAperformingAanAassessmentAonAanAinfant.AWhichAfindingAisAconsideredAanAabnormalAc
ardiovascularAassessmentA3.AthatAshouldAbeAdocumentedAandAreportedAtoAtheAphysician?
A)ADecreasedAheartArate
B)AVisibleApulsationAthroughAaAthinAchestAwall
C)ASinusAdysrhythmiaAthatAincreasesAwithAinspirationAandAdecreasesAwithAexpirationA
D)APresenceAofAanASAheartAsoundA-ACORRECTAANSWER-Ans:AA
Feedback:
InfantsAandAchildrenAshouldAhaveAaAmoreArapidAheartArate,AinsteadAofAaAdecreasedAheartArate,Aunti
lAaboutAageA8Ayears.ACommonAcardiovascularAfindingsAincludeAvisibleApulsationAifAtheAchestAwallAis
Athin,AsinusAdysrhythmiaA(theArateAincreasesAwithAinspirationAandAdecreasesAwithAexpiration),Aand
AtheApresenceAofAanASAheartAsound.
TheAnurseAisAconductingAanAassessmentAonAtheAintegumentaryAsystemAofAaAclientAageA74Ayears.AW
hichAofAtheAfollowingA4.AfindingsAshouldAtheAnurseAdocumentAasAanAanomalyAthatAmayAwarrantAfol
low-up?
A)ATheAclientAstatesAthatAaAmoleAonAhisAforeheadAhasAbecomeAlargerAinArecentAmonths.
B)ADecreasedAskinAturgorAisAevidentAwhenAtheAskinAisAfoldedAandAthenAreleased.
C)ASmall,Around,AredAspotsAareApresentAonAtheAclient'sAforearmsAbilaterally.
D)AThereAareAsomeAraised,AbrownAareasAonAtheAbacksAofAtheAclient'sAhands.A-ACORRECTAANSWER-
Ans:AA
Feedback:
ChangesAinAtheAsizeAorAappearanceAofAaAmoleAalwaysArequireAfurtherAassessmentAandAfollow-
upAdueAtoAtheirAassociationAwithAskinAcancer.ADecreasedAskinAturgorAisAanAexpectedAfindingAinAold
erAadults,AasAareAdiffuseAredAspotsA(cherryAangioma)AandAraised,AdarkAareasA(senileAlentigines).
AsAaAcomponentAofAaAheadAtoAtoeAassessment,AtheAnurseAisApreparingAtoAassessAconvergenceAofAt
heAclient'sAeyes.AHowA5.AshouldAtheAnurseAconductAthisAassessment?
A)AAskAtheAclientAtoAfollowAherAfingerAasAsheAslowlyAmovesAitAtowardsAtheAclient'sAnose.
