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Health Assessment Final Study Guide 2016, Exams of Nursing

A study guide for a health assessment final exam. It covers topics such as the concept of health, evidence-based nursing practice, interview techniques, assessment techniques, vital signs, and respiratory assessment. The guide includes multiple-choice questions with verified answers. useful for nursing students preparing for a health assessment final exam.

Typology: Exams

2022/2023

Available from 12/01/2023

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QUESTION 2023

Exam 1: The concept of health and healing has evolved in recent years. Which is the best description of health? Health is the absence of disease Health is a dynamic process toward optimal functioning Health depends on an interaction of mind, body and spirit within the environment Health is the prevention of disease

Which best describes evidence-based nursing practice? Appraising and looking at the implications of one or two articles as they related to the culture and ethnicity of the patient. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient’s values and circumstances. Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practice One of your patients says she is very nervous and nauseated, and she feels like she will vomit. This data would be what type of data?

Objective Reflective Subjective Introspective Which is an example of objective data? Patient’s history of allergies Patient’s use of medications at home Last menstrual period 1 month ago. 2 x 5 cm scar present on the right lower forearm The nurse uses health promotion activities with a new patient. What would this focus include? The nurse would try to change the patient’s perception of disease The nurse would search for identification of biomedical model interventions The nurse would help to identify negative health acts of the patient The nurse would empower the patient to choose a healthier lifestyle The major factor contributing to the

need for cultural care nurse is: An increase birth rate Limited access to health care services Demographic change A decreasing rate of immigration The term culturally competent implies that the nurse: Is prepared in nursing. Possesses knowledge of the traditions of diverse peoples. Applies underlying knowledge to providing nursing care Understands the cultural context of the patient’s situation is exhibiting an accurate understanding of the other person’s feelings within a communication context. Empathy

Liking others Facilitation A nonverbal listening technique A patient asks the nurse, “May I ask you a question?” This is an example of: An open-ended question A reflective question A closed question A double-barreled question Which demonstrates a good understanding of the interview process? The nurse stops the patient each time something is said that is not understood. The nurse spends more time listening to the patient than talking. The nurse is consistently thinking of his or her next response so the patient will know he or she is understood. The nurse uses “why” questions to seek clarification of unusual symptoms or

behavior. For what or with whom should touch be used during the interview? Only with individuals from a Western culture As a routine way of establishing contact with the person and communicating empathy Only with patients of the same gender Only if the interviewer knows the person well Knowledge of use of personal space is helpful for the health care provider. Personal distance is generally considered to be: a. 0 – 1. 1.5 – 4 feet 4 – 12 feet 12 or more feet Tom Selleck, a patient on your floor, tells you, “Everyone here ignores me.” You respond: “Ignores you?” This technique is best described as:

Clarification Selective listening Reflecting Validation What does active listening NOT include? Taking detailed notes during the interview Watching for clues in body language Repeating statements back to the person Asking open-ended questions to explore the person’s perspective You have a reason to question the reliability of the information being provided by a patient. One way to verify the reliability within the context of the interview is to: Rephrase the same questions later in the interview Review the patient’s previous medical records Call the person identified as the emergency contact to verify data

provided Provide the patient with a printed history to complete and then compart the data provided

During the initial interview, the nurse says, “Mrs. J. Tell me what you do when your headaches occur?” This is an example of which type of information? The patient’s perception of the problem Aggravating or relieving factors The frequency of the problem The severity of the problem A genogram is used for which reasons? Past history Past health history, specifically hospitalizations Family history The 8 characteristics of presenting symptoms What is the best description of “review of systems” as part of the health history? The evaluation of the past and present health state of each body system A documentation of the problem as described by the patient

The recording of the objective findings of the practitioner A statement that describes the overall health state of the patient Which finding is considered to be subjective? Temperature of 101.2F Pulse rate of 96 beats/minute Measured weight loss of 20 lbs since the previous measurement Pain lasting 2 hours During assessment, which part of the hand is best for detecting vibration? Fingertips Index finger and thumb in opposition Dorsum of the hand Ulnar surface of the hand The bell of the stethoscope is used: For soft, low-pitched sounds For high-pitched sounds To hold firmly against the skin To magnify sounds At the conclusion of the patient

examination, the examiner should: Document findings before leaving the examination room Have findings confirmed by another nurse Summarize findings to the patient Relate objective findings to the subjective findings for accuracy For a health assessment, which assessment technique will you use first? Palpation Inspection Percussion Auscultation You are assessing a patient’s gait. What do you expect to find? Gait is varied, depending on the height of the person Gait is equal to the length of the arm Gait is as wide as the shoulder width Gait is half the height of the person

Select the best description of an accurate assessment of a patient’s pulse. Count for 15 seconds if the pulse is regular Begin counting with zero; and count for 30 seconds Count for 30 seconds and multiple by 2 for all cases Count for a full minute; begin counting with one After assessing the patient’s pulse, the nurse determines it is “normal”. This would be recorded as: 3+ 2+ 1+ 0 Select the best description of an accurate assessment of the patient’s respirations. Count for a full minute before taking the pulse

Count for 15 seconds and multiply by 4 Count after informing the patient where you are in the assessment process Count for 30 seconds after pulse assessment Pulse pressure is described as: The difference between the systolic and diastolic pressure A reflection of the viscosity of the blood Another way to express the systolic pressure A measure of vasoconstriction Why is it important to match the appropriate size of blood pressure cuff to the person’s arm and shape and not to the person’s age? Using a cuff that is too narrow will give a false reading that is high Using a cuff that is too wide will give a false reading that is low Using a cuff that is too narrow will give a false reading that is low

Using a cuff that is too wide will give a false reading that is high At which phase does the individual become aware of a painful sensation Modulation Transduction Perception Transmission The most reliable indicator of pain in the adult is: The degree of physical functioning The nonverbal behaviors The MRI findings The patient’s self-report While examining the broken arm of a 4- year-old boy, select the appropriate assessment tool to evaluate his pain status: 1-10 numeric rating scale Wong-Baker scale Simple descriptor scale 0-5 numeric rating scale Which is considered a common

physiologic change that occurs with pain? Polyuria Hyperventilation

Hyperactive bowel sounds Tachycardia Checking for skin temperature is best accomplished by using: The palmar surface of the hands The ventral surface of the hands The fingertips The dorsal surface of the hand Assessing a patient’s skin turgor is done to assess which clinical findings? Edema Dehydration Vitiligo Scleroderma You note a lesion during a skin assessment. Which is the best way to document this finding? Raised, irregular lesion the size of a quarter, located on the dorsum of left hand Open lesion with no drainage, no odor, approximately ¼ inch in diameter Pedunculated lesion below left scapula

with consistent red color and no drainage or odor Dark brown raised lesion, with irregular border, on dorsum of right foot, 3 cm in size, with no drainage You examine the nail beds of a patient. Which finding indicates a normal angle? 60 degrees 100 degrees 160 degrees 180 degrees An area of thin shiny skin with decreased visibility of normal skin markings is most likely: Lichinification Plaque Atrophy Keloid A configuration of individual lesions arranged in circles or arcs, as occurs with ringworm is described as: Linear lesion

Clustered lesion Annular lesion Gyrate lesion A risk for melanoma is: Brown eyes Darkly pigmented skin Skin that freckles or burns before tanning Use of sunscreen products Herpes zoster (shingles) is characterized by: A bacterial cause Lesion on only one side of body; does not cross midline Absence of pain or edema

Pustular, umbilicated lesion Which facial bones articulate at a joint instead of a suture? Zygomatic Maxilla Nasal Mandible Identify the blood vessel that runs diagonally across the sternomastoid muscle. Temporal artery Carotid artery External jugular vein Internal jugular vein The isthmus of the thyroid gland lies just below the: Mandible Cricoid cartilage Hyoid cartilage Thyroid cartilage If the thyroid gland were enlarged bilaterally, which maneuver would be appropriate for you to assess?

Check for deviation of the trachea Listen for a bruit over the carotid artery Listen for a murmur over the aortic area Listen for a bruit over the thyroid lobes It is normal to palpate a few lymph nodes in the neck of a healthy person. What are the characteristic of these nodes? Mobile, soft, nontender Large, clumped, tender Matted, fixed, tender, hard Matted, fixed, nontender Normal cervical nodes are: Warm to palpation Fixed Smaller than 1 cm Firm The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents that following vital signs: 98, 48, 14, 104/68. Which statement is true concerning these results?

The patient is experiencing tachycardia These are normal vital signs for a healthy, athletic adult The patient’s pulse rate is not normal, his physician should be notified On the basis of these readings, the patient should return to the clinic in 1 week The patient’s blood pressure is 118/82mmHg. He asks the nurse, “What do the numbers mean?” The nurse’s best reply is: “The numbers are within the normal range and are nothing to worry about.” “The bottom number is the diastolic pressure and reflects the stroke volume of the heart”

“The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts” “The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure.” The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: Detect the presence of an auscultatory gap More clearly hear the Korotkoff sounds Avoid missing a falsely elevated blood pressure More readily identify phase IV of the Korotkoff sounds

Exam II When assessing a patient’s lungs, the nurse recalls that the left lung: Consists of two lobes Is divided by the horizontal fissure Primarily consists of an upper lobe on the posterior chest Is shorter than the right lung because of the underlying stomach Which statement about the apices of the lungs is true? The apices of the lungs: Are at the level of the second rib anteriorly Extend 3-4 cm above the inner third of the clavicles Are located at the sixth rib anteriorly and eighth rib laterally Rest on the diaphragm at the 5 th intercostal space in the midclavicular line (MCL) The nurse is observing the auscultation technique of another nurse. The correct method is to use when

progressing from one auscultory site on the thorax to another is comparison. Side-to-side Top-to-bottom Powerior-to-anterior Interspace-by-interspace When inspecting the anterior chest of an adult, the nurse should include which assessment? Diaphragmatic excursion Symmetric chest expansion Presence of breath sounds Shape and configuration of the chest wall During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? In an obese patient When part of the lung is obstructed or collapsed When bulging of the intercostal spaces

is present When accessory muscles are sued to augment respiratory effort A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? Unequal chest expansion Increased tactile fremitus Atrophied neck and trapezius muscles Anterioposterior-to-transverse diameter ratio of 1:1 During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? Airway obstruction Emphysema Pulmonary consolidation Asthma In assessing a patient’s major risk