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NUR 104 HEALTH ASSESSMENTS FINAL EXAM|LATEST 2026-2027 WITH 120Qs&As|BAY STATE COLLEGE
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Holistic Care ANS :->>>health care that takes into account the whole person interacting in the environment Steps of the Nursing Process
Preparing for Assessment o Review client's record (learn basic info.) o Review client's status with other health care team members o Reflect on own personal biases o Educate about client's diagnosis and tests performed A 77-year-old retired bus driver presents at his wife's request to the clinic for a physical examination. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for more than 40 years. He denies any tobacco or drug use and has not drunk alcohol since getting married. His parents both died of cancer in their 60s. On examination his vital signs are in expected ranges. His head, cardiac, and pulmonary examinations are unremarkable. Abdominal examination reveals normal bowel sounds. Results of palpation of the liver are abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? ANS :->>>Irregular, large liver The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should ANS :->>>palpate deeply while quickly releasing pressure.
While testing a client's deep tendon reflexes the nurse asks the client to perform the action shown. What is the purpose of this action? ANS :->>>Increase reflex activity What task should a nurse ask a client to perform to assess the function of cranial nerve XI? ANS :->>>shrug shoulders against resistance The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem? ANS :->>>Myasthenia gravis Which of the following would lead the nurse to suspect a hydrocele versus other causes of scrotal swelling? ANS :->>>A positive transillumination test When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present? ANS :->>>Beaded or thickened cord
What information should nurse include in the teaching plan for a client considering a vasectomy? ANS :->>>offers permanent birth control A nurse inspects the genitalia of an elderly client and notices that the mucosa is dry and atrophied. The nurse should educate the client about her increased risk of what condition? ANS :->>>Infection The wet mount prepared after a female client's pelvic examination reveals motile organisms greater than 10 WBCs per high powered microscopy. The nurse should gather supplies for which diagnostic follow-up? (Select all that apply.) a. Syphilis serology b. Chlamydia culture c. Gonorrhea culture d. HIV testing a, b, c, d The visible portion of the clitoris is termed the
b; A clinical judgment about client responses to health difficulties A nurse is caring for three clients whose care involves complex situations and multiple responsibilities. What is the key to resolving problems for this nurse? Critical Thinking After a health assessment the nurse determines that a client would benefit from health promotion interventions. Which item should the nurse refer to when determining the best actions for the client? a. Healthy People 2020 b. the client's past medical history a; Healthy People 2020 Phases of an Interview o Preparatory o introductory o working o termination Working Phase
The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client. The nurse and client collaborate to identify the client's problems and goals. Types of Nonverbal Communication o Appearance o Demeanor o Facial Expression o Attitude o Silence o Listening Types of Verbal Communication o Open-ended questions o Close-ended questions o Laundry List o Rephrasing o Well-placed phrases o Inferring o Providing info.
Review of Systems Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting, and apply the following infection control practices during the delivery of health care. Dorsal Recumbent Position Sim's Position Knee-to-Chest Position Lithotomy Position A nurse must assess a client's red reflex. Which piece of equipment will the nurse need for this? opthamalascope
A nurse needs to examine a client's hip joint. Which client position would be best for this assessment? Prone For which assessment would the nurse plan to use direct percussion? sinuses The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? Assessment data in the medical record A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? It allows several health team members to view the client record simultaneously When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician?
Health Promotion Nursing Diagnoses a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential Risk Nursing Diagnoses Describes human responses to health conditions/life processes that may develop Actual Nursing Diagnoses (1) The patient's identified need or problem (2) The etiology or underlying cause (3) Signs and symptoms Which diagnoses would be best for a set of signs & symptoms? a. ineffective airway clearance b. ineffective gas exchange c. ineffective breathing pattern d. activity intolerance e. impaired verbal communication f. impaired swallowing g. impaired physical mobility
h. imbalanced nutrition i. fatigue j. acute pain k. ineffective tissue perfusion l. impaired skin integrity a, d, e, g, k, l Interventions for Ineffective Airway Clearance teach effective cough technique such as low pressure coughs) is effective to maintain open airways and it spares energy Interventions for Ineffective Gas Exchange Maintain an oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater. Interventions for Ineffective Tissue Perfusion Submit patient to diagnostic testing as indicated. The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)
o How old are you? What is your date of birth? Note if the client is male or female. o With which gender do you identify? o What is your marital status? o What is your educational level and where are you employed? Health History Data to Collect During Mental Status Examination o What is currently your most urgent health concern? o Why are you seeking health care? o Any other health issues o Headaches o Trouble breathing or palpitations o Insomnia o Irritability or mood swings o fatigue o suicidal thoughts o thoughts of hurting or killing others o medical treatment, hospitalizations, or counseling related to mental health o head injury o meningitis, stroke... o military background o family history
Glascow Coma Scale (GCS) The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what? Patient advocate While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating? confabulation When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of aphasia Questions (Domestic Violence) o Has anyone in your home ever hurt you? o Do you feel unsafe in your home?
o Has anyone ever refused to give you or let you take your medications? The nurse is conducting the initial prenatal visit with a client who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the client describes isolation? a. "My boyfriend hits the kitchen wall with his fist just inches from my head." b. "I have not seen my parents in 6 months; they live only 30 minutes away." b The nurse suspects that a client has experienced emotional abuse. For what should the nurse specifically assess this client? Select all that apply. a. insults b. harassment c. intimidation d. financial harm a, b, c, d A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse? Psychological
A parent brings her 5-year-old child to the clinic, reporting that she has noticed the child does not seem to be hearing well. There also has been a noticeable speech delay. What does the nurse understand can be a predisposing factor to possible hearing loss? chronic middle ear infection A nurse provides care for a client who experiences anxiety, gastrointestinal complaints, and a fear of being poisoned or killed. The nurse recognizes this as which culture-bound syndrome? rootwork When the nurse asks the client for the reason for coming to the health clinic, the client responds by saying, "bad blood." The nurse recognizes that the client is most likely referring to which of the following? a. Sexually transmitted infection b. Sudden collapse preceded by dizziness a SPIRIT Spiritual Belief System Personal Beliefs Integration w/ a spiritual community
