Week 3 Health Assessment Review Latest Exam 2023-24 answered, Exams of Community Health

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Week 3 Health Assessment Review

Latest Exam 2023-24 answered

The _____________ assessment is often collected in a primary care setting, such as a women's health clinic. Complete Focused Initial Closing - Correct answer Complete When a client is experiencing a short-term problem, such as a rash, the care provider conducts a(n) __________________ assessment. problem-centered complete follow-up exit - Correct answer problem-centered Persons with chronic conditions, such as sickle-cell anemia, are seen by their primary care provider for ______________ assessment. focused complete follow-up interim - Correct answer follow-up

For a client with cardiac arrest, a(n) __________________ assessment may be obtained from relatives. comprehensive emergency focused rapid - Correct answer emergency What determines the frequency of assessment needed for each individual? - Correct answer The person's health and wellness needs; Data obtained from each assessment determines not only treatment for current alterations in health, but the frequency and type of follow-up assessments. While the CDC and health insurance companies often provide evidence-based recommendations for care, it is the clinical judgment of the care team that makes the final determination. While age is included in the assessment data for each individual, it is not the only evidence used to determine assessment frequency. Which statements about holistic health are correct? Select all that apply. -Societal influences, including family, have little influence on individual health practices. -Disease results from factors within and outside of the body. -Lifestyle choices have no impact on overall health. -Views the mind, body, and spirit as vital to overall wellness. -Each person is an active part of their own health and wellness. - Correct answer - Disease results from factors within and outside of the body. -Views the mind, body, and spirit as vital to overall wellness. -Each person is an active part of their own health and wellness.

While Mr. Chaudhury (pronouns: he/him/his) is recovering from surgery, the healthcare provider prescribes his influenza vaccination (flu shot). The nurse verified that Mr. Chaudhury had not gotten one this year and left a form for him to review and complete. While handing back the complete form, Mr. Chaudhury asked why the same questions are asked every year. Review Mr. Chaudhury's responses before answering the question. What is the best response by the nurse? "It is for insurance purposes." "It provides information on your current state of health." "So long as you give answers, I am not sure it matters." "Your answers help determine if it is safe for you to receive the vaccine today." - Correct answer "Your answers help determine if it is safe for you to receive the vaccine today." Client with a fever on the second day after surgery. - Correct answer Health Problem: Client with a fever on the second day after surgery. Frequency of Follow-Up: 2-4 hours Rationale: Fever after surgery is a cue that an infection may be occurring, which requires further assessment of the operative site (redness, swelling, and drainage may indicate infection), respiratory system (medications that depress the respiratory center can allow secretions to accumulate in the lungs causing atelectasis, which can become pneumonia), and the immune system (specifically the serum white blood cells that would begin increasing in response to an infection). Individual with stable heart failure. - Correct answer Health Problem: Individual with stable heart failure. Frequency of Follow-Up: 2-3 months Rationale: A person with a stable, chronic condition can be seen in the provider's office periodically.

Child treated at an urgent care center for a rash. - Correct answer Health Problem: Child treated at an urgent care center for a rash. Frequency of Follow-Up: As needed, if rash does not go away Rationale: Anyone treated for a rash should follow up with their healthcare provider if the rash lingers or worsens after treatment is provided, as needed. Client with acute chest pain being treated in the emergency department. - Correct answer Health Problem: Client with acute chest pain being treated in the emergency department. Frequency of Follow-Up: Continuous Rationale: A person having acute chest pain will receive continuous monitoring, interventions, and follow-up assessment during treatment. Hospitalized client experiencing an allergic reaction to a new medication - Correct answer Focused Assessment An adult with asthma that is stable - Correct answer Follow-Up Assessment An expectant woman at home with severe morning sickness - Correct answer Follow- Up Assessment A young adult who walks into the emergency department saying they cut their hand on a broken glass - Correct answer Focused Assessment

While dining with friends, the health professional notices a woman at the next table holding her hands to her neck and goes to help. The health professional begins 1. (a complete; a focused; an emergency; a follow-up) assessment of her 2. (airway; breathing; circulation; health) status by asking her, "Are you 3. (dying; choking; allergic) to any medications ?" - Correct answer 1. an emergency

2. airway
3. chocking Indicate which aspects of the complete health assessment can or cannot be delegated by the nurse to an unlicensed assistive person (UAP) to complete. Vital signs Physical assessment of lungs Known allergies Current medications Height and weight Family history - Correct answer Can be Delegated: Vital Signs; Height and weight. Cannot be Delegated: Physical assessment of the lungs; known allergies; current medications; family history The novice nurse completing a focused assessment prior to administering a cardiovascular medication notices a rubbing sound when assessing the apical pulse. The client denies pain and the vital signs are normal. The abnormal sound has not been previously documented on the client's health record. The highest priority action for the nurse to take at this time is -Request a more experienced colleague assess the heart sounds. -Administer the medications. -Notify the prescribing healthcare provider of the changed assessment.

-Wait 10 minutes and reassess the apical pulse. - Correct answer -Request a more experienced colleague assess the heart sounds. The health professional responds to an emergency call for help in the lobby of the health facility and finds a car in the lobby and several people injured. Which person will the health professional examine first? -The individual lying on the floor screaming that their leg is broken. -The colleague with a torn uniform, walking with a limp, directing people out of the lobby -The car driver who is slumped over the steering wheel, not moving -The older adult bleeding from the head, sitting quietly on the floor talking to a crying child - Correct answer The car driver who is slumped over the steering wheel, not moving As a student, it probably will not happen often that you need to prioritize the order in which you assess clients in a mass casualty situation. Yet as a novice health examiner, you should realize that the person requiring an emergency assessment requires immediate assistance and that using the ABCs is the way to rapidly prioritize care needs. The older adult bleeding from the head, the limping colleague, and the individual crying out that their leg is broken are all talking and alert at this time, so their ABCs are good. The driver of the car, however, is not moving and requires a rapid assessment of their status to determine their health needs. Place the actions taken when conducting a complete health assessment in order from first to last. -Obtain a detailed health history. -Assure the client is comfortable. -Perform hand hygiene. -Verify the client's identity. -Document assessment findings and plan of care.

-Discuss findings and next steps. -Introduce self. -Assess the client's current state of health. -Perform hand hygiene again. -Complete a full physical assessment. - Correct answer Perform hand hygiene. Introduce self. Verify the client's identity. Assess the client's current state of health. Obtain a detailed health history. Complete a full physical assessment. Discuss findings and next steps. Assure the client is comfortable. Perform hand hygiene again. Document assessment findings and plan of care. A woman seeing a midwife for the first time after discovering she is pregnant. - Correct answer Complete assessment A man runs into an urgent care center and tells the receptionist that his partner stopped breathing a couple of minutes ago. - Correct answer Emergency assessment A toddler is having the stitches removed from their arm at the doctor's office. - Correct answer Follow-up assessment

The healthcare provider assesses the abdomen of a postoperative client who has not passed gas since surgery, 24 hours ago. - Correct answer Focused assessment A _______ ______ __________ to establish a database is performed the first time a person sees a new care provider. The individual who stops breathing is in grave danger of dying and requires an ________ ___________ with immediate intervention. Before removing stitches, the provider will complete a ________ ___________ related to the assessment data collected when the injury was treated. To understand why the gastrointestinal system of a postoperative client is not functioning after surgery, a ________ ___________ of that system is performed. - Correct answer Complete Health Assessment Emergency Assessment Follow-up Assessment Focused Assessment Individual who fell down a flight of stairs and lost consciousness - Correct answer Focused Assessment Adolescent with asthma meeting with the school nurse to see how they are doing - Correct answer Follow-Up Assessment Middle-adult woman being seen for middle back and upper arm pain that has been present off and on for 2 days - Correct answer Focused Assessment Child whose parent shares that they have recently begun refusing to go to school because of a stomachache - Correct answer Focused Assessment

Detailed health history - Correct answer Follow-Up Assessment & Complete Assessment Full physical assessment - Correct answer Complete Assessment & Follow-Up Assessment Targeted physical assessment - Correct answer Complete Assessment, Focused Assessment, Follow-Up Assessment, & Emergency Assessment In which situations is verifying a person's identity required when they are in the hospital? Select all that apply. -Before completing an assessment -Before transporting an individual to a test -When meeting the person for the first time -Prior to administering blood pressure medication -When delivering a meal tray -When answering their call for assistance - Correct answer -Before completing an assessment -Before transporting an individual to a test -When meeting the person for the first time -Prior to administering blood pressure medication -When delivering a meal tray The health examiner preparing to perform a physical assessment of the abdomen is aware that the order each technique is performed is important in obtaining the best assessment.

Drag each assessment technique into the order it should be completed in an abdominal assessment, from first to last. Percussion Auscultation Inspection Palpation - Correct answer Inspection Auscultation Percussion Palpation While performing a cardiac assessment on a client with an incompetent heart valve, the nurse anticipates hearing a low-pitched (click; rub; murmur; squeak) using the (bell; diaphragm) portion of the (otoscope; stethoscope; ophthalmoscope.) - Correct answer Murmur Bell Stethoscope A client who speaks Spanish arrives at the triage desk in the emergency department (ED) and requests an interpreter. What is the best action for the nurse to take? -Page an interpreter from the hospital's interpreter services. -Have the Spanish-speaking triage receptionist interpret. -Obtain a Spanish-English dictionary and attempt to triage the client. -Have one of the client's family members interpret. - Correct answer Page an interpreter from the hospital's interpreter services.

Using a dictionary slows the triage process and should be used as a last resort. Family members may not appropriately understand what is asked of them and may paraphrase what the client is saying. Also, client confidentiality as well as accuracy of information may be compromised when a family member or non-healthcare provider acts as an interpreter. Ensuring the lighting in the examination room is bright is key to an accurate inspection for which reasons? Select all that apply. -Detecting odors from wounds. -Observing changes or differences in skin color. -Noticing pulsations. -Seeing differences in skin texture. -Visualizing deeper masses. - Correct answer The correct answers are: -Observing changes or differences in skin color. -Seeing differences in skin texture. -Noticing pulsations. Bright lighting allows the nurse to observe the color of skin, notice alterations in skin color or texture, detect visible pulsations, and note areas of deformity. Deeper masses, especially in the abdomen, may not be visible and will be detected during palpation. Odors are detected using the sense of smell. Neither palpation or smell require bright lighting to improve the accuracy of assessment data. Light Palpation - Correct answer Assess surface abnormalities Depress with the finger pads Use the lightest touch possible Deep Palpation - Correct answer Use one hand on top of the other

Depress the skin 1½ to 2 inches Assess internal organs and masses Structures with relatively more (fluid; air; density) typically produce a louder, deeper, and longer sound because it (vibrates freely; is muffled by surrounding fluids; fails to penetrate tissues). A solid structure, like the (thigh muscle; liver; large intestine) gives a softer, higher, (longer; shorter; deeper) sound because it does not vibrate as easily. - Correct answer air vibrates freely liver shorter Which heart sounds are best heard with the bell of the stethoscope? - Correct answer Murmurs Which of the following should always be followed by the examiner when practicing assessment techniques at home or in the learning laboratory? Select all that apply. Right to refuse Privacy Respect Confidentiality Comfort Safety - Correct answer Right to refuse Privacy Respect

Confidentiality Comfort Safety A client walks into the room and states, "I am so dizzy, I feel like I'm going to fall." Prioritize the following actions from first to last. Perform a focused neurologic assessment. Ask about current medications. Get the individual a chair. Call for assistance. Obtain vital signs. - Correct answer Get the individual a chair. Call for assistance. Ask about current medications. Obtain vital signs. Perform a focused neurologic assessment. ___________________ will provide the best information regarding impaired arterial blood flow to the legs. (Palpation of pulses; Inspection of the skin; Palpation of the calf muscle; Auscultation of the femoral arteries) - Correct answer Palpation of pulses

The nurse is assisting a school-aged gymnast who fell from a balance beam during practice. The gymnast is crying and holding their deformed lower leg. ______________ ____________is the proper sequence in which the initial assessment of the lower extremities should be performed. (Deep palpation, light palpation, inspection) (Inspection, light palpation, auscultation) (Inspection, light palpation) (Auscultation, deep palpation, light palpation) - Correct answer (Inspection, light palpation) When performing deep palpation during a physical assessment, which part of the hand should the nurse use? Dorsum Finger pads Ball of the hand Palmar surface - Correct answer Finger pads Having misplaced their stethoscope, a nurse borrows one from a colleague. After entering the client's room, washing their hands, making introductions, and stating the purpose of the assessment, the nurse performs proper identification of the client before correctly auscultating the lungs. Which critical health assessment steps were omitted? Select all that apply. -Ensuring privacy and confidentiality by closing the door. -Running warm water over the stethoscope for client comfort. -Cleaning the stethoscope with alcohol. -Using alcohol-based hand disinfectant.

-Asking the individual to change into a hospital gown. - Correct answer Ensuring privacy and confidentiality by closing the door. Cleaning the stethoscope with alcohol. The nurse is performing an assessment of a client's abdomen. Palpation of the right upper quadrant elicits significant pain. Based on knowledge of normal anatomy and pathophysiology, which organs are likely causing the pain? Select all that apply. Pancreas Liver Spleen Appendix Gallbladder - Correct answer Liver & Gallbladder The liver and gallbladder are in the right upper quadrant. Pain associated with palpation in the right upper quadrant could suggest an abnormality of the liver or the gallbladder. A client in the emergency department (ED) is complaining of right lower quadrant abdominal pain. Which techniques in what order would be performed during a comprehensive abdominal examination to evaluate this client? - Correct answer Inspection, auscultation, palpation. The proper order of an abdominal assessment is inspection, auscultation, percussion, and palpation. Because the generalist nurse does not usually perform percussion, the correct answer, in this case, is inspection, auscultation, and palpation. During which portion of the physical assessment should gloves be used? Integumentary Ophthalmic Neurologic

Oropharyngeal - Correct answer For the safety of the nurse, gloves should be worn when the chance of exposure to the client's mucous membranes or body fluids is likely. Of the options listed, contact with body fluids is most likely during the oropharyngeal examination. A (symptom; sign) is a(n) (subjective; objective) abnormal assessment finding detected on physical examination or through diagnostic testing. A (symptom; sign) is a(n) (subjective; objective) feeling a client has that is associated with a disorder. - Correct answer Sign, objective symptom, subjective Which are components of a health history? Select all that apply. Vital signs Reason for seeking care Medication reconciliation Skin inspection Biographic data Review of systems - Correct answer A health history may include biographic data, the reason for seeking care, present health or history of present illness, past history, medication reconciliation, family history, review of systems, functional assessment, developmental assessment, and cultural assessment. Skin inspection and vital sign assessment are completed as part of the physical assessment, not the health history. Which question would be asked as part of the review of systems? "Do you use any drugs or alcohol?" "Do you have any allergies to any medications?"

"Do you have any difficulty with vision?" "Do you have any family history of cancer?" - Correct answer The purpose of the review of systems is to evaluate each body system to uncover dysfunction or disease. Asking about a client's vision provides information about their eye health, which is part of the sensory system. The other questions provide information about other aspects of the health history. The examiner is documenting the reason for seeking care. Which statement is documented correctly? Client has pain in the right ankle. Client presents with a sprained ankle. Client states, "I have pain in my right ankle." Assessment of right ankle is needed due to "pain." - Correct answer The reason for seeking care is a brief statement documented in quotes indicating that these are the client's own words, such as the client stating, "I have pain in my right ankle." It is not a diagnostic statement by the examiner. Which information is included in past history? Select all that apply. Date of birth Hospitalizations Childhood illnesses Immunizations Pain scale - Correct answer Past history includes immunizations, hospitalizations, and childhood illnesses. The pain scale is part of the present health or history of present illness. Date of birth is included in biographical data.

Which information should be included in a medication reconciliation? Select all that apply. -St. John's Wort 300 mg for depression -Atenolol 50 mg for high blood pressure -Acetaminophen 500 mg as needed for pain -Tobacco 6 cigarettes per day -Multivitamin 1 tablet - Correct answer Medications include prescriptions, over-the- counter drugs, and herbal supplements. Alcohol, tobacco, and recreational drugs are not included. The client states, "My last physical exam was last year." This would be documented under (functional assessment; review of systems.) - Correct answer The review of systems includes the date of the client's last physical exam and other health promotion practices. The functional assessment measures the client's ability to complete tasks and activities associated with daily living. Which question would be asked as part of a developmental assessment? "Does your child have a cough?" "When was your child born?" "Are the child's grandparents still living?" "When did your child get their first tooth?" - Correct answer Developmental milestones, such as the first tooth, are included in the developmental assessment. Asking about symptoms is part of the history of present illness. Date of birth is collected with other biographical information. Information about grandparents' health is obtained during the family history.

The examiner would like to assess the quality of the client's pain. Which question should the examiner ask? "How is the pain impacting your life?" "What does the pain feel like?" "What makes the pain better?" "On a scale of 0-10, how would you rate your pain?" - Correct answer Quality refers to the description of the pain in the client's own words and the examiner could ask, "What does the pain feel like?" Asking about what makes the pain feel better is a palliative question. Severity is measured by rating the pain. Understanding the impact of pain on lifestyle is also important but does not measure quality. The client states they had their appendix removed 10 years ago. The examiner would document this under which portion of the health history? Past history Functional assessment Review of systems Family history - Correct answer Surgical history would be asked and documented under the past history portion of the health history. Information about the health of close relatives is obtained during the family history. The review of systems is an inventory of each body system through a set of questions that gather data related to the present illness and health promotion practices. A functional assessment measures the person's ability to complete tasks and activities associated with daily living.

During a clinic appointment, the examiner notes that a client with cancer looks fatigued and is wearing dirty clothes. The client has lost 20 pounds since their last visit. Which statements by the examiner therapeutically assess the client's functional ability? Select all that apply. "How is your lack of energy impacting what you want to do?" "Tell me more about your support system." "Can you tell me how you are doing at home managing your daily activities?" "I am going to contact the social worker since it seems you need assistance at home." "I think you need a home care nurse to come in at least once a week." - Correct answer The examiner should ask about the client's support system, how they are managing daily activities, and how their lack of energy is impacting them as part of the assessment of functional ability. Questions should be asked in a therapeutic manner with the focus on functional ability. "I think you need a home care nurse to come in at least once a week" and "I am going to contact the social worker since it seems you need assistance at home" are based on the examiner's opinion and not client data. The examiner has collected the following subjective data from a 55-year-old client: Reason for seeking care: Low back pain History of present illness: Started two days ago after lifting furniture. Stabbing pain in the lower back rated 7/10. Lying flat makes pain decrease. Ice makes it better temporarily. Past history: Left knee replacement 5 years ago Medication reconciliation: Acetaminophen 500 mg every 6 hours for pain as needed Family history: History of high blood pressure on father's side; diabetes on mother's side Review of systems: Non-remarkable Functional assessment: Cannot work due to pain What would the examiner assess first?

Assess range of motion of the arms. Complete a focused assessment of the left knee. Complete a focused assessment of the back. Discuss financial options. - Correct answer The information collected indicates the current problem is low back pain. This would be the examiner's main focus of the physical examination. The left knee replacement is in the past and financial options are a secondary priority and more the work of a social worker. Range of motion of the arms does not address potential issues with the lower back. The examiner is completing a health history on a client who presents with abdominal pain. Which is an example of biographic information that may be obtained during a health history? Past surgeries Current occupation Personal values and beliefs History of immunizations - Correct answer Current occupation is part of biographic data. Past surgeries and immunizations are in past history. Personal values and beliefs can be under functional assessment or cultural assessment. An examiner is performing a health history on a client who is being admitted to the hospital. Which questions should be used to gather subjective data? Select all that apply. "Can I listen to your lungs?" "How does the shortness of breath impact your life?" "Do you have a history of heart disease?" "How often do you forget to take a dose of your medication?"

"Where are you working right now?" - Correct answer Subjective data is provided by the client and cannot be directly verified by the nurse. Asking the client if they are working, have a history of heart disease, how often they miss a dose of their medication, and how shortness of breath impacts their life is one way to obtain subjective data. "Can I listen to your lungs?" is not a health history question and is used in the physical assessment. A client is struggling to complete the health history questionnaire because English is not their primary language. Which action should the examiner implement? Request an interpreter to assist the client. Read the questionnaire to the client. Do not have the client complete the questionnaire. Have the client call a family member. - Correct answer Communicating through an interpreter aids in effective, accurate communication and provides a better experience for the client. Reading the questionnaire to the client will not increase the understanding of the questions. The health history is an essential part of the assessment process, so it cannot be omitted. Asking the client to call a family member may not be an option and there is an assumption that the client wants to share medical information with the family. The examiner is observing behavior which includes (facial features, dress, eye color) , (sexual development, consciousness, mood) , (grooming, race, body type) , and (personal hygiene, age, blood type.) - Correct answer Dress, grooming, personal hygiene, and mood are aspects of behavior that are observed by the examiner. While dressing, grooming, and personal hygiene are part of the physical appearance, they are controlled by the actions the person takes to care for themselves, while mood is more directly reflected in the person's behavior. Age, sexual development, level of consciousness, skin color, and facial features are part of physical appearance that are not impacted by a person's behavior

(Posture, Body mass index, Head circumference) is a marker of health and an indicator of nutritional status. - Correct answer Body Mass Index (BMI) is a marker of health and an indicator of nutritional status. It is calculated as weight (kg)/height (m2). Head circumference is often measured in newborns and infants to monitor growth and development and screen for hydrocephalus. Posture reflects musculoskeletal health, not nutritional status. Which of the following best describes the purpose of a general survey? To collect subjective information To collect information about chronic conditions To determine the focus and depth of the physical assessment To provide vital signs - Correct answer Data collected from the general survey is used to determine the focus and depth of assessment of each system. The general survey does not include the collection of subjective information or information about chronic conditions. It is also not to provide vital signs. Which of the following is included in the general survey? Select all that apply. Vital signs Physical appearance Mobility Behavior Palpation Family history Body structure - Correct answer The four areas in a general survey are physical appearance, body structure, mobility, and behavior. Vital signs are taken after the general survey. Palpation is an assessment technique, and family history is part of the health history.

Which aspects of the client are observed by the examiner during a physical appearance survey? Select all that apply. Dress Personal hygiene Age Level of consciousness Skin color Facial features Sexual development - Correct answer Physical appearance includes age, sexual development, level of consciousness, skin color, and facial features. Dress, grooming, personal hygiene, and mood are part of behavior. Which of the following findings during the general survey indicate a change in mobility? Client is 5'2" and 160 pounds Client's body is symmetric Client is seated in a tripod position Client had a stroke 2 years ago and has a walker. - Correct answer The stroke and walker are evidence of a mobility impairment. Position, symmetry, and body measurements do not indicate a change in mobility. Included in General Survey - Correct answer Speech clear Upright posture Appears stated age

Body symmetric Dressed appropriately for season Not included in General Survey - Correct answer History of asthma Client states pain 3/10 Denies cough "I feel happy." The examiner observes the client staggering into the room. The examiner notes this activity to obtain data related to which of the following? Level of consciousness Mood Gait Range of motion - Correct answer Staggering describes the client's gait. Range of motion, level of consciousness, and mood cannot be determined with this data. The examiner is entering the room to assess a newly admitted client. Which of the following best describes the purpose of a general survey? To provide information to guide the physical assessment To measure vital signs To collect the information necessary for diagnostic testing To give an opportunity for the client to voice complaints - Correct answer Data collected from the general survey is used to determine the focus and depth of assessment of each system. Measuring vital signs is part of the physical assessment. Information needed for diagnostic testing is administration. The client voicing their complaints occurs during the interview.