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Introduction |/to |/health |/assessment |/- |/NUR
|/ 216 |/EXAM |/QUESTIONS |/WITH |/ANSWERS
Select |/the |/action |/the |/PN |/participates |/in |/with |/the |/nursing |/process. |/- |/CORRECT |/ANSWERS |/✔✔Assist |/the |/RN |/with |/collecting |/data |/from |/the |/client What |/does |/HIPAA |/refer |/to? |/- |/CORRECT |/ANSWERS |/✔✔Health |/Insurance |/Portability |/and |/Accountability |/Act therapeautic |/communication |/involves |/which |/of |/the |/following? |/(Select |/all |/that |/apply) |/- |/CORRECT |/ANSWERS |/✔✔Open-ended |/question, |/If |/the |/client |/speaks |/a |/different |/language |/than |/the |/nurse, |/finding |/someone |/in |/the |/facility |/that |/speaks |/their |/language. Which |/of |/the |/following |/techniques |/is |/used |/with |/palpation? |/- |/CORRECT |/ANSWERS |/✔✔Use |/the |/palmar |/side |/of |/the |/hands |/or |/the |/pads |/of |/the |/fingers Which |/of |/the |/following |/actions |/by |/the |/nurse |/are |/examples |/of |/infection |/control? |/(Select |/all |/that |/apply) |/- |/CORRECT |/ANSWERS |/✔✔- Using |/an |/alcohol |/pad |/to |/wipe |/the |/diaphragm |/of |/the |/stethoscope |/between |/clients.
-Using |/an |/alcohol-based |/rub |/when |/hands |/are |/not |/visibly |/soiled. |/ -Hand |/washing |/with |/soap |/and |/water |/for |/ 15 |/seconds Which |/of |/the |/following |/are |/tools |/used |/with |/auscultation? |/(Select |/all |/that |/apply.) |/- |/CORRECT |/ANSWERS |/✔✔-Stethoscope -Doppler Place |/each |/step |/of |/the |/nursing |/process |/in |/the |/correct |/order. |/- |/CORRECT |/ANSWERS |/✔✔Assessment, |/Analysis, |/Planning, |/Implementation, |/Evaluation Place |/the |/steps |/for |/communicating |/with |/members |/of |/the |/health |/care |/team |/in |/the |/correct |/order. |/- |/CORRECT |/ANSWERS |/✔✔-Identify |/the |/member |/by |/the |/name |/and |/title. -Provide |/information |/regarding |/to |/the |/current |/situation. Provide |/information |/regarding |/the |/background |/situation. -Provide |/suggestions |/that |/may |/be |/helpful |/to |/the |/situation. -Give |/the |/most |/recent |/set |/of |/vital |/signs |/to |/the |/team |/member. -Repeat |/the |/orders |/back |/that |/are |/given |/to |/you |/by |/the |/provider Which |/of |/the |/following |/is |/the |/first |/action |/during |/the |/physical |/assessment |/of |/the |/client? |/- |/CORRECT |/ANSWERS |/✔✔Inspecting |/the |/client
|/Korotkoff |/sound |/or |/phase? |/- |/CORRECT |/ANSWERS |/✔✔You |/might |/not |/hear |/a |/fifth |/korotkoff |/sound To |/auscultating |/a |/patient's |/apical |/pulse |/accurately, |/you |/position |/the |/bell |/of |/the |/diaphragm |/of |/your |/stethoscope |/over |/the |/point |/of |/maximal |/impulse, |/which |/is |/located: |/- |/CORRECT |/ANSWERS |/✔✔at |/the |/fifth |/intercostal |/space |/at |/the |/left |/midclavicular |/line. The |/difference |/between |/a |/patient's |/systolic |/and |/diastolic |/blood |/pressures |/is |/called: |/- |/CORRECT |/ANSWERS |/✔✔the |/pulse |/pressure When |/assessing |/a |/patient's |/respiration, |/it |/is |/recommended |/that |/the |/patient: |/- |/CORRECT |/ANSWERS |/✔✔have |/the |/head |/of |/the |/bed |/elevated |/ 45 |/to |/ 60 |/degrees. When |/auscultating |/a |/patient's |/apical |/pulse, |/you |/listen |/until |/you |/hear |/the |/S1 |/and |/S2 |/heart |/sounds |/clearly |/and |/regularly. |/S2 |/is |/produced |/when |/the: |/- |/CORRECT |/ANSWERS |/✔✔semilunar |/valves |/close The |/most |/important |/factor |/in |/measuring |/blood |/pressure |/accurately |/is: |/- |/CORRECT |/ANSWERS |/✔✔using |/a |/cuff |/of |/the |/appropriate |/size |/for |/the |/patient
The |/best |/way |/to |/determine |/the |/depth |/of |/a |/patient's |/respiration |/is |/to: |/- |/CORRECT |/ANSWERS |/✔✔observe |/the |/degree |/of |/chest-wall |/movement |/during |/inspiration |/and |/expiration. You |/are |/preparing |/to |/use |/a |/tympanic |/thermometer. |/Which |/of |/the |/following |/steps |/has |/the |/highest |/priority |/in |/the |/accurate |/use |/of |/the |/piece |/of |/equipment |/for |/measuring |/body |/temperature? |/- |/CORRECT |/ANSWERS |/✔✔Gently |/pulling |/the |/pinna |/back |/and |/upward You |/are |/assessing |/the |/vital |/signs |/of |/a |/newly |/admitted |/patient. |/To |/establish |/an |/accurate |/baseline |/of |/the |/patient's |/respiration, |/you: |/- |/CORRECT |/ANSWERS |/✔✔observe |/the |/patient's |/chest |/movements |/while |/appearing |/to |/assess |/his |/pulse Which |/of |/the |/following |/accurately |/describes |/body |/temperature? |/- |/CORRECT |/ANSWERS |/✔✔The |/difference |/between |/heat |/produced |/by |/and |/lost |/from |/the |/body Which |/of |/the |/following |/temperatures |/is |/within |/the |/normal |/range |/for |/adults |/and |/is |/documented |/correctly? |/- |/CORRECT |/ANSWERS |/✔✔T |/= |/99.6º |/F |/(O) Which |/of |/the |/following |/is |/true |/regarding |/assessing |/a |/patient's |/pulse? |/- |/CORRECT |/ANSWERS |/✔✔The |/human |/pulse |/is |/the |/palpable |/bounding |/of |/the |/blood |/flow |/in |/a |/peripheral |/artery.
To |/facilitate |/straightening |/the |/natural |/curvature |/of |/the |/adult |/ear |/canal, |/you |/gently |/pull |/the |/patient's |/pinna |/(top |/of |/the |/ear) |/- |/CORRECT |/ANSWERS |/✔✔back, |/up, |/and |/out When |/using |/a |/tympanic |/membrane |/thermometer, |/correctly |/position |/the |/speculum |/probe |/with |/respect |/to |/the |/ear |/canal |/to |/ensure |/- |/CORRECT |/ANSWERS |/✔✔an |/appropriate |/seal |/is |/created |/to |/prevent |/the |/ear |/canal |/from |/being |/exposed |/to |/ambient |/temperature. You |/prepare |/to |/assess |/the |/patient's |/pulse |/and |/respiratory |/rate. |/You |/support |/her |/arm |/and |/palpate |/her |/wrist |/to |/locate |/the |/radial |/pulse |/along |/a |/groove |/located |/- |/CORRECT |/ANSWERS |/✔✔on |/the |/thumb |/side |/of |/the |/wrist. After |/assessing |/the |/patient's |/pulse, |/you |/begin |/to |/observe |/her |/breathing |/pattern |/immediately |/without |/changing |/the |/position |/of |/your |/hand. |/You |/do |/this |/primarily |/to |/- |/CORRECT |/ANSWERS |/✔✔keep |/the |/patient |/from |/altering |/the |/rate, |/rhythm, |/or |/depth |/of |/her |/respiration. Positioning |/and |/supporting |/the |/patient's |/arm |/at |/heart |/level |/is |/important |/because |/- |/CORRECT |/ANSWERS |/✔✔-an |/arm |/positioned |/above |/heart |/level |/can |/cause |/a |/falsely |/low |/reading. -an |/unsupported |/arm |/can |/cause |/a |/falsely |/high |/reading.
To |/ensure |/an |/accurate |/reading |/with |/the |/aneroid |/sphygmomanometer |/you |/are |/using, |/you |/position |/yourself |/- |/CORRECT |/ANSWERS |/✔✔-within |/ 3 |/feet |/of |/the |/manometer. -at |/eye |/level |/with |/the |/BP |/gauge. You |/have |/reviewed |/the |/patient's |/records |/to |/determine |/her |/baseline |/BP, |/but |/if |/that |/had |/not |/been |/possible |/it |/would |/be |/appropriate |/for |/you |/to |/- |/CORRECT |/ANSWERS |/✔✔-measure |/her |/BP |/on |/one |/arm, |/remove |/the |/cuff, |/wait |/at |/least |/ 2 |/minutes, |/measure |/it |/on |/the |/other |/arm, |/and |/average |/the |/two |/values. -inflate |/the |/cuff |/to |/ 30 |/mm |/Hg |/above |/the |/point |/of |/the |/previously |/palpated |/systolic |/pressure. When |/listening |/to |/Korotkoff |/sounds, |/you |/would |/use |/your |/stethoscope's |/- |/CORRECT |/ANSWERS |/✔✔bell Mr. |/Lu |/is |/admitted |/with |/an |/abdominal |/pain. |/His |/oral |/temperature |/is |/100.4°F |/(38°C), |/pulse |/is |/ 88 |/beats/min, |/respirations |/are |/ 18 |/breaths/min, |/and |/blood |/pressure |/is |/118/78 |/mm |/Hg. |/These |/findings |/are: |/- |/CORRECT |/ANSWERS |/✔✔Abnormal Ms. |/Martin |/vomited |/ 200 |/mL |/of |/stomach |/contents |/after |/breakfast. |/Her |/vital |/signs |/include |/tympanic |/temperature, |/97.6°F |/(36.4°C); |/pulse, |/ 99 |/beats/min; |/respirations, |/ 16 |/breaths/min; |/and |/blood |/pressure,
2nd |/sound—Occurs |/as |/further |/deflation |/of |/the |/cuff |/takes |/place |/and |/is |/a |/soft, |/swishing |/sound. 3rd |/sound—Begins |/midway |/through |/the |/BP |/and |/is |/a |/sharp, |/rhythmic |/tapping |/sound. 4th |/sound—Similar |/to |/the |/3rd |/sound, |/but |/softer |/and |/fading. 5th |/sound—Diastolic |/BP. |/Silence; |/no |/more |/sounds |/are |/noted. What |/are |/the |/primary |/vital |/signs |/of |/the |/nursing |/assessment? |/- |/CORRECT |/ANSWERS |/✔✔PULSE, |/TEMPERATURE, |/BP, |/RESP What |/information |/is |/needed |/when |/assessing |/the |/respiratory |/vital |/signs? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔RHYTHM, |/EFFORT, |/DEPTH, |/RATE Which |/describes |/the |/first |/contact |/and |/overall |/impression |/of |/the |/client? |/- |/CORRECT |/ANSWERS |/✔✔General |/survey Calculating |/the |/body |/mass |/index |/(BMI) |/is |/typically |/part |/of |/a |/physical |/assessment. |/For |/which |/types |/of |/clients |/is |/the |/BMI |/not |/helpful? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔Pregnant |/women, |/growing |/child |/and |/athlete
A |/client |/with |/a |/history |/of |/congestive |/heart |/failure |/complains |/that |/all |/his |/or |/her |/shoes |/are |/too |/tight. |/Which |/should |/this |/information |/alert |/the |/nurse |/to? |/- |/CORRECT |/ANSWERS |/✔✔edema Which |/assessments |/are |/done |/as |/part |/of |/assessment |/of |/joint |/mobility |/and |/muscle |/function? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔1. Active |/range |/of |/motion
Passive |/range |/of |/motion Which |/is |/referred |/to |/as |/the |/assessment |/of |/arousal |/and |/orientation? |/- |/CORRECT |/ANSWERS |/✔✔level |/of |/consciousness. Question |/6. |/Which |/describes |/breath |/sounds |/auscultated |/over |/the |/trachea? |/- |/CORRECT |/ANSWERS |/✔✔bronchial |/breath |/sounds |/- |/are |/high-pitched |/sounds |/that |/are |/heard |/over |/the |/trachea Question |/7. |/Which |/is |/part |/of |/the |/assessment |/of |/the |/musculoskeletal |/system? |/- |/CORRECT |/ANSWERS |/✔✔Gait |/- are |/part |/of |/the |/neurological |/assessment.
-If |/the |/client |/is |/unresponsive, |/these |/other |/neurological |/tests |/cannot |/be |/completed. The |/nurse |/is |/assessing |/the |/genitalia |/of |/a |/female |/client |/and |/notices |/foul |/smelling |/discharge |/from |/the |/vaginal |/area. |/What |/should |/the |/nurse |/ask |/the |/client? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔1. |/"Are |/you |/sexually |/active?" 2."Have |/you |/ever |/been |/treated |/for |/a |/sexually |/transmitted |/infection |/(STI)?" What |/must |/the |/nurse |/consider |/in |/regards |/to |/the |/integrity |/of |/the |/aging |/adult's |/skin? |/Select |/All |/That |/Apply. |/- |/CORRECT |/ANSWERS |/✔✔1. |/Skin |/is |/thinner |/and |/more |/fragile.
- |/Glandular |/activity |/decreases.
- |/Collagen |/and |/elastin |/fibers |/weaken |/and |/become |/less |/elastic. What |/would |/be |/an |/appropriate |/outcome |/for |/a |/nursing |/diagnosis |/of |/Impaired |/Walking |/r/t |/foot |/pain |/secondary |/to |/arthritis? |/- |/CORRECT |/ANSWERS |/✔✔demonstrates |/measures |/to |/increase |/mobility An |/84-year-old |/was |/admitted |/with |/a |/medical |/diagnosis |/of |/Malignant |/Hypertension |/and |/Pneumonia |/and |/needs |/assistance |/with |/self-care, |/including |/oral |/hygiene. |/Why |/is |/it |/important |/for |/the |/nurse |/to |/fully |/inspect |/and |/assess |/the |/oral |/cavity |/while |/assisting |/with |/oral |/hygiene
|/in |/this |/client? |/- |/CORRECT |/ANSWERS |/✔✔Due |/to |/increased |/risk |/of |/systemic |/infection
- |/The |/client |/is |/at |/higher |/risk |/for |/developing |/a |/systemic |/infection, |/which |/could |/be |/triggered |/by |/poor |/oral |/hygiene. Which |/factors |/can |/affect |/a |/person's |/hygiene |/practices? |/Select |/All |/That |/Apply. |/- |/CORRECT |/ANSWERS |/✔✔culture, |/developmental |/level |/and |/economic |/status Question |/17. |/Which |/health |/factors |/affect |/a |/person's |/self-care |/ability? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔1. |/Pain
- |/Limited |/mobility Question |/18. |/Which |/are |/appropriate |/client |/teaching |/topics |/for |/nurses |/to |/provide |/to |/clients |/regarding |/nail |/care? |/Select |/all |/that |/apply. |/- |/CORRECT |/ANSWERS |/✔✔1. Inspect |/nails |/daily.
Clip |/toenails |/straight |/across.
Use |/moisturizing |/lotion |/to |/soften |/cuticles.
The |/nurse |/is |/assessing |/the |/abdomen |/for |/a |/client |/returning |/from |/an |/abdominal |/surgery. |/Which |/assessment |/technique |/should |/the |/nurse |/perform |/first? |/- |/CORRECT |/ANSWERS |/✔✔inspection PQRST |/- |/CORRECT |/ANSWERS |/✔✔provocative/palliative quality region/radiation severity |/ timing ISBAR |/- |/CORRECT |/ANSWERS |/✔✔Identify/Introduction Situation Background Assessment Recommendation OLDCARTS |/- |/CORRECT |/ANSWERS |/✔✔Onset, |/Location, |/ Duration, |/ Character, |/ Aggravating |/factors, |/ Relieving |/Factors, |/
Treatment, |/ Severity
