Holistic Health Assessment Final Exam Study Guide | Questions and Answers (Complete Solutions)

Holistic Health Assessment Final Exam Study Guide | Questions and Answers (Complete Solutions) The nurse is assessing a patient's blood pressure and selects a cuff that is too small for the patient's arm. Which finding should the nurse expect? A falsely high blood pressure reading To assess for orthostatic hypotension, in which order should the nurse obtain the blood pressure and pulse measurements? Supine, Sitting, Standing A patient's blood pressure is consistently 134/86 mmHg. According to current guidelines, how should the nurse categorize this blood pressure? Stage 1 Hypertension A nurse notes a patient's heart rate is 48 beats per minute. Which term should the nurse use to document this finding? Bradycardia A nurse notes a patient's heart rate is 106 beats per minute. Which term should the nurse use to document this finding? Tachycardia Using the FAST acronym for stroke screening, the nurse observes the patient's face while they smile. Which finding is a 'red flag'? Uneven or drooping smile on one side During a stroke assessment (FAST), the nurse asks the patient to close their eyes and hold both arms out with palms up. One arm slowly drifts downward. How should the nurse document this? Pronator drift The nurse is assessing a patient's speech as part of the FAST screening. Which observation requires immediate intervention? Slurred or garbled speech In the FAST acronym, what does the 'T' stand for, and why is it critical in stroke care? Time; to note the exact onset of symptoms for treatment eligibility The nurse performs a Timed Up and Go (TUG) test on an elderly patient. The patient takes 15 seconds to complete the task. How should the nurse interpret this result? The patient is at an increased risk for falls A TUG score of _____ seconds or more is generally associated with a high risk for falls. 12 Which factor is included in the Morse Fall Scale to determine a patient's fall risk? History of falling During a respiratory assessment, the nurse performs the egophony test. When the patient says 'E', the nurse hears a clear 'A' through the stethoscope. What does this suggest? Lung consolidation or pneumonia While palpating the chest, the nurse notes increased tactile fremitus over the right lower lobe. This finding is most consistent with which condition? Pneumonia The nurse is auscultating a patient's heart and hears a high-pitched, scratchy sound that is loudest when the patient leans forward. Which condition should the nurse suspect? Pericardial friction rub The nurse assesses a patient's peripheral pulses and documents them as '2+'. How should this amplitude be interpreted? Normal A nurse is unable to palpate a patient's dorsalis pedis pulse. What is the priority nursing action? Use a Doppler ultrasound device to locate the pulse In which order should the nurse perform an abdominal assessment? Inspection, Auscultation, Percussion, Palpation The nurse hears loud, gurgling bowel sounds in all four quadrants. Which term should the nurse use to document this? Borborgmi (hyperactive sounds) While auscultating the carotid artery, the nurse hears a blowing, swishing sound. This finding most likely indicates: A bruit Where is the most appropriate location for the nurse to assess skin turgor in an elderly patient? Over the sternum or under the clavicle A nurse observes a pressure injury that appears as a shallow, open ulcer with a red-pink wound bed and no slough. How should the nurse stage this injury? Stage 2 At what angle should the head of the bed be positioned to accurately assess for Jugular Venous Distention (JVD)? 30 to 45 degrees The nurse asks a patient to whisper 'one-two-three' while auscultating the lungs. If the sound is heard clearly through the stethoscope, what does this indicate? Consolidation of the lungs (whispered pectorliquy) Where should the nurse expect to hear vesicular breath sounds during a normal assessment? Over the majority of the peripheral lung fields A patient is experiencing an asthma attack. The nurse hears high-pitched, musical sounds primarily during expiration. How should this be documented? Wheezing _________ crackles are high-pitched, short, soft sounds (like hair rubbing) occurring late in inspiration due to airway opening, often indicating interstitial fibrosis or congestive heart failure. Fine ___________ crackles are lower-pitched, louder, longer, and bubbling sounds (like velcro or straw bubbling) heard earlier, indicating secretions/fluid in airways. Coarse What is the primary cause of crackles (rales) heard during lung auscultation? Fluid in the alveoli or the sudden opening of collapsed small airways The S1 heart sound corresponds to which mechanical event in the cardiac cycle? Closure of the atrioventricular (mitral and tricuspid) valves Where is the S2 heart sound heard most loudly? At the base of the heart (second intercostal space) When testing a patient's pupils for accommodation, the nurse should observe for which response as the patient's gaze moves from a distant to a near object? Pupillary constriction and convergence According to the Glasgow Coma Scale (GCS), what is the lowest possible score a patient can receive? 3 The nurse assesses for rebound tenderness (Blumberg sign) in a patient with suspected appendicitis. Where is the correct location for this assessment? McBurney's point (Right Lower Quadrant) A nurse notes that a patient has pitting edema in the lower extremities that leaves a 4mm indentation that disappears in 10-15 seconds. How should this be graded? 2+ The nurse assesses a patient's capillary refill time and finds it is 5 seconds. This finding most likely indicates: Decreased peripheral perfusion A patient in their third trimester of pregnancy is noted to have an exaggerated inward curvature of the lumbar spine. Which term describes this finding? Lordosis An elderly patient has an exaggerated outward curvature of the thoracic spine. The nurse documents this as: Kyphosis When testing muscle strength, the nurse finds the patient can move their limb through a full range of motion against gravity but cannot resist any applied pressure. How should this be graded? 3/5 The nurse is performing the Romberg test. What is the priority safety action during this assessment? Standing close to the patient to prevent a fall from happening Which assessment finding requires the nurse to take immediate action and notify the provider? Sudden onset of unilateral facial drooping During an assessment, the nurse hears a high-pitched, crowing sound on inspiration. Which condition is the most likely cause? Upper airway obstruction (Stridor) Which of the following is an example of subjective data collected during a health assessment? The patient states, 'I feel dizzy when I stand up' A nurse documents that a patient's skin is 'cool and clammy.' This is an example of: Objective data What is the purpose of calculating a pulse deficit? To identify an irregular heart rhythm like atrial fibrillation Which temperature measurement route is generally considered to provide the most accurate core body temperature? Rectal When examining an adult's ear with an otoscope, in which direction should the nurse pull the pinna? Up and back What is a normal finding when palpating a healthy adult's lymph nodes? Small, mobile, and non-tender The nurse notes the patient's thyroid gland is enlarged. What is the next step in the assessment? Auscultate for a bruit using the bell of the stethoscope A patient's vision is recorded as 20/40 using the Snellen chart. How should the nurse interpret this? The patient can read at 20 feet what a person with normal vision can read at 40 feet Which statement represents the best practice for documenting assessment findings? 'Right lower lobe with fine crackles auscultated at end-inspiration' While assessing tactile fremitus, the nurse finds it is decreased over a large area of the left lung. Which condition could cause this? Pneumothorax While assessing tactile fremitus, the nurse finds it is increased over a large area of the right lung. Which condition could cause this? Pneumonia What is the expected percussion sound over most of the abdomen? Tympany The nurse is assessing a patient's apical pulse and finds it is irregular. What is the best course of action? Count the apical pulse for one full minute _______________________ looks at the whole person (physical, emotional, cultural, spiritual). Holistic Assessment A ___________________________ is classified as a full head-to-toe; usually on admission. Comprehensive Assessment A ______________________ targets a specific problem or system. Focused Assessment An _________________________________ is classified as a shortened survey, often routine or shift-based. Abbreviated Head-to-Toe Assessment The Nursing Process includes: 1.) Assessment 2.) Diagnosis 3.) Planning 4.) Implementation 5.) Evaluation Critical Thinking Qualities include: 1.) Purposefulness 2.) Reflectiveness 3.) Using logic 4.) Open-mindedness 5.) Using evidence-based 6.) Using patient-centered care The _____________ will always be the primary data source Patient The __________ , __________ , or _____________ can be classified as secondary data sources. Family / Chart / Caregivers What does COLDSPA stand for? 1.) Character 2.) Onset 3.) Location 4.) Duration 5.) Severity 6.) Pattern 7.) Associated factors. Orthostatic blood pressure can occur when the following happens in order: Lying, sitting, standing Temperature Routes include: 1.) Oral 2.) Tympanic 3.) Axillary 5.) Rectal Neuro Prioritization Red Flags include: 1.) Sudden weakness 2.) Speech changes 3.) Confusion 4.) Unequal pupils What is the FAST stroke assessment used for? Used for assessing stroke symptoms. What is the Timed Up and Go (TUG) assessment used for? A test for mobility and fall risk. What is the Morse Fall Scale used for? A tool for assessing fall risk. __________________ breath sounds are classified as abnormal lung sounds. Adventitious Voice Transmission Tests include: 1.) Egophony 2.) Tactile fremitus 3.) Bronchophony Heart Sound Locations include: 1.) Aortic Area: 2nd intercostal space, right sternal border. 2.) Pulmonic Area: 2nd intercostal space, left sternal border. 3.) Erb's Point: 3rd intercostal space, left sternal border. 4.) Tricuspid Area: 4th or 5th intercostal space, left sternal border. 5.) Mitral Area (Apex): 5th intercostal space, left mid-clavicular line. Peripheral pulse amplitudes include: 1.) 0 (Absent/No pulse): Pulse cannot be felt, indicating severe vascular compromise. 2.) 1+ (Diminished/Weak/Thready): Weaker than expected, hard to find, disappears with slight pressure. 3.) 2+ (Normal/Brisk): Expected strength, easily palpated, normal circulatory status. 4.) 3+ (Increased): Stronger than normal, increased stroke volume. 5.) 4+ (Full/Bounding): Very strong, persists despite moderate pressure. To perform an abdominal assessment the nurse must perform which of the following actions in order. Inspection, Auscultation, Percussion, and Palpation FICA stands for what? 1.) Faith 2.) Importance 3.) Community 4.) Address in care Therapeutic Communication Techniques include: 1.) Open-ended questions 2.) Active listening 3.) Reflection 4.) Clarification Developmental considerations should ________________________________ and ________________________ Assess communication / Teach based on age Which type of health assessment is most appropriate for a patient being admitted to a medical-surgical unit for the first time? Comprehensive assessment A nurse is evaluating a patient's spiritual needs using the FICA framework. Which question aligns with the "I" in FICA? 'How important is your faith in your life?' During the nursing process, in which phase does the nurse establish short-term and long-term goals for the patient? Planning Which of the following is considered secondary objective data? A lab report in the medical record showing a low hemoglobin level A patient presents with a cough. Using the COLDSPA mnemonic, which question assesses the "Character" of the symptom? 'What does the cough feel or sound like?' When assessing the sinuses, where should the nurse palpate to evaluate the frontal sinuses? Directly above the eyebrows Which developmental theory focuses on psychosocial conflicts at each stage of the lifespan, such as "Trust vs. Mistrust"? Erikson A nurse is performing a shift-based assessment on a stable patient. This is also known as what type of assessment? Abbreviated assessment The nurse is using an otoscope to examine a patient's ear. What is the primary purpose of this tool? To inspect the external auditory canal and tympanic membrane Which blood pressure range is classified as Stage 1 Hypertension in an adult? 136/88 Stage 1 hypertension typically involves a systolic range of __________ mmHg or a diastolic range of __________ mmHg. 130-139 / 80-89 A patient reports "I feel like my heart is racing." The nurse records a heart rate of 115 bpm. How should the nurse document this finding? Tachycardia According to Piaget's theory, which stage of development involves a child beginning to perceive the world through four distinct periods of cognitive growth? Cognitive development Which sinus is located deep within the skull? Sphenoid sinus What is the first step of the nursing process? Assessment A nurse observes that a patient's pupillary response is sluggish. Which tool is used to further assess the internal structures of the eye? Ophthalmoscope When using the COLDSPA mnemonic to assess pain, the "A" stands for: Associated factors Which assessment type targets a specific problem or body system, such as a patient complaining of new-onset abdominal pain? Focused assessment ___________________________________ is a widely used 10-15 minute screening tool designed to detect mild cognitive impairment (MCI) and early dementia. The Montreal Cognitive Assessment (MoCA) The nurse is assessing a patient's risk for pressure injuries. Which tool is most likely being used? Braden Scale The nurse asks the patient, "How would you like me to address these spiritual issues in your care?" This addresses which part of the FICA framework? Address Which of the following is a barrier to therapeutic communication? Use of bias In the nursing process, which phase involves the actual performance of nursing interventions? Implementation Subjective data is best described as: Information reported by the patient The nurse is palpating the sinuses located between the eyes, near the bridge of the nose. These are the: Ethmoid sinuses Which developmental theory focuses on moral reasoning? Kohlberg When documenting an assessment, the nurse should use which type of language? Nonjudgmental The nurse is assessing a patient's cognitive function. Which tool is appropriate for this task? MoCA (Montreal Cognitive Assessment) A patient has a temperature of 101.4°F. This is documented as: Febrile Which of the following is a component of a holistic assessment? Cultural and spiritual beliefs The nurse identifies that a patient's blood pressure cuff is too small. What effect will this have on the reading? The reading will be falsely high When using the COLDSPA mnemonic, "Onset" refers to: When the symptom began Which phase of the nursing process involves comparing the patient's current status with the established goals? Evaluation A nurse asks, "Do you have a spiritual community that supports you?" This is the "C" in which framework? FICA The maxillary sinuses are located: Behind the cheekbones near the upper jaw Which theory suggests that development is a lifelong process of resolving positive and negative outcomes? Erikson