Health Assessment
A nurse notices multiple lesions on a client's back that are 0.5 cm in width, elevated, circumscribed, and
filled with serous fluid. The nurse documents these lesions as:
Vesicles
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in
which of the following conditions?
In a severely dehydrated individual
"The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is
very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby s
birth and that it seems to be getting bigger. One possible explanation for this is:"
Cephalhematoma
A client reports a rash that "itches" but denies fever, shortness of breath, or other symptoms. Which
questions does the nurse ask to help determine if the client is experiencing an allergic reaction? Select
all that apply.
"Are you taking any new medications?"
"Have you been using any different soaps?"
"Have you been exposed to any new cleaning solutions?"
Physical growth is the best index of a child s:
general health
The nurse is assessing capillary refill on a client and notes a color return that takes 4 seconds on each
hand. The nurse would correctly document this finding as which of the following?
Sluggish
, Which of the following factors is most likely to affect the nutritional status of an 82-year-old person?
Living alone on a fixed income
A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1 to
10 scale. Which of the following assessment findings indicates an acute pain response to poorly
controlled pain?
Increased blood pressure and Pulse
"During an examination, a nurse notes a lesion on the client s upper back. What is the best way to
document the size of this lesion?"
Use a centimeter rule to measure the lesion
A patient s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an
examination of the:
thyroid gland
When the nurse assesses an apical heart rate and notes bradycardia. What was the apical heart rate?
Less than 60 beats/minute
"When evaluating a patient s pain, the nurse knows that an example of acute pain would be:"
Kidney stones
A nurse notices multiple lesions on a client's back that are 0.5 cm in width, elevated, circumscribed, and
filled with serous fluid. The nurse documents these lesions as:
Vesicles
The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in
which of the following conditions?
In a severely dehydrated individual
"The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is
very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby s
birth and that it seems to be getting bigger. One possible explanation for this is:"
Cephalhematoma
A client reports a rash that "itches" but denies fever, shortness of breath, or other symptoms. Which
questions does the nurse ask to help determine if the client is experiencing an allergic reaction? Select
all that apply.
"Are you taking any new medications?"
"Have you been using any different soaps?"
"Have you been exposed to any new cleaning solutions?"
Physical growth is the best index of a child s:
general health
The nurse is assessing capillary refill on a client and notes a color return that takes 4 seconds on each
hand. The nurse would correctly document this finding as which of the following?
Sluggish
, Which of the following factors is most likely to affect the nutritional status of an 82-year-old person?
Living alone on a fixed income
A patient states that the pain medication is not working and rates his postoperative pain at a 10 on a 1 to
10 scale. Which of the following assessment findings indicates an acute pain response to poorly
controlled pain?
Increased blood pressure and Pulse
"During an examination, a nurse notes a lesion on the client s upper back. What is the best way to
document the size of this lesion?"
Use a centimeter rule to measure the lesion
A patient s laboratory data reveal an elevated thyroxine level. The nurse would proceed with an
examination of the:
thyroid gland
When the nurse assesses an apical heart rate and notes bradycardia. What was the apical heart rate?
Less than 60 beats/minute
"When evaluating a patient s pain, the nurse knows that an example of acute pain would be:"
Kidney stones
