Holistic Health Assessment Questions
Correctly Solved
During the admission assessment, the nurse identifies the client has a history of
Raynaud's. What assessment finding would the nurse expect to find? - ✅✅ Cold
fingers and hands
The posterior tibial pulse can be palpated at the - ✅✅ Ankle
While assessing the peripheral vascular system of an adult client, the nurse detects
cold clammy skin and loss of hair on the client's legs. The nurse suspects that the
client may be experiencing - ✅✅ arterial insufficiency.
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago.
The nurse should assess the client for - ✅✅ lymphedema.
When assessing temperature of the skin, which portion of the hand should the
examiner use? - ✅✅ Backs of fingers
After describing the pathophysiology of pain, an instructor determines that the
students have understood the teaching when they identify which of the following
as being responsible for transmitting the sensations to the central nervous system?
Transduction
Modulation
Nociceptors
Cytokines - ✅✅ Nociceptors
Reasoning
The source of pain stimulates peripheral nerve endings or nociceptors, which
transmit the sensations to the central nervous system. Transduction begins when a
mechanical, thermal or chemical stimulus results in tissue injury or damage,
stimulating the nociceptors. Modulation inhibits the pain message and involves the
body's own endogenous neurotransmitters in the course of processing the pain
stimuli. Cytokines are released due to an inflammatory process resulting from the
painful stimulus.
When beginning the collection of the client data base, which of the following
would be most important for the nurse to do?
, Identify health problems
Establish a trusting relationship
Determine the client's strengths
Make inferences - ✅✅ Establish a trusting relationship
Reasoning
It is essential for the nurse to develop trust and rapport with the client to elicit
accurate and meaningful information. This trust is the focus of the interview and
must be developed in the initial phase of the interview. Determining the client's
strengths, identifying health problems, and making inferences occur during the
working phase of the interview.
While auscultating the heart at the third intercostal space, left sternal border, the
nurse notes a high-pitched, scratchy sound that increases with exhalation with the
client leaning forward. The nurse would document which of the following? - ✅✅
Pericardial friction rub
A client with dehydration or volume depletion has barely visible neck veins, even
when lying flat. These are described as what? - ✅✅ Flat Neck Veins
A nurse auscultates the heart of a client with hypertension for the past ten (10)
years. With the client in the left lateral position, the nurse hears a heart sound that
occurs just before S1. The nurse recognizes this sound as what pathological
process? - ✅✅ Atrial contractions heard as vibrations against stiff walled
ventricles
During a cardiac examination, the nurse can best hear the S1 heart sound by
placing the stethoscope at the client's - ✅✅ apex of the heart.
In order to palpate an apical pulse when performing a cardiac assessment, where
should the nurse place the fingers? - ✅✅ left midclavicular line at the fifth
intercostal space
Across the lifespan, a nurse knows what characteristic of the female heart is
consistently true? - ✅✅ Is normally smaller than the male heart
The nurse hears high-pitched swooshing sounds over the carotid artery on the right
side. What is this sound indicative of? - ✅✅ Bruits
Correctly Solved
During the admission assessment, the nurse identifies the client has a history of
Raynaud's. What assessment finding would the nurse expect to find? - ✅✅ Cold
fingers and hands
The posterior tibial pulse can be palpated at the - ✅✅ Ankle
While assessing the peripheral vascular system of an adult client, the nurse detects
cold clammy skin and loss of hair on the client's legs. The nurse suspects that the
client may be experiencing - ✅✅ arterial insufficiency.
A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago.
The nurse should assess the client for - ✅✅ lymphedema.
When assessing temperature of the skin, which portion of the hand should the
examiner use? - ✅✅ Backs of fingers
After describing the pathophysiology of pain, an instructor determines that the
students have understood the teaching when they identify which of the following
as being responsible for transmitting the sensations to the central nervous system?
Transduction
Modulation
Nociceptors
Cytokines - ✅✅ Nociceptors
Reasoning
The source of pain stimulates peripheral nerve endings or nociceptors, which
transmit the sensations to the central nervous system. Transduction begins when a
mechanical, thermal or chemical stimulus results in tissue injury or damage,
stimulating the nociceptors. Modulation inhibits the pain message and involves the
body's own endogenous neurotransmitters in the course of processing the pain
stimuli. Cytokines are released due to an inflammatory process resulting from the
painful stimulus.
When beginning the collection of the client data base, which of the following
would be most important for the nurse to do?
, Identify health problems
Establish a trusting relationship
Determine the client's strengths
Make inferences - ✅✅ Establish a trusting relationship
Reasoning
It is essential for the nurse to develop trust and rapport with the client to elicit
accurate and meaningful information. This trust is the focus of the interview and
must be developed in the initial phase of the interview. Determining the client's
strengths, identifying health problems, and making inferences occur during the
working phase of the interview.
While auscultating the heart at the third intercostal space, left sternal border, the
nurse notes a high-pitched, scratchy sound that increases with exhalation with the
client leaning forward. The nurse would document which of the following? - ✅✅
Pericardial friction rub
A client with dehydration or volume depletion has barely visible neck veins, even
when lying flat. These are described as what? - ✅✅ Flat Neck Veins
A nurse auscultates the heart of a client with hypertension for the past ten (10)
years. With the client in the left lateral position, the nurse hears a heart sound that
occurs just before S1. The nurse recognizes this sound as what pathological
process? - ✅✅ Atrial contractions heard as vibrations against stiff walled
ventricles
During a cardiac examination, the nurse can best hear the S1 heart sound by
placing the stethoscope at the client's - ✅✅ apex of the heart.
In order to palpate an apical pulse when performing a cardiac assessment, where
should the nurse place the fingers? - ✅✅ left midclavicular line at the fifth
intercostal space
Across the lifespan, a nurse knows what characteristic of the female heart is
consistently true? - ✅✅ Is normally smaller than the male heart
The nurse hears high-pitched swooshing sounds over the carotid artery on the right
side. What is this sound indicative of? - ✅✅ Bruits
