Skills Question (Health Assessment)
The nurse is preparing to conduct a 10-minute head-to-toe assessment on a
client admitted with pneumonia. What should the nurse do first? - correct
answers Complete a general inspection.
An emergency room nurse is conducting a quick head-to-toe assessment of a
client reporting flu-like symptoms. What pulse grade would the nurse
document if the client's radial pulses were "full, easy to palpate, and cannot be
obliterated"? - correct answers +2 pulse
The nurse is performing a quick head-to-toe assessment on a client admitted
with an infected left heel wound. When auscultating the lower lobes of the
client's lungs, what might the nurse expect to find? - correct answers Soft, low
pitched sounds bilaterally
The nurse is planning to assess an older adult client admitted with abdominal
pain. Which special considerations are important to contemplate when
assessing the older adult client? Select all that apply. - correct answers Short
term memory may diminish with age., Older adults take longer to perform
certain actions., Presence of heart sound S4 is considered normal.
The nurse is completing a quick head-to-toe assessment on a client admitted
with right-sided heart failure. Which body parts should be examined for
peripheral edema? Select all that apply. - correct answers Sacrum, Feet,
Hands
A nurse is preparing to perform a general survey of a client. What equipment
would the nurse require to perform this assessment? Select all that apply. -
correct answers Standing scale, Tape measure, Sphygmomanometer,
Stethoscope
, Which senses are used when the nurse performs the inspection phase of
assessment? Select all that apply. - correct answers Smell, Hearing, Sight
When performing a general survey assessment, how would the nurse assess
the client's orientation? Select all that apply. - correct answers Question where
the client is now., Query about today's date and season., Request the client
states his or her name.
The nurse is preparing to obtain biographical data from a client before
initiating a health assessment. Which biographical data should the nurse plan
to collect? Select all that apply. - correct answers Gender, Occupation, Date
of birth, Name
The nurse is about to conduct a general survey on a client being admitted to
the medical-surgical unit. What should the nurse do first? - correct answers
Identify the client by two methods.
The nurse is asking admission interview questions, and the client has
explained the reason for seeking care. Which is the most appropriate way to
document the response? - correct answers Client states, "I feel winded all of
the time, and yesterday I started spitting up a lot of phlegm."
The nurse is performing a general survey on a client who is being admitted to
the medical unit with abdominal pain. Which components would the nurse
assess during the general survey? Select all that apply. - correct answers
Assess the client's vital signs
The nurse is beginning a general survey on a client who is being admitted to
the hospital for abdominal pain. After identifying the client, which components
would the nurse include in the general survey? Select all that apply. - correct
answers Does the person's body structure match the stated age?, Is the
client's color appropriate for ethnicity?, Are there any tubes, lines, or drains?,
Does the client appear to be alert?
The nurse is preparing to conduct a 10-minute head-to-toe assessment on a
client admitted with pneumonia. What should the nurse do first? - correct
answers Complete a general inspection.
An emergency room nurse is conducting a quick head-to-toe assessment of a
client reporting flu-like symptoms. What pulse grade would the nurse
document if the client's radial pulses were "full, easy to palpate, and cannot be
obliterated"? - correct answers +2 pulse
The nurse is performing a quick head-to-toe assessment on a client admitted
with an infected left heel wound. When auscultating the lower lobes of the
client's lungs, what might the nurse expect to find? - correct answers Soft, low
pitched sounds bilaterally
The nurse is planning to assess an older adult client admitted with abdominal
pain. Which special considerations are important to contemplate when
assessing the older adult client? Select all that apply. - correct answers Short
term memory may diminish with age., Older adults take longer to perform
certain actions., Presence of heart sound S4 is considered normal.
The nurse is completing a quick head-to-toe assessment on a client admitted
with right-sided heart failure. Which body parts should be examined for
peripheral edema? Select all that apply. - correct answers Sacrum, Feet,
Hands
A nurse is preparing to perform a general survey of a client. What equipment
would the nurse require to perform this assessment? Select all that apply. -
correct answers Standing scale, Tape measure, Sphygmomanometer,
Stethoscope
, Which senses are used when the nurse performs the inspection phase of
assessment? Select all that apply. - correct answers Smell, Hearing, Sight
When performing a general survey assessment, how would the nurse assess
the client's orientation? Select all that apply. - correct answers Question where
the client is now., Query about today's date and season., Request the client
states his or her name.
The nurse is preparing to obtain biographical data from a client before
initiating a health assessment. Which biographical data should the nurse plan
to collect? Select all that apply. - correct answers Gender, Occupation, Date
of birth, Name
The nurse is about to conduct a general survey on a client being admitted to
the medical-surgical unit. What should the nurse do first? - correct answers
Identify the client by two methods.
The nurse is asking admission interview questions, and the client has
explained the reason for seeking care. Which is the most appropriate way to
document the response? - correct answers Client states, "I feel winded all of
the time, and yesterday I started spitting up a lot of phlegm."
The nurse is performing a general survey on a client who is being admitted to
the medical unit with abdominal pain. Which components would the nurse
assess during the general survey? Select all that apply. - correct answers
Assess the client's vital signs
The nurse is beginning a general survey on a client who is being admitted to
the hospital for abdominal pain. After identifying the client, which components
would the nurse include in the general survey? Select all that apply. - correct
answers Does the person's body structure match the stated age?, Is the
client's color appropriate for ethnicity?, Are there any tubes, lines, or drains?,
Does the client appear to be alert?
