NR-304 Final review lecture
What is the purpose of the health history? - answer Provide the database of subjective
data about Pt's health
What are the specific categories contained in the health history? - answer-
demographics
-Reason for Seeking care
-Current medical Hx
-Past medical Hx (immunization, surgeries)
-Family Hx
-Medication reconciliation
-ROS
-Functional assessment
After completing an initial assessment on a client, the nurse has charted:
Vital signs: t-100.1 oral, Apical HR 98 irregular, RR 24 shallow, B/P 128/90, Pulse ox
90% on RA
What type of data is this?
What are you worried about? - answer-This is Objective Data
-Worried about Respirations, Pulse Ox, Perfusion, Infection; overall pneumonia
During assessment of the lower extremities of a male client the nurse is unable to
palpate the dorsalis pedis pulse.
What action should the nurse take first?
a.Notify the Physician
b.Return in a few hours and reassess
c.Ask the client if this is "normal" for him
d.Reposition the fingers and assess again - answerD
An example of objective data obtained during the physical assessment includes:
Select all that apply
a.Sore throat
b.Audible wheeze
c.Headache
d.Tinnitus
e.Pressure ulcer rt. ankle - answerB, E
Name the four components of general survey. - answerPBMB
-Physical appearance
-Body structure
-Mobility
-Behavior
, A mother is at the clinic with her 2-year-old son and states "he won't go to sleep at night
and during the day he has several fits. I get so upset when this happens."
The nurse's best verbal response should be:
a."Go on, I'm listening
b."Tell me what you mean by fits."
c."Yes, it can be upsetting when a child has a fit."
d."Don't be upset when he has a fit, all 2-year-olds have fits." - answerB
-Clarification; Assisting the Narrative
Which of the following statements illustrates the use of open-ended questions?
Select all that apply
a.Elicits cold facts
b.Builds & enhances rapport
c.Leaves interactions neutral
d.Calls for short one-to two-word answers
e.Used when narrative information is needed - answerB, E
A client's reason for seeking care is "shortness of breath". When obtaining a health
history, which of these questions, by the nurse, would obtain the most helpful
information?
a.Will you please describe the activities that cause you to be short of breath?
b.Have you been short of breath for long?
c.Hon, are you short of breath now?
d.Do you have interstitial pneumonia? - answerA
During an exam the nurse notices the client has round, flat red lesions on the skin of the
forearm. The nurse suspects:
a.Petechiae
b.Pruritis
c.Herpes zoster
d.Psoriasis - answerA
-Herpes are vesicles
Vesicular - answerrefers to soft, low-pitched, normal breath sounds heard over
peripheral lung fields
Presbyopia - answerimpaired vision as a result of aging
-Near-sightedness
-Loss of accommodation
Tuning fork is used in which tests? - answerWeber & Rinne
A 65-year-old man with emphysema has come to the clinic for a follow-up appt. On
assessment of the skin, the nurse might expect to assess the following:
What is the purpose of the health history? - answer Provide the database of subjective
data about Pt's health
What are the specific categories contained in the health history? - answer-
demographics
-Reason for Seeking care
-Current medical Hx
-Past medical Hx (immunization, surgeries)
-Family Hx
-Medication reconciliation
-ROS
-Functional assessment
After completing an initial assessment on a client, the nurse has charted:
Vital signs: t-100.1 oral, Apical HR 98 irregular, RR 24 shallow, B/P 128/90, Pulse ox
90% on RA
What type of data is this?
What are you worried about? - answer-This is Objective Data
-Worried about Respirations, Pulse Ox, Perfusion, Infection; overall pneumonia
During assessment of the lower extremities of a male client the nurse is unable to
palpate the dorsalis pedis pulse.
What action should the nurse take first?
a.Notify the Physician
b.Return in a few hours and reassess
c.Ask the client if this is "normal" for him
d.Reposition the fingers and assess again - answerD
An example of objective data obtained during the physical assessment includes:
Select all that apply
a.Sore throat
b.Audible wheeze
c.Headache
d.Tinnitus
e.Pressure ulcer rt. ankle - answerB, E
Name the four components of general survey. - answerPBMB
-Physical appearance
-Body structure
-Mobility
-Behavior
, A mother is at the clinic with her 2-year-old son and states "he won't go to sleep at night
and during the day he has several fits. I get so upset when this happens."
The nurse's best verbal response should be:
a."Go on, I'm listening
b."Tell me what you mean by fits."
c."Yes, it can be upsetting when a child has a fit."
d."Don't be upset when he has a fit, all 2-year-olds have fits." - answerB
-Clarification; Assisting the Narrative
Which of the following statements illustrates the use of open-ended questions?
Select all that apply
a.Elicits cold facts
b.Builds & enhances rapport
c.Leaves interactions neutral
d.Calls for short one-to two-word answers
e.Used when narrative information is needed - answerB, E
A client's reason for seeking care is "shortness of breath". When obtaining a health
history, which of these questions, by the nurse, would obtain the most helpful
information?
a.Will you please describe the activities that cause you to be short of breath?
b.Have you been short of breath for long?
c.Hon, are you short of breath now?
d.Do you have interstitial pneumonia? - answerA
During an exam the nurse notices the client has round, flat red lesions on the skin of the
forearm. The nurse suspects:
a.Petechiae
b.Pruritis
c.Herpes zoster
d.Psoriasis - answerA
-Herpes are vesicles
Vesicular - answerrefers to soft, low-pitched, normal breath sounds heard over
peripheral lung fields
Presbyopia - answerimpaired vision as a result of aging
-Near-sightedness
-Loss of accommodation
Tuning fork is used in which tests? - answerWeber & Rinne
A 65-year-old man with emphysema has come to the clinic for a follow-up appt. On
assessment of the skin, the nurse might expect to assess the following:
