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Health Assessment Final Review Flashcards | StudBud
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Health Assessment Final Review
Health Assessment Final Review
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Taking Health Assessment to a new level!
Flashcards
70 cards
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Practice quiz
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Questions
70
Answers
1
The P wave represents
Repolarization of the atria
Depolarization of the atria
Depolarization of the ventricles
Repolarization of the ventricles
2
Client has emphysema, you should expect:
Deep respirations, Clubbing, Dyspnea
Dyspnea, Clubbing, Barrel Chest
Barrel Chest, Dyspnea, Narrowed bronchioles
Chronic cough with phlegm & Clubbing
3
A woman in her 5th month of pregnancy has BP of 98/66. Her 2nd month her BP was 122/80.
The decline in blood pressure is an expected change
She has increased cardiac output so her BP should be higher
She has decreased cardiac output so her BP should be lower
The decrease in blood pressure is dangerous to the fetus
4
Nurse is feeding a client with dysphagia. What action is correct?
Have the patient sip water between bites
Tilt the client's head back and chest forward
Offer tablespoon sized bites of food
Use a spoon instead of a cup to feed the client
5
You find a client wandering outside. He flinches when his abdomen is palpated and only nods
He is not fluent in English
He is confused
He is hungry
He prefers to be alone
6
Client complains of a cough with rust colored sputum, low-grade fever, and night sweats. It is
Cystic Fibrosis
Lung Cancer
Pneumonia
Tuberculosis
7
Your client displays signs of loneliness and isolation. What response should you provide?
I will come to sit with you every hour
I'll assign an assistive personnel to your room for company
Do you have a cell phone so you can call friends or family?
You will be discharged in a couple of days
8
Septicemia is an infection carried through out the body by the blood
True
False
9
Evidence-Based Practice is defined as what?
Quality nursing care in an efficient and economic manner
Problem-solving approach integrating best current evidence
Scholarly inquiry on nursing and biomedical research
Nursing care based on tradition
10
Surgical asepsis is defined as using clean technique to prevent the spread of microorganisms
True
False
11
Which activity represents secondary prevention?
School nurse provides a program on healthy eating
Patient attends cardiac rehabilitation sessions weekly
50 y/o woman attends a health fair to get her BP checked
Home health care nurse visits pt. to change wound dressing
12
You are assessing a client who has lost 12 kg (26 lbs) in the past 3 months & calls herself fat
Identify nutritional status
Notify the provider for a mental health consult
Plan a therapeutic diet
Reassure her that she is not fat
13
Which factor places a child at risk for ear infection?
Tugging on the ear
Using cotton swabs every day to clean the outer ear
Excessive cerumen
Cigarette smoke
14
A nurse in a med-surg unit is caring for 4 clients who are 24-36 hours post op. Risk for DVT?
Cataract Extraction
Hip Arthroplasty
Laparoscopic Appendectomy
Mastectomy
15
Nurse is giving influenza vaccines to seniors at a health fair in a mall. Level of prevention?
Secondary Prevention
Primary Prevention
Quaternary Prevention
Tertiary Prevention
16
What racial group has the highest risk of stroke?
Caucasians
Blacks
Hispanics
African Americans
17
What are overarching goals of Healthy People 2020? (2 Answers)
Increase the span of healthy life
Create access to preventative services for all
Increase quality and years of life
Eliminate health disparities
18
You are caring for a client with acute dysphagia. What should be in the plan of care?
Instruct the client to tilt their head forward and swallow
Place the client in Semi-Fowler's position during meals
Encourage them to take larger bites
Give them a straw for liquids
19
You ask a friend what they got for #16 on homework. They do not answer & stares blankly at you
Could be a stroke
Could be a seizure
Could be on drugs
Could be a heart attack
20
18 y/o comes in w/ fever & cough. Nurse takes vitals and auscultates lungs and heart. ADPIE?
Assessment
Implementation
Evaluation
Diagnosis
21
You are caring for a client with tuberculosis. Which precaution should you select?
Airborne
Droplet
Reverse Isolation
Contact
22
What is Cheyne-Stokes respiration?
Normal to shallow breaths
Shallow to normal breaths alternating with periods of apnea
Very deep to very shallow with periods of apnea
Shallow to deep with periods of apnea
23
You are caring for a child with otitis media, what should you expect?
Pain
Edema
Erythema
Tugging
24
A dying client states that his mother died in the hospital and he didn't have a proper goodbye.
I wonder if you are afraid of dying alone
I will call your family to come in as soon as possible
I will assign someone to sit with you
I will sit with you until you feel better
25
You are assessing a client with hypoxia, what should you expect?
Crackles in the lungs
Bradypnea
Tachycardia
Pallor
26
While auscultating a client's heart sounds, the nurse hear turbulence between S1 & S2. This is
An expected finding
A bruit
A systolic murmur
A pulsation
27
Client has severe gangrenous infection of the right lower leg. You should prepare the pt. by
Telling them that the pain is mostly psychological
Telling them the pain will go away soon
Telling them that your pain will go away gradually
Telling them that a tingling sensation is expected
28
A newborn is covered with meconi, breathing well, heart rate 120, and is pink. What is priority
Suction trachea
Suction the mouth then the nose with a bulb syringe
Insert endotracheal tube
Stimulate the newborn to cry
29
What are the signs and symptoms of heart failure?
JVD, Orthopnea, Rapid weight loss, Anxiety
JVD, Dyspnea, Anxiety, Orthopnea
Anxiety, Orthopnea, Weight gain from excess fluid, JVD
Dyspnea, Anxiety, Increased appetite, JVD
30
Older client complains constipation. What should you teach him?
Always Ignore the urge to defecate
Eat more raw vegetables
Drink 4 glasses of water daily
Limit activity
31
A nurse notices bluish lips and a dark line along the gingival margin in an African American
He is cyanotic
He has poor circulation
This is a normal finding
He is dehydrated
32
A patient needs to learn how to use a walker. Which domain is required for learning this skill?
Affective domain
Psychomotor domain
Cognitive domain
Attentional domain
33
Which of the following is the earliest sign of increased ICP that a nurse can assess?
Head injury
Decreased level of consciousness
Stroke history
Edema
34
Assessing a post-operative patient following abdominal surgery. What finding should you report?
Yellow-green drainage
Temperature 96.7°F
Blood Pressure 99/65
Heart rate 85
35
The parent of a pediatric patient tells you, "I do not believe in vaccinations". You should say
"Why don't you believe in them?"
"Help me understand your perspective"
"Do you want a brochure on vaccinations?"
"I completely understand"
36
When assessing a dark-skinned client for jaundice you should inspect the conjuctiva
False
True
37
A client is undergoing a lumbar puncture. What is the priority action to ensure privacy?
Pull the curtains around the bed
Ask everyone to leave the room
Use sterile drapes to cover the client
Close the door to the room
38
Patient comes in ED with suspected drug overdose. His respirations are 12 per minute.
COPD
Hypoventilation
Cheyne-Stokes
Bradypnea
39
Patient presents to ED with Heart Failure with dyspnea, tachypnea, and an O2 Sat 88%. Priority?
Administer Digoxin to decrease heart rate
Assess lung sounds in an hour
Place patient in High Fowler's position
Check MAR if you can administer Morphine sulfate
40
Support of the cause of the client regarding health, safety and personal rights
Confidentiality
Advocacy
Accountability
Responsibility
41
A pediatric nurse just received shift report on patients with asthma. Priority?
An infant with a weak cry and less breath sounds
An infant wheezing won't stop crying
School-aged child wheezing and doesn't feel good
Adolescent wheezing and speaking in short sentences
42
You are auscultating hearts sounds and hear an extra sound before the first heart sound S1.
S4
S3
S1
S2
43
Your client tells you that he has frequent nosebleeds and asks the best way to stop them.
Hold your breath for 15 seconds while pinching your nose
Lay down on your side and pinch your nose
Sit up with your head tilted forward and pinch your nose
Tilt your head back and pinch your nose
44
Patient comes in ED with SOB and wheezing. Nurse gives nebulizer now & in 4 hours. Which ADPIE?
Planning
Assessment
Evaluation
Implementation
45
ADLs include of:
Bed Making, Eating, Toileting
Eating, Bed Making, Dressing
Toileting, Eating, Bathing
Bathing, Eating, Ambulating
46
Pt. had an MI 4 weeks ago. Doing daily cardiac rehabilitation sessions. Level of prevention?
Quaternary Prevention
Secondary Prevention
Primary Prevention
Tertiary Prevention
47
You are talking with a 13 y/o female during an assessment. What statement should concern you?
I have a pimple on my nose that I can't get rid of
All my friends have gotten their periods except me
My family thinks I am not responsible
None of the kids like me and I don't like them either
48
Client just had a right tympanoplasty. What should you teach the client?
Clean ear with cotton swab daily
Always have your head elevated
Administer antibiotics in ear canal
Avoid blowing the nose
49
You are teaching a client about constipation who is using laxatives. What should you include?
Take more laxatives
Eat less frequently with smaller meals
Always Ignore the urge to defecate
Make sure to drink enough fluids
50
92 year-old client has had a stroke. The right side of his face is drooping. You should suspect
Dysphasia
Epistaxis
Dysphagia
Rhinorrhea
51
You are caring for a client who is immobile. What is your priority action?
Apply compression socks
Administer anxiety medication
Do ROM exercises
Auscultate breath sounds every 2 hours
52
Briefly describe emphysema
Chronic airflow obstruction
Chronic cough and phlegm
Small bronchioles are narrowed
Destruction and enlargement of the lung alveoli
53
3 y/o with asthma develops bilat wheezing: O2 Sat 91%, Resp 46, chest pain. Priority action?
Notify healthcare provider
Notify charge nurse
Administer oxygen
Reassess again in an hour
54
Client has a cast on the left leg. You feel that it is warm what should you expect?
Infection
Lack of blood flow
Shifting of the cast
This is a normal finding
55
Patient states he is losing his smell, what could cause this?
Chronic allergies, Chronic alcohol use, Age
Cigarette smoking, Chronic allergies, Age
Age, Cigarette smoking, Chronic alcohol use
Cigarette smoking, History of strep throat, Age
56
A patient is suffering from problems due to immobility, what are your findings?
Crackles in the lungs & Cataracts
Crackles in the lungs & Polyuria
Pressure Ulcers & Diarrhea
Pressure Ulcers and Crackles in the lungs
57
The nurse notices a student entering a room with a client with tuberculosis with only gloves.
Remind the student to DON N95 respirator
Remind the student to keep the door open
Remind the student to take your own stethoscope inside
Remind the student to DON eye protection
58
You are triaging clients in an urgent care clinic. Who is priority?
Toddler who is screaming from a laceration
Adolescent female with slurred speech
Adult with painful sunburn on his face and arms
Adult male who reports epigastric pain and is diaphoretic
59
Case of a mother and her 1 y/o. Prolonged use of a bottle can increase the risk for what?
Tooth decay and Edema
Ear infection and Edema
Edema and obesity
Tooth decay and ear infection
60
Which precaution is followed during the insertion of an indwelling urinary catheter?
Medical asepsis technique
Surgical asepsis technique
61
A client is referred for suspicion of cataracts. You should expect them to report:
Loss of peripheral vision
Decreased ability to perceive colors
Loss of central vision
Seeing bright flashes of light and floaters
62
You are assessing a client with hyperthyroidism, what are the manifestations?
Cold sensitivity
Constipation
Gain of 10 pounds in 3 weeks
Mood changes
63
What is the direction of blood flow?
RA, RV, PV, L, LA, LV
RA, RV, PV, L, LV, LA
RA, RV, PA, L, PV, LV, LA
RA, RV, PA, L, PV, LA, LV
64
What is holistic care?
Social, spiritual, physical, psychological, socioeconomic
Social, physical, spiritual, atomistic, emotional
Emotional, psychosocial, spiritual, physical, socioeconomic
Psychological, physical, social, spiritual, emotional
65
You are admitting a client with active tuberculosis to a med-surg room. What do they need?
Room with other clients with droplet precautions
Room with outside airflow
Room in the ICU
Room with a non-surgical client
66
Pt. states she joined a fitness club and attends aerobic classes. Stage of behavioral change?
Action
Preparation
Contemplation
Precontemplation
67
You are caring for a client who is anxious and is unable to concentrate. What is your response?
I will give you you medication for your anxiety
Are you worried about someone?
Sounds like you are having a difficult time
Why do you think you are so anxious?
68
40 y/o male who lives a sedentary lifestyle with vitals: HR 44, Resp 18, BP 166/139, Temp 99.8F
Temperature 99.8°F
Respiratory Rate 18
Heart rate 44
Blood Pressure 166/139
69
52 y/o scheduled for colonoscopy. He is worried that he will feel pain. What should you say?
You provider will give you a sedative before the examination
I will call your family to come visit you
I will get someone to stay with you until the procedure
I know you are anxious but this is normal for your age
70
Warning signs of a stroke include all EXCEPT
Dysphagia
Nausea & vomiting
Weakness
Respiratory distress
