Health Assessment Review 2

Question 1

A nurse notes a rash that is located on one side of the body & does not cross the midline. The nurse describes this as:

Accepted Answer

Zosteriform

Question 2

A nurse detects an extra heart sound immediately after S2 which they identify as an S3 heart sound. The nurse suspects:

Accepted Answer

Congestive heart failure

Question 3

When assessing for jaundice in individuals with dark skin, it is important to assess:

Accepted Answer

The sclera of the eyes and the hard palate

Question 4

During change of shift report the nurse uses a standardized method of communicating. One example for this situation is:

Accepted Answer

SBAR

Question 5

The nurse assesses peripheral vision by performing the following test:

Accepted Answer

Confrontation

Question 6

The nurse checks skin turgor to assess

Accepted Answer

Hydration

Question 7

Nurses are mandated reporters for the following groups:

Accepted Answer

Children, elderly, disabled

Question 8

The patient has asthma. The adventitious lung sound most likely would be?

Accepted Answer

Wheezes

Question 9

The nurse asks the pt to describe their headaches using descriptive terms such as aching, piercing, stabbing. This is:

Accepted Answer

Character

Question 10

Clubbing of the nails may be due to

Accepted Answer

Chronic states of poor oxygenation

Question 11

The nurse percusses a dull note over the right lobe of the lung. They suspect

Accepted Answer

Consolidation of lung tissue

Question 12

The following are techniques when introducing sensitive topics:

Accepted Answer

Introduce the topic before asking sensitive questions, Build a trusting relationship first, Ask permission

Question 13

A patient arrives in the ED after sustaining multiple traumatic injuries. The highest priority is:

Accepted Answer

Airway

Question 14

The nurse will use a standardized tool for the assessment of drug use. They plan to use:

Accepted Answer

DAST-10

Question 15

The nurse is assessing a bedridden pt's skin and notices a small area that resembles an erosion

Accepted Answer

Stage II

Questions 15