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2024 HEALTH ASSESSMENT (NUR 104) FINAL EXAM WITH CORRECT ANSWERS
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2024 HEALTH ASSESSMENT (NUR 104) FINAL EXAM WITH CORRECT ANSWERS
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2024 HEALTH ASSESSMENT (NUR104) FINAL EXAM WITH CORRECT
ANSWERS
The nurse is planning to assess a client's abdomen for rebound tenderness.
The nurse should - CORRECT-ANSWERSpalpate deeply while quickly
releasing pressure.
What term would the nurse use to document a client's report of pain in the
lower-middle area of the abdomen? - CORRECT-ANSWERSHypogastric
A client is unable to perform abduction with the right arm and reports pain
when attempting to do so. The nurse notices that the muscles surrounding
the right shoulder are smaller than those on the left shoulder. The nurse
recognizes this finding as the possibility of what condition? - CORRECT-
ANSWERSRotator cuff tear
Holistic Care - CORRECT-ANSWERShealth care that takes into account the
whole person interacting in the environment
Steps of the Nursing Process - CORRECT-ANSWERS1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Types of Assessments - CORRECT-ANSWERSo Initial Comprehensive
o Ongoing or Partial
o Emergency
Preparing for Assessment - CORRECT-ANSWERSo Review client's record
(learn basic info.)
o Review client's status with other health care team members
o Reflect on own personal biases
o Educate about client's diagnosis and tests performed
A client waiting to be seen for a clinic appointment is observed periodically
shaking the left wrist. On what should the nurse focus when assessing this
client? - CORRECT-ANSWERSCarpal tunnel syndrome
,A nurse notices that a client's flexibility of the right elbow is less than the left
elbow. What is an appropriate action by the nurse in regard to this finding? -
CORRECT-ANSWERSMeasure movement with a goniometer
While testing a client's deep tendon reflexes the nurse asks the client to
perform the action shown. What is the purpose of this action? - CORRECT-
ANSWERSIncrease reflex activity
What task should a nurse ask a client to perform to assess the function of
cranial nerve XI? - CORRECT-ANSWERSshrug shoulders against resistance
The client presents at the clinic with a complaint of weakness that is made
worse with repeated effort and improves with rest. The client's complaint is
consistent with what health problem? - CORRECT-ANSWERSMyasthenia
gravis
Which of the following would lead the nurse to suspect a hydrocele versus
other causes of scrotal swelling? - CORRECT-ANSWERSA positive
transillumination test
When assessing a client during the physical examination of the genitalia, the
nurse palpates the scrotal contents. Which finding should the nurse
recognize as an indication that an infection or cysts are present? - CORRECT-
ANSWERSBeaded or thickened cord
What information should nurse include in the teaching plan for a client
considering a vasectomy? - CORRECT-ANSWERSoffers permanent birth
control
A nurse inspects the genitalia of an elderly client and notices that the
mucosa is dry and atrophied. The nurse should educate the client about her
increased risk of what condition? - CORRECT-ANSWERSInfection
The wet mount prepared after a female client's pelvic examination reveals
motile organisms greater than 10 WBCs per high powered microscopy. The
nurse should gather supplies for which diagnostic follow-up? (Select all that
apply.)
a. Syphilis serology
b. Chlamydia culture
c. Gonorrhea culture
d. HIV testing - CORRECT-ANSWERSa, b, c, d
The visible portion of the clitoris is termed the - CORRECT-ANSWERSglans
Steps in Data Analysis - CORRECT-ANSWERS1. Identify abnormalities
, 2. Cluster data
3. Draw inferences
4. Propose nursing diagnoses
5. Check defining characteristics
6. Confirm or rule out diagnoses
7. Document
Data Clustering - CORRECT-ANSWERSoccurs when related cues are grouped
together, also assists in identification of nursing diagnosis
The nurse is completing an admission database entry and must include
priority nursing diagnoses for the plan of care. Which statement describes a
nursing diagnosis?
a. The collection of subjective and objective data
b. A clinical judgment about client responses to health difficulties - CORRECT-
ANSWERSb; A clinical judgment about client responses to health difficulties
A nurse is caring for three clients whose care involves complex situations
and multiple responsibilities. What is the key to resolving problems for this
nurse? - CORRECT-ANSWERSCritical Thinking
After a health assessment the nurse determines that a client would benefit
from health promotion interventions. Which item should the nurse refer to
when determining the best actions for the client?
a. Healthy People 2020
b. the client's past medical history - CORRECT-ANSWERSa; Healthy People
2020
Phases of an Interview - CORRECT-ANSWERSo Preparatory
o introductory
o working
o termination
Working Phase - CORRECT-ANSWERSThe nurse then listens, observes cues,
and uses critical thinking skills to interpret and validate information received
from the client. The nurse and client collaborate to identify the client's
problems and goals.
Types of Nonverbal Communication - CORRECT-ANSWERSo Appearance
o Demeanor
o Facial Expression
o Attitude
o Silence
o Listening
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