Health Assessment Exam 1 Study Help

The nurse is obtaining a health history from the newly admitted client who has chronic pain in the right knee. Which would the nurse include in the pain assessment? Select all that apply.

• Pain history, including location, intensity, and quality of pain

• Client’s purposeful body movement in arranging the papers on the bedside table

• Pain pattern, including precipitating and alleviating factors

• Vital signs, such as increased blood pressure and heart rate

• The client’s family statement about increases in pain with ambulation

Answer explanation

The initial pain assessment should include information about the location, quality, intensity, onset, duration, and frequency of pain, as well as factors that relieve or exacerbate the pain. Vital signs are a secondary

assessment related to the initial pain assessment. Accurate pain assessment includes pain history with the client’s identification of pain location, intensity, and quality, and helps the nurse identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain, and its assessment helps the nurse anticipate and meet the needs of the client. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Assessment of the

precipitating factors helps the nurse prevent the pain and determine its cause. Elevated blood pressure and heart rate are physiological responses to pain and not a direct evaluation of pain. Pain is a subjective experience, and the nurse has to ask the client directly instead of accepting the statement of the family members.

The nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. Which type of pain would the client experience?

• Visceral pain

• Somatic pain

• Referred pain

• Intractable pain

Answer explanation

Visceral pain arises from visceral organs such as the pancreas, which results from the stimulation of pain receptors in the abdominal cavity. Somatic pain arises from bone, joint, muscle, skin, or connective tissue and is usually aching or throbbing in quality and well localized. Referred pain is experienced in clients with tumors, in which pain is felt in a part of the body other than its actual source. Intractable pain is a neuropathic pain that is severe, constant pain that is not curable.

Which methods qualify as alternative therapies for pain? Select all that apply.

• Prayer

• Hypnosis

• Medication

• Aromatherapy

• Guided imagery

Answer explanation

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

The nursing student is caring for a client who has difficulty speaking English. Which statement made by the nursing student would cause communication problems with the client?

• "I will give the client the call light."

• "I will involve the client’s family members as interpreters."

• "I will provide a dictionary to the client if the client can read."

• "I will use boards and pictures to communicate with the client."

Answer explanation

The nurse would not involve the client’s family, especially children, as interpreters because they may misinterpret the client’s feelings. The nurse would provide a call bell to the client to help the client ask for assistance. The nurse would provide a dictionary to the client if the client can read to help the client easily interpret her or his feelings. The nurse would use boards and pictures to aid in clear and effective communication with the client.

A client had surgery on the shoulder, and the nurse is to obtain a brachial pulse. Where on the illustration would the nurse indicate to best obtain the brachial pulse rate?

• A

• B

• C

• D

Answer explanation

One of the several pulse points in the body is the brachial artery (option b); it is the main artery of the upper arm and it bifurcates into the radial and ulnar arteries. Option a is not a major artery of the arm; it is not a pulse point. Option c is the radial artery, which is where the radial pulse is palpated. Option d is the ulnar artery, which is where the ulnar pulse is palpated.

Which physical assessment technique involves listening to the sounds of the body?

• Palpation

• Inspection

• Percussion

• Auscultation

Answer explanation

Auscultation involves listening to the sounds of the body. Palpation involves using the sense of touch to assess

and collect data. An inspection involves the nurse carefully looking to collect data. Percussion involves tapping

the skin with the fingertips to vibrate underlying tissues and organs.

Which is a description of the percussion technique?

• Listening to sounds that the body makes

• Using the sense of touch to assess and collect data

• Carefully looking for abnormal findings

• Tapping the skin with the fingertips to vibrate underlying tissues

Answer explanation

Percussion is a technique used to assess the skin by tapping the skin with the fingertips to vibrate underlying tissues and organs. Auscultation involves listening to the sounds that the body makes. Palpation involves

using the sense of touch to assess and collect data. Generally during an inspection, the nurse would carefully look for abnormal findings

Which statement regarding an interpreter is correct?

• Relatives or friends of the client can serve as interpreters.

• The interpreter would be able to make literal, word-for-word translations.

• Interpreting not only the language but also the culture is important.

• As long as the health care provider is caring for the client, the interpreter should be available.

Answer explanation

The health care facility should be able to provide interpreters to the clients who cannot speak English or do not speak English well enough to meet their communication needs. The interpreter should be able to interpret not only the language but also the culture. Health care facilities should not rely on relatives or friends of the client for interpreting, because they may not be as open as needed during the encounter. Literal translations are not necessary; words in one language can carry many different connotations in another language. The interpreter should be available at all points of contact but not when communication between the client and the health care provider is not occurring.

Which kind of health care service involves vaccinating people against diseases?

• Continuing care

• Preventive care

• Restorative care

• Secondary acute care

Answer explanation

Taking the initiative to vaccinate people against diseases is an example of preventive care. Continuing care describes a variety of health, personal, and social services provided over a prolonged period. Restorative care helps individuals regain maximal functional status and enhance quality of life through promotion of independence and self-care. Secondary acute care deals with emergency care, acute medical-surgical care, and radiological procedures for acute problems.

A client says, "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client’s health belief in this scenario?

• Spiritual factors

• Emotional factors

• Developmental stage factors

• Intellectual background factor

Answer explanation

Religious practices are one way in which people exercise spirituality. In the given scenario, the client asks the nurse to refrain from cutting the religious thread. This is an example of a spiritual factor. Emotional factors involve the client’s degree of stress, depression, or fear. The nurse considers the client’s developmental stage when using the client’s health beliefs and practices as a basis for planning care. Intellectual background factors are a person’s beliefs about health that are shaped by their knowledge, lack of knowledge, or incorrect information about body functions and illnesses.