Health Assessment

Which of the following is an objective finding?

• Patient is 65 years old

• patient reports feeling dizzy

• patients temperature is 101.2

• patient is an ex-smoker

Which of the following occurs in the pre-interaction phase of the interview?

• You ask patient open and close-ended questions

• summarize your interaction before you leave the room

• read the patient's chart

• explain why you are there

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client’s

• perception of pain.

• height

• weight

• temperature

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

• from right to left

• from left to right

• from head-to-toe

• alphabetical

To alleviate a client’s anxiety during a comprehensive assessment, the nurse should

• begin with intrusive procedures first to get them completed quickly.

• explain each procedure being performed and the reason for the procedure.

• remain in the examination room while the client changes into a gown.

• ask the client to sign a consent for the physical examination.

Which action by a nurse is appropriate before beginning a physical examination of a client?

• Wash hands before examination in the examination room

• Recap used needles and place in puncture-resistant containers

• Approach the client from the left side of the examination table

• Remove gloves only after examination is over

A nurse is reviewing the four basic physical examination techniques and their sequence prior to receiving a new client from postanesthetic recovery. The nurse should plan to perform which technique first?

• Palpation

• Inspection

• Percussion

• Auscultation

A nurse begins her examination of a client with a skin disorder by using inspection techniques. Which skin characteristics can the nurse observe by using inspection?

• Color

• Temperature

• Texture

• Elasticity

A nursing instructor is teaching a student about the importance of maintaining client confidentiality. Teaching has been successful when the student states:

• "Patient information is to be discussed only with health workers directly involved in the client's care."

• "I can talk about the client in the elevator if I speak quietly."

• "I can share my computer password with my co-worker so she can help me chart."

• "I can photocopy some forms from my client's chart to take home to study."

A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a client's record?

• "Patient is upset with her husband."

• "Dr. Smith did not answer the client's questions."

• "Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."

• "Patient spoke to nurse in a sarcastic tone."