NUR 3120 Health Assessment & Promotion

The nurse is assessing a client who admits to being physically abused by her spouse. The client says, “I wish I would have agreed with my husband, because then I wouldn’t have been hit.” What is the nurse’s best response?

• “Changing your reaction to your spouse will likely change his actions against you.”

• “Try not to blame yourself. You will know better for next time.”

• “Your husband has to want to change. Let’s focus on you for now.”

• “It is not your fault that your husband lost control. Changing your actions will not prevent him from abusing you again.”

When documenting intimate partner violence and elder abuse, the nurse should include:

• Photographic documentation of the injuries

• A summary of the abused patient's statements

• No documentation of statements made by the client

• A general description of injuries in the progress notes

A client tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

• Flexion

• Abduction

• Adduction

• Extension

Which of the following are health effects of violence experienced by older adults that have been abused or neglected? (Select all that apply)

• STIs (Sexually transmitted infections)

• Fluctuations in blood pressure and pulse

• Infections progressing to sepsis

• Cardiac complications due to stress

• The ability to perform ADLs independently

The nurse works at a clinic where routine, universal screening for intimate partner violence is done. How often should the nurse screen the women coming into the office?

• Every health care encounter

• Once a year

• Only if the nurse is suspicious there may be abuse occurring

• Twice a year

A nurse in the ED is admitting a client and suspects the client has experienced an injury from an intimate partner. Which of the following best describes what the nurses role is with abuse? (Select all that apply)

• Tell the client to leave the partner

• Use assessment tools to screen for IPV

• Report any suspected abuse

• Avoid asking how the client was injured

• Document appropriately

A client is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

• Flexion

• Abduction

• Adduction

• Extension

The nurse suspects that a client has carpal tunnel syndrome and wants to perform the Phalen’s test. To perform this test, the nurse should instruct the client to:

• Dorsiflex the foot

• Plantarflex the foot

• Hold both hands back to back while flexing the wrists for 60 seconds

• Hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds

When assessing muscle strength, the nurse observes that a client has complete range of motion against gravity with full resistance. What Grade should the nurse record using a “0 to 5” point scale?

• 2

• 3

• 4

• 5

An 85-year-old client comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

• Long bones tend to shorten with age.

• The shortening of the vertebral column.

• There is a significant loss of subcutaneous fat.

• There is a thickening of the intervertebral disks.