Chapter 25 Health Assessment

Chapter 25  Health Assessment

Complete Chapter Questions And Answers
 

Sample Questions

1.
Upon entering the client’s room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client’s plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing?
A)
Ongoing partial assessment
B)
Comprehensive assessment
C)
Focused assessment
D)
Emergency assessment
Ans:
A

Feedback:

An ongoing partial assessment is conducted at regular intervals during care of the client and concentrates on identified health problems and the effectiveness of interventions. A comprehensive assessment includes a health history and complete physical examination and is usually conducted when a client first enters a health care setting. A focused assessment is conducted to assess a specific problem. An emergency assessment is a type of rapid focused assessment conducted to determine a potentially fatal situation.

2.
An older adult asks the nurse about the appearance of flat brown age spots on the hands. After examining the client’s hands, the nurse recognizes these skin characteristics as a common skin variation in the older adult and documents the variations as which of the following?
A)
Senile lentigines
B)
Lanugo
C)
Senile keratosis
D)
Cherry angiomas
Ans:
A

Feedback:

Senile lentigines are flat, brown age spots, senile keratosis are raised, dark areas, and cherry angiomas are small, round red spots. All are common skin variations in the older adult. Lanugo is a fine downy hair that appears on the newborn for the first two weeks of life.

3.
The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician?
A)
Decreased heart rate
B)
Visible pulsation through a thin chest wall
C)
Sinus dysrhythmia that increases with inspiration and decreases with expiration
D)
Presence of an S heart sound
Ans:
A

Feedback:

Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound.

4.
The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up?
A)
The client states that a mole on his forehead has become larger in recent months.
B)
Decreased skin turgor is evident when the skin is folded and then released.
C)
Small, round, red spots are present on the client’s forearms bilaterally.
D)
There are some raised, brown areas on the backs of the client’s hands.
Ans:
A

Feedback:

Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).

5.
As a component of a head to toe assessment, the nurse is preparing to assess convergence of the client’s eyes. How should the nurse conduct this assessment?
A)
Ask the client to follow her finger as she slowly moves it towards the client’s nose.
B)
Ask the client to look ahead while slowly bringing a pen light in from the side and to the client’s pupil.
C)
Ask the client to hold his head stationary while following a pencil from left to right.
D)
Ask the client to read a Snellen chart from a distance of 20 feet.
Ans:
A

Feedback:

Eye convergence is assessed by holding your finger 6″ to 8″ from the patient’s nose and asking the patient to follow it as it moves closer. A pen light is used to assess pupillary reaction. Visual acuity is assessed with the use of a Snellen chart. Following a pencil from side to side is a test for extraocular movements.