Nursing Assessment Quiz - Week 1 to 6
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Questions and Answers

What is the primary focus of the examiner's question regarding Mrs. J.'s headaches?

  • To evaluate the effectiveness of her treatments
  • To explore her perception of the headache episodes (correct)
  • To gather information about her coping strategies
  • To understand Mrs. J.'s medical history

Which aspect is the examiner likely not focusing on when asking about Mrs. J.'s actions during headaches?

  • Her personal understanding of headache impact
  • The triggers that may worsen her headaches
  • The strategies she employs to manage pain
  • The duration of her headache episodes (correct)

In asking Mrs. J. what she does when her headaches occur, the examiner is indirectly assessing which of the following?

  • Her social interactions during headache episodes
  • Her awareness of environmental headache triggers
  • Her identification of effective remedies (correct)
  • Her emotional response to recurring pain

What underlying theme could be inferred from the examiner’s inquiry about Mrs. J.'s headaches?

<p>The importance of patient engagement in treatment (C)</p> Signup and view all the answers

Which of the following could be considered a secondary factor in Mrs. J.'s headache management based on the examiner's question?

<p>The environmental conditions during headaches (B)</p> Signup and view all the answers

What response should the nurse expect in the vital signs of a client experiencing pain?

<p>An elevated blood pressure (D)</p> Signup and view all the answers

When assessing vital signs for a client with pain, which outcome is least likely to occur?

<p>A decrease in blood pressure (D)</p> Signup and view all the answers

What term describes an excessive curvature of the spine that often results in a hunchback appearance?

<p>Kyphosis (D)</p> Signup and view all the answers

In a 50-year-old patient complaining of pain, what physiological change is most commonly observed?

<p>Elevated blood pressure (D)</p> Signup and view all the answers

Which of the following symptoms would most likely be noted by the nurse in a pain assessment?

<p>Elevated heart rate (D)</p> Signup and view all the answers

Which condition is characterized by a lateral curvature of the spine?

<p>Scoliosis (D)</p> Signup and view all the answers

What term is used for an excessive inward curve of the lower back?

<p>Lordosis (C)</p> Signup and view all the answers

Which vital sign change is least expected in a 50-year-old client with pain?

<p>Normal body temperature (A)</p> Signup and view all the answers

Barrel chest is primarily associated with which of the following?

<p>Chronic obstructive pulmonary disease (COPD) (C)</p> Signup and view all the answers

Which range of motion (ROM) movements are primarily associated with the knee joint?

<p>Flexion and extension (C)</p> Signup and view all the answers

Which instrument is specifically designed to visualize the external auditory canal and tympanic membrane?

<p>Otoscope (C)</p> Signup and view all the answers

What is the primary function of an otoscope in clinical practice?

<p>To examine the ear's external structures (B)</p> Signup and view all the answers

Which of the following is NOT an appropriate use of a tuning fork?

<p>Examining the ear canal (B)</p> Signup and view all the answers

What is the initial technique a nurse should utilize when conducting a physical assessment?

<p>Inspection (C)</p> Signup and view all the answers

In evaluating a patient’s ear, which instrument would you choose to examine the tympanic membrane specifically?

<p>Otoscope (A)</p> Signup and view all the answers

Which instrument is least likely to be used for auditory assessment?

<p>Percussion hammer (C)</p> Signup and view all the answers

In what order should a nurse ideally perform assessment techniques during a physical examination?

<p>Inspection, Palpation, Percussion, Auscultation (D)</p> Signup and view all the answers

Which assessment technique is primarily employed to evaluate sounds produced by organs and tissues?

<p>Auscultation (B)</p> Signup and view all the answers

Which physical assessment technique involves using the hands to feel body structures?

<p>Palpation (A)</p> Signup and view all the answers

Which of the following techniques is least likely to be performed first in a physical assessment?

<p>Auscultation (A)</p> Signup and view all the answers

Which of the following indicates a condition that warrants a follow-up assessment in a pediatric context?

<p>Requirement for a follow up assessment (A), Abnormal finding for a 5-year-old child (B)</p> Signup and view all the answers

What is typically considered a normal finding for a child at the age of 5?

<p>Normal finding for a 5-year-old child (D)</p> Signup and view all the answers

Which of these findings would most likely suggest the presence of an acute infection?

<p>Indication of an acute infection (A)</p> Signup and view all the answers

When assessing a 5-year-old child, which of the following would classify as an abnormal finding?

<p>Abnormal finding for a 5-year-old child (B)</p> Signup and view all the answers

Which of the following scenarios typically requires additional evaluation in a pediatric patient?

<p>Indication of an acute infection (C), Abnormal finding for a 5-year-old child (D)</p> Signup and view all the answers

Flashcards

Patient Perception

The patient's understanding of their own headache, including how they experience it and describe it.

Aggravating Factors

Things that make the headache worse or more frequent. These can include activities, food, or environmental triggers.

Relieving Factors

Things that help to reduce or eliminate the headache, such as medication, rest, or specific positions.

Initial Interview

The first meeting between a medical professional and a patient to gather information about their health and concerns.

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Examiner's Goal

To understand the patient's experience with headaches and identify potential causes.

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Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

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Vital Signs

Measurements of a person's basic body functions, such as heart rate, blood pressure, temperature, and oxygen saturation.

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Elevated Blood Pressure

A reading that is higher than the normal range, indicating potential stress on the cardiovascular system.

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Decreased Oxygen Saturation

Lower than normal levels of oxygen in the blood, which can indicate problems with breathing or circulation.

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Normal Pulse Rate

A regular heart rate that falls within the expected range for a healthy adult, usually between 60 and 100 beats per minute.

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First assessment technique

The initial step in a physical assessment, involving visual observation of the patient.

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Inspection

The visual examination of the patient's body, including posture, gait, skin color, and any visible abnormalities.

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Palpation

Using touch to assess the patient's body, noting temperature, texture, and presence of masses or tenderness.

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Percussion

Tapping on the patient's body to elicit sounds that reveal the density of underlying tissues.

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Auscultation

Using a stethoscope to listen to the sounds of the patient's body, such as heart, lungs, and bowels.

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External Auditory Canal

The passage leading from the outer ear to the eardrum (tympanic membrane).

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Tympanic Membrane

A thin, cone-shaped membrane that separates the outer ear from the middle ear. It vibrates in response to sound waves.

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Otoscope

A medical instrument used to examine the external ear canal and tympanic membrane.

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Ophthalmoscope

A medical instrument used to examine the interior of the eye, including the retina.

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Tuning Fork

A tool used to test hearing by vibrating it and placing it on the head or near the ear.

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Kyphosis

An exaggerated outward curvature of the thoracic spine, resulting in a rounded upper back.

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Scoliosis

A sideways curvature of the spine, often resulting in an uneven back.

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Lordosis

An inward curvature of the lumbar spine, resulting in an exaggerated arch in the lower back.

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Knee ROM

Range of Motion (ROM) of the knee joint, including flexion (bending) and extension (straightening).

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Barrel Chest

A chest that is abnormally rounded or flared, often associated with respiratory conditions.

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Follow-up Assessment

An evaluation done after an initial assessment to check on progress, address ongoing concerns, or monitor treatment effectiveness.

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Abnormal Finding (5-year-old)

A result or observation that deviates significantly from what is expected or typical for a healthy 5-year-old child.

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Normal Finding (5-year-old)

A result or observation that falls within the expected range for a healthy 5-year-old child.

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Acute Infection

A sudden and severe infection that typically has a rapid onset and a short duration.

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Indication of Acute Infection

A sign or symptom that suggests a person is experiencing a sudden and severe infection.

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Study Notes

Week 1

  • 5 questions cover: interviewing, health history, communication, and documentation.

Week 2

  • 10 questions cover: general survey, vital signs, symptom and pain assessment, and assessment techniques.

Week 3

  • 7 questions cover: thorax and lungs.

Week 4

  • 8 questions cover: heart and neck vessels (PV).

Week 5

  • 5 questions cover: head, face, neck, regional lymphatic system, eyes, ears, nose, mouth, and throat.

Week 6

  • 2 questions cover: musculoskeletal system (MSK).

Objective Data

  • Example of objective data: A 2.5 cm scar on the right lower forearm.

Reliable Pain Indicator

  • The client's description of pain is the most reliable indicator of pain.

Review of Systems

  • The review of systems section in a health history provides objective findings related to each body system.

Subjective Skin Data

  • Skin appears dry is an example of subjective data about the client's skin.

Assessment Sequence

  • The correct sequence for a physical assessment includes: introducing oneself, hand washing, explaining the procedure, then putting on gloves, and performing the inspection first, followed by auscultation.

Communication Framework (Patient Status Change)

  • The SBAR framework (Situation, Background, Assessment, Recommendation) is used for communicating a change in patient status to another healthcare provider.

Reason for Seeking Care

  • "Reason for seeking care" is a more comprehensive term now taking the place of "chief complaint".
  • This implies a change in diagnostic approach.

Medical Record Notation Example

  • "I have had a cold for about a week, and now I am having difficulty breathing." This is an example of a reason for seeking care.

Interview Question Example

  • "Mrs. J., tell me what you do when your headaches occur," targets information about the patient's perception of the problem and the triggers for the headaches.

Genogram Usage

  • A genogram is specifically used for family history.

Review of Systems

  • A review of systems is the evaluation of the past and present health state of each body system.

Assessing an 87-Year-Old Client

  • If a nurse finds a 126 bpm pulse rate in an 87-year-old client, taking a full set of vital signs for a complete assessment is best practice.

Pulse Rate Assessment

  • Assessing pulse rate involves noting rate, rhythm, force, and strength.

Sudden Postural Change

  • A person who stands up quickly after lying down for a longer period of time could experience orthostatic hypotension.
  • This is a possibility for an elderly client.

Blood Pressure (BP) Category

  • Patient whose BP has ranged from 124/84 to 130/82 mmHg for two months is considered to have normal BP.

Difficulty Breathing Positions

  • When a client with COPD is having difficulty breathing, they may assume a tripod position- leaning forward to support their breathing.

Assessment Techniques

  • Auscultation uses listening to sounds, percussion involves using tapping to differentiate tissue types, and inspection involves using sight.
  • Palpation involves using touch.

Breath Sounds

  • High-pitched, inspiratory crowing sounds are likely stridor.
  • Documenting breath sounds that have high-pitch musical notes as "stridor" is correct.

Normal Lymph Node

  • Normal lymph nodes are movable, soft, and non-tender.

Tonsils in Children

  • Normal findings in a 5 year-old child are pink tonsils that are slightly rough-surfaced and have indentations rated between 1 and 3.

Mouth Assessment

  • Healthy mouth includes pink moist gingivae, with localized edema.

Ocular Assessment

  • Bright pink membrane for the tympanic membrane is considered normal.

Visual Acuity Testing

  • In order to assess visual acuity, the client should stand 20 feet from the Snellen chart.

Visual Accommodation

  • Pupillary constriction when looking at a near object is a normal visual accommodation finding.

Visual Accommodation Problems

  • Changes in peripheral vision in response to light signals a potential visual accommodation problem.

Hearing assessment

  • air conduction is the assessment of hearing through sound waves.

Vertebral Column Examination

  • The client should be placed in a prone position to inspect the vertebral column.

Abnormal Curvatures (Spine)

  • An S-shaped curvature of the thoracic and lumbar spine is considered scoliosis.

Knee Movement

  • The knee's typical movements are flexion (bending) and extension (straightening).

Assessing Crepitus

  • Using percussion is how crepitus, a crackling sensation, is best assessed.

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NURS 104 Questions (PDF)

Description

This quiz covers vital topics in nursing assessment across six weeks, focusing on areas such as interviewing, health history, vital signs, and physical examinations. With a variety of question counts each week, this quiz offers a comprehensive overview of essential assessment techniques and subjective/objective data interpretation. Test your knowledge and skills vital for nursing practice.

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