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40 terms

Health Assessment #2

"Pain indicates pathology or injury and is not a normal process of aging"
Which statement indicates that the nurse understand the pain experienced by an elderly person?
When assessing a patient's pain, the nurse knows that an example of visceral pain would be:
Unexplained weight loss often accompanies illnesses.
A 60 year old male patient has been treated for pneumonia for the past 6 weeks. He is seen today the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:
Appear unhurried and confident when examining him
A man is at the clinic for a physical examination. He states that he is "very anxious" about the physical examination. What steps can the nurse take to make him more comfortable?
Finger foods and nutritious snacks that can't cause choking
The nurse is discussing appropriate foods with the mother of a 3 year old child. Which of these foods are recommended?
Subjective report
The nurse is assessing a patient's pain. The nurse knows that the most reliable indicator of pain would be the:
Breast milk provides the nutrients necessary for growth as well as natural immunity
A pregnant woman is interested in breastfeeding her baby, and asks several questions about the topic. Which information is appropriate for the nurse to share with her.
Increased blood pressure and pulse
A patient states that the pain medication is "not working" and rates his postoperative pain at a 10 or a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 and 138/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?
"When did you first notice this change?"
A patient tells the nurse that his food just doesn't have any taste anymore. The nurse's best response would be:
Consider this a normal finding.
When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should:
Living alone on a fixed income
The nurse is reviewing the nutritional assessment of an 82 year old patient. Which of these factors is most likely to affect the nutritional status of an elderly person?
Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when the nurse is assessing a patient?
When performing a physical assessment, the technique the nurse will always use first is:
Is used to listen for high-pitched sounds
The nurse is preparing to use a stethoscope for auscultation. Which statement is true regarding diaphragm of the stethoscope? The diaphragm:
A procedure that induces pain in adults will also induce pain in the infant
The nurse knows that which statement is true regarding the pain experienced by infants?
Kidney stones
When evaluating a patient's pain, the nurse knows that an example of acute pain would be:
It is important to maintain adequate fat and caloric intake
The nurse is providing nutrition information to the mother of a 1 year old child. Which of the statements represents accurate information for this age group?
Inspection takes time and reveals a surprising amount of information.
The nurse is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment
If a 29 year old woman weighs 156 pounds and the nurse determines her ideal body weight to be pounds, how would the nurse classify the woman's weight?
When assessing a patient's pulse the nurse should also notice which of these characteristics?
"What does your pain feel like?"
When assessing the quality of a patient's pain, the nurse should ask which question?
"Your pulse is 80 beats per minute. This is within the normal range."
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which of these statements by the nurse is most appropriate?
Sufficient nutrients to provide for daily body requirements and for increased metabolic demands
When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is:
"How much pain do you have now?"
When assessing the intensity of a patient's pain, which question by the nurse is appropriate?
Yield a falsely high blood pressure
The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to:
The absorption of nutrients may be impaired.
The nurse is providing care for a 68 year old woman who is complaining of constipation. What concern exists regarding her nutritional status?
The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?
Consider this a normal finding for a 1 month old infant
A 1 month old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on interpretation of these findings, the nurse would:
Dorsal surface of the hand because the skin is thinner than on the palms
The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? Use the:
Wash hands before and after every physical patient encounter
When performing a physical examination, safetly must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse should take when performing a physical examination?
When auscultating the blood pressure of a 25 year old patient, the nurse notices the phase I Korotkoff sounds begin at 200mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
Organizes the assessment so that the patient does not change positions too often
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement? The nurse:
Snacks should be high in protein, iron, and calcium
A mother and her 13 year old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of these statements represents information the nurse should discuss with them?
Attempt to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
When measuring a patient's weight, the nurse keeps in mind which of these guidelines?
Food frequency questionnaire
A patient is asked to indicate on a form how many times he eats a specific food. This would describe which of these methods for obtaining dietary information?
5 month old infant
The nurse recognized that which of these persons is at greatest risk for under nutrition?
"How much do you think you should weigh"
The nurse is performing a nutritional assessment on a 15 year old girl, who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weights 110 pounds. The nurse's appropriate response would be:
She has experienced chronic pain for years and has adapted to it.
A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is "bad this morning" and rates it at an 8 on a 1 to 10 scale. What does the nurse suspect?
Pulse for 1 minute if the rhythm is irregular
Which technique is correct when the nurse is assessing the radial pulse of a patient? Count the: