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Nursing Health Assessment NP ASSESMENT Chamberlain College Nursing -Question and answers rated A+ The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate,...

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  • 16 augustus 2024
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Nursing Health Assessment
The nurse is preparing to perform a health assessment of the abdomen. In
which order should the nurse perform the assessment?
1. Auscultate, percuss, palpate, inspect
2. Inspect, auscultate, palpate, percuss
3. Inspect, auscultate, percuss, palpate
4. Palpate, percuss, auscultate, inspect - correct answer ✔Inspect,
auscultate, percuss, palpate


The nurse is performing a health assessment and notes a yellow tinge to the
sclera of the eye. The nurse should document this as being
1. cyanosis.
2. jaundice.
3. pallor.
4. erythema. - correct answer ✔jaundice


While performing an assessment of the integument system, the nurse notes
the client's eyeballs are protruding and the upper eyelids are elevated. What
term should the nurse use to document this finding?
1. Erythema
2. Cyanosis
3. Exophthalmos
4. Normocephalic - correct answer ✔Exophthalmos


The nurse is preparing for morning rounds. What should the nurse avoid
delegating to unlicensed assistive personnel?
1. Vital signs

,2. Filling of water pitchers
3. Skull and face assessment
4. Ambulation of surgical clients - correct answer ✔Skull and face
assessment


The nurse is performing a lung assessment on a client with suspected
pneumonia. Which finding should the nurse report to the physician
immediately?
1. Chest symmetrical
2. Breath sounds equal bilaterally
3. Asymmetrical chest expansion
4. Bilateral symmetric vocal fremitus - correct answer ✔Asymmetrical chest
expansion


While performing a health assessment, in which position should the nurse
place the client for inspection of the jugular veins?
1. 90-degree angle
2. 30- to 45-degree angle
3. 15-degree angle
4. 60-degree angle - correct answer ✔30- to 45-degree angle


The nurse is assessing peripheral pulses on a client with suspected peripheral
vascular disease. Which finding should the nurse report to the physician
immediately?
1. Pulses equal bilaterally
2. Full pulsations
3. Thready pulses
4. Pulses present bilaterally - correct answer ✔Thready pulses

,During the assessment of a client's breasts, the nurse finds both breasts
rounded, slightly unequal in size, skin smooth and intact, and nipples without
discharge. What should the nurse do next?
1. Notify the charge nurse.
2. Notify the physician.
3. Document the findings in the nurse's notes as normal.
4. Document the findings in the nurse's notes as abnormal. - correct answer
✔Document the findings in the nurse's notes as normal


Type: MCSA
The nurse is preparing a client for an abdominal examination. What should the
nurse done before beginning the examination?
1. Ask the client to urinate.
2. Ask the client to drink 8 ounces of water.
3. Assess vital signs.
4. Assess heart rate. - correct answer ✔Ask the client to urinate


The nurse is performing a musculoskeletal assessment on a client admitted
with a possible stroke. When testing for muscle grip strength, the nurse should
ask the client to perform which action?
1. Grasp the nurse's index and middle fingers while the nurse tries to pull the
fingers out.
2. Hold an arm up and resist while the nurse tries to push it down.
3. Flex each arm and then try to extend it against the nurse's attempt to keep
the arm in flexion.
4. Shrug the shoulders against the resistance of the nurse's hands - correct
answer ✔Grasp the nurse's index and middle fingers while the nurse tries to
pull the fingers out.

, The nurse is preparing to conduct a mental status assessment. What should
the nurse include in this assessment?
1. Cognitive and affective functions
2. Cognitive and effective functions
3. Affective and memory functions
4. Affective and knowledge functions - correct answer ✔Cognitive and
affective functions


The nurse is caring for a client following a cerebrovascular accident (stroke).
The client is able to comprehend what is being said to him; however, he is
unable to respond by speech or writing. What type of aphasia should the
nurse realize this patient is demonstrating?
1. Auditory aphasia
2. Acoustic aphasia
3. Sensory aphasia
4. Expressive aphasia - correct answer ✔Expressive aphasia


The nurse is preparing to assess a client's reflexes. What equipment should
the nurse gather before entering the room?
1. Sterile gloves
2. Clean gloves
3. Percussion hammer
4. Penlight - correct answer ✔Percussion hammer


The nurse is assisting the physician who is preparing to test a sexually active
female client for cervical cancer. What should the nurse expect the health
care provider to perform?
1. Pap test

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