Kaplan Health Assessment 1 – Flashcards
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Which of these methods should the nurse use to test the gag reflex? a) request the patient speak b) ask the patient to stick out the tongue and move it from side to side c) touch the back of the throat with a cotton tipped applicator d) instruct the patient to drink a small amount of water
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c) touch the back of the throat with a cotton tipped applicator ex: assess functioning cranial nerve IX to protect airway, do not gag reflex if patient does not have an intact cough or swallow reflex *no gag reflex means patient is at risk for aspiration
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The nurse identifies that the correct area to assess the apical pulse is which of the following? a) second intercostal space to the right of the sternum b) third intercostal space to the left of the sternum c) fifth intercostal space at the left midclavicular line d) fifth intercostal space to the left of the sternum
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c) fifth intercostal space at the left midclavicular line ex: mitral area; location where the heart can be best heard: PMI
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The nurse tests the pH of a child's urine. The nurse expects which of the following findings? a) pH 3.4 b) pH 6.0 c) pH 8.2 d) pH 8.5
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b) pH 6.0 ex: range for pH of urine is 4.5-8; tends to be primarily acidic; helps protect against bacterial infection.
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If a person's visual acuity is tested with a Snellen chart and reported to be 20/60, the nurse knows that the number 60 indicates which of the following? a) The distance at which the person stood from the chart b) The distance at which a person with normal vision can read the chart c) The person's vision is 60% less than that of a person with normal vision d) The person has three times poorer vision in the right eye than in the left eye
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b) The distance at which a person with normal vision can read the chart ex: snellen chart measure visual acuity; person stands 20 ft from chart, if a person can read numbers, visual acuity is 20/20. 20/60 indicates a person can read at 20 ft what a person with 20/20 can read from 60 ft.
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The nurse auscultates a patient's lung fields and identifies a pleural friction rub. A pleural friction rub can BEST be described as a) gurgling sounds commonly heard on inspriation b) squeaky sounds heard during inspiration and expiration c) grating sound or vibration heard during inspiration and expiration d) loud transmission of voice sounds caused by consolidating lung
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c) grating sound or vibration heard during inspiration and expiration ex: caused by inflamed pleura; does not clear by coughing
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The home health nurse assesses capillary refill time on a middle-aged client. Which of the following results is considered to be within normal range? a) 1-3 seconds b) 2-4.6 seconds c) 6-8 seconds d) 8-10 seconds
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a) 1-3 seconds ex: capillary refill reflects adequacy of peripheral circulation; 1-3 is WNL. x> 3 is considered sluggish. indicative of blood vessel narrowing
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The nurse recognizes physical assessment should be completed in what order? a) inspection, palpation, percussion, and auscultation b) inspection, auscultation, percussion, and palpation c) auscultation, inspection, palpation, and percussion d) percussion, auscultation, inspection, and palpation
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a) inspection, palpation, percussion, and auscultation ex: correct order: IPPA
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After demographic data is collected by the nurse about a client during an initial health history interview, which should be the next focal area of assessment? a) overview of past health history b) reason for seeking healthcare now c) support system in past and present d) pattern of sleep, diet, exercise and stress management
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b) reason for seeking healthcare now ex: identification of current health concern is the primary initial importance in an initial health history; usually subjective c/o.
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After completing the data collection process of the client's health history interview, which action should the nurse take FIRST? a) inform that client about what to expect during the physical examination b) summarize the highlights of the interview and permit to add or clarify information c) thank the client and contact the physician to report findings d) document the history in the client's record of the client including normal and abnormal findings
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b) summarize the highlights of the interview and permit ex: termination of the health history interview should be done by summarizing what the nurse assesses to be highlights of what was shared.
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The medical nurse is placing a pulse oximetry probe on a patient newly admitted for evaluation of a seizure disorder. The patient asks the nurse "why do I have this thing on me?" Which of the following is the best response? a) "It enables your IV fluids to run at a nice steady state" b) "it monitors your pulse rate on an ongoing basis" c) "it tells us if your blood pressure stays within normal limits" d) "it measures the amount of oxygen circulating in your blood"
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d) "it measures the amount of oxygen circulating in your blood"
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The nurse prepares to assess a client's ears and hearing. The nurse should gather which of the following equipment? a) a tuning fork and otoscope b) c) d)
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a) a tuning fork and otoscope
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