Kaplan Health Assessment 1 – Flashcards
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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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