5th edition Ch 1-34 Questions and Answers

Health Assessment in Nursing Weber & Kelley 5th edition Ch 1-34 Questions and Answers 100% Complete Updated 2023

• A client at 22 weeks' gestation comes to the clinic complaining of earache and

decreased hearing. Otoscopic examination of the ear is normal. The nurse explains to the client that her symptoms are pregnancy-induced as a result of what physiologic change?

• Thickened, dry cerumen
• Infection of the inner ear
• Vascularity of the eardrum
• Auditory nerve compression - AnswerC) Vascularity of the eardrum

• A client has presented to the clinic for the treatment of an ovarian cyst. Which of the

following would be most important for the nurse to do immediately before performing this woman's physical exam?

• Explain the purpose of the interview to the client.
• Construct the client's family genogram.
• Establish the client's reliability as historian.
• Collect necessary equipment essential to the exam. - AnswerD) Collect necessary

equipment essential to the exam.

• A client has suffered a suspected a rotator cuff tear. Which of the following would the

nurse expect to find?

• Limitation of all shoulder motion
• Chronic pain
• Limited abduction
• Sharp catches of pain with movement - AnswerC) Limited abduction

• A client tells the clinic nurse that she has sought care because she has been

experiencing excessive tearing of her eyes. Which assessment should the nurse next perform?

• Inspect the palpebral conjunctiva.
• Assess the nasolacrimal sac.
• Perform the eye positions test.
• Test pupillary reaction to light. - AnswerB) Assess the nasolacrimal sac.

• A nurse has completed a comprehensive assessment of a client and has begun the

process of data analysis. Data analysis should allow the nurse to produce which of the following direct results?

• Outcomes evaluation
• Nursing diagnoses
• Holistic interventions
• An interdisciplinary plan of care - AnswerB) Nursing diagnoses
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• A nurse has completed the general survey of a client who has been trAnswerferred to

the unit. The information gathered during the general survey primarily provides the nurse with which of the following? Select all that apply.

• An indication of the level of physical distress experienced by the client
• Clues about the overall health of the client
• A direct link to the client's medical diagnosis
• Indications about normal variations in the status of body systems
• Data relating to the patient's level of social support - AnswerA, B, D
• An indication of the level of physical distress experienced by the client
• Clues about the overall health of the client
• Indications about normal variations in the status of body systems

• A nurse is completing the intake assessment of an older adult who has just relocated

to a long-term care facility. Which of the following nursing actions would be most important to ensure accurate data when gathering the resident's information?

• Documenting the data
• Validating the data
• Identifying client support systems
• Determining client needs - AnswerB) Validating the data

• A nurse is performing an assessment within the legal parameters of assessment and

diagnosis. These legal guidelines would be specified in which of the following?

• The state's Nurse Practice Act
• The client's informed consent documents
• The nurse's terms of license
• The institution's policies and procedures guidelines - AnswerA) The state's Nurse

Practice Act

• A nurse is preparing a presentation for a local community group on family violence

and child abuse. Which of the following would be most appropriate for the nurse to research when defining child abuse in legal terms?

• The Prevent Child Abuse America group
• The Child Abuse Prevention and Treatment Act
• The Child Abuse Prevention Network
• The Child Well-being and Domestic Violence Project - AnswerB) The Child Abuse

Prevention and Treatment Act

• A nurse is preparing to assess a client who is new to the clinic. When beginning the

collection of the client database, which of the following actions should the nurse prioritize?

• Establishing a trusting relationship
• Determining the client's strengths
• Identifying potential health problems
• Making clinical inferences - AnswerA) Establishing a trusting relationship
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• A nurse is preparing to assess a family. The nurse best adopts the view of the family

unit as being a system by using which approach?

• Focusing on each individual member's health problems
• Identifying strengths and problem areas within the family structure
• Educating the sick client about methods to maintain independence
• Fostering emotional support for each family member - AnswerB) Identifying strengths

and problem areas within the family structure

• A nurse is working with a client who has received a terminal diagnosis. To help the

nurse identify the client's possible coping responses, which of the following would be most important for the nurse to understand about spirituality?

• It varies in different situations.
• It increases in significance with illness.
• It decreases in importance with age.
• It remains static throughout the lifespan. - AnswerA) It varies in different situations.

• A nurse on a postsurgical unit is admitting a client following the client's

cholecystectomy (gall bladder removal). What is the overall purpose of assessment for this client?

• Collecting accurate data
• Assisting the primary care provider
• Validating previous data
• Making clinical judgments - AnswerD) Making clinical judgments

• A palliative care nurse is explaining the basis of pain to a group of nurses who

provide care on a general medical unit. Which of the following factors would the nurse include? Select all that apply.

• Physiologic
• Psychosocial
• Cutaneous
• Somatic
• Visceral - AnswerA, B
• Physiologic
• Psychosocial

• A preadolescent girl comes to the clinic for a sports physical exam. The nurse notes

beginning breast development and documents which of the following?

• Gynecomastia
• Thelarche
• Menarche
• Adolescence - AnswerB) Thelarche

• Assessment of a client reveals a history of insulin-dependent diabetes mellitus,

weight loss, polyuria, poor skin turgor, nausea, loss of appetite, and a blood glucose level measured by finger stick of 348 mg/dL. Which of the following nursing diagnoses would be the nurse's priority? 3 / 4

• Risk for imbalanced fluid volume related to inadequate oral intake and frequent

urination

B) Imbalanced nutrition: more than body requirements related to diabetes

C) Potential complication: hypertension

• Powerlessness related to diabetes self-care and management - AnswerA) Risk for

imbalanced fluid volume related to inadequate oral intake and frequent urination

• During a client's vascular assessment, the nurse is palpating the pulse just under the

client's inguinal ligament. The nurse is assessing which pulse?

• Temporal
• Brachial
• Popliteal
• Femoral - AnswerD) Femoral

• During deep palpation of the client's abdomen, the nurse identifies a soft, nontender,

solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate?

• Refer the client for medical follow-up.
• Evaluate further for a problem with the spleen.
• Assess urinary output.
• Document the position of the liver. - AnswerD) Document the position of the liver.

• The nurse is assessing a client's breasts. When assessing the area of the breast

most vulnerable to breast cancer, where should the nurse to assess?

• Upper inner quadrant
• Lower inner quadrant
• Upper outer quadrant
• Lower outer quadrant - AnswerC) Upper outer quadrant

• The nurse is assessing a client's psychosocial development in light of Freud's theory.

The nurse would interpret the client's status as the outcome of conflict between what variables?

• Cultural norms and personality traits
• Biological desires and social expectations
• Sexual desires and relational desires
• Sociocultural norms and health needs - AnswerB) Biological desires and social

expectations

• The nurse is assessing a fair-skinned, Caucasian woman with red hair and freckled

skin. During health promotion, the nurse should focus education on which of the following topics?

• Management of dry skin
• Susceptibility to bruising
• Risks of fungal infections
• Risks of sun exposure - AnswerD) Risks of sun exposure
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