NR 306 CJE Health Assessment Benchmark W7 at Chamberlain University
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Free NR 306 CJE Health Assessment Benchmark W7 at Chamberlain University Questions
The nurse working in a community clinic performs an initial assessment on a client who does not speak English. Which action by the nurse would cause a barrier to communication?
- A Seeks family members who may assist in the interview process.
- B Maintains a respectful and professional demeanor.
- C Instructs the client to use paper and pen to communicate.
- D Allows for additional time to complete the assessment process.
Explanation
Explanation
While family members may seem like an immediate solution for translation, relying on them for the interview can introduce privacy concerns, misinterpretation, and bias. Family members may not accurately convey medical information or may unintentionally omit sensitive details. It's best to use a professional interpreter to ensure clear, accurate, and confidential communication during assessments. The other actions listed—maintaining professionalism, using paper and pen for communication, and allowing extra time—are supportive strategies that promote effective communication with the client.A group of student athletes have come to the clinic for their annual sports physicals. During the assessment, which findings does the nurse determine to be objective data? Select all that apply.
- A Two students talk excitedly together about the last game.
- B A student reports having a limp after twisting his leg in practice.
- C Results of a scoliosis screening check on each student.
- D One student says that he has a swollen toe.
- E A student has grown one inch since his last physical.
- F One student has a dry cough.
Explanation
Explanation
Objective data refers to measurable and observable findings that are directly collected by the nurse or healthcare provider.C. Results of a scoliosis screening check on each student
This is an objective finding because it is based on a physical examination and measurable data that can be documented (e.g., curvature of the spine).
E. A student has grown one inch since his last physical
This is objective data because it is a measurable, quantitative change in height, recorded during the assessment.
A nurse and unlicensed assistive personnel (UAP) follow a prescribed standard of care for clients with a hip fracture. The standard of care indicates that the legs should be abducted. How would the nurse instruct the UAP to position the client safely?
- A Keep the legs tightly closed with blanket rolls at each thigh.
- B Open the legs wide and position a triangular pillow between the legs.
- C Open the legs and rotate the thighs internally so that the toes point inward.
- D Flex the client's hips and firmly plant the feet on the bed surface.
Explanation
Explanation
Abduction of the legs is a key part of managing a hip fracture to prevent dislocation and promote healing. A triangular pillow (or abduction pillow) is placed between the legs to keep them abducted at an appropriate angle. This positioning ensures that the hip joint remains stable, reducing the risk of internal rotation or adduction of the leg, which could lead to complications like hip dislocation. This intervention supports proper alignment and comfort while the client heals.The nurse performs a health history interview. What question will the nurse ask to best evaluate the client's values?
- A "What things do you do to help cope with life stressors?"
- B "How do you like to spend your day?"
- C "What are the most important things to you in life?"
- D "How do you feel about your life accomplishments?"
Explanation
Explanation
Values reflect what a person considers meaningful, significant, and central to their life decisions. Asking, “What are the most important things to you in life?” directly explores the client’s beliefs, priorities, motivations, and guiding principles. This open-ended question allows the client to express what they value most—such as family, health, faith, independence, or security—providing insight that supports individualized, patient-centered care and helps guide planning, education, and shared decision-making.The nurse teaches the parent of a child with recurrent ear infections about risk factors for infection and hearing loss. What instructions should the nurse include in the teaching? Select all that apply.
- A Avoid secondhand smoke.
- B Have an audiogram yearly.
- C Use sterile cotton-tipped applicators for cleansing.
- D Apply sunscreen to the ear when in the sun.
- E Clean only the external ear.
- F Stay current with all immunizations.
Explanation
Explanation
A. Avoid secondhand smoke
Secondhand smoke irritates the eustachian tube, increasing mucus production and inflammation. This makes fluid more likely to accumulate behind the tympanic membrane, placing the child at significantly higher risk for recurrent otitis media. Eliminating smoke exposure is one of the most effective preventive measures for reducing ear infections.
E. Clean only the external ear
Parents should avoid inserting cotton-tipped applicators or any objects into the child’s ear canal. Doing so can push debris inward, introduce bacteria, cause trauma, or perforate the tympanic membrane. Cleaning should be limited to the outer ear with a soft cloth to maintain natural protective mechanisms inside the canal.
F. Stay current with all immunizations
Vaccines—especially pneumococcal and influenza—reduce infections that commonly precede or trigger otitis media. Preventing these illnesses helps decrease the frequency of ear infections and lowers the risk of complications such as hearing loss. Ensuring up-to-date immunizations is a key component of otitis media prevention.
The nurse teaches a health promotion class to a group of middle-aged women. Which should the nurse include in teaching about modifiable risk factors?
Select all that apply.
- A Hormonal birth control
- B Absence of BRCA 1 OR BRCA 2 genes
- C Alcohol consumption
- D Breast implants
- E Obesity
- F Family history of breast cancer
Explanation
Explanation
A. Hormonal birth control
Hormonal contraceptives containing estrogen and/or progesterone are associated with a slightly increased risk of breast cancer. Because a woman can modify or discontinue use based on risk-benefit discussions with her provider, this is considered a modifiable risk factor. Teaching should emphasize individualized decision-making and regular screening for women using hormonal birth control.
C. Alcohol consumption
Alcohol intake increases circulating estrogen levels and promotes inflammation, both of which elevate breast cancer risk. Because alcohol use is fully modifiable, education should stress limiting or avoiding alcohol as an effective breast cancer risk-reduction strategy. Even small daily amounts have been shown to increase risk.
E. Obesity
Obesity—especially after menopause—is a well-established modifiable risk factor. Fat tissue produces estrogen, which can stimulate breast cancer growth. Weight reduction through diet, activity, and lifestyle changes lowers estrogen levels and significantly reduces risk. Obesity is also linked to worse breast cancer outcomes, making prevention efforts essential.
While examining the skin of a client who said, "she slipped at home," the nurse notes bruises of varying stages noted to the superior posterior torso. What would be an appropriate action for the nurse to take?
- A Report the suspicion of intimate partner violence (IPV) to the local authorities.
- B Ask the screening questions for violence that are included in every health assessment.
- C Encourage the client to leave her abusive living situation as soon as possible.
- D Confront the client about her description of the event and the true origin of the injuries.
Explanation
Explanation
Bruises in various stages of healing, particularly on the posterior torso, raise concern for possible intimate partner violence. The nurse’s next appropriate action is to proceed with routine, validated IPV screening questions in a nonjudgmental, private, and supportive manner. This allows the client to disclose safely and voluntarily while maintaining autonomy. Screening is the required first step before reporting, safety planning, or discussing resources. Confrontation or giving directives may shut down communication and place the client at greater risk.The nurse palpates tender, warm anterior cervical lymph nodes while assessing a client's neck. What question should the nurse ask to evaluate the finding further?
- A "Have you recently had a sore, dry, or scratchy throat?"
- B "Do you have pain in either of your ears?"
- C "Do you have any pain or stiffness in your neck?"
- D "Have you recently had a fever, dizziness, or headache?"
Explanation
Explanation
Tender, warm anterior cervical lymph nodes are commonly associated with infections in the head and neck area, such as a sore throat or upper respiratory infection (e.g., pharyngitis, tonsillitis). The nurse should ask about symptoms related to a throat infection, as this would help determine if the swollen lymph nodes are responding to local infection. Other options, such as pain in the ear or stiffness in the neck, may also be relevant but are less directly associated with this specific finding.The nurse is assessing an older adult client newly admitted to the medical–surgical unit. Which assessment findings are expected with this population? Select all that apply.
- A Shallow breaths with diminished breath sounds in bases.
- B Supraclavicular retractions and accessory muscle use.
- C Decreased respiratory rate of 10 breaths per minute.
- D Reports of dyspnea on exertion.
- E Crackles on inspiration that clear with coughing.
Explanation
Explanation
A. Shallow breaths with diminished breath sounds in bases
Older adults commonly experience decreased chest wall compliance and weaker respiratory muscles. This leads to shallower breaths and decreased airflow reaching the lung bases, causing diminished breath sounds. These changes are expected and reflect normal aging of the respiratory system.
D. Reports of dyspnea on exertion
With aging, lung elasticity decreases and alveolar surface area is reduced, making oxygen exchange less efficient. The cardiovascular system also becomes less responsive. As a result, older adults frequently report dyspnea with activity, which is a normal age-related finding rather than a disease-specific symptom.
E. Crackles on inspiration that clear with coughing
Older adults often have decreased ability to clear secretions due to weaker cough reflexes and limited mobility. Secretions that accumulate in the lower airways may produce crackles, but these typically clear with coughing. This is considered a common and expected age-related assessment finding.
The nurse assesses a 20-year-old male, noting a swelling over the pelvic area while the client is standing that decreases when he lays down. The nurse suspects an indirect inguinal hernia. What other questions should the nurse ask the client for cues to validate this assumption? Select all that apply.
- A Do you have pain in the pelvic area that wakes you up at night?
- B Have you noticed a change in your urinary stream when urinating?
- C Do you have any pain when straining?
- D Does your scrotum feel heavy when you walk?
- E Do you notice pain in your pelvic area when you lift heavy objects?
- F Do you notice a bulge in your pelvic area when you lift heavy objects?
Explanation
Explanation
C. Do you have any pain when straining?
Indirect inguinal hernias often worsen with activities that increase intra-abdominal pressure—such as coughing, straining, or bearing down. Pain or discomfort during these actions is a classic associated symptom and helps validate the suspicion of a hernia.
D. Does your scrotum feel heavy when you walk?
A feeling of heaviness or dragging in the scrotum is a common complaint with indirect inguinal hernias because the herniated bowel or tissue may descend into the inguinal canal or scrotum, especially with standing or activity. This symptom supports the assessment cue.
F. Do you notice a bulge in your pelvic area when you lift heavy objects?
Indirect inguinal hernias frequently produce a visible or palpable bulge that becomes more pronounced with lifting, straining, or prolonged standing. Asking about activity-related bulging helps verify herniation behavior and supports the diagnosis.
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