NUR216 Health Assessment Exam 4 - Arizona College of Nursing
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Free NUR216 Health Assessment Exam 4 - Arizona College of Nursing Questions
A client reports experiencing unintentional urine leakage throughout the day. What assessment question is important for the nurse to ask the client?
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"Do you have a family history of kidney disease?"
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"What color is your urine when you go to the bathroom?"
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"Does the leakage occur with activities like coughing, laughing, or lifting?"
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"How much fluid do you typically drink in a day?"
Explanation
Correct Answer: (C) "Does the leakage occur with activities like coughing, laughing, or lifting?" This question helps the nurse identify whether the client is experiencing stress incontinence, which occurs when increased intra-abdominal pressure from activities like coughing, laughing, or lifting causes involuntary urine leakage, guiding appropriate assessment and intervention.
Why the other options are incorrect:
A. Family history of kidney disease is not directly relevant to assessing the type or cause of urinary incontinence.
B. Urine color relates to hydration status or potential infection, not the mechanism or type of incontinence being experienced.
D. Fluid intake amount, while relevant to overall urinary health, does not help identify the specific type or trigger of the incontinence the client is experiencing.
The nurse is performing a health history on a client and asks about past medical conditions. Which of the following statements represents subjective data?
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The nurse measures the client's blood pressure at 140/90 mmHg.
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The client reports a history of high blood pressure.
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The nurse observes the client has a rash on their arms.
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The nurse notes that the client's skin appears pale.
Explanation
Correct Answer:
B
Why the other options are incorrect:
A. A measured blood pressure reading is objective data obtained directly by the nurse.
C. An observed rash is objective data, as it is a visible finding noted by the nurse.
D. Pale skin observed by the nurse is objective data based on direct visual assessment.
The nurse is preparing to replace a colostomy pouch for a client who has recently undergone surgery. After removing the existing pouch, which action should the nurse take to ensure the skin around the stoma remains protected?
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Measure the size of the stoma to determine the appropriate pouch size
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Assess the stoma for any signs of infection or irritation
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Apply a layer of moisturizing lotion to the skin surrounding the stoma
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Gently cleanse the area around the stoma with warm water and a soft cloth
Explanation
Gently cleansing the peristomal skin with warm water and a soft cloth removes any stool or drainage residue and prepares the skin for a new pouch application, directly protecting the skin from irritation and breakdown.
Why the other options are incorrect:
A. Measuring the stoma size is important for proper pouch fit but does not directly protect the skin from irritation at this step.
B. Assessing for infection or irritation is an important assessment step, but it does not itself provide the action of protecting the skin.
C. Moisturizing lotion should not be applied to the peristomal skin, as it can interfere with proper adhesion of the ostomy pouch and increase the risk of leakage.
A client's physical examination reveals the following vital signs: temperature of 99.6°F (37.6°C) orally; heart rate of 115 beats/minute, and a weak and thready pulse; and a blood pressure of 82/54 mmHg. The client is weak after vomiting for two days and has not been able to eat or drink anything during this time. The client has not urinated for 12 hours and has dry mucous membranes. When assessing their skin turgor, the nurse notes tenting and it is slow to return to normal. The nurse recognizes that the client is displaying symptoms associated with which condition?
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Hypokalemia
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Hypovolemia
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Hypervolemia
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Hyponatremia
Explanation
Correct Answer: (B) Hypovolemia. The combination of tachycardia, hypotension, weak thready pulse, dry mucous membranes, poor skin turgor with tenting, and decreased urine output following prolonged vomiting without oral intake are classic signs of hypovolemia due to significant fluid loss.
Why the other options are incorrect:
A. Hypokalemia may present with muscle weakness and cardiac changes, but it does not specifically account for the full constellation of dehydration signs such as poor skin turgor and dry mucous membranes.
C. Hypervolemia presents with signs of fluid overload such as edema, jugular vein distention, and hypertension, which is the opposite of this client's presentation.
D. Hyponatremia can cause weakness and confusion but does not specifically explain the classic dehydration findings of poor skin turgor, dry mucous membranes, and hypotension seen in this client.
The nurse is assessing an older adult client and notes rectal tissue protruding out of the anus upon inspection. Which condition should the nurse suspect?
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Hemorrhoid
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Rectal prolapse
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Anal abscess
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Perianal fistula
Explanation
Correct Answer: (B) Rectal prolapse Rectal prolapse occurs when the rectal tissue protrudes through the anus, often due to weakened pelvic floor muscles, which is more common in older adults and matches the finding described.
Why the other options are incorrect:
A. Hemorrhoids are swollen veins in the rectal area but do not typically present as full rectal tissue protrusion.
C. An anal abscess presents as a painful, swollen, infected area, not protruding rectal tissue.
D. A perianal fistula is an abnormal tunnel-like connection near the anus, not tissue protrusion.
The nurse is preparing to perform a focused abdominal assessment on a client. What is the correct sequence that the nurse uses to assess the abdomen?
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Inspect, auscultate, palpate, and percuss
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Inspect, auscultate, percuss, and palpate
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Palpate, inspect, auscultate, and percuss
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Auscultate, inspect, palpate, and percuss
Explanation
Correct Answer: (B) Inspect, auscultate, percuss, and palpate For abdominal assessment, the correct sequence differs from other body systems because palpation and percussion can alter bowel sounds. The nurse should inspect first, then auscultate before touching the abdomen, followed by percussion, and palpation last.
Why Other Options are Incorrect:
A. Percussion should precede palpation, not follow it, since palpation can stimulate bowel activity and alter findings.
C. Palpating before auscultating can artificially stimulate peristalsis, leading to inaccurate assessment of bowel sounds.
D. Inspection must always come first in any physical assessment sequence, and this option incorrectly places auscultation before inspection.
The nurse is conducting an assessment of a client who has been dealing with significant stress due to ongoing financial difficulties and family responsibilities. The client has been seeking coping strategies but reports feeling increasingly unable to manage their stress levels. Which finding is most critical for the nurse to address?
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The client states they have been isolating from family and friends.
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The client reports feeling "on edge" and restless most of the time.
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The client is expressing thoughts of hopelessness and worthlessness.
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The client reports frequent indigestion and gastrointestinal discomfort.
Explanation
Correct Answer: (C) The client is expressing thoughts of hopelessness and worthlessness. Thoughts of hopelessness and worthlessness are critical findings that may indicate risk for depression or suicidal ideation, requiring immediate nursing assessment and intervention to ensure client safety, making this the priority finding.
Why the other options are incorrect:
A. Social isolation is a concerning finding but does not pose the same immediate safety risk as expressions of hopelessness and worthlessness.
B. Feeling "on edge" and restless reflects anxiety symptoms but is not as urgent or safety-critical as thoughts of hopelessness.
D. Indigestion and gastrointestinal discomfort are physical stress symptoms but do not indicate the same level of psychological risk as hopelessness and worthlessness.
The nurse is teaching a client with neurogenic bowel due to a spinal cord injury about bowel retraining. Which instruction should the nurse prioritize to promote long-term success in achieving regular bowel elimination?
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Using a cleansing enema daily to stimulate bowel movements
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Reducing fluid intake to prevent bowel incontinence
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Limiting physical activity to conserve energy for digestion
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Establishing a consistent time each day for toileting
Explanation
Correct Answer: (D) Establishing a consistent time each day for toileting. A consistent daily toileting schedule helps train the bowel to develop a predictable elimination pattern by taking advantage of the body's natural reflexes, which is the foundation of successful long-term bowel retraining in neurogenic bowel.
Why the other options are incorrect:
A. Daily cleansing enemas are not recommended for routine long-term bowel retraining, as they can lead to dependence and do not establish a natural elimination pattern.
B. Reducing fluid intake is inappropriate and can lead to hard, constipated stool, worsening bowel dysfunction rather than improving continence.
C. Limiting physical activity is counterproductive, as physical activity promotes bowel motility and should be encouraged, not restricted, in bowel retraining.
The nurse is conducting a rectal exam on an elderly client. Which of the following is the most appropriate consideration when performing this assessment in older adults?
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Ensure the client is in a comfortable and private position.
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Use a strong, deep palpation to assess for abnormalities.
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Do not ask the client to report any pain or discomfort.
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Perform the exam quickly to minimize discomfort.
Explanation
Ensure the client is in a comfortable and private position. Older adults often have increased sensitivity, mobility limitations, and dignity concerns, so ensuring comfort and privacy is essential for both an accurate assessment and a respectful, therapeutic patient experience.
Correct Answer Is:
(A)
Why the other options are incorrect:
B. Strong, deep palpation is not appropriate and could cause unnecessary pain or tissue injury, especially in elderly clients.
C. The nurse should always ask about and monitor for pain or discomfort during any assessment, not disregard it.
D. Rushing the exam can increase client discomfort and anxiety and compromise the thoroughness of the assessment.
The nurse is caring for a client with post-operative ileus who has not had a bowel movement in three days. The provider prescribes a high-volume tap water enema. As the nurse prepares the equipment, the client asks, "Is this really necessary? I thought my body would start working on its own." What is the nurse's best response?
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"You can refuse the enema if you do not want it, but your provider may be upset."
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"Your provider ordered this enema to help stimulate your bowels until normal function returns."
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"You should not question the provider's decision, as this is part of your treatment plan."
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"This enema will permanently correct your bowel function."
Explanation
Correct Answer: (B) "Your provider ordered this enema to help stimulate your bowels until normal function returns." This response provides the client with clear, accurate information about the purpose of the enema, addressing the client's concern while respecting their right to understand their treatment, which supports informed consent and therapeutic communication.
Why the other options are incorrect:
A. This response inappropriately frames the client's right to refuse treatment as something that will upset the provider, which is coercive and not therapeutic.
C. This response dismisses the client's right to ask questions about their care and does not respect the client's autonomy or need for information.
D. This statement is inaccurate, as an enema is a temporary intervention to stimulate bowel movement and does not permanently correct bowel function.
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