4/20 Physical Assessment

A nurse is caring for a client receiving contact isolation. The nurse must take a client's rectal temperature with a plastic thermometer. Which should the nurse do?

Wear gloves throughout the procedure

A nurse is assessing a postoperative client for signs of hemorrhage. Which clinical manifestations are indicative of shock? Select all that apply

all

A nurse obtains the blood pressure of several adults. Which blood pressure result should cause the most concern?

140/90 mm Hg

Edrophonium IV is administered to a client suspected of having myasthenia gravis. Within 30 seconds after administration of the edrophonium, the client experiences a cholinergic reaction with increased muscle weakness, bradycardia, diaphoresis, and hypotension. The primary health-care provider prescribes atropine sulfate 1 mg IV milliliters of atropine sulfate the nurse should administer. Record your answer using a whole number

2 mL

When evaluating the vital signs of a group of clients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually as its lowest?

4 a.m. to 6 a.m.

Which assessment requires the nurse to assess the client further?

65 year old man with a respiratory rate of 10

A nurse is caring for a patient who sustained trauma in an automobile collision. The nurse makes the following assessments. Does not open the eyes when asked a question but opens eyes and withdraws from painful stimulus when turned and positioned; makes sounds but does not speak words. The nurse uses the Glasgow Coma Scale (GCS) to rate the patient's level of consciousness. Which point total on the Glasgow Coma Scale should the nurse document in the patient's clinical record indicating the patient's level of consciousness?

8

When evaluating the vital signs of a group of clients the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at its highest?

8 p.m. to 10 p.m.

At which day and time did the client have a pulse rate of 75 beats per minute?

9-9 at 1800

A nurse is performing a physical assessment on a newly admitted client. The photograph reflects the condition of the client's tongue. Which nursing intervention should the nurse anticipate will address the origin of this client's problem?

Administering prescribed antifungal medication

A nurse in the emergency department is engaging in an initial assessment of a client. Which assessment takes priority?

Airway clearance

Which physical examination method should a nurse use when assessing a client for borborygmi?

Auscultation

A nurse is assessing a client's heart rate by palpating the carotid artery. Which of the following can cause urine to appear red?

Beets

A client has a serious vitamin K deficiency. For which clinical manifestations should the nurse assess this patient? Select all that apply

Bleeding gums Ecchymotic

Which usually is unrelated to a nursing physical assessment?

Blood and urine values

An adult client's vital signs are: oral temperature 99 degrees F, pulse 88 beats per minute with a regular rhythm, respirations 16 breaths per minute and deep, and blood pressure 180/110 mm Hg. Which sign should cause concern?

Blood pressure

A nurse concludes that a client has inadequate nutrition. Which patient adaptations support this conclusion? Select all that apply.

Cachectic appearance Spoon-shaped nails

A nurse is assessing a client's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?

Carotid

A nurse is teaching a community health class about cancer prevention for people who are asymptomatic and not at risk for cancer. Which screening guideline for this group of people should the nurse include?

Colonoscopy at 50 years of age and every 10 years thereafter

Which nursing action is common to all instruments when taking a temperature?

Ensure that the instrument is clean

A client has had a 101 degree F fever for the past 24 hours. How often should the nurse monitor this client's temperature?

Every 4 hours

A nurse is caring for a client who is experiencing an increase in clinical manifestation associated with multiple sclerosis. Which term describes a recurrence of clinical manifestation?

Exacerbation

A nurse identifies that a client exhibiting signs of the onset phase (cold or chill phase) of a fever. Which assessment supports this condition? Select all that apply

Goose bumps on the skin Cyanotic nail beds

A nurse is monitoring the status of postoperative clients. Which vital sign will change first when a postoperative client has internal bleeding?

Heart rate

A nurse in the emergency department is caring for a patient who is diagnosed with hypothermia. Which factor present in the patient's history may have precipitated this condition?

High alcohol intake

A client is admitted to the emergency department with difficulty breathing. Which client response identified by the nurse causes the most concern?

Low pulse oximetry

A nurse is unable to palpate a client's brachial pulse. Which pulse should the nurse assess to determine adequate brachial blood flow in this client?

Radial

A nurse in the clinic must obtain the vital signs of each patient via an electronic thermometer before patients are assessed by the primary health-scare provider. Which patient characteristics indicate that the nurse should take the patient's temperature via the rectal rather than the oral route? Select all that applytics indicate that the nurse should take the patient's temperature via the rectal rather than the oral route? Select all that apply

Mouth breather Presence of confusion

A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?

Palpation

Which method of examination is being used when the nurse's hands are used to assess the temperature of a client's skin?

Palpation

A nurse is planning care for a patient who has intolerance to activity. Which is the first assessment that should be made by the nurse?

Pattern of vital signs

A nurse must assess for the presence of bowel sounds in a postoperative client. Which technique should the nurse employ to obtain accurate results when auscultating the client's abdomen?

Perform auscultation before palpation of the abdomen

The nurse is obtaining a client's blood pressure. Which information is most important for the nurse to document?

Position of the patient if the patient is not in a sitting position

A patient with hypertension is given discharge instructions to take the blood pressure every day. A nurse is evaluating a family member taking the client's blood pressure as part of the client's discharge teaching plan. Which behaviors indicate that the family member needs additional teaching? Select all that apply

Positions the arm higher than the level of the heart Releases the valve on the manometer so that the gauge drops 10 mm Hg per heartbeat Inserts the earpieces of the stethoscope into the ears so that they tilt slightly backward

A nurse is assessing the patient's heart rate by palpating the carotid artery. Which action should the nurse implement when assessing a pulse at this site?

Press gently when palpating the site

A nurse is caring for a client who had surgery for a hysterectomy 2 days ago. After reviewing the patient's medical record, which piece of data should cause the nurse the most concern?

Respirations: 10 breaths per minute

A client has an elevated temperature and reports feeling cold. Which additional physical changes should the nurse expect during the onset phase (cold or chill phase) of a fever? Select all that apply.

Shivering

A nurse is assessing a patient who states "I feel cold". Which mechanism that helps regulate body temperature will increase body heat?

Shivering

Which is common to the collection of all specimens for culture and sensitivity tests regardless of their source?

Surgical asepsis must be maintained

A client has lost aprox. 2 units of blood during a vaginal delivery. For which responses to this blood loss should the nurse assess this patient? Select all that apply

Tachycardia

A nurse is performing a psychosocial assessment. Which assessment should be identified as a subtle indicator of depression?

Unkempt appearance

A nurse is interviewing a newly admitted client. Which word used by the patient describe information associated with the defervescence phase (fever abatement, flush phase) of a fever? Select all that apply

Warm Sweaty

A nurse concludes that a client is experiencing pyrexia. Which client assessment precipitated this conclusion?

rectal temperature of 101 degrees F