Basic physical assessment Prep- U

To evaluate a client's cerebellar function, a nurse should ask "Do you have any problems with balance?" "Do you have any difficulty speaking?" "Do you have any trouble swallowing food or fluids?" "Have you noticed any changes in your muscle strength?"

"Do you have any problems with balance?"

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem? 16 breaths/min and deep in character 18 breaths/min and inhaled through the mouth 20 breaths/min and shallow in character 28 breaths/min and audible

28 breaths/min and audible

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment? Assess the dressing, drain, and amount of drainage. Ask about the client's level of pain. Assess the vital signs and oxygen saturation levels. Monitor for urinary retention.

Assess the vital signs and oxygen saturation levels.

A cloth chest restraint has been prescribed for a client who is restless and combative due to alcohol intoxication. What is an appropriate nursing intervention for this client? During this period of restraint, restrict any family visitation to the client. Secure the restraints to the bed with knots to ensure the client cannot undo them. Document the client's mental status every shift. Check the extremities for circulation based on hospital protocols.

Check the extremities for circulation based on hospital protocols.

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate? Educate the client about ways to maintain normal vision. Refer the client to a healthcare provider for possible corrective lenses. Encourage the client to purchase corrective lenses for reading. Tell the client that corrective lenses will be required for driving.

Refer the client to a healthcare provider for possible corrective lenses.

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? Respect the adolescent's wishes and maintain her confidentiality. Because the adolescent is a minor, inform her parents about her medical history. Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record. Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.

Respect the adolescent's wishes and maintain her confidentiality.

The nurse is asked to assess urine output for a client. Which statements would be expected outcomes of adequate output? Select all that apply. Daily early morning weight helps to identify retention of fluids. If the client perspires from a fever, there will be increased urine output. The presence of pitting edema will determine dehydration status. Urine output is increased with diuretic administration Skin is warm and dry to touch with appropriate color.

Urine output is increased with diuretic administration Daily early morning weight helps to identify retention of fluids.

The emergency department (ED) nurse should assess which client first? a 3-day-old who the parents identify as having yellow discoloration on the chest and abdomen a 12-year-old who has a bleeding laceration on the knee possibly requiring stitches a 72-year-old who fell from the porch and has a painful probable fracture of the right arm a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain

a 40-year-old who was involved in a motorcycle accident and is now stating abdominal pain

The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply. a client with intractable vomiting and diarrhea a client who underwent cholecystectomy today a client with pain related to pancreatitis a client with colon cancer who is receiving chemotherapy

a client who underwent cholecystectomy today a client with pain related to pancreatitis

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area? on the bridge of the client's nose below the client's eyebrows below the client's cheekbones over the client's temporal area

below the client's cheekbones

When percussing a client's chest, what should the nurse expect to hear? hyperresonance tympany resonance dullness

resonance

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? a core body temperature of 97.9° F (36.6° C) confusion when listening to explanations of procedures polydipsia urine output of 90 mL over the past 6 hours

urine output of 90 mL over the past 6 hours

At 8:00 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10:00 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next? Check to see that the client had a chest X-ray the previous day as ordered. Check the client's serum electrolyte levels and complete blood count (CBC). Immediately notify the health care provider of these findings. Sign the preoperative checklist for this client.

Immediately notify the health care provider of these findings.

Which sentence correctly describes the prone position? The body is supine. Arms are elevated at shoulder level. The body is facedown. The body is facing backward.

The body is facedown.

The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury? The client will use the adaptive devices to assist with feeding. The client's vital signs will stabilize, returning to normal range. The client's skin will remain clean, dry, and intact. The client will return to optimal level of functioning.

The client's vital signs will stabilize, returning to normal range

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. What is the next action by the nurse? Insert an oral airway. Withhold food and fluids. Position the client on the side. Introduce a nasogastric (NG) tube.

Withhold food and fluids.

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? a passage of flatus pre- and post-feeding inability of the client to receive a rapid flow of the feeding intermittent epigastric tenderness formula in the client's mouth during the feeding, and increased cough

formula in the client's mouth during the feeding, and increased cough

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding? pulse pressure pulse deficit pulse rhythm pulsus regularis

pulse deficit

A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding? pulse amplitude +2 bilaterally pulses weak pulse amplitude +1 bilateral lower extremities poor quality of peripheral pulses

pulse amplitude +1 bilateral lower extremities

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? "Are you having pain in your leg?" "Tell me what you are feeling." "Do you need pain medication?" "Are you feeling all right?"

"Tell me what you are feeling."

A client has a 10-year history of rheumatoid arthritis and is concerned now that the client's child is experiencing some morning stiffness and pain. What would be the most appropriate response by the nurse? "Rheumatoid arthritis does not have a genetic basis, so there is nothing to be concerned about." "There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated." "Have your child take aspirin for a few days to see if the stiffness is relieved." "It is normal to have aches and pains, so your concern is probably unwarranted."

"There is some evidence that a genetic basis for the disease may exist, so you might want to have your child evaluated."

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? Assess the client's level of pain, and administer prescribed analgesics. Assess the client's level of anxiety, and provide emotional support. Prepare the client for pulmonary artery catheterization. Ensure that the client's family is kept informed of the client status.

Assess the client's level of pain, and administer prescribed analgesics.

Which component of a client's medical record is the major source of subjective data about the client's health status? health history physical findings laboratory test results radiologic findings

health history

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli? spontaneous verbal tactile painful

tactile

A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should have the client inhale and exhale though the mouth during auscultation. palpate the radial artery during auscultation. use the bell of the stethoscope. palpate both carotid arteries firmly first, then auscultate to compare.

use the bell of the stethoscope.

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma? "The stoma should appear dark and have a bluish hue." "At first, the stoma may bleed slightly when touched." "The stoma should remain swollen distal to the abdomen." "A burning sensation under the stoma faceplate is normal."

"At first, the stoma may bleed slightly when touched."

A nurse is assessing a client who has a rash on the chest and upper arms. Which questions would the nurse ask in order to gain further information about the client's rash? Select all that apply. "When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What is your ethnic background?" "What have you been using to treat the rash?" "Have you recently traveled outside the country?" "Do you smoke cigarettes or drink alcohol?"

"When did the rash start?" "Are you allergic to any medications, foods, or pollen?" "What is your ethnic background?" "What have you been using to treat the rash?"

The nurse is preparing to administer fentanyl 25 mcg I.V. The available dose is 100 mcg/2 ml vial. How much medication will the nurse ask another nurse to witness as a waste? Record your answer using one decimal place.

1.5 ml

A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment? Assess the dressing, drain, and amount of drainage. Ask about the client's level of pain. Assess the vital signs and oxygen saturation levels. Monitor for urinary retention.

Assess the vital signs and oxygen saturation levels.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse? Check vital signs and level of consciousness; then place the client in a quiet area with a family member. Monitor the level of agitation and, when the client calms down, refer to the community addiction team. Notify the emergency physician and request a telephone order for sedation. Administer the medication and place the client in a quiet place for monitoring. Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

A home care nurse is assessing a new client whose albumin level is 1.5 g/dL (15 g/L) and whose body weight is 25% below the ideal weight. What action should the nurse take? Obtain order for total protein level. Perform 3-day diet recall with client. Obtain order for enteral feedings. Perform capillary refill time assessment.

Perform 3-day diet recall with client.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? One breast is larger than the other. The lump is firm and non-movable. The lump is round and movable. Nipple retractions are noted.

The lump is round and movable.

When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply. allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy favorite foods siblings with allergies

allergies to any medications allergies to items other than medications, such as foods and animals reaction to the allergen severity of the allergy

A client, age 75, is admitted to the hospital. Because of the client's age, how should the nurse modify the client's assessment? shortening it due to possible client fatigue speaking loudly and slowly addressing the client by first name allowing extra time for the assessment

allowing extra time for the assessment

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include increased coronary artery blood flow. decreased posterior thoracic curve. decreased peripheral resistance. delayed gastric emptying.

delayed gastric emptying.

A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client? overhydration causes the skin to tent dehydration causes the skin to appear edematous and spongy inelastic skin turgor is a normal part of aging normal skin turgor is moist and boggy

inelastic skin turgor is a normal part of aging

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client? auscultation inspection palpation percussion

palpation

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate: metabolic acidosis. metabolic alkalosis. respiratory alkalosis. respiratory acidosis.

respiratory acidosis.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis? mild fever clear speech tripod position gradual onset of symptoms

tripod position

A nurse correctly identifies which items as belonging to the dorsal cavity? mediastinum mouth vertebral canal reproductive organs

vertebral canal

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse? Administer an antiemetic to reduce the nausea, and send the client to physiotherapy. Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment. Notify the dietitian to change the diet to clear fluids, and cancel physiotherapy until the client's strength resumes. Place the client on NPO status, and notify the health care provider immediately.

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

A tornado strikes a community, resulting in multiple trauma victims. What is the most appropriate action of the nurse working in an acute care unit of the receiving facility in implementing the disaster preparedness plan? Contact and inform all registered nurses about the disaster to elicit their help in assisting with the casualties. Follow the formal written plan of action for coordinating the response of the hospital staff. Volunteer to report to whichever unit needs the most assistance. Transport medical supplies to where casualties are being evaluated.

Follow the formal written plan of action for coordinating the response of the hospital staff.

The charge nurse on a pediatric unit is making client assignments for the evening shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)? a 2-year-old with immunodeficiency disease receiving chemotherapy a 3-year-old with a cardiac disease receiving a platelet transfusion a 4-year-old with chronic graft-versus-host disease who is incontinent a 5-year-old who received chemotherapy one week ago, admitted with a decreased level of consciousness and temperature of 101°F (38°C)

a 4-year-old with chronic graft-versus-host disease who is incontinent

When palpating the bladder of an adult client, a nurse would identify which finding as normal? a soft, smooth bladder a hard, rough bladder a nonpalpable bladder a palpable bladder located 3″ to 5″ (7.5 to 12.7 cm) above the symphysis pubis

a nonpalpable bladder

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? alterations in speech and aphasic status quality and rate of pulses, respirations, and blood gas values changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person whether blood pressure is maintained within the lower end of desired parameters

changes in level of consciousness or responsiveness as evidenced

The nurse is assessing the progression of jaundice in a neonate who requires phototherapy. Place the assessment areas in the expected order. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. chest face extremities abdomen

face chest abdomen extremities Jaundice progresses in a cephalocaudal and proximodistal pattern beginning with the face, chest, abdomen, and then extremities.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? two to three bowel sounds per minute high pitched, tinkling bowel sounds high pitched gurgling noises in four abdominal quadrants sounds heard only in bilateral lower quadrants

high pitched gurgling noises in four abdominal quadrants

Which finding would be expected in a client with chest trauma, rib fractures, and respiratory acidosis?" Kussmaul respirations due to inability to take deep breaths hypoventilation due to inability to take deep breaths because of pain hyperventilation due to inability to take deep breaths, so short fast breaths are more comfortable a massive diffusion disturbance due to the rib fractures

hypoventilation due to inability to take deep breaths because of pain

A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? in the supine, sitting, and standing positions ambulating the client around the room and then assessing blood pressure taking blood pressure on the left arm and again in 5 minutes on the right arm assessing at the beginning and the end of the examination

in the supine, sitting, and standing positions

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are progressively deeper breaths followed by shallower breaths with apneic periods. rapid, deep breaths with abrupt pauses between each breath. rapid, deep breaths and irregular breathing without pauses. shallow breaths with an increased respiratory rate.

progressively deeper breaths followed by shallower breaths with apneic periods.

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?"

"What does the pain feel like?"

A client is drinking 3000 mL of fluid a day during the acute phase of kidney failure. Which assessment finding would be expected? dark and straw-colored urine straw-colored urine light amber urine dark amber urine

straw-colored urine

The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment? Keep the client warm. Maintain room temperature at 78°F (25.6°C). Keep the client uncovered. Match the room temperature to the client's body temperature.

Keep the client warm.

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition? allergies sinusitis ringworm fifth disease

allergies

A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make? skin color, warmth of extremities, and mental status metabolic rate, orientation, and presence of reflexes level of consciousness, pain level, and wound dressing emotional status, response to anesthesia, and social support systems

level of consciousness, pain level, and wound dressing

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment? signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes signs of abdominal distension, auscultation of reduced bowel sounds, and tympany upon percussion signs of kidney suppression with enlargement of the kidneys, reduced urine flow, and concentrated urine signs of metabolic alkalosis with disorientation because of loss of intestinal fluids

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes

The nurse is assessing the ears of an infant. What will the nurse do to best visualize the tympanic membrane? Grasp the auricle with the nondominant hand, and pull down and back. Grasp the auricle with the nondominant hand, and pull up and back. Grasp the auricle with the nondominant hand, and pull straight up. Grasp the auricle with the nondominant hand, and pull down and forward.

Grasp the auricle with the nondominant hand, and pull down and back.