Ch 28 Health Assessment Prep U

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms? Hyponatremia Hypokalemia Hyperkalemia Hypernatremia

Hyponatremia

The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action? Elevate the client's right leg. Notify the healthcare provider. Apply sequential compression devices. Obtain a Doppler to verify absent pulse.

Obtain a Doppler to verify absent pulse.

It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what? Instills a friendly feeling toward you in the patient Causes assessment findings to be more accurate Speeds up the pace of the assessment Opens up teaching/learning moments

Opens up teaching/learning moments

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed? Serous Fibrinous Purulent Sanguineous

Sanguineous

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision? Otoscope Snellen chart Stethoscope Ophthalmoscope

Snellen chart

A nurse is conducting a physical examination and is percussing the gastric area of a patient. What percussion tone is normally heard in this area? Tympany Resonant Dull Flat

Tympany

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique? assess abdominal reflex find the lower pole of the left kidney determine the liver border change the character of bowel sounds

assess abdominal reflex

The client has decreased sensation in his legs. What additional assessment should the nurse include? Surgical site Fall Sepsis Bloodstream infection

fall

When supine, a client's knees do not touch the examination table. On what area should the nurse focus to learn more information about this finding? flexion and extension limb length gait abduction and adduction

flexion and extension

When assessing the abdomen, which assessment technique is used last? Percussion Palpation Auscultation Inspection

palpation

The nurse is conducting a head-to-toe assessment on a client. The nurse would would be concerned if the following characteristics were noted? (Select all that apply.) pressure ulcers Rashes Freckles Goose bumps Lesions

pressure ulcers Rashes Lesions

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time? Pedal pulses Oxygen saturation Safety Hearing acuity

safety

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply. Blood pressure 124/72 Heart rate 75 beats per minute Altered mental state Documented or suspected infection Respiratory rate 36 breaths per minute Temperature greater than 102 °F (38.9 °C)

Altered mental state Documented or suspected infection Respiratory rate 36 breaths per minute Temperature greater than 102 °F (38.9 °C)

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client? Begin antibiotic therapy through intravenous route Administer a nebulizer treatment Encourage turning, coughing, and deep breathing Order a chest x-ray

Encourage turning, coughing, and deep breathing

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? Ask the client to fold the gown to the waist and sit with the arms hanging freely Assist client to supine position with head elevated Have the client stand and face the nurse with gown raised Lower the examination table with client in supine position

Have the client stand and face the nurse with gown raised

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? Palpation Ausculation Percussion Inspection

Palpation

During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment? Stand behind the patient and palpate the sides of the trachea. Observe the midline of the patient's neck while asking him or her to bear down. Lightly percuss slightly off midline over the patient's trachea. Auscultate over the patient's trachea while asking the patient to hold his or her own breath.

Stand behind the patient and palpate the sides of the trachea.

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed? State's nurse practice act Hospital policy Federal law Supervising physician

State's nurse practice act

When collecting subjective data, the nurse gives the client time and encouragement to do what? Express complaints Tell about the client's concerns List common findings Tell stories about his or her family

Tell about the client's concerns

Which situation would require the nurse to perform an urgent assessment? Select all that apply. Heart rate 64 Temperature 102.5 F (39.2 C) Pulseless leg Respiratory rate 24 Oxygen saturation 87%

Temperature 102.5 F (39.2 C) Pulseless leg Oxygen saturation 87%

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Wearing client identification bracelet Call bell within reach Bed at mid-level, locked position Correct intravenous lines and fluids Correct tubes and drains intact

Wearing client identification bracelet Call bell within reach Correct intravenous lines and fluids Correct tubes and drains intact

How should a nurse assess graphesthesia as a part of the physical assessment of arms, hands, and fingers? Place a quarter or key in the client's hand Write a number in the palm of the client's hand Evaluate sensitivity of position of fingers Ask the client to touch finger to nose with eyes closed

Write a number in the palm of the client's hand

Before beginning a physical assessment it is important for the nurse to acquire your client's written permission to perform the physical examination. acquire your client's verbal permission to perform the physical examination. explain to the client in detail how each body system will be assessed. explain to the client the purpose of every physical assessment technique you will be using.

acquire your client's verbal permission to perform the physical examination.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? after assessing cranial nerve function after assessing the anterior and posterior thorax after assessing the abdomen after assessing the motor function of the lower extremities

after assessing the motor function of the lower extremities

When integrating the total physical examination the nurse should perform the Mental Status Exam after examining all other body systems. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. integrate the rectal examination with the abdominal examination. assess peripheral vascular status when examining the lower extremities.

assess peripheral vascular status when examining the lower extremities.

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding? routine dental visits occur cranial nerve VII intact the client is pleasant the client likes children

cranial nerve VII intact

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side? determine symmetry compare with the medical record identify problems validate findings

determine symmetry

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? elbow flexion knee extension hip adduction hip abduction

elbow flexion (Elbow flexion should be assessed with the client in a seated position. Hip abduction, hip adduction, and knee extension should be assessed with the client in the supine or standing position.)

Two body systems that may be logically integrated and assessed at the same time are the eye and ear exams. ear and nose exams. ear exam and cranial nerves IV, VI, and VIII. eye exam and cranial nerves II, III, IV, and VI.

eye exam and cranial nerves II, III, IV, and VI.

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care? Depression Altered nutrition Fatigue Decreased activity level

fatigue

As part of the equipment, a nurse makes sure to have a speculum for an assessment to perform on a client. In which part of the assessment is the nurse most likely to use a speculum? Musculoskeletal Mouth and throat Male genitalia Female genitalia

female genitalia

During a physical examination the nurse assesses a client's anterior neck, carotid arteries, heart and lung sounds, and breasts before assisting the client to a seated position to examine the back. What is the best explanation for using this approach? the nurse was following the front to back assessment approach there was limited time available to complete the entire assessment the nurse did not want to miss collecting important information it limits the number of times the client had to change position

it limits the number of times the client had to change position

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose? otoscope ophthalmoscope cotton swab pen light

otoscope

The nurse is seeing a client with a recent history of exposure to a family member who has influenza. The client reports a throbbing toothache when bending forward. Which assessment should the nurse be sure to include in the physical examination? asking the client to smell coffee beans palpation of the sinuses assessing the heart sounds with the client in a lateral position palpation of the thyroid

palpation of the sinuses

The nurse is preparing to assess a client's anterior thorax. In which position should the client be placed to assess the heart? sitting supine standing right lateral

sitting

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a stethoscope for which purpose? to auscultate the lungs to check radial pulses to assess jugular venous pressure to assess pedal pulses

to auscultate the lungs

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information? (select all that apply) apical heart rate presence of cyanosis respiratory rate edema of the face and limbs presence of fluid in the lungs

edema of the face and limbs presence of cyanosis respiratory rate (By just observing the client, the nurse can assess for swelling in the face and limbs typically known as edema. In clients with congestive heart failure, edema can result from the expansion of extracellular fluid. Body areas commonly affected by this type of swelling are the eyes, hands, and lower legs. Cyanosis, a bluish discolouration of lips and skin due to decreased oxygenation of the blood, can be observed by the nurse during the general survey. The respiratory rate can be observed by watching the rise and fall of the client's chest over one minute. If the client has noisy breathing, this makes assessment of the respiratory rate even less difficult for the nurse to do as part of the general survey. Both apical heart rate and assessment for fluid in the lungs must be done using a stethoscope over the client's chest for auscultation.)

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage? Hearing loss Puffy "moon" face Tongue deviation Asymmetrical smile

Asymmetrical smile

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation? Auscultation of a patient's bowel sounds. Ausculation of a patient's heart murmur. Ausculation of a patient's apical heart rate. Auscultation of a patient's breath sounds.

Ausculation of a patient's heart murmur.

Order the parts of the physical examination of the neck in the correct sequence from first to last. All options must be used. 1 Palpate the thyroid. 2 Inspect the front of the neck for masses, enlarged nodes, or deviation. 3 Test the head and neck for range of motion. 4 Inspect the thyroid gland. 5 Palpate the head, neck, and subclavicular lymph nodes. 6 Inspect the position of the trachea

2, 6, 4, 3, 5, 1 (During the physical examination of the neck, begin with the assessments that will cause the least amount of discomfort to the most. Inspecting is noninvasive and should be done first. Inspecting first provides cues as to where to focus the assessment. Testing range of motion requires the client to move and may cause some discomfort depending on the nature of the chief report. This should be completed before the nurse begins to palpate. Palpation tends to cause the greatest discomfort during the physical examination. This should be left to the end of the assessment of each body area. The last part of this sequence should be to palpate the thyroid last because the nurse should move behind the client in order to effectively assess this area of the neck.)

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client? Collaborate with the physician to treat anemia Have the client explain an energy-conservation plan to offset the effects of fatigue Evaluate adequacy of exercise Evaluate urinary patterns

Collaborate with the physician to treat anemia

the nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client? Increase to 90 beats/minute Decrease to 44 beats/minute Increase to 112 beats/minute Decrease to 54 beats/minute

Decrease to 44 beats/minute

A high school football player presents to the hospital with dizziness, headache, sleepiness, increased tenting of the skin, and decreased turgor following an intensive practice in the summer heat. Which of the following nursing diagnoses can the nurse formulate based on this information? Deficient Fluid Volume Acute Confusion Risk for Imbalanced Fluid Volume Activity Intolerance

Deficient Fluid Volume

The nurse is preparing to conduct a physical examination of an adolescent client as part of general physical assessment. Which examination approach would be the most appropriate this client? Grouping body systems together to limit position changes Major body systems first approach Head-to-toe assessment Examining the right side of the body and then the left

Head-to-toe assessment

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this? Popliteal pulses 1-2+ Pulses 2-3+ Pulses 3-4+ Popliteal pulses 4+

Pulses 2-3+

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure? Identifying risk factors for altered health. Palpating the integument. Assessing the head and neck. Taking vital signs.

Taking vital signs. (The general survey is the first component of the physical assessment. It includes observing the patient's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the patient's overall health. Palpating the integument and assessing the head and neck are part of the physical assessment and identifying risk factors for altered health occurs in the health history.)

During the eye assessment, a nurse performs part of the neurologic examination for which cranial nerve? X VII XI IX

VII

The best approach to use when performing a total physical examination on a client is a toe-to-head integrated assessment of body systems. a head-to-toe integrated assessment of body systems. any approach that is convenient for you and the client. a total body system approach examining each body system individually.

a head-to-toe integrated assessment of body systems

The nurse completes the assessment of a client's heart. What should be assessed next? lower extremities breasts back abdomen

breasts

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? hand grasps cranial nerves bowel sounds carotid arteries

carotid arteries

A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client? evaluative focused urgent complete

complete

What type of assessment would a nurse perform on a patient being admitted to the hospital? Comprehensive Screening Acute Focused

comprehensive

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina? Deep palpation Transillumination Light palpation Inspection

Inspection (The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge)

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test? "Tell me which number I am tracing on your back with my finger." "Quickly flip your hands back and forth on your knees as I demonstrate." "Touch the tip of your nose, then the tip of my finger as I move my finger." "With your eyes closed, identify the object I place in your hand."

"With your eyes closed, identify the object I place in your hand."

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding? Ask if the client wants an observer for the assessment Ask for the client's permission to perform the assessment Uncover only the part being examined, covering everything else Decide whether to alter the process of starting at the head and proceeding to the feet

Ask for the client's permission to perform the assessment (Following completion of the health history previously described, the nurse explains the process for the physical examination, from head to toe and including auscultation of the heart and lung sounds, auscultation and palpation of the abdomen, and screening for neuromuscular problems. Because some assessments may be uncomfortable (eg, breast, gynecological), the nurse asks the client for permission to perform them. Once the nurse has the client's permission, the nurse would ask the client if the client prefers to have a third person in the room or, if appropriate, a same-gender nurse. The nurse would take care to preserve modesty; however, this would not be the immediate next step. Alterations to the order of the examination would be unlikely unless the client had an emergency concern.)

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority? Talking with family members Troubleshooting the infusion pump Assessing nutrition Assessing for pain

Assessing for pain

To properly evaluate the jugular venous pressure in a client, the nurse should perform which intervention? Lower the examination table with client in supine position Untie client's gown to expose posterior chest Secure gown and assist client to standing position Assist client to supine position with head elevated

Assist client to supine position with head elevated

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away? Complete blood count Electrolyte panel Liver function panel Coagulation studies

Complete blood count

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's: Health maintenance Coping skills Judgement and insight Level of consciousness

Level of consciousness

The nurse has palpated a patient's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted? The patient's weak pulses may be indicative of cardiovascular disease. The patient shows no signs of a circulatory health problem. The patient has increased radial pulses that may result from hypertension. The patient has normal peripheral pulses.

The patient's weak pulses may be indicative of cardiovascular disease.

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response? cranial nerve VIII is intact the client knows the difference between left and right the client understands directions cranial nerve XI is intact

cranial nerve VIII is intact

While conducting a physical examination with the client in the seated position, the nurse begins the cardiovascular assessment. In order to listen for aortic insufficiency, the nurse should ask the client to move into which position? prone supine standing lean forward

lean forward (Leaning forward brings the ventricular apex and left ventricular outflow closer to the chest wall, enhancing detection of the point of maximal impulse and aortic insufficiency. For much of the cardiovascular examination, the client should be in the supine position; however, it is difficult to assess aortic insufficiency in this way. The three positions required for the cardiovascular assessment are sitting, lying with the head of the bed increased to 30 degrees, and left lateral decubitus.)