chapter 12

The nurse assesses a client with lower abdominal pain who reports localized tenderness in the right lower quadrant with right flank pain. Which assessment should the nurse conduct next?

Palpate the right lower quadrant for rebound tenderness

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?

Parkinson's disease

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Vestibule, nasal passages, and nasopharynx

he nurse suspects an abdominal aortic aneurysm when what is assessed?

abdominal bruit

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

cup of water

Which genetic disorder would the nurse ask about when conducting a family history regarding upper respiratory illness?

cystic fibroses

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

frenulum

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?

hypothyroidism

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

irritable bowel syndrome

The headache impact test is used for?

may be used to assess the impact of headache on a client's activities of daily living

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

open the mouth

A client has a history of multiple abdominal surgeries from a gunshot wound 3 years ago. The client is currently reporting severe abdominal pain. Auscultation reveals high-pitched, rushing sounds. These sounds could be a sign of what condition?

partial bowel obstruction

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

receding and ischemic gums

A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?

sit with head erect and at eye level of the nurse

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

the node is fixed and rubbery

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection. On inspection of the patient's tongue, the nurse should anticipate what appearance?

thick white plaques on the tongue surface

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

Did you have any visual changes before the headache?

You are assessing a patient for acute cholecystitis. What sign would you assess for?

Murphy's sign

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds

Where are acorn-shaped enlarged bones found?

Paget's disease

A client's bladder is found to be distended. At which location would the nurse begin palpating?

at the symphysis pubis

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

before I get ready to examine the painful area, I will let you know in plenty of time

What is the most common type of hyperthyroidism?

grave's disease

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

hypothyroidism

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

suprapubic

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

4+

For a 60 year old client who is deemed to be average risk for colorectal cancer, the nurse should provide which of the following instructions? (Select all that apply.) A- Schedule a flexible sigmoidoscopy every 5 years. B- Follow an every 10-year colonoscopy schedule. C- Determine when to have a double contrast barium enema every 2 years. D- Have a fecal occult blood test done annually.

A B D

The peritoneum is a serous membrane that contains which of the following?

A parietal layer

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regards to this finding?

How many times have you been pregnant?

A nurse examines a client with a paralytic ileus. Which alteration in bowel sounds should the nurse expect to find with auscultation of the client's abdomen?

absent

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

acromegaly

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?

acute bacterial sinusitis

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

acute infection

When assessing for an appendicitis, what signs might the nurse look for? (Select all that apply.) A- Psoas sign B- Rovsing sign C- Cutaneous hyperesthesia

all of them

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

always use seatbelt

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?

an enlarged liver during palpation

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?

angular chelitis

During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. What would be most important for the nurse to assess?

checking for a deviated nasal septum

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

compressing the arteries bilaterally

The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?

decreased serum calcium level from blood work

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

document this as an expected assessment finding

The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?

either side of frenulum on floor of mouth

A client diagnosed with Sjogren syndrome should be given which instructions?

eye dropping and sucking on hard candy is used to relieve dryness

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

flex the head toward the side being examined

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

history of allergies

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

impending stroke

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

in the midline, a few centimeters behind the tip of the mandible

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following?

linea alba

The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ?

liver

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible

masses

The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?

monitor pulse and blood pressure every 15 minutes until stable

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?

sternocleidomastoid

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

sternomastoid

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

stop palpating and get medical assistance

A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?

the quadrant should be palpated last

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

the underlying bones

What's a mnemonic assessment tool used for?

to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain.

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

tympany

During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis?

vision acuity