Chapter 25 - Physical/ Health Assessment
To evaluate a client's cerebellar function, a nurse should ask:
"Do you have any problems with balance?To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination
Students in a health class are discussing birth control and prevention of sexually transmitted disease. The school nurse would know that teaching has been effective if the students state which of the following?
"Responsible sex involves using condoms and spermicides for protection and birth control.This comment indicates an understanding of ways to lessen the incidence of sexually transmitted illnesses by condom use. It also indicates that use of a spermicide and condom will help to prevent unwanted pregnancies.
The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?
Inspect the left lower leg for areas of redness. Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.
vesicular breath sounds
normal sound of respirations heard on auscultation over peripheral lung areas
A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?
Obtain vital signs.The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored.
S1 is loudest at the apex, and S2 is loudest at the base.
The S1 sound — the "lub" sound — is loudest at the apex of the heart. It sounds longer, lower, and louder there than the S2. The S2 — the "dub" sound — is loudest at the base. It sounds shorter, sharper, higher, and louder there than the S1.
he nurse is caring for a client who has become unresponsive, the blood pressure is 80/40 mm Hg, and SpO2 is 90% on 50% face mask. The nurse should:
The rapid response team should be called immediately to evaluate and treat the client.
A client is experiencing acute alcohol withdrawal. What complication should the nurse anticipate based on the present condition?
There is an increased potential for seizures and hallucinationsThe seizure threshold is lowered in the brain with acute alcohol withdrawal. Associated electrolyte imbalances exist.
Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation
Urinary output of 20 mL/hr over 2 hours.Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the physician.
A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should
With the client holding his breath, the nurse uses the bell of the stethoscope to auscultate the carotid arteries for bruits.
The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?
a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and This child is exhibiting signs and symptoms of epiglottitis, which is a medical emergency due to the risk of complete airway obstruction.
After completing the health history and physical assessment
organize all health assessment data to identify actual and potential health problems, identify nursing diagnoses, plan appropriate care, and evaluate the patient's responses to interventions.
Diagnostic procedures and tests
provide crucial information about a patient's health, and their results become a part of the total health assessment.
adventitious breath sounds
abnormal breath sound heard over the lungs
precordium
anterior surface of the chest wall overlying the heart and its related structures
body mass index
ratio of height to weight
A 23-year-old nulliparous client visiting the clinic for a routine examination tells the nurse that she desires to use the basal body temperature method for family planning. What instructions should the nurse give the client
basal body temperature method requires that the client take her temperature each morning before getting out of bed, preferably at the same time each day before eating or any other activity. Just before the day of ovulation, the temperature falls by 0.5° F (0.28° C).
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). The nurse should
client's urine specific gravity is elevated. Specific gravity is a reflection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute.
ecchymosis
collection of blood in subcutaneous tissues that causes a purplish discoloration
complete blood count
determine anemia
test for occult blood
determines blood in the stool
ECG (electrocardiogram)
evaluates the report of chest pain
diaphoresis
excessive amount of perspiration, such as when the entire skin is moist
bronchial sounds
heard over the trachea; high in pitch and intensity, with expiration being longer than inspiration
four primary assessment technique
inspection, palpation, percussion, and auscultation
bronchovesicular sounds
normal breath sounds heard over the upper anterior chest and intercostal area
petechiae
small, purplish hemorrhagic spots on the skin that do not blanch with applied pressure
bruits
unusual sound, usually abnormal, heard in auscultation
