Developmental Stages: Health & Physical Data Collection

The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?

"I don't need to do that; I'm too old for that." Rationale: BSE should be done even after menopause. No one is too old to get breast cancer. The other options... "I examine my breasts in the shower." "I do BSE 7 days after I get my period." "I lie on my back to examine my breasts." , reflect an accurate understanding of BSE.

The nurse is checking the apical heart rate of a client with a complaint of angina. The nurse places the stethoscope in which anatomical area? Refer to figure.

4. Rationale: The apical heart rate is assessed best by placing the stethoscope in the mitral area, which is located in the fifth intercostal space on the left side of the chest at the apex of the heart. The aortic area is located in the second intercostal space just right of the sternum. Erb's point is located in the third intercostal space just left of the sternum. The pulmonic area is located in the second intercostal space just left of the sternum.

The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? Refer to figure.

2. Rationale: The spleen is located in the left upper quadrant of the abdomen and can be palpated in the area. Therefore, the other options are incorrect.

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first? Refer to the figure.

3. Rationale: When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are normally always present here. The nurse then proceeds to the other quadrants 1, 2, and 4.

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

Acute otitis media with effusion. A physical obstruction to the transmission of sound waves. Rationale: A conductive hearing loss is as a result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?

Asks the client to block one ear at a time Rationale: In a voice test, the nurse, while facing the client, stands 1 to 2 feet away and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately. Although closing the eyes would prevent lip reading, it is not a condition of the screening.

The nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which finding would most likely assist in verifying the suspicion?

Bald spots on the scalp. Rationale: Bald spots on the scalp are most likely to be associated with physical abuse. The most likely findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain; swelling or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may be indicative of physical neglect.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply.

Collect data to determine factors for fall risk. Instruct the client to ask for assistance when getting up to walk. Rationale: In the Romberg test, the client is asked to stand with the feet together, the arms at the sides, and to close the eyes and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking. Decreasing the light in the environment is done if a client has photophobia (sensitive to light). Clients with a shuffling gait as with Parkinson's disease should lift their legs high when walking. Clients experiencing dysphagia, which often occurs with stroke, should eat sitting upright and perform double swallowing.

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition?

Hyperlipidemia. Rationale: Garlic is an herbal supplement that is used to treat hyperlipidemia and hypertension. An herbal supplement that may be used to treat eczema is evening primrose. Insomnia has been treated with both valerian root and chamomile. Migraines have been treated with feverfew.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?

Document the findings. Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. Therefore, because the findings are normal, the nurse should document the findings.

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision. Rationale: The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise. Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.

A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. The student displays correct understanding if the student lists which signs? Select all that apply.

Hegar's Chadwick's McDonald's Rationale: Hegar's sign is softening of the lower uterine segment. This allows the body of the uterus to flex against the cervix, which is termed McDonald's sign. Chadwick's sign is a purple or blue discoloration of the cervix, vagina, and vulva caused by increased vascular congestion. Moro's sign is also called the startle reflex seen in normal newborns. McBurney's sign is pain in the lower right abdominal quadrant and is frequently seen in appendicitis.

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas?

In the groove behind the medial malleolus and the Achilles tendon. Rationale: The posterior tibialis pulse can be located in the groove behind the medial malleolus or the inside of the ankle behind the bone. The femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spine. Popliteal pulses, although difficult to palpate, may be felt behind the knee in the popliteal fossa. The dorsalis pedis pulse is located on the top of the foot.

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

Inspecting the abdomen. Rationale: Examination of the abdomen begins with inspection. Auscultation follows inspection, then palpation and percussion is done last.

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection. Rationale: The appropriate technique for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered. The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa. Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze. Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. The Ishihara chart is used to detect color blindness. A Snellen eye chart is used to determine visual acuity and cranial nerve II (optic nerve) functioning. Testing the corneal light reflex, shining a penlight in the eyes of a client gazing straight ahead, should demonstrate the corneal reflection in the exact position in each eye and parallel alignment.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. Rationale: Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply.

The client reports stiffness and soreness in the neck area. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. Rationale: Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses, or fungi. The client with meningitis experiences discomfort when pressure is placed on certain areas that irritate the inflamed meninges. Neck stiffness (nuchal rigidity) is an early sign of meningitis. A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner and the client reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Unequal pupils and slowed pupillary response to light is a sign of increased intracranial pressure. This may occur in clients who are critically ill, but it is not a sign of meningeal irritation. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. This posturing occurs with severe brain damage and the client requires emergency medical attention.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested. Rationale: Visual acuity is tested in one eye at a time, and then in both eyes together, with the client comfortably seated. Begin with the right eye while the left eye is covered, and then test the left eye with the right eye covered, followed by testing both eyes together. Visual acuity is measured with or without corrective lenses, with the client standing at a distance of 20 feet from the chart.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

Wheezes and use of accessory muscles. Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands. Rationale: Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the central nervous system such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart sounds is important but is secondary to determining the neurological status. There is no information related to the need to check for a pulse deficit (difference between the apical and radial pulse). The use of incentive spirometry is indicated for shallow breathing and post-operatively.

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply.

Perform TSE after a shower or bath. Perform TSE on the same day each month. Perform TSE by rolling each testicle between the thumb and fingers. Rationale: The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The nurse should instruct the client to select a day of the month and perform the examination on the same day each month to avoid forgetting to do the examination. TSE is done by the client rolling each testicle between the thumb and fingers. The client should seek medical attention if a lump, mass, or swelling of the testicle is detected. The bladder does not have to be empty to complete the examination. There is no connection between urethral discharge and TSE.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Listening to lung sounds Obtaining the client's temperature Obtaining information about the client's respirations Rationale: A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply. Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes. Listen in each quadrant for gurgling sounds indicating movement. If no sounds are audible in 2 minutes, notify the primary health care provider. If 20 sounds are noted within 1 minute, notify the primary health care provider.

Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes. Listen in each quadrant for gurgling sounds indicating movement. Rationale: Dividing the abdomen into four quadrants allows listening to each section of the colon. Not hearing audible peristalsis within 5 minutes may indicate a paralytic ileus. Listening in each quadrant for gurgling sounds indicates peristalsis, which may be missed if not listened for separately. Option 4 is incorrect; the nurse should listen for 5 minutes in each quadrant before determining that bowel sounds are absent. Option 5 is incorrect because 20 sounds within 1 minute would be within the normal range.