EAQ: Health and Physical Assessment
The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond? 1 "You need to receive the pneumococcal vaccine every other year." 2 "The pneumococcal vaccine should be received in early autumn every year." 3 "You should get the flu and pneumococcal vaccines at your annual physical examination." 4 "It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."
"It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose." The Centers for Disease Control and Prevention recommend that adults be immunized with pneumococcal vaccine at age 65 years or older with a single dose of the vaccine; if the pneumococcal vaccine was received before 65 years of age or if there is the highest risk of fatal pneumococcal infection, revaccination should occur 5 years after the initial vaccination. The pneumococcal vaccine should not be administered every 2 years. The pneumococcal vaccine should not be administered annually.
Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. 1 Client with corneal arcus 2 Client with periorbital edema 3 Client with decreased skin turgor 4 Client with paleness of conjunctivae 5 Client with yellow lipid lesions on eyelids
Client with corneal arcus Client with yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.
Arrange the steps taken by a nurse while assessing the visual level of a client in sequential order. Direct the client to stand or sit 60 cm away from eye level Close the opposite eye to superimpose the field of vision Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye Ask the client to report when he or she is able to see the finger Move a finger equidistant between the nurse and the client outside the field of vision
Direct the client to stand or sit 60 cm away from eye level Ask the client to close his or her left or right eye gently and look directly at the nurse's opposite eye Close the opposite eye to superimpose the field of vision Move a finger equidistant between the nurse and the client outside the field of vision Ask the client to report when he or she is able to see the finger The first step while assessing the visual level of the client is to direct the client to stand or sit 60 cm away at eye level. Next, the nurse should ask the client to gently close or cover one eye and look at the nurse's eye directly opposite. Then, the nurse should also close his or her right eye to superimpose the field of vision. After this, the nurse should move a finger equidistant between the nurse and the client outside the field of vision. Finally, the nurse should ask the client to report when he or she is able to see the finger.
Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination? 1 Inflating the cuff too slowly 2 Wrapping the cuff too loosely 3 Applying the stethoscope too firmly 4 Repeating the assessment too quickly
Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.
A pregnant woman in her second trimester arrived at the hospital for a general health checkup. The physician recommended a pelvic examination to the client. Which position is most suitable for assessing the client in this condition? 1 Sims position 2 Supine position 3 Lithotomy position 4 Dorsal recumbent position
Lithotomy position Lithotomy position provides maximum exposure to the female genitalia and easy examination of the region. Therefore this position is recommended for examining pregnant women. Sims position is indicated for rectal and vaginal examinations. Supine position is recommended for examining anterior thorax, lungs, breasts, axilla, heart abdomen, extremities, and pulse. Dorsal recumbent position is mainly indicated to examine the abdomen because it promotes abdominal relaxation.
The nurse cares for an unconscious client who underwent head surgery. Which site would be best used to monitor body temperature? 1 Skin 2 Oral 3 Axilla 4 Rectal
Rectal Although the oral route is the most common route for monitoring body temperature, clients who are unconscious should have their temperatures monitored rectally. Skin temperature may be impaired due to diaphoresis; this measurement may not reliable. The axilla temperature may underestimate the core temperature.
A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse should monitor for which initial sign of fluid overload? 1 Crackles in the lungs 2 Decreased heart rate 3 Decreased blood pressure 4 Cyanosis
Crackles in the lungs Crackles, or rales, in the lungs are an early sign of pulmonary congestion and edema caused by fluid overload. Clients with fluid overload will usually demonstrate an increased heart rate and increased blood pressure. A decreased heart rate and decreased blood pressure and cyanosis in a client with fluid overload would be very late and fatal signs.
The nurse is assessing a young client who presents with recurrent gastrointestinal disorders. On further assessment, the nurse learns that the client is experiencing job-related pressure. What is the most important nursing intervention for this client? 1 Educate the client on managing stress. 2 Teach the client to maintain a balanced diet. 3 Instruct the client to have regular health checkups. 4 Ask the client to use sunscreen when working outdoors.
Educate the client on managing stress. The client is experiencing job-related pressure, so the nurse should educate the client about managing stress as it is a lifestyle risk factor. Stress threatens both mental health and physical well-being. Stress is associated with illnesses such as heart disease, cancer, and gastrointestinal disorders. The nurse teaches the client to maintain a balanced diet as a primary preventive care to promote health. The nurse should instruct the client to have regular health checkups as a primary preventive measure. The nurse should ask the client to use sunscreen when working outdoors to avoid excess sun exposure and prevent skin cancer.
The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant when? 1 First 2 Second 3 Third 4 Last
Last The nurse should systematically assess the abdomen concluding with the symptomatic area. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere with the assessment.
A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. What are the best sites to assess this condition? Select all that apply. 1 Lips 2 Sclera 3 Mouth 4 Sacrum 5 Nail beds 6 Shoulders
Lips Mouth Nail beds Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, while shoulders are assessed to confirm the condition of erythema.
A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator? 1 Pulse rate 2 Tissue turgor 3 Specific gravity 4 Body temperature
Tissue turgor Skin elasticity will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not decrease.
