health aseessment random questions review

To assess for the presence of a carotid artery bruit, which action should the nurse include?

A bruit indicates the presence of turbulent blood flow and is best assessed by lightly placing the bell of the stethoscope over the artery and listening for a blowing or whooshing sound.

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture.A. extrapyramidal systemB. cerebellumC. upper and lower motor neuronsD. basal ganglia

B. cerebellumThe cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., the posture balance of the body), and muscle tone.The extrapyramidal system maintains muscle tone and control body movements, especially gross automatic movements such as walking.The upper motor neurons are located within the central nervous system and influence or modify the lower motor neurons and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves.The basal ganglia controls automatic associated movements of the body.

During the assessment of sensory function of a client, the nurse learns that the client has decreased pain sensation. Which of the following should the nurse document about this finding?A. AnesthesiaB. AnalgesiaC. HypalgesiaD. Hypoesthesia

C. HypalgesiaHypalgesia is the term used for decreased pain sensation.Analgesia is the absence of pain sensation.Anesthesia is the inability to perceive the sense of touch.Hypoesthesia is decreased, but not absent touch sensation.

The nurse asks the client to close their eyes, then moves the client's finger up and down. The client identifies the direction of movement. Which of the following is being tested?A. StereognosisB. TopognosisC. KinesthesiaD. Graphesthesia

C. KinesthesiaKinesthesia is awareness of position and sense of joint movement. The client should be able to identify the direction of movement with their eyes closed.Stereognosis is the ability to identify an object placed in the hand with eyes closed.Graphesthesia is the ability to perceive writing on the skin.Topognosis is the ability of the client to identify an area of the body that has been touched.

The nurse plans to assess a client's cardinal fields of vision. What action should the nurse include?

Fields of vision are assessed by observing the movement of the client's eyes as they follow the examiner's finger through the cardinal fields of vision.

A Nurse is preparing to measure the apical pulse of a client. The nurse places the diaphragm of the stethoscope on which cardiac site?

Mitral area

A Nurse is performing an abdominal assessment on a client. The nurse determines which of the following findings should be reported to the physician?

Pulsations between the umbilicus and pubisRationale: Presence of pulsation in that area indicates presence of aortic aneurysm- should be reported to physician

During a physical exam, the nurse observes the external genitalia of an older adult female. The nurse notes that the client's pubic hair is thin and sparse. What follow-up action should the nurse take in response to this finding?

Rationale Changes in estrogen production following menopause result in many physical changes, including a reduction and thinning of pubic hair in the older adult woman. The nurse should document this normal finding in the client's medical record.

In assessing a client's muscle strength in the arms, the nurse observes as the client flexes both elbows fully and smoothly. What action should the nurse take next?

Rationale Muscle strength is assessed by applying opposing force to the client's flexed muscle and noting the client's strength in resisting that force.

The nurse listens for a client's heart sounds by firmly pressing the diaphragm of the stethoscope against the client's chest. After hearing normal heart sounds, the nurse wants to listen for extra heart sounds. What action should the nurse take first?

Rationale The diaphragm of the stethoscope is best for hearing high pitched sounds, including normal heart and lung sounds. To best listen for extra heart sounds, the nurse should first turn the endpiece of the stethoscope so that the bell of the stethoscope can be used to hear these low-pitched sounds.

During the health history, a client describes a symptom to the nurse. Which information about the symptom is best obtained by use of a numeric scale?

Rationale The severity of a symptom, which is a subjective description of how "bad" the symptom feels to the client, can be rated by a scale such as a numeric or picture scale, allowing for more consistent, ongoing evaluation of improvement or worsening of the symptom's severity. Pain is a good example of how severity might be ranked using a scale.

After performing an initial abdominal assessment on a client with a diagnosis of a cholelithiasis, the nurse documents that the bowels sounds are normal. Which of the following sounds would be considered as norma?

Relatively high pitched clicks or gurgles auscultated on all four quadrants

A Nurse is preparing to perform an Abdominal examination of a patient. The best position to place the client is

Supine with head raised slightly and knees slightly flexed Rationale: The Position relaxes the abdominal muscles- a totally supine position makes the abdominal muscles to be taut

In assessing a client's chest expansion, the nurse's hands are positioned on the client's posterior thorax. As the client takes a deep breath, the nurse should observe which movement?

The nurse's hands are positioned so that the thumbs are located bilaterally at the level of T9 or T10. During the client's inhalation, the nurse should observe for symmetric movement of the thumbs and note any asymmetric movement, indicating a problem with lung expansion.

The nurse assesses the skin of an older adult client. Which finding warrants the most immediate follow-up by the nurse?

bruises of several different colors.. rationale: bruises of several colors indicate brusing that occurred at different times. This warrants the most immediate assessment to determine fall risk or possible elder abuse.

The nurse learns in report that a client has developed ascites. Which action best confirms the presence of ascites?

check for an abdominal fluid wave. rationale- to best confirm the presence of ascites, fluid accumulation in the abdomen, the nurse should palpate for the presence of an abdominal fluid wave.