HEALTH ASSESS- PREP U - CH18, 7, 8, 9
A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? swelling warmth redness tenderness subcutaneous nodules
swelling warmth reness tenderness
The nurse is going to take blood pressure on a client who has had a previous left mastectomy with lymph node dissection. What would be an appropriate action by the nurse?
take the blood pressure in the right arm
A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of
arthritis
A nurse conducts a physical exam of the musculoskeletal system of a patient who reports upper arm pain. What instruction should the nurse provide the patient when assessing flexion of the elbow?
"Bend your elbow"
A nurse enters a client's room to conduct an assessment. The client is crying and states they have so much pain. What is the best response of the nurse?
"Could you tell me more about your pain?"
A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mmHg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?
120/55 mmHg
How would a nurse document normal muscle strength?
5/5
A client presents to the ED with pain in the upper right quadrant that worsens after eating. The clients describes the pain as sharp. stabbing, and sometimes intense. This is a description of which type of pain?
Acute
A nurse performs a focused assessment on a patient reporting back pain. The nurse uses COLDSPA to further assess the client's pain. Character: sharp; onset: yesterday; location: low back; duration: persistent since yesterday; severity: 8 out of 10; pattern: continuous; associated factors: movement. The nurse determines the patient is experiencing which of the following classifications of pain?
Acute inflammatory pain
Which joint movement is a nurse testing when asking a client to move an extremity towards the body?
Adduction
A nurse reviews the vital signs of a new client: temp 99.3 F (37.38C), pulse 105 beats/min, blood pressure 143/83 mm Hg. and respiratory rate 22 breaths/min. What action should the nurse take first?
Ask the client if they are experiencing any discomfort
The nurse palpates a client's pulse and notes that the rate is 61 beats per minute, with an amplitude that is weak and thready. What would the nurse do next?
Assess the client's pulse at the carotid site
A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The clients shows signs of pain by facial expression. The nurse knows the popping and cracking noises should be charted by what?
Crepitus
A nurse is caring for a client who is recovering from a stroke. The nurse assesses the muscle strength of the client's arm and finds that the joint exhibits active motion against gravity. Which of the following should the nurse document to classify muscle strength based on this finding?
Average weakness
A client presents to the clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?
Cervical strain
The information gathered during a general during a general survey provides the nurse primarily with which of the following?
Clues about the overall health of the client
A nurse takes the vital signs on a new 35-year-old client: temperature 98.5° F (36.94° C), pulse 87 beats/min and regular, blood pressure 125/77 mm Hg on the right arm and 120/75 mm Hg on the left arm, and respiratory rate 16 breaths/min. What action should the nurse take?
Document normal findings
A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?
Dorsiflexion and plantar flexion
A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?
Flexion
While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint? What would the nurse include?
Flexion
The nurse is assessing the range of motion (ROM) of a client's joints. What would the nurse use to assess flexion and extension of a joint if the client complains of pain on examination?
Goniometer
A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?
Gouty arthritis
A client complains of pain in several ares of the body. How should the nurse assess this client's pain?
Have the client rate each location seperately
A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?
How does the pain influence you overall mood?
The nurse explains to the client that smoking has what effect on the body? Select all that apply Hypertension Vasoconstriction Peripheral vascular disease Vasodilation Hypotension
Hypertension Vasoconstriction Peripheral vascular disease
The nurse notes limitation in active range of motion of a client's right shoulder. What would the nurse do next?
Measure range of motion with a goniometer
A client recovering from a stroke complains of pain. The nurse suspects this client is most likely experiencing which type of pain?
Neuropathic
During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?
Nurse R may obtain a blood pressure reading that is higher than actual blood pressure.
In assessing a client's temporomandibular (TMJ), the nurse asks the client to move the jaw forward. This movement is known as which of the following?
Protraction
What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome?
Reports of tingling, numbness, and pain in the involved wrist
The nurse is taking routine vital signs toward the end of the shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?
Retake the blood pressure
The nurse is assessing an elderly client's BP and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to the client's arteries?
Rigid
The nurse enters an older client's room to assess for pain and discovers the client is hard of hearing. What is the nurse's best action?
Speak to the client face to face
The nurse assesses a client's musculoskeletal system as shown. What is the nurse assessing?
Supraspinatus strength
A client has an oral temperature of 37.2C (99F). The nurse interviews the client. Which of the following pieces of data could be an influence on this high body temp?
The client has just run 3 miles outside before coming to the interview
After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if the alignment is normal with noticeable defect?
The head is midline and aligned with the spine
A nurse is assessing the blood pressure of a client using the Korotkoff's sounds technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?
There is an osculatory gap
A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding?
Toes point out
How would a nurse measure maximum flexion of a joint?
Using a goniometer
A nurse notices that a client's flexibility of the right elbow is less than the left elbow. What is an appropriate action by the nurse in regard to this finding?
measure movement with a goniometer
A patient has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?
scoliosis