Health Assessment

The nurse obtains a client's weight as part of the health history. The client weighs 186 lb. The nurse determines that this client weighs how many kilograms? Please round your answer to the nearest tenth.

84.5 To convert the client's weight in pounds to kilograms, the nurse would divide 186 by 2.2 to arrive at a weight of 84.5 kg.

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-ft (2-m) ladder. Which action by the nurse is the most important to take? A. Assess pupil shape and reactivity to light B. Assess the client's orientation to person, place, and time C. Assess BP and apical heart rate D. Assess the client's arterial blood gases level

A. Assess pupil shape and reactivity to light Changes in pupillary shape and reactivity to light are early signs of increased intracranial pressure (ICP). The client's orientation to person, place, and time cannot be assessed because he is unconscious. Changes in blood pressure (widening pulse pressure) and decreased heart rate are a late sign of ICP. Although carbon dioxide levels will increase intracranial pressure, it is not a test that the nurse can do at the bedside to assess ICP.

The nurse should use the bell of the stethoscope during auscultation of: A. a client's heart murmur B. a client's apical heart rate C. a client's breath sounds D. a client's bowel sounds

A. a client's heart murmur The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? A. Warm the equipment B. Ask the client to empty her bladder C. Place the client in a semi-Fowler's position D. Measure height and weight

B. Ask the client to empty her bladder Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next? A. Palpate the abdomen B. Auscultate the abdomen C. Measure abdominal girth D. Percuss the abdomen

B. Auscultate the abdomen The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment? A. Ongoing assessment B. Comprehensive assessment C. Emergency assessment D. Focused assessment

B. Comprehensive assessment A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations.

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

B. Cyanosis The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis, which is an indication of hypoxia (inadequate oxygenation). Therefore, the nurse should immediately report this finding to the provider.

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? Select all that apply. A. "Close your eyes." B. "Tell me when you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

C. "Clench your teeth." E. "Tell me when you feel a touch."

During assessment of the lower extremities, the nurse notes the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4 mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result? A. bilateral lower extremities within normal limits B. 1+ pitting edema noted on bilateral lower extremities C. 2+ pitting edema noted on bilateral lower extremities D. brawny edema noted over bilateral lower extermities

C. 2+ pitting edema noted on bilateral lower extremities Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour. Brawny edema occurs when fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, and there is no pitting, so the tissue palpates as firm or hard and the skin surface is shiny, warm, and moist.

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve? A. Olfactory B. Optic C. Facial D. Vagus

C. Facial

A nurse is performing a head and neck exam for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

C. Tooth loss D. Glare intolerance E. Thickened eardrums NOT A or B: The nurse should expect an older adult's gums to be pale; The nurse should expect an older adult's vocal pitch to rise

A 34-year-old client of Chinese descent has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pain, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client? A. the face and hands B. the neck and chest C. the sclera of the eye D. the mucous membranes of the mouth

C. the sclera of the eye Jaundice can be observed in the face and body of people with very fair beige-colored skin with pinkish undertones, as is often seen in northern Europeans. The naturally fair skin of Asians has a yellowish undertone, as does the skin of southern Europeans, and some Hispanics and African Americans. The best location to observe for jaundice in this population is the sclera of the eye. Jaundice in people with light brown skin with reddish undertones, such as Native Americans, some Hispanics and blacks, North Africans, and Arabians is best observed in the sclera. People with very dark brown skin with purplish undertones, such as Sub-Saharan Africans, some blacks, Indians, and Native Australians often have normal yellow subconjunctival fatty deposits in the outer sclera. Do not confuse this with scleral jaundice. The best location to observe jaundice in this population is the junction of the hard and soft palate in the mouth, viewed with a non-LED flashlight. LED flashlights have an ultra-bright, bluish-white light that can alter color perception. The mucous membranes of the mouth is the location to observe for cyanosis.

What percentage of weight change in 6 months is considered abnormal? A. 1% B. 2% C. 5% D. 10%

D. 10%

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant? A. Hairless, shiny legs B. 2+ edema to lower extremities C. Thick overgrown toenails D. An absent popliteal pulse

D. An absent popliteal pulse Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.

A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease? A. Palpate the thyroid gland B. Inspect the client's ability to move his neck C. Inspect & palpate the left and then the right carotid arteries D. Inspect & palpate the supraclavicular area

D. Inspect & palpate the supraclavicular area Inspection and palpation of the supraclavicular area can detect enlarged lymph nodes. Palpation of the thyroid gland can reveal thyroid enlargement, tenderness, or nodules. Inspection of the client's ability to move the neck assesses neck range of motion. Inspection and palpation of the left and right carotid arteries evaluates circulation through these arteries.

Which technique should the nurse use to assess the pupillary light reflex on a client? A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. B. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. C. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. D. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

A. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

A nurse is auscultating the lungs of a client. During the auscultation, the nurse hears high-pitched, harsh, blowing sounds over the larynx and trachea. The nurse identifies these sounds as which type? A. Bronchial breath sounds B. Bronchovesicular breath sounds C. Vesicular breath sounds D. Adventitious breath sounds

A. Bronchial breath sounds Normal breath sounds vary over different parts of the lungs. Bronchial breath sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Adventitious breath sounds (added, abnormal sounds) are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways.

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face

A. Capillary refills less than 3 seconds D. Thick skin on the soles of the feet [AND palms of hands] E. Numerous light brown macules on the face [such as freckles] NOT B or C: The nurse should not expect pitting edema, which can reflect excess fluid that has accumulated in the body tissues; The nurse should not expect pallor in the nail beds, which can reflect anemia or impaired circulation

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? A. Circumoral cyanosis when the client is at rest B. A blue-black macular area over the sacral area C. The anterior fontanel bulging when the client cries D. The abdomen appearing large in relation to the pelvis

A. Circumoral cyanosis when the client is at rest Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, African-American, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present? A. Crackles B. a friction rub C. Sonorous wheeze D. Sibilant wheeze

A. Crackles Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. Sibilant wheezes are high-pitched and shrill sounding breath sounds that occur when the airway becomes narrowed. They often have a musical quality to them. These are the typical wheezes heard when listening to an asthmatic patient. A sonorous wheeze is an added sound with a musical pitch occurring during inspiration or expiration, heard on auscultation of the chest, and caused by air passing through bronchi that are narrowed by inflammation, spasm of smooth muscle, or presence of mucus in the lumen. A friction rub is a continuous, grating-type sound.

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply. A. Decreased near vision B. Decreased facial hair C. Increased gag reflex D. Increased systolic and diastolic BP E. Decreased tissue elasticity F. Increased mental confusion

A. Decreased near vision D. Increased systolic and diastolic BP E. Decreased tissue elasticity Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging. Decreased facial hair, increased gag reflex, and increased mental confusion are not normal signs of aging.

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. What would be the nurse's response to this finding? A. Document and report the finding of abnormal Rhonchi breath sounds B. Document the finding of normal bronchovesicular breath sounds C. Document and report the finding of abnormal stridor breath sounds D. Document the finding of normal bronchial sounds

A. Document and report the finding of abnormal Rhonchi breath sounds

The nurse is palpating a client's precordium. Which result is an expected clinical finding? A. Palpable pulsation over the mitral area B. Palpable thrill over the aortic area C. Palpable heave over the pulmonic area D. Palpable vibration over the right sternal border

A. Palpable pulsation over the mitral area A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

A nurse is assessing a client's thyroid gland as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline

A. Palpating the thyroid in the lower half the neck D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline NOT B or C: An avg size thyroid gland is not visible on inspection; A bruit indicates increased bood flow, possibly due to hyperthyroidism

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? A. Palpation B. Inspection C. Percussion D. Auscultation

A. Palpation The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

A. Tympany [drumlike percussion over abdomen; indicates air in stomach] B. High-pitch clicks [occurring about 35 times/min] NOT C, D, or E: Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to come foods; Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings; Bruits indicate narrowed blood vessels and are unexpected findings

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A. Wheezes B. Fine crackles C. Pleural friction rub D. Stertorous breathing

A. Wheezes Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should: A. avoid a position change that requires turning B. have the client turn from side to side and assess pain C. have the client lay on his right side, then palpate the area D. elevate the legs, bending at the knee while the client is supine

A. avoid a position change that requires turning Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: A. ptosis B. entropion C. ectropion D. miosis

A. ptosis Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? A. Hypertension and circulatory overload B. Decreased cardiac output C. Impaired kidney function D. Inflammation of a vein

B. Decreased cardiac output Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse.Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses.

A nurse is assessing an adult client's ear canals with an otoscope as part of a head and neck exam. Which of the following action should the nurse take? (Select all that apply) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2 to 2.5cm (0.8 to 1in.) D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the TM in a cone shape

B. Insert the speculum slightly down and forward D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape NOT A or C: The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years; The nurse should insert the speculum 1 to 1.5 cm (0.4 to 0.6 in.)

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? A. It is normal B. It is distended C. It is dissecting D. It is inflamed

B. It is distended Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.

A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling

B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity NOT A or E: The older adult client as aging occurs will have skin that becomes thin and translucent and is not a factor for tenting of the skin; The oder adult client who has aging skin does become wrinkled, but is not a factor for tenting of the skin

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temp.

B. Skin color [Nurse should asses the peripheral vascular system to verify adequate circulation, which includes skin color & edema & skin temp.; Pallor and cyanosis reflect inadequate circulation] C. Edema [Reflects inadequate venous circulation] E. Skin temp. [Coolness of the extremity compared with the nonoperative extremity indicates inadequate circulation] NOT A or D: Determining range of motion helps the nurse evaluate joint function, not circulation; Inspecting for skin lesions is part of an integumentary assessment, but it does not evaluate circulation. Some skin lesions do reflect inadequate circulation, but they would not have developed in the immediate postoperative period

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next? A. ask the client if she feels dizzy B. ask the client if she has noted any blood in her stools lately C. ask the client if her gums bled this morning when she brushed her teeth D. nothing, the nurse shouldn't alarm her unnecessarily

B. ask the client if she has noted any blood in her stools lately Any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool. Asking her if she's dizzy is a very broad, closed-ended question that would not elicit information specifically related to the rectal bleeding.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: A. clear B. blurred C. clouded D. 20/20

B. blurred Visual problems with close objects occur more frequently after the age of 40.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A. suspect and inflamed pleura rubbing against the chest wall B. document normal breath sounds C. recommend testing for pneumonia D. assess for asthma

B. document normal breath sounds Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: A. front of the ear B. mastoid process C. top of the head D. affected ear

B. mastoid process

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? A. whether they have anemia B. whether they have a program of regular physical activity C. whether they have proper dietary habits D. whether they have home maintenance skills

B. whether they have a program of regular physical acitivity Regular physical activity contributes to a person's physical and psychological well-being.

A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. The assessment reveals that the client opens the eyes to pain, exhibits abnormal flexion posturing, and produces sounds that are not identifiable. Which score would the nurse assign the client? A. 12 B. 9 C. 6 D. 3

C. 6 Based on the assessment findings, the client would receive a score of 2 for eyes opening to pain, a score of 3 for abnormal flexion posturing, and a score of 1 for incomprehensible sounds, for a total score of 6.

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A. inflammation B. arthritis C. Crepitus D. Fremitus

C. Crepitus Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

During an abdominal exam, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement fo the flanks. Which of following possible causes of distention should the nurse expect? A. Fat B. Fluid C. Flatus D. Hernias

C. Flatus With flatus, the protrusion is mainly midline, and there is no change in the flanks; With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut; With fluid, the flanks also protrude, and when the client turns onto one side, the protrusion moves to the dependent side; With hernias, protrusions through the abdominal muscle wall are visible, especially when the client raises her head

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical exam. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

C. Resonance E. Bronchovesicular sounds NOT A, B, or D: Rhonchi are coarse sounds that result from fluid or mucus in airways; Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways; Tactile fremitus is an expected vibration the nurse can expect to feel or palpate as the client vocalizes. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply. A. Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration B. Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration C. Soft, low-pitched, whispering sounds heard over most of the lung fields D. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly E. Blowing, hollow sounds auscultated over the larynx and trachea F. Bubbling, crackling, or popping sounds auscultated during inspiration and expiration

C. Soft, low-pitched, whispering sounds heard over most of the lung fields D. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly E. Blowing, hollow sounds auscultated over the larynx and trachea Vesicular breath sounds are soft, low-pitched, whispering sounds heard over most of the lung fields, with sound on inspiration being longer than expiration. Bronchovesicular sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Bronchial sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Musical or squeaking sounds describe a sibilant wheeze. Sonorous or coarse sounds with a snoring quality describe a sonorous wheeze. Bubbling, crackling, or popping sounds describe crackles.

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's: A. symptoms B. review of symptoms C. chief concern D. objective assessment

C. chief concern The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern.

When percussing the liver, the sound should be: A. resonant B. hyperresonant C. dull D. flat

C. dull The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? A. assess the cause of the client's wound B. provide a warm, quiet, dimly lit room C. evaluate the BP and pulse D. interview to obtain the health history

C. evaluate the BP and pulse In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.

A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale? A. 4 B. 8 C. 12 D. 15

D. 15 The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented client.

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? A. document a normal skin finding on the client chart B. assess the client for cardio disorders C. report the finding as a positive sign for CF D. assess the client for dehydration

D. assess the client for dehydration Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.

When a client enters the acute care facility, the nurse should perform a: A. focused health assessment B. spiritual health assessment C. physical health assessment D. comprehensive health assessment

D. comprehensive health assessment A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.

To assess a client's visual accommodation, the nurse has the client: A. stand 20 feet from Snellen chart B. sit still while a penlight is shined at the pupil C. look straight ahead with one eye covered D. look at a close object, then at a distant object

D. look at a close object, then at a distant object

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should: A. assess the client's vital signs first B. interpret the effect of deep palpation C. inspect the symmetry of the facial features D. observe the client's body language

D. observe the client's body lang When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.