Health Assessment Exam 3

A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure, 94 mm Hg. The nurse determines that the right ankle brachial index would be which of the following?

0.50

A nurse is determining a client's ankle brachial index. Which result would indicate to the nurse that the client's circulation is normal and free of arterial occlusion?

1.1

When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency?

14-year history of smoking a pack a day

Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following?

3+

The nurse assesses brisk reflexes in a client during a neurological assessment. The nurse should document this finding as which of the following?

3+

Assessment reveals that a client has slight weakness with active range of motion against some resistance. The nurse would document this as which of the following?

4/5

A nurse practitioner refers clients for osteoporosis screening according to the latest U.S. Preventive Services Task Force (USPSTF) recommendations. According to these recommendations, what client should be screen for osteoporosis?

A 69-year-old woman with no major risk factors for osteoporosis

A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. The nurse auscultates the client's bowel sounds, noting them to be which of the following?

Absent

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Absorbing large amounts of water

An older adult client presents with cramping type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect?

Arterial insufficiency

During a health visit, a client says, ìI know that arteries and veins are both blood vessels, but what's the difference?î Which of the following would the nurse include in the response?

Arteries have thicker walls than veins.

The nurse is performing light palpation of the client's abdomen. How can the nurse best prevent voluntary guarding during this phase of assessment?

Ask the client to breathe slowly and deeply.

When testing muscle strength, a client has difficulty moving her right arm against resistance. Which of the following should the nurse do next?

Ask the client to move the part against gravity.

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. How should the nurse proceed with assessment?

Assess the client for other signs and symptoms of liver disease.

The nurse is preparing to palpate the anatomic snuffbox. At which location would the nurse palpate?

At the back of the wrist and extended thumb

A client's bladder is found to be distended. At which location should the nurse begin palpating?

At the symphysis pubis

A nurse is preparing to assess a client's cerebellar function. Which of the following aspects of neurological function should the nurse address?

Balance

Inspection of a client's knee reveals swelling, and the nurse suspects that there is significant fluid in the knee. Which of the following would the nurse use to confirm the suspicion?

Ballottement test

The nurse is preparing to assess the abdomen of a client who is complaining of abdominal pain. Which statement by the nurse would be most appropriate?

Before I get ready to examine the painful area, I will let you know in plenty of time.

The nurse has had a client place the backs of both her hands against each other while flexing her wrists 90 degrees with fingers pointed downward and wrists dangling. The presence of pain or tingling during this test suggests what health problem to the nurse?

Carpal tunnel syndrome

A nurse is providing health education about osteoporosis to a community group. What ethnicity is considered to be an independent risk factor for osteoporosis?

Caucasian

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next?

Compare measurements of both extremities.

The nurse is assessing the eyes of a client who has a lesion of the sympathetic nervous system. What assessment finding should the nurse anticipate?

Constricted pupils, unresponsive to light

The nurse is assessing an adolescent client and notes 45 degree flexion of the cervical spine. What is the nurse's most appropriate action?

Continue the exam because this curve is normal.

A client has sustained an injury to the cerebellum. Which area should be the nurse's primary focus for assessment?

Coordination

During the nursing history of a newly admitted client, the nurse is reviewing a client's current medication regimen. What medication category creates a risk for decreased bone density?

Corticosteroids

A nurse suspects intra abdominal bleeding in a client who was recently involved in a motor vehicle accident. Which finding would most likely lead the nurse to this suspicion?

Cullen's sign

The nurse is conducting a focused musculoskeletal assessment of an older adult client. When analyzing assessment data, the nurse should be aware of what age related physiological changes? Select all that apply

Decreased bone density, Decreased joint flexibility, Joint capsule calcification, Reduced muscle strength

The nurse is preparing to assess the size of the client's aorta. The nurse should palpate at which location?

Deep epigastrium to the left of midline

While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply.

Deep, Circular in shape, Client report of severe pain

A client complains of temporomandibular joint (TMJ) pain. Which of the following would the nurse most likely assess?

Difficulty chewing

Which of the following would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Difficulty speaking

The nurse has attempted to palpate the client's popliteal pulses but is unable to feel them, despite confirming appropriate landmarking and client positioning. What is the nurse's best response?

Document the finding and proceed with the assessment.

The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test?

Document the lack of patency in the ulnar and/or radial arteries.

During deep palpation of the client's abdomen, the nurse identifies a soft, nontender, solid mass extending 2 to 3 cm below the right costal margin. Which of the following actions would be most appropriate?

Document the position of the liver.

A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next?

Document this finding as normal.

The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis?

Dry, shiny, hairless shins and feet

A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next?

Examine the lower arm and hand for infection sites.

A nurse asks a client to bring his hands together behind his head with his elbows flexed. The nurse is testing which of the following?

External rotation

A nurse is reviewing the various causes associated with abdominal distention. Which of the following should the nurse identify? Select all that apply.

Fat, Stool, Gas, Fibroid tumors

During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse?

Femoral

Which of the following would the nurse expect to find when examining a client with a herniated lumbar disc?

Flattened lumbar curve

The nurse demonstrates the correct technique for assessing the psoas sign by which action?

Flexing the client's right hip, applying downward pressure on the right thigh

While assessing the knee joint of a client, a nurse also explains about the typical motions associated with that joint. Which of the following would the nurse include?

Flexion

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. Which of the following would the nurse suspect?

Gouty arthritis

The nurse is assessing an 81 year old client's peripheral vascular function. What principle should guide the nurse's analysis of assessment data

Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency.

Inspection of a client's foot reveals an enlarged, painful, inflamed bursa (bunion) on the medial side of the foot. The nurse should make a referral for what health problem?

Hallux valgus

When assessing a client for possible varicose veins, the nurse should do which of the following actions?

Have the client stand for the exam.

Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease?

Have you experienced a change in your usual sexual activity?

A nurse is preparing a program on osteoporosis for a local women's group. Which of the following should the nurse cite as a risk factor?

History of smoking

The nurse is percussing a client's liver and is assessing liver descent. The nurse should have the client do which of the following?

Hold the breath

The nurse is using Doppler ultrasound to auscultate the peripheral pulses of a client with peripheral vascular disease. What action should the nurse perform during this assessment?

Hold the probe at a 60- to 90-degree angle to the client's skin.

A nurse is testing the range of motion of the thoracic and lumbar spine. Which of the following would the nurse document as an abnormal finding?

Hyperextension of 15 degrees

A client has presented with signs and symptoms that are suggestive of Bell's palsy. What assessment finding is most consistent with this diagnosis?

Inability to wrinkle the forehead

While assessing a client's abdomen, the nurse observes involuntary reflex guarding on expiration. The nurse would interpret this as most likely indicating which of the following?

Infection

A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Inspect, auscultate, percuss, palpate

A nurse determines that the liver span of an older adult male client measures 6 cm. The nurse would interpret this as indicating which of the following?

It is a normal-sized liver.

A client has suffered a suspected a rotator cuff tear. Which of the following would the nurse expect to find?

Limited abduction

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Listen for at least five minutes before documenting an absence of bowel sounds.

A nurse is having difficulty eliciting a patellar reflex during a client's neurological assessment. Which of the following would be most appropriate for the nurse to have the client do?

Lock the fingers together and pull against each other.

Which of the following would be most appropriate when the nurse notes limitation in active range of motion of a client's right shoulder?

Measure range of motion with a goniometer.

When testing the range of motion of the cervical spine, the nurse notes impaired range of motion and neck pain. A review of the client's history reveals fever, chills, and headache. Which of the following would the nurse suspect?

Meningitis

Which of the following would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome?

Numbness

A client has sought care because of chronic constipation. During the health history interview, the nurse should address what potential contributing factor?

Overuse of laxatives

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth.

A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action?

Palpate the brachial pulse.

To promote relaxation of the client's abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse should document which of the following?

Positive Rovsing's sign

Assessment reveals that an older adult client has osteomalacia. Which of the following would be most important to include in the client's teaching plan?

Practice risk prevention for fractures.

An adult client states that his mother has been living with peptic ulcer disease, and he is motivated to ensure that he does not develop the disease as he ages. What health promotion advice should the nurse provide?

Quit smoking as soon as possible.

After teaching a group of students about the bones and their functions, the instructor determines that the teaching was successful when the students state that blood cells are produced in which of the following?

Red marrow

When asked to touch her ear to her shoulder, a client reports pain. Which of the following should the nurse do next?

Refer the client for further evaluation.

A client complains of headaches each morning that resolve after getting out of bed. Which of the following would be most appropriate for the nurse to do?

Refer the client for immediate medical follow-up.

The nurse is evaluating a new nursing graduate's ability to perform a rebound tenderness test for suspected appendicitis. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Right lower quadrant

A nurse is preparing to palpate a client's spleen. Which position should the nurse use to best facilitate palpation?

Right side-lying

The nurse is planning the care of a 77 year old woman who has recently been diagnosed with osteoporosis. What nursing diagnoses should the nurse address in the client's plan of care? Select all that apply.

Risk for injury related to osteoporosis, Activity intolerance related to osteoporosis, Impaired physical mobility related to osteoporosis

Which of the following should a nurse suspect if dullness is percussed at the last left interspace at the anterior axillary line on deep inspiration?

Splenomegaly

The nurse is assessing a client who is in liver failure and who has developed ascites. When measuring the client's abdominal girth, the nurse should place the client in which position?

Standing

During palpation of the client's abdomen, the nurse feels a prominent, nontender, pulsating 6 cm mass above the umbilicus. What action should the nurse take?

Stop palpating and get medical assistance.

Which test would be most appropriate for the nurse to perform when a client complains of low back pain?

Straight leg test

A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique?

Student compresses the client's nail bed until it blanches.

The nurse is performing blunt percussion of a client's kidneys. For what abnormal finding is the nurse primarily assessing?

Tenderness

The nurse is conducting a musculoskeletal assessment of an older adult client. What aspect of the client's medical history requires the nurse to alter the usual sequence or content of this assessment?

The client had a total hip replacement 2 years ago.

The nurse is assessing the gastrointestinal system of an 81 year old client. What age related change should the nurse consider when collecting and analyzing assessment data?

The client is more vulnerable to impaired nutrition due to decreased appetite.

The nurse is performing an assessment of a client's musculoskeletal system. The nurse should begin the assessment by examining which of the following?

The client's gait

The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency?

The client's legs are visibly pale when elevated above the examination table.

The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound?

The client's toe is receiving an inadequate supply of blood.

The nurse reads in a client's electronic health record that her most recent ankle brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care?

The nurse should implement interventions to address severe arterial insufficiency.

The nurse is percussing a client's abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

Tympany

The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients?

Ulnar

A group of nursing students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes?

Upper abdomen

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area

Upper arm

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next?

Use Doppler ultrasonography to locate the pulse.

When assessing cranial nerves IX and X, which of the following would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral?

Venous insufficiency

The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem?

Venous insufficiency

When reviewing the medications currently taken by a 50 year old client who is complaining of constipation, teaching is indicated when the nurse notes which medication?

Vitamin supplement with iron

The nurse is performing the bulge test during the assessment of a client's knee. This test will allow the nurse to make what determination?

Whether the client's swollen knee is caused by tissue swelling or by fluid accumulation

The clinic nurse is reviewing the medication history of a 39 year old woman. Which medication would the nurse identify as a potential risk factor for thrombophlebitis?

an oral contraceptive

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

ìDo you take painkillers like aspirin on a regular basis?