Hesi - Assessment

A client with dark skin is reporting a painful and itching area on the lower left leg. What should the nurse look for when assessing this client's skin for inflammation? -Change in consistency. -Change in turgor. -Redness. -Pallor.

Change in consistency. Inflammation in a dark-skinned client appears as a change in consistency. Further findings that indicate inflammation are changes in texture and excessive warmth.

A client reports lower abdominal pain and a feeling of pressure in the bladder. Which assessment finding indicates acute urinary retention? -Hyperactive bowel sounds. -Dull sound percussed over bladder. -Bruits auscultated in left lower quadrant. -Tenderness with palpation of lower back.

-Dull sound percussed over bladder. Clients with acute urinary retention may present with lower abdominal pain and bladder distension. Percussion (tapping on the body wall) is performed to detect differences in pitch. A dull sound produced when percussing a distended urinary bladder is an indication of urinary retention.

The nurse is assessing a postmenopausal client who has a BMI of 32. The client has a chest measurement of 42 inches, waist measurement of 45 inches, and hip measurement of 50 inches. What important message should the nurse explain to the client to promote health promotion? -"A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease." -"Your hip circumference is larger than normal and it puts you at a higher risk of hip disease." -"At least your BMI is normal, so you just need to exercise." -"You will need to lose weight so you are not at risk for hypertension."

"A waist circumference is greater than 35 inches in women puts you at higher risk for type 2 diabetes and heart disease." A waist circumference of equal to or greater than 35 inches in women and equal to or greater than 40 inches in men increases the risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease in people with a BMI between 25 and 35.

A client is reporting chest pain. What statement made by the client, helps the nurse to understand this client has a naturalistic belief in the cause of illness? -"My life is really out of balance." -"I knew I should have changed my diet." -"I should have gone to church last week." -"I forgot to take my medicines last night."

"My life is really out of balance." The cause of disease may be viewed from three ways: biomedical, naturalistic, magicoreligious. People who conform to the naturalistic perspective of disease causation, believe that the forces of nature must be kept in a natural balance or harmony.

During a skin asssessment, the nurse notes, round and discrete lesions that are dark red in color and will not blanch. The lesions range from 1 to 3 mm in size. What is the first question the nurse should ask the client? -"Have you noticed any unusual bleeding?" -"Have you fallen recently?" -"How often do you drink alcohol?" -"Have you been exposed to anyone with a rash lately?"

-"Have you noticed any unusual bleeding?" Petechiae are small, reddish-purple lesions that do not fade or blanch when pressure is applied and often indicate an increase in capillary fragility. Petechiae is a condition usually seen in client's with thrombocytopenia. Petechiae may indicate abnormal clotting factors. Most of the diseases that cause petechiae cause bleeding and microembolism formation.

While performing a mental status exam (MSE), the nurse asks a client to remember three unrelated words and repeat them later. The client was able to repeat the words as directed. Which computer documentation is accurate? -"Exhibits an above average intelligence." -"Reflects no apparent lapses in concentration." -"Demonstrates appropriate judgment in everyday scenario." -"Short-term memory is intact."

-"Short-term memory is intact." The nurse can determine that the client's short-term memory is functional. The situation as described depicts the expected outcome of a mental status exam in that the client is able to remember and repeat the words as directed.

A male executive is seen in the primary care clinic for a physical examination. While obtaining the client's health history, the nurse inquires about his drug and alcohol use. The executive denies drug use, but reports that he has "two glasses of wine" per night. Which response is best for the nurse to provide? -"You alcohol intake should be reduced by 8 ounces daily." -"Does your use of alcohol concern any of your family members?" -"What effect do you think your use of alcohol may have on you?" -"The amount of alcohol you are drinking concerns me."

-"What effect do you think your use of alcohol may have on you?" The client's perception of his alcohol use determines whether or not his pattern of alcohol consumption is a problem for him.

While assessing level of consciousness, the nurse finds that a client localizes to pain, is confused during conversation, and opens the eyes to sound. How should the nurse document the Glasgow score of this client? -12. -10. -9. -7.

-12 The Glasgow Coma Scale is used to establish baseline data based on eye opening, motor response, and verbal response. The lowest possible score is 3 and thehighest is 15. This client's Glasgow Coma Scale (GCS) score is 12: Opening eyes to sound is a score of 3, localizing to pain is a 5, and confusion during a conversation is a 4 (3 + 5 + 4 = 12).

A nurse is completing a nutritional assessment with a client. What is the easiest method for the nurse to use to get information about the client's nutritional intake? -24-hour dietary recall -Food diary. -Intake and output record. -Lab information (albumin, pre-albumin).

-24-hour dietary recall Nutritional history, which includes the client's recall of food and fluid intake during a 24-hour period, is an important factor in determining a client's nutritional status. The nurse should include the client's dietary recall when performing a nutritional screening.

The nurse is assessing a client who has a history of aortic regurgitation. Where should the nurse place the stethoscope diaphragm to listen for this condition? -2nd intercostal space along the right sternal border. -2nd intercostal space along the left sternal border. -3rd intercostal space on the right midclavicular line. -5th intercostal space on the left midclavicular line.

-2nd intercostal space along the right sternal border. The best way to listen for high-pitch aortic heart sounds, such as an aortic regurgitation murmur, is to place the stethoscope diaphragm onto the 2nd intercostal space along the right sternal border.

The nurse is assessing a client's middle lung lobe. What is the best location for the nurse to place a stethoscope diaphragm to hear normal lung sounds in this lobe? -4th intercostal space, right midclavicular line. -5th intercostal space, left midclavicular line. -Left mid-posterior lung field. -Right mid-posterior lung field.

-4th intercostal space, right midclavicular line. The 4th intercostal space, right midclavicular line is the best location for the nurse to place a stethoscope diaphragm to hear lung sounds in the client's middle lobe. The left side has only two lobes (upper and lower) and middle lobe sounds cannot normally be heard in the posterior lung fields.

The nurse is performing a head-to-toe assessment on a client. The nurse is assessing the client's pupillary light reflex by first darkening the room and asking the person to gaze into the distance. Then, the nurse advances a light toward one eye from the client's side. What would the nurse expect to see at this time? -A consensual response in the opposite eye. -No change in the eye on the opposite side of the face. -Dilation of the eye on the opposite side of the face. -Dilation of the eye on the same side of the face.

-A consensual response in the opposite eye. To test the pupillary light reflex, the nurse should darken the room and ask the client to gaze into the distance to dilate the pupils. Then the nurse should advance a bright light into one pupil and note any response. Normally there will be (1) constriction of the same-sided pupil (a direct light reflex) and (2) simultaneous constriction of the other pupil (a consensual light reflex). The approximate pupil size that occurs when the light is shined into the eye should be estimated in millimeters using a gauge located on the penlight or in a healthcare record. The response to light and the pupil size should also be documented.

A client has been diagnosed with bilateral lower lobe atelectasis. What percussion sound should the nurse expect to hear when percussing over the client's lower lobes? -Dull, thud-like. -Hyperresonant, booming. -Tympanic, drum like. -Flat, extremely dull.

-Dull, thud-like. An atelectatic or consolidated lung will produce a dullness or thud-like sound when percussed during an assessment.

The nurse is assessing a client's range of motion as the client bends the right knee up to the chest while keeping the left leg straight, but is unable to keep the left thigh on the table. The assessment is repeated for the left knee, and the client is unable to keep the right thigh on the table. How should the nurse document this finding? -Flexion contraction that indicates muscle atrophy. -Limited internal rotation of the hips that suggests degeneration. -A normal left and right hip flexion with expected range of motion. -A flexion deformity referred to as a positive Thomas test.

-A flexion deformity referred to as a positive Thomas test. Flexion flattens the lumbar spine, and the opposite thigh should remain on the table. The inability to perform the hip range of motion (ROM) as expected indicates flexion deformity referred to as a positive Thomas test.

As a part of a routine health assessment, the nurse assesses the kidneys as part of the abdominal assessment. Which assessment finding should the nurse concludes is normal when palpating the client's right kidney? -A round smooth mass that slides between the fingers. -The right kidney is palpated higher than the left kidney. -The kidney slides forward and has movable nodules throughout. -has A vibration is felt slightly left of the abdominal midline.

-A round smooth mass that slides between the fingers. Occasionally, when assessing the adult kidneys, the nurse may feel the lower pole of the right kidney as a round, smooth mass that slides between the fingers - or the nurse will feel nothing at all. Either condition is normal. The nurse should search for the right kidney by placing hands together in a "duck-bill" position at the client's right flank. The nurse should then press two hands together firmly and ask the client to take a deep breath. In most people, the nurse will feel no change.

When performing range of motion exercises on the joints of an older adult client, the nurse notes that joint range is greater with passive ranging than with active ranging. A goniometer indicates that this difference is as much as 15% in some joints. How should this finding be documented? -Normal. -Expected in older adults. -Minor deviation. -Abnormal

-Abnormal This finding is abnormal and may be indicative of generalized muscle weakness or a joint disorder.

During an external examination of the eyes, the nurse gently palpates the eyes while the client's eyelids are closed. The eyes are both very firm and resist movement back into the orbit. How should the nurse document this finding? -Abnormal finding. -Expected finding. -Normal variation. -Sign of aging

-Abnormal finding. This is an abnormal finding that may be indicative of glaucoma, hyperthyroidism, or a retroorbital tumor.

Which part of the body should the nurse examine when assessing for peripheral edema in a client with heart failure? -Face. -Ankles. -Knees. -Jugular veins.

-Ankles. Edema is caused by fluid accumulating in the interstitial spaces. Dependent extremities such as the feet and ankles are more prone to peripheral edema caused by conditions such as heart failure, so the nurse should assess the ankles for dependent edema.

During a health history interview, a male client reports that he smokes cigarettes and does not plan to quit. Which action is most important for the nurse to take? -Document the client's statement verbatim. -Calculate the client's pack year history. -Express support for the client's right to choose. -Ask about family history of lung cancer.

-Ask about family history of lung cancer. Calculation of cigarette pack year history provides useful screening data regarding the client's risk for health problems, which serves as the basis for the plan of care.

What is the best nursing response to an older client who has not mentioned incontinence during a genitourinary assessment? -Ask the client specifically about any leakage of urine. -Document that the client reports having no incontinence. -Have the client cough and then check for urine leakage. -Determine if the client has ever had urinary tract surgery

-Ask the client specifically about any leakage of urine. Incontinence is a manageable condition, but many clients do not report incontinence due to embarrassment. The nurse needs to ask the client directly about urine leakage to avoid missing this information.

A client is in the clinical for a yearly physical examination. Which action should the nurse take when preparing to examine the client's abdomen? -Keep the room cool so the client is not perspiring. -Ask the client to urinate before beginning the examination. -Examine painful or tender areas first. -Position the client supine with arms over the head.

-Ask the client to urinate before beginning the examination. An empty bladder aids in abdominal wall relaxation. The nurse should ask the client to empty the bladder before examining the abdomen.

The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? -Recall of information. -Orientation to surroundings. -Attention to details. -Ability to follow complex commands.

-Attention to details. When conducting the MMSE and having the client count backwards by 7s; this evaluates their ability to do simple calculations and is specific to the client's attention to detail and staying focus and not getting distracted by external stimuli.

The nurse is preparing to assess the hearing of a client with a history of prolonged exposure to occupational noise. Which hearing test provides the most reliable assessment of hearing status? -Audiometry. -Whispered voice. -Weber. -Rinne

-Audiometry. Prolonged exposure to loud occupational noise can cause sensorineural hearing loss by damaging the cochlear hair cells. Audiometry is the most reliable method of testing the acuity of auditory sensory perception.

The nurse is performing a thoracic assessment on a client with chronic asthma and hyperinflation of the lungs. Which finding should be expected for this client? -Kyphosis. -Barrel chest. -Pectus Excavatum. -Pectus Carinatum

-Barrel chest. A barrel chest is associated with chronic asthma and hyperinflation of the lungs. The nurse can expect to note an increased anteroposterior chest diameter and ribs that are horizontal instead of having a normal downward slope.

A nurse is working in a healthcare facility that serves a diverse population. What action(s) by the nurse will allow the nurse to empathize with and understand this population? (Select all that apply.) Be open to people who are different. -Have a curiosity about people. -Become culturally competent. -Interact with each person in the same way. -Request nurses take care of patients with the same ethnicity. -Always request an interpreter for people from other countries.

-Be open to people who are different. -Have a curiosity about people. -Become culturally competent. As a health professional, the nurse is expected to listen to, empathize with, and understand people. To fulfill this role, nurses must first be open to people who are different from them, have a curiosity about people, and begin a journey to being culturally competent.

Which respiratory condition should the nurse document after measuring a respiratory rate of 8 breaths/minute? -Tachypnea. -Bradypnea. -Hyperventilation. -Hypoventilation

-Bradypnea. Bradypnea is a regular but slow rate of breathing indicated by a respiratory rate less than 10 breaths/minute. A client with a respiratory rate of 8 breaths/minute has bradypnea.

During the initial assessment, the nurse notes that a client has blurred vision with cloudy lenses. Which condition should the nurse document? -Pink eye. -Cataracts. -Glaucoma. -Corneal abrasion

-Cataracts The nurse should be sure to identify signs of visual impairment so that safety precautions may be implemented when necessary. Signs of cataracts include cloudy lenses and blurred vision.

An older client pushes the nurse's hand away when palpation is initiated during physical assessment. Which additional objective sign aids the nurse in assessing for abdominal tenderness? -Takes deep breaths when palpation is performed. -Changes vocal pitch when abdomen is palpated. -Closes eyes during palpation of the abdomen. -Smiles when asked if pain is illicit with palpation.

-Changes vocal pitch when abdomen is palpated. An objective sign that can aid in assessing a client for abdominal tenderness is a sudden change in vocal pitch when speaking while the abdomen is palpated.

The nurse is assessing a healthy young adult during an annual physical examination. Which assessment technique should the nurse implement when palpating the abdominal aorta? -Deep palpation above and to the left of the umbilicus. -Palpation of abdomen as client completes a deep breath. -With client standing, compress the abdomen as the nurse stands behind the client. -With palm of one hand, compress the abdomen 2 finger breaths below xiphoid process.

-Deep palpation above and to the left of the umbilicus. Deep palpation above and to the left of the umbilicus is effective in sensing the pulsation of the aorta.

The nurse palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) -Diminished hair on legs -Bruising on extremities -Skin cool to touch -Capillary refill less than 3 seconds -Darkened skin on extremities

-Diminished hair on legs -Skin cool to touch Diminished hair on the legs and skin that is cool to touch are symptoms of decreased arterial blood flow. The other options are not indicators for impaired peripheral circulation.

While performing a head-to-toe assessment, the nurse assesses the client's pupillary accommodation. During the second portion of the test, the nurse notes that the client's pupils constrict and there is convergence of the axes of the eyes. What action should the nurse implement next? -Document a normal finding. -Request a referral to an ophthalmologist. -Repeat the test after having the client rest for 5 minutes. -Ask the client, "Have you noticed that you cannot see things close up?"

-Document a normal finding. When testing for pupillary accommodation, the nurse asks the client to focus on a distant object and then shift the gaze to a penlight tip near the nose. Focusing on a distant object causes both pupils to dilate; shifting the gaze to a near object (a finger or a penlight tip), which is held about 7 to 8 cm (3 inches) from the client's nose, should result in bilateral pupillary constriction with both eyes focused on the object simultaneously.

The nurse is conducting a family history as part of the assessment interview. Which action should the nurse take to ensure that sufficient information about the client's blood relatives is obtained? -Document at least 3 generations of the client's family medical history. -Ask about any genetic conditions that may be present in the family. -Instruct the client to develop a genogram to bring to the next visit. -Request medical records of all the client's immediate family members.

-Document at least 3 generations of the client's family medical history. The family history assists the healthcare provider in determining the client's health risks. It is recommended that family medical history be traced back three generations. These generations consists of the client's blood-relatives of any siblings, parents, and maternal and paternal grandparents.

The nurse is requesting the client to perform a Romberg Test to assess neurological status. During the test, the nurse notes that the client sways slightly. What is the nurses next action? -Document the normal finding. -Have the client widen the base of the feet. -Ask the client to walk to the door and back. -Ask the client if there is any dizziness.

-Document the normal finding. To perform a Romberg Test, the client is asked to stand up with feet together and arms at the sides. Once in a stable position, the client is asked to close the eyes and hold the position for about 20 seconds. Normally a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur.

A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? -Face the client so the client can see the RN's mouth. -Increase one's speech volume when interacting with the client. -Repeat information to the client if misunderstood. -Check if the client's hearing aides are working properly. -Reduce environmental noise surrounding the client.

-Face the client so the client can see the RN's mouth. -Check if the client's hearing aides are working properly. -Reduce environmental noise surrounding the client. A client with hearing loss can develop the ability to read "lips," so facing the client during conversation allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication. Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process. Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech. If a client shows signs of confusion, rephrasing the question, instead of repeating, should be done to decrease client anxiety and facilitate understanding.

A client is in the clinic and is reporting lower abdominal pain and constipation. Which information is of greatest concern to the nurse when obtaining the health history from this client? -Administration of rubeola vaccine at age 7. -Removal of gallbladder 5 years ago. -Family history of colon cancer on mother's side. -Family history of hypertension on father's side.

-Family history of colon cancer on mother's side. Abdominal pain and constipation can be signs of colon cancer, and some forms of colon cancer can be hereditary. A family history of colon cancer is of significant concern, and the nurse should report this information to the healthcare provider.

Which term should the nurse use to document in the client's medical record for a high-pitched scratchy sound during auscultation of the heart? -Murmur. -Ejection click. -Friction rub. -Normal heart sound.

-Friction rub. A high-pitched, scratchy or grating sound heard during auscultation of the heart is called a pericardial friction rub, which is associated with inflammation of the pericardium, often seen during the following week in a client after a myocardial infarction. To best hear the pericardial friction rub, the nurse should have the client sitting upright and leaning forward while the client holds breath and the nurse listens with the diaphragm of the stethoscope at the apex and left lower sternal border.

Which condition is indicated by a fluorescent, yellow-green color when the nurse uses a Wood's lamp to examine a client's skin lesions? -Fungal infection. -Bacterial infection. -Allergic reaction. -Skin cancer.

-Fungal infection. A Wood's lamp produces a black-light effect to examine skin lesion color and to detect fungal skin infections. A fluorescent, yellow-green or blue-green color indicates a fungal infection.

The nurse is completing a physical exam on an adult client. Which thyroid finding is considered normal? -Gland is not palpable. -Gland is solid bilaterally. -Bruits are detected bilaterally. -Nodules are palpated

-Gland is not palpable. ??????? In a normal healthy adult, thyroid glands are usually not palpable.

Which tool should the nurse use when assessing the neurological status of a client with traumatic brain injury? -Glasgow Coma Scale. -Braden Scale. -Numerical pain scale. -Cranial nerve examination.

-Glasgow Coma Scale. The Glasgow Coma Scale is the best method for assessing the neurological status and level of consciousness following a traumatic brain injury. The Glasgow Coma Scale assesses eye opening, motor responses, and verbal responses and has a scale of 3 to 15 (15 is awake, alert, and oriented).

A client is in the clinic for a routine health examination. The nurse notices the client appears underweight. Which question is most important for the nurse to ask when completing the health history of this client? -What types of food do you like or dislike? -Have you experienced sudden weight loss? -Do you use dietary supplements every day? -Can you recall the last 24 hours of food intake?

-Have you experienced sudden weight loss? A client who is underweight may have an underlying illness, for example, weight loss without any change in dietary and/or physical activity could be an indicator of the presence of cancer or a metabolic syndrome such as Grave's disease. It is important to determine if the weight loss has been sudden, gradual, and/or intentional because this information will guide the remaining dietary history.

A client has come to the clinic for a routine health assessment. What is the best assessment question for the nurse to ask a client after observing tophi on the client's ear cartilage? -Have you had sudden and severe pain in the toes or feet? -Do you have a family history of osteoporosis? -Have you ever had pain along the side of your leg? -Do you have a history of rheumatoid arthritis or bursitis?

-Have you had sudden and severe pain in the toes or feet? Tophi (plural form of tophus) are deposits of uric acid crystals found in the skin, cartilage, and or on the surface of joints. Tophi are seen in advanced stages of gout, a condition in which uric acid crystals have deposited into the joints in particularly, the toes. Gout will often present clinically as sudden and severe pain in the toes or lower extremities. The nurse should ask about a history of sudden and severe pain in the toes or lower extremities after observing tophi on the ear cartilage.

Which information should the nurse obtain to identify the client's self-perception of health status? -Vital signs. -Health history. -Informed consent. -Genetic predisposition

-Health history A health history is a collection of subjective data. Obtaining a detailed health history is a good way for the nurse to assess the client's perception of current health status.

The nurse performs a physical assessment on an older female client. Which change from the prior exam may be an indication of osteoporosis? -Thick and brittle fingernails. -Decreased range of motion. -Weight gain of 15 pounds. -Height reduction of 1.5 inches

-Height reduction of 1.5 inches Osteoporosis is a loss of bone density that causes brittle bones and an increased risk for fractures. Reduced height in an older female clients with osteoporosis is generally the result of shortening of the vertebral column due to loss of water and thinning of the intervertebral discs.

The nurse is assessing a client who reports having shoulder pain. Which sign is the best indicator of a rotator cuff tear? -Inability to adduct the arm from the body. -Inability to slowly lower the arm when abducted. -Inability to externally rotate the arm. -Inability to internally rotate the arm.

-Inability to slowly lower the arm when abducted. Rotator cuff damage can be assessed with the Drop Arm test, in which the affected arm is passively abducted at 90 degrees and the client is unable to keep the arm elevated or slowly and smoothly lower the arm from this position without moving the shoulder forward to have the other muscles compensate for the torn rotator cuff muscle.

A client is being assessed upon admission to the medical-surgical unit. The nurse is preparing to complete a head-to-toe assessment and will begin at the head of the client. Which technique should the nurse use to begin the assessment? -Inspect the hair and skin. -Palpate the temperature of the skin. -Percuss for tenderness. -Auscultate the temporal arteries

-Inspect the hair and skin. The usual order for a physical assessment is inspection, palpation, percussion, and auscultation. When beginning a physical assessment, the nurse should perform an inspection, which is a general survey of the individual as a whole and of each body system.

A client presents with a rash along the occipital area of the hairline and reports intense itching. How should the nurse begin the objective part of the examination? -Inspect the scalp looking for nits. -Palpate the area to determine if there are lesions. -Ask the client whether the client has been in a foreign country. -Take the client's temperature.

-Inspect the scalp looking for nits. Pediculosis capitis (head lice) is caused by lice that typically irritate the scalp around the occipital area and behind the ears. The scalp irritation causes intense itching in the area.

Which statement is accurate about assessing the spleen? -It must be enlarged at least three times normal size for it to be palpable. -It is easily felt by reaching the left hand behind the 11th and 12th ribs. -It is normally felt by rolling the client on the right side and palpating. -It is a firm mass palpated slightly left of midline in the upper abdomen.

-It must be enlarged at least three times normal size for it to be palpable. Normally the spleen is not palpable at all and must be enlarged by three times its normal size to be felt. To search for it, the nurse must reach the left hand over the abdomen and behind the left side at the 11th and 12th ribs and lift up for support. The nurse should place the right hand obliquely on the left upper quadrant (with the fingers pointing toward the left axilla) and push the hand deeply down and under the left costal margin while asking the client to take a deep breath. Under normal circumstances, the nurse should feel nothing firm.

The nurse is examining the hip joint of a client who reports hip pain. Which other assessment is most helpful in determining the cause of the client's pain? -Knee joint evaluation. -Cranial nerve testing. -Postural alignment. -Deep tendon reflexes.

-Knee joint evaluation. A client with hip pain usually experiences radiation of pain to the groin or knee. Although the hip is difficult to palpate, the knee is readily accessible. A client with hip pain should be assessed for knee joint mobility, structural abnormalities, and fluid accumulation.

The nurse examines the skin of an older adult client. Which skin variation is considered a normal finding for a client in this age group? -Dryness. -Lentigines. -Bruising. -Tenting.

-Lentigines. Lentigines or commonly referred to as liver spots are irregularly shaped dark spots on the skin caused by aging and extensive sun exposure. This skin variation is a normal finding in an older adult client.

A client comes to the clinic with a report of fever and a recent exposure to someone who was diagnosed with meningitis. Which nursing assessment should be completed during the initial examination of this client? -Level of consciousness. -Gait characteristics. -Presence of trauma. -Bladder control ability.

-Level of consciousness. Initial symptoms of meningitis include headache, fatigue, stiff neck, and changes in level of consciousness. It is necessary to determine if the client is demonstrating signs of meningitis before planning immediate care.

During cardiac auscultation, the nurse hears a split in the second heart sound when listening at the second left intercostal space of a male client. To assess this sound more fully, what action should the nurse implement? -Inch the stethoscope down the left side of the client's sternum. -Ask the client to cough and then listen at the site again. -Instruct client to hold his breath so the sound is clearer. -Listen to the sound while observing the client's respirations

-Listen to the sound while observing the client's respirations A split S2 is heard only in the pulmonic valve area (second left interspace). Listening while observing respirations allows the examiner to determine the type of S2 split that is occurring. Other actions are not useful in auscultating a split S2.

A client has just returned from the recovery room and asks to get out of bed to go to the bathroom. The nurse decides to obtain orthostatic vital signs first. How will the nurse position the client to begin this procedure? -Lying. -Sitting. -Leaning. -Standing

-Lying. When obtaining orthostatic vital signs, the nurse takes serial measurements of pulse and blood pressure. The order of positions for obtaining orthostaticvital signs is lying, sitting, and then standing.

Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? -Ask closed-ended questions with the assistance of the interpreter. -Maintain eye contact with the client while listening to the translation. -Instruct interpreter to answer questions from interpreter's point of view. -Protect the client's privacy by asking a limited number of questions.

-Maintain eye contact with the client while listening to the translation. When completing an assessment, the RN should maintain eye contact with the client to gather additional information from the client's nonverbal cues.

How should the nurse assess for lower extremity edema in a client who has been diagnosed with heart failure? -Measure bilateral ankle circumference with a non-stretchable tape measure. -Press skin over the tibia and report edema according to the grading scale. -Ask if the client feels the bilateral edema has changed and to what extent. -Inspect the lower extremities together to compare the amount of swelling.

-Measure bilateral ankle circumference with a non-stretchable tape measure. Accurate assessment of lower extremity edema is required when a client is treated for heart failure. Measuring ankle circumference is more accurate than subjective measures that rely on individual interpretation.

Which procedure should the nurse use to assess for a pulse deficit? -Compare the brachial pulse and femoral pulse. -Document the observed pulse rate and quality. -Obtain the systolic blood pressure and subtract the apical pulse. -Measure the apical pulse and compare it to the peripheral pulse

-Measure the apical pulse and compare it to the peripheral pulse A pulse deficit is a palpable difference between the apical pulse at the point of maximal impulse and the radial pulse palpated at the wrist. The nurse should measure the apical pulse and compare it to the peripheral pulse to assess for a pulse deficit. If the pulse number is different from the apical pulse, then the radial pulse rate should be subtracted from the apical pulse and the remaining number is the number that should be recorded for the pulse deficit.

Which term should the nurse use to document the condition of a client who reports waking up frequently during the night to urinate? -Nocturia. -Polyuria. -Oliguria. -Dysuria

-Nocturia. Nocturia is the medical terminology used to described when a client wakes up throughout the night more than usual to urinate. The nurse should document this condition as "nocturia" in the client's medical record.

During the interview portion of the health assessment, a nurse notes the person's posture, physical appearance, and ability to converse. How should the nurse document these findings? -Objective. -Subjective. -Expected. -Reportable.

-Objective. Although the purpose of the interview is not to collect objective data, there are some things the nurse observes at this time: person's posture, physical appearance, ability to carry on a conversation, and overall demeanor.

Which technique should the nurse use to assess a client for scoliosis? -Watch gait while the client ambulates down the hallway. -Observe spine while the client is erect and bent forward. -Palpate neck while the client rotates head from side to side. -Assess for presence of pain when the client twists the torso.

-Observe spine while the client is erect and bent forward. Scoliosis is a lateral curvature of the spine seen upon inspection of the spine while the client stands erectly and then bends forward.

The nurse observes peristaltic movement in the left lower quadrant of a client's abdomen. Which further assessment of the area should the nurse perform? -Observe the direction of movement. -Auscultate the area of movement. -Lightly palpate the area of movement. -Percuss the area of movement

-Observe the direction of movement. Increased peristaltic movements are occasionally seen in very thin clients and may indicate the presence of an intestinal obstruction. In addition to noting the quadrant of origin, the nurse should also note the direction of the peristaltic flow and report these findings to the healthcare provider.

When assessing facial nerve function of a 96-year-old, the nurse asks the client to smile in an exaggerated manner. Which finding is most important for the nurse to further asses? -Only one side of the mouth moves when smiling. -The client's teeth have a yellowed appearance. -The client smiles broadly but appears anxious. -The client asks the nurse to repeat the directions.

-Only one side of the mouth moves when smiling The facial nerve innervates the muscles of facial expression. Asymmetry in facial movement may indicate damage to the facial nerve and requires further assessment by the nurse.

After completing the initial general assessment, the nurse is now completing a focused abdominal assessment of a client who was admitted for abdominal pain. Which assessment is most important for the nurse to implement? -Inspect for abdominal distension then percuss for tympany. -Palpate the abdomen after auscultating for bowel sounds. -Measure the client's oxygen saturation. -Ask if pain medication was taken

-Palpate the abdomen after auscultating for bowel sounds. During a focused assessment of the abdomen, the nurse should palpate for abdominal tension and tenderness after auscultating for bowel sounds, which can be altered by palpation and percussion. The abdominal assessment should progress in the sequence of inspection, auscultation, palpation, and then percussion.

The nurse is completing a physical assessment of a client who feel from a tree. The client's abdomen is soft with hyperactive bowel sounds in all four quadrants. Which assessment technique should the nurse implement when evaluating the client's spleen? -Elevate head of bed 30 degrees to percuss the spleen. -Palpate the splenic borders before percussing. -Percuss the splenic area as the client takes a deep breath. -Place client in a Trendelenburg position to isolate the spleen.

-Percuss the splenic area as the client takes a deep breath If the spleen is enlarged due to an infection or trauma, tympany changes are noted with dullness upon inspiration.

Following abdominal auscultation of a client who is admitted for signs of splenomegaly, which additional assessment should the nurse use to verify splenomegaly? -Rebound tenderness. -Percussion. -Deep palpation. -Inspection

-Percussion When splenomegaly is suspected, percussion of the spleen produces a dull sound and is a safe method of verifying enlargement.

The nurse is interviewing a client who reports having a persistent, productive cough during the winter caused by bronchitis. Which additional finding should the nurse assess for bronchitis? -Phlegm production and wheezing. -Smoking history. -Hemoptysis. -Night sweats.

-Phlegm production and wheezing. A chronic, seasonal cough related to bronchitis is likely accompanied with phlegm production and wheezing. Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes.

Which technique should the nurse implement when performing a Weber test? -Tap the patellar tendon using a reflex hammer. -Shine the light of an ophthalmoscope into the pupil. -Visualize the tympanic membrane using an otoscope. -Place a vibrating tuning fork midline on top of the head.

-Place a vibrating tuning fork midline on top of the head. The Weber test is used to evaluate hearing by bone conduction through the skull, which should sound equally loud in both ears. The tuning fork should be struck and then placed on the midline of the head. If the client describes hearing that sounds louder in one ear than the other, it may indicate unequal hearing loss and further assessment is needed.

The nurse is assessing a client who has a history of mitral stenosis. How should the nurse assess this client with a stethoscope to listen for this condition? -Place the bell on the 5th intercostal space, left midclavicular line. -Place the bell on the 2nd intercostal space, left midclavicular line. -Put the diaphragm on the 5th intercostal space, left sternal border. -Put the diaphragm on the 2nd intercostal space, left sternal border.

-Place the bell on the 5th intercostal space, left midclavicular line. The best way to listen for low-pitch mitral heart sounds, such as a mitral stenosis murmur, is to place the bell of stethoscope onto the 5th intercostal space at the left midclavicular line.

A client reports pain when taking a deep breath. Which lung auscultation sound should the nurse anticipate hearing? -Pleural friction rub. -Rhonchus. Incorrect -Coarse crackles. -Wheezing

-Pleural friction rub. A pleural friction rub is often associated with pain on deep inhalation. Pleural friction rubs are associated with pleurisy, tuberculosis, pulmonary infarction, pneumonia, or lung cancer

What is the best place for the nurse to hear lower lobe lung sounds with a stethoscope? -Posterior chest below the 3rd intercostal space. -Posterior-axillary line at the 4th intercostal space. -Anterior chest at the level of the 4th intercostal space. -Anterior-axillary line at the 5th intercostal space.

-Posterior chest below the 3rd intercostal space. The posterior chest below the level of the 3rd intercostal spaces is occupied entirely by the lower lobes. This makes the posterior chest the best place for the nurse to hear lower lobe lung sounds with a stethoscope.

The nurse is assessing the posterior pharynx during a physical examination. Which technique should the nurse use? -Press the tongue down one side at a time with a tongue depressor. -Ask the client to open the mouth and say "ah." -Listen for hoarseness after asking the client to speak. -Palpate the neck and ask the client to swallow.

-Press the tongue down one side at a time with a tongue depressor When assessing the posterior pharynx, a tongue depressor should be used to press down one side of the tongue at a time to avoid stimulating the gag reflex.

The nurse is testing the client's shoulders for range of motion. What should the nurse document to record normal internal rotation? -Ability to lift both arms over head and swing each arm across front of the body. -Range of 90 degrees when the hands are placed at the small of the back. -A 90 degree range with both hands behind the head with elbows out. -Rolling of shoulders in a circular motion clockwise and counter clockwise.

-Range of 90 degrees when the hands are placed at the small of the back. To document normal internal rotation of the shoulders, the client should be able to demonstrate a range of 90 degrees when the hands are placed at the small of the back.

The nurse is conducting an interview with a client who speaks limited English. What action should the nurse implement? -Seek the assistance of a healthcare team member who speaks the client's preferred language. -Continue with the client's assessment interview using simple English words. -Have the client reschedule for a time when a family member can be there to interpret. -Ask the client to call a friend who speaks English and is able to interpret.

-Seek the assistance of a healthcare team member who speaks the client's preferred language. A healthcare team member who speaks the client's preferred language or a medical interpreter must be provided whenever English is not the preferred language of the client.

While conducting an interview to obtain a health history, the nurse notices that the client pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? -Reassure the client that there are no wrong answers. -Tell the client to return later for another interview. -Continue to ask questions until the client responds. -Sit quietly to allow the client to respond comfortably

-Sit quietly to allow the client to respond comfortably A silent attentiveness or "intelligent repose" communicates that the nurse has time and is willing to listen to the client's responses.

When assessing a client with dyspnea, the nurse hears an audible inspiratory crowing sound. Which lung sound should the nurse document? -Stridor. -Crackles. -Wheezing. -Pleural rub.

-Stridor Stridor is an audible monophonic inspiratory crowing sound. Stridor in a client with dyspnea indicates an airway obstruction.

A client states that she had a mastectomy of her left breast last year and now experiences lymphedema. What should the nurse expect to find when examining the client? -Swelling of the left arm and non-pitting edema -Bilateral swelling of the arms with weakened pulses.. -Complaints of pain when taking the blood pressure on the affected side. -Metastasis of cancer due to cancer being in the lymph nodes

-Swelling of the left arm and non-pitting edema Lymphedema is caused by lymphatic system blockage occurring after breast and lymph node surgery. A client with lymphedema typically presents with unilateral swelling, non-pitting edema, and tight fitting jewelry. Treatment is required to prevent a chronic progressive condition.

The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? -The client cannot understand the nurse. -The client is uncomfortable with the nurse. -The client is treating the nurse with respect. -The client is purposefully disrespecting the nurse.

-The client is treating the nurse with respect. In some Asian cultures, it is not appropriate to look a person of authority in the eye, so the client is being respectful by looking down while speaking with the nurse.

The client is experiencing severe pruritus and small papules and burrows on areas over one hand and the inner thighs. Which assessment data best explains the condition the client is experiencing? -The client works in a daycare setting that has had a scabies outbreak. -The client has been using a chemical stripping agent for home remodeling. -The client has a family history of psoriasis in both parents and a sibling. -The client routinely works with clay and paint as a hobby.

-The client works in a daycare setting that has had a scabies outbreak. Scabies is a highly contagious condition that causes pruritus, small papules, vesicles and burrows in the skin as the scabies mite burrows into the superficial layer of the skin to lay her eggs. Scabies is often spread among children and others in close contact.

The nurse is assessing a client for a hip flexion contracture. Which finding indicates a negative Thomas test when the client's right knee is brought toward the chest? -The left leg internally rotates. -The left leg rises off of the table. -The left leg remains on the table. -The left leg externally rotates

-The left leg remains on the table. The Thomas test is performed by having the client bring one knee toward the chest while the other leg remains extended on the table. A positive Thomas test is elicited when the extended leg rises off the table, when the opposite leg's knee is brought up to the client's chest, indicating hip flexor contracture. If the extended leg (the left leg, in this example) remains on the table, the test is negative.

An adult client is in the clinic for a regular physical examination. The nurse is assessing the client's hydration status by pinching then releasing the client's skin. Which finding is indicative of good hydration status? -The skin remains tented. -The skin appears blanched and returns to pink. -The skin slowly falls back into place. -The skin immediately returns to normal position

-The skin immediately returns to normal position Skin turgor refers to elasticity and is assessed by gently pinching and then releasing the skin on the forearm, back of the hand, or under the clavicle. If skin turgor is normal, the skin will return to normal position immediately when released. Poor skin turgor is indicative of dehydration and is determined when the tented skin does not return or slowly returns back to place.

The nurse is assessing a client who has experienced a sudden onset of hearing loss in the right ear. Which finding should alert the nurse to a potentially serious medical condition that requires further evaluation? -The client works in a busy office setting. -There is no sign of associated infection. -The client has no prior history of hearing loss. -The hearing loss involves high frequencies.

-There is no sign of associated infection. Sudden hearing loss is sometimes associated with an upper respiratory infection or ear infection. Sudden hearing loss without the presence of an infection can be an indication of a more serious condition that requires further evaluation.

When teaching a client how to perform a monthly breast self-assessment, the nurse should tell the client that it is most important to assess which part of the breast more closely for changes? -Upper outer quadrant. -Lower inner quadrant. -Upper inner quadrant. -Lower outer quadrant.

-Upper outer quadrant. Although the client should be instructed to perform a thorough breast self-assessment every month to check for tissue changes, evidence has shown that the upper outer quadrant is the site of most breast tumors.

The nurse is assessing a client with liver disease who is jaundice and exhibits scleral edema. During the health assessment, the nurse should implement which technique to determine evidence of hepatomegaly? -Tap the liver's boundaries lightly with a percussion hammer to produce a sound. -Push gently using fingers of both hands to determine the boundaries of the liver. -Use a bouncing motion to tap the middle finger placed within boundaries of the liver. -Cup hands and clap with alternating contact with the skin over regions of the liver.

-Use a bouncing motion to tap the middle finger placed within boundaries of the liver. Percussion is a tapping techniques done with short, sharp strokes to assess underlying structures, such as the liver which is solid and should have a dull sound. When percussing the liver for abnormal sounds, the middle finger of dominant hand is used to tap with a bouncing motion on the opposite middle finder that is placed within the boundaries of the liver, which if diseased is no longer dense and does not reveal a dull sound.

The nurse is assessing for the presence of a hernia. Which action should the nurse ask the client to perform while lying supine? -Bring the knees toward the chest. -Place the chin onto the chest. -Roll from one side to the other. -Use abdominal muscles to sit up

-Use abdominal muscles to sit up Engaging the abdominal muscles can reveal a protruding hernia. When assessing for the presence of a hernia, the nurse should ask the client to use the abdominal muscles to sit up without hand support.

A client reports feeling increasingly fatigued for several months, and the nurse observes that the client's lips are pale. Which additional data should the nurse collect based on this presentation? -Current alcohol and tobacco use. -A 24-hour dietary recall. -Use of vitamin and iron supplements. -Daily pattern of oral hygiene practices

-Use of vitamin and iron supplements. Increasing fatigue and pale lips could indicate anemia. The nurse should determine if the client is taking vitamin or iron supplements to manage anemia.

A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) -Use simple sentences during the examination. -Move to another question if the client seems confused. -Reduce environmental detractors during the examination. -Allow family to answer for the client to decrease frustration. -Ask questions one at a time to decrease confusion

-Use simple sentences during the examination. -Reduce environmental detractors during the examination. -Ask questions one at a time to decrease confusion Communication techniques for clients with cognitive impairments should be simple, with out environmental distractions, and direct.

The nurse performs the Weber and Rinne tests to assess which cranial nerve? -VIII. -VI. -I. -V

-VIII. The Weber and Rinne tuning fork tests are used to evaluate for hearing loss. These tests are performed to assess cranial nerve VIII, also known the acoustic or vestibulocochlear nerve.

An older client has just returned to the room following a surgical procedure. Which pain scale should the nurse use when assessing the client's pain level? -Verbal descriptor scale. -Wong-Baker scale. -Numeric rating scale. -Faces pain scale-revised.

-Verbal descriptor scale. The descriptor scale uses words rather than numbers or pictures to describe pain. This method of reporting pain is less confusing and less abstract for older adults. The choices provided for rating the intensity of pain include the following: no pain, mild pain, moderate pain, and severe pain.

Which question should the nurse ask in order to test a client's remote memory? -What is your date of birth? -Who is your current healthcare provider? -What medications are you taking? -How did you arrive at the hospital today?

-What is your date of birth? Cognition is typically evaluated in a rapid and focused manner and includes the assessment of memory. Remote memory, or long-term memory, can be tested by asking the client's date of birth.

During a client's routine well-woman physical exam, the nurse examines the breasts. Which assessment technique should the nurse implement to evaluate for any abnormal lumps? -Palpate each breast simultaneously noting any differences. -Inspect the areolar area's color, shape, and the nipples for galactorrhea. -Check for breast symmetry while the client's hands are above the head. -With both arms at client's side, lift one arm and palpate the axilla.

-With both arms at client's side, lift one arm and palpate the axilla. Lymph nodes or masses should not be palpated in the axilla. The best way to assess the axilla is to have the client relax arms at her side so that muscles are relaxed. Typically, breasts are not exactly the same size or shape and assessing symmetry will not uncover small lumps.

A client reports a recent onset of nausea and vomiting. What subjective information is important for the nurse to ascertain? -Ask how much weight the client gained on vacation. -Ask whether the client has been in a foreign country recently. -Observe the symmetry of the abdomen. -Count the bowel sounds in each abdominal quadrant.

Ask whether the client has been in a foreign country recently. GI upset and diarrhea occur when exposed to new local pathogens in developing countries. Water supply may be contaminated.

Which findings can the nurse determine by palpating a client's skin? (Select all that apply.) -Pruritus. -Diaphoresis. -Pallor. -Jaundice. -Scaling

Diaphoresis. -Scaling Palpation, or touch, can provide information about skin texture, including the presence of scaling and skin moisture, including diaphoresis, or perspiration. Pruritus, or itching, is a subjective finding reported by the client, and pallor and jaundice describe skin color, assessed through observation.

While palpating a client's breasts, the nurse detects a nontender, solitary, round lobular mass that is solid and firm and slides easily through the breast tissue . The findings of this breast exam are consistent with which condition? -Mastitis. -Paget disease. -Fibroadenoma. -Plugged mammary duct.

Fibroadenoma. Fibroadenoma are benign tumors that are nontender masses that are round and lobular and when palpated move easily through breast tissue and feel solid and firm. They are diagnosed by palpation, ultrasound, and needle biopsy. They are usually not surgically removed unless they enlarged to greater than 5 cm in size.

The nurse is performing a routine physical examination on an adult client. When gathering a health history, which question is included in the CAGE questionnaire? -When did you have your last alcoholic drink? -How does alcohol usually affect you? -What is your favorite alcoholic drink? -Have you ever felt guilty about your drinking?

Have you ever felt guilty about your drinking? The CAGE questionnaire can be used to screen clients for excessive or uncontrolled drinking. CAGE is the acronym for Cut down, Annoyed, Guilty, and Eye-opener. To assess for possible alcohol abuse, the nurse should ask if the client has ever felt guilty about drinking.

The nurse is assessing bowel sounds for a hospitalized client. The nurse has heard bowel sounds in the right upper quadrant. What action should the nurse take next? -Auscultate over the other 3 abdominal quadrants. -Count the number of bowel sounds per minute. -Note the character and frequency of bowel sounds. -Count to determine how many bowel sounds occur in one minute

Note the character and frequency of bowel sounds. Bowel sounds originate from air and fluid movement through the stomach and intestines. A wide range of normal sounds can occur depending on when the last meal was ingested. The nurse should assess for hyperactive or hypoactive bowel sounds during auscultation, noting the character and frequency. It is not necessary to count the number of bowel sounds per minute, and to listen to all four quadrants. It is necessary to listen for bowel sounds for a minimum of 5 minutes before declaring bowel sounds absent.

The nurse uses a tongue depressor to assess a client's mouth. Which structure should the nurse be able to visualize? -Esophagus. -Pharynx. -Trachea. -Maxillary sinus.

Pharynx. Depressing the tongue when examining the mouth allows the nurse to visualize the pharynx, tonsils, and adenoids.

The nurse enters an examination room to conduct a routine health assessment on an adolescent female client, who is accompanied by her mother. Which action by the nurse is likely to facilitate accurate responses to personal and social history questions? -Include the mother in the interviewing process. -Request that the mother leave the exam room. -Allow the client to broach discussion of any sensitive topics. -Use highly structured and directed questions to explore sensitive topics.

Request that the mother leave the exam room. The teen needs to be able to explore sensitive issues in a private and confidential setting, so the parent should be asked to leave the room. The personal and social history contains many areas of special sensitivity to adolescents including such issues as drug and alcohol use and sexual activity. The teen should provide the personal and social history, not the parent.

Client reports to the nurse a recent exposure to the mumps. Which assessment finding suggests the client has contracted the mumps.

Swelling anterior to the ear lobe on one side of the face Mumps cause swelling and tenderness of parotid salivary glands. Can be unilateral or bilateral

A postmenopausal female client is undergoing a routine physical examination. She has reported nothing out of the ordinary. When performing the examination of the genitourinary system, the nurse finds an irregularly enlarged uterus with firm, mobile, painless nodules in the uterine wall. How should the nurse explain this finding to the client? -You have benign fibroid tumors, a common occurrence in women your age. -This is a sign of uterine cancer and I will report this to the healthcare -provider. -This is a sign of endometriosis, so we will need to biopsy the lesions. -This is a very common finding in pregnancy and it will go away..

You have benign fibroid tumors, a common occurrence in women your age. With myomas (uterine fibroids), subjective findings are varied depending on the size and location of the lesions. Often there are no symptoms. Symptoms that may occur include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache, or excessive uterine bleeding and anemia if myoma disturbs endometrium. Objective findings: uterus irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall. These benign tumors are common; by age 50 years 70% of White women and greater than 80% of Black women will have at least one.