Saunders Health Assessment ish

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?

"I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward."

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems?

1. History of headaches 2.Previous back injury 3.History of hypertension 4.History of diabetes mellitus

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis?

1. tongue 2.nail beds 3. mucuos membranes

The nurse reviews the findings from a physical exam done on a client for ear or hearing disorders and notes documentation that the client has hyperacusis. Which would the nurse expect to note on assessment of the client?

Intolerance for sound levels that do not bother other people

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

Just under the left clavicle

The nurse is assessing for the presence of pallor in a dark-skinned client. What finding should the nurse look for?

Loss of normal red tones in the skin

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest?

Over the fifth intercostal space in the left midclavicular line

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

Pain with dorsiflexion of the foot

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination?

Pull the pinna up and back before inserting the speculum.

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?

Redness and swelling in the ear canal

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test?

The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

The functional status of the vestibular apparatus in the inner ear This test also assesses intactness of the cerebellum and proprioception.

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area?

The major bronchi

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how should the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?

Waves of loud gurgles auscultated in all 4 quadrants (borborygmi)

The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen chart is 20/30. How should the nurse explain these results to the client?

You can read at a distance of 20 ft what a person with normal vision can read at 30 ft

what are neurogenic hyperventilations indicative of?

a dysfunction in the low midbrain and middle pons

What are apnuestic respirations indicative of?

a dysfunction in the middle or caudal pons.

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time?

At a specific day of the month and on that same day every month thereafter

The nurse would perform which action to assess for a pulse deficit?

Auscultate the apical heartbeat while palpating the radial artery.

The nurse is planning to test the sensory function of the olfactory nerve (cranial nerve 1). The nurse would gather which items to perform the test?

Cloves, peppermint, and soap

After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description bestdescribes normal bowel sounds?

Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?

Stroking the foot from the heel to the toe

The nurse is preparing to perform an abdominal examination on a client. The nurse should place the client in which position for this examination?

Supine with the head raised slightly and the knees slightly flexed

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse in a health care clinic is preparing to test a client for accommodation. Initially, the nurse should ask the client to take which action?

Focus on a distant object.

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action?

Identify 3 numbers or letters traced in the client's palm.

Nystagmus

characterized by fine, involuntary eye movements

The nurse is preparing to test the sensory function of cranial nerve V in a client. The nurse should obtain which item to test the sensory function of this nerve?

cotton wisp

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?

"This is mostly used in a walk-in clinic or emergency department."

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment?

1.Auscultating lung sounds 2.Obtaining the client's temperature 3.Obtaining info on the client's respirations

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal?

1.Muscle strength graded 5/5 2.Symmetrical movements bilaterally 3.Increased muscle size on the dominant arm 4.A 1-cm hypertrophy of the right upper arm

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.

1.Set the room temperature at a comfortable level. 2.Remove distracting objects from the interviewing area. 3.Ensure comfortable seating at eye level for the client and nurse.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action?

Ask the client to give permission for a family member to stay during the interview.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

6 cardinal gazes

20/60 vision

A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?

alpate for increased skin temperature around the wound edges

Heart Murmur

an abnormal heart sound and is described as a faint or loud blowing, swooshing sound with a high, medium, or low pitch

Ataxic respirations

are totally irregular in rhythm and depth

Neurogenic hyperventilation

regular, rapid and deep, sustained respiration

normal bowel sounds

relatively high-pitched clicks or gurgles 5-30 per minute, in all 4 quadrants

Cheyne-Stokes respirations

rhythmic respirations with periods of apnea

The nurse is performing a physical examination on an assigned client. Which item should the nurse select to test the function of cranial nerve II?

snellen chart

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

difficulty walking

Ataxia

disturbance in gait.

The nurse should ask a client to take which action when testing the function of the spinal accessory nerve (CN XI)?

elevate the shoulders

Tapping the Achilles tendon with a reflex hammer describes

gastrocnemius muscle contraction

what are ataxic respirations indicative of?

indicate a dysfunction in the medulla

Apneustic respirations

irregular respirations with pauses at the end of inspiration and expiration

Hyperreflexia

is an excessive reflex action.

A pericardial friction rub

is described as a scratchy, leathery heart sound

ringing in the ears

tinnitus

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site?

mitral area

The registered nurse (RN) is educating a new RN on how to interpret vision tests using a Snellen chart. After the client's vision is tested with a Snellen chart, the results of testing are documented as 20/40. Which statement by the new RN indicates that the teaching has been effective?

"The client can read at a distance of 20 ft (6 meters) what a person with normal vision can read at 40 ft (12 meters)."

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves III, IV, and VI. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Ask the client to shrug the shoulders against the nurse's resistance.

A child is seen in the school nurse's office with complaints of pain in his right forearm. In reviewing the child's record the nurse notes that he has a history of being physically abused by the mother. Which should be the initial intervention with this child?

Assess the child's physical status.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

Holding the sides of the client's great toe and, while moving it, asking what position it is in

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

Identify an object placed in the client's hand.

The 5 P's

If a child sustains a fracture, the extent of the injury is immediately assessed using the 5 "P's"-pain and point of tenderness, pulses distal (not proximal) to the fracture site, pallor, paresthesia (sensation) distal to the fracture site, and paralysis (movement distal to fracture site)

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?

Instruct the client that he or she may need glasses when driving.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

One week after menstruation begins

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

Plan short sessions with the client to obtain data.

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the primary health care provider (PHCP)?

Pulsation between the umbilicus and the pubis

Accommodation Test

The nurse tests for accommodation by initially asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 in (7.5 cm) from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes

What are Cheyne-Stokes respirations indicative of?

a metabolic dysfunction in the cerebral hemisphere or basal ganglia

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse should instruct the client that while examining the left breast she should place a pillow under which area?

left shoulder

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate?

normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min- document these findings

sensorineural hearing loss

occurs as a result of a pathological process in the inner ear, a defect in cranial nerve VIII, or a defect of the sensory fibers that lead to the cerebral cortex

Conductive Hearing Loss

occurs as a result of a physical obstruction to the transmission of sound waves

pronator drift

occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted.

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will bestobserve these lesions in which body area?

petechiae are best observed in the conjunctivae and oral mucosa

The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

plural friction rub

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action should the nurse take first?

stop the IV infusion