Chapter 25, health Assessment ppc2

What percentage of weight change in 6 months is considered abnormal?

10%

Which respiratory sound indicates an upper airway obstruction?

Stridor

The nurse is performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment? Select all that apply

"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?"

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

"What brings you here today?"

A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the client?

Bed Scale

Which framework is used during the focused assessment?

Body systems framework

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Decreased cardiac output

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first?

Evaluate the blood pressure and pulse

A nurse asks a client to raise her eyebrows, smile and show her teeth, and puff out her cheeks. This nurse is most likely assessing which cranial nerve?

Facial (VII) Cranial nerve VII controls the muscles of the face. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?

Inspect and palpate the supraclavicular area.

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?

Inspect the left lower leg for areas of redness.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

Objective data

The nurse is preparing to perform an assessment of a client's thyroid gland. What is the best technique for the nurse to use?

Observe the thyroid gland with the neck slightly hyperextended.

A client reports severe abdominal pain that started about an hour after eating lunch. Assessment reveals absent bowel sounds and rebound tenderness in the right lower quadrant. What does the nurse suspect these findings may indicate? Select all that apply.

Paralytic ileus Peritonitis

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority?

Patency of airway

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply.

Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated." Client informs the nurse there is a floater in the left eye

A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?

The client makes noises when he breathes. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.

A nurse is examining the skin of a client visiting a dermatologist and documents the existence of a wheal. What might the nurse assume from this finding? Select all that apply.

The client may have a mosquito bite. The client may have hives.

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

The sclera of the eye

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray.

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for?

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:

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

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:

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

When a client enters the acute care facility, the nurse should perform a:

comprehensive health assessment.

The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order.

inspection auscultation percussion palpation

During a health assessment, the nurse uses deep palpation to assess a client's:

liver

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?" Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol abuse. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next?

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

A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next?

Auscultate the abdomen.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

Auscultation Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?

Check the client's ear canals for cerumen. Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response?

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." The client's reason for seeking care should always be stated in the client's own words which should be document in quotations. This subjective data is important for all health care providers to review.

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply.

Collection of subjective data Complete set of vital signs Functional ability evaluation (Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client. The development of the care plan, which includes goals with outcome criteria and client education, are done after the admission assessment.)

A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of vodka daily and that he's had a recent weight gain of 3 lb (1.35 kg) in 3 days. Further questioning by the nurse reveals that he was an intravenous drug user in the past but is now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal girth. Which assessment finding supports the nurse's conclusion that the client has liver dysfunction?

Jaundice

When percussing the liver, the sound should be:

dull

A nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply.

Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis)

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene?

Palpation of both carotid arteries at the same time The charge nurse should intervene when the new nurse palpates both carotid arteries at once. Bilateral palpation can obstruct blood flow to the brain. Insertion of the otoscope is correct as well as assessment of the red reflex using an ophthalmoscope. It is correct for the nurse to occlude only one side of the nose while the client breathes.

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

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

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

84.5

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?

Palpation

A nurse assesses a client's nails. What is a normal finding?

160-degree angle of nail attachment Nails are normally convex and the cuticle is pink and intact. The angle of attachment of the nail is 160 degrees; clubbing is present when the angle of the nail base exceeds 180 degrees. Normally, nails are firm and smooth and capillary refill should be brisk—less than 3 seconds.

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age does she need to begin having mammograms. What is the nurse's best response?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?

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

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

Crackles

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply.

Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity

The nurse is testing the peripheral vision of a client. Which actions are recommended guidelines for this test? Select all that apply.

Have the client cover one eye with a hand or index card. The nurse should cover an eye opposite the client's closed eye. Hold one arm outstretched to the side equidistant from the nurse and client, and move fingers into the visual fields from various peripheral points.

Which statement accurately represents a characteristic of the third or fourth heart sound?

S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-age and older adults. This sound is best heard with the stethoscope bell at the mitral area, with the client lying on the left side. S4 is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require?

Tuning fork

To assess subjective data related to a client's elimination pattern, the nurse:

asks the client about changes in elimination patterns.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation

The nurse should use the bell of the stethoscope during auscultation of:

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

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

auscultation of short, high-pitched popping sounds during inspiration Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. Tactile fremitus is a tremulous vibration of the chest wall during speaking that is palpable on physical examination. Percussion of low, hollow sounds over the lateral lung fields are normal. A normal assessment finding is an anteroposterior to lateral ratio of 1:2 for clients over 6 years.

A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:

density and location of lungs Percussion over the lung fields helps identify the density and location of the lungs. Palpation assesses for masses, crepitus, muscle development, and tenderness. Lung auscultation assesses for normal breath sounds and for abnormal (adventitious) breath sounds.

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:

fissure A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.

To assess a client's visual accommodation, the nurse has the client:

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

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:

mastoid process Strike the tuning fork and place its stem firmly against the mastoid process.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should:

observe the client's body language.

A client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is:

subjective data.

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client?

whether they have a program of regular physical activity

When examining a client upon admission to the hospital, it is important to:

provide privacy and confidentiality.

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"Take your blood pressure medications exactly as your doctor prescribed them." Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.

During assessment of the lower extremities, the nurse notes the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4 mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?

2+ pitting edema noted on bilateral lower extremities

A 52-year-old male client is admitted to the medical-surgical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He tells the nurse that he hasn't seen any blood in his stool and that he usually drinks a six-pack of beer a day. In trying to pinpoint the cause of the client's pain, which action would the nurse take?

Ask the client to tell her more about the pain.

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-ft (2-m) ladder. Which action by the nurse is the most important to take?

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

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider?

Auscultation of a bruit A bruit on auscultation suggests an aneurysm or arterial stenosis. Auscultation of peristalsis sounds and percussion of tympanic sounds over the intestines are gastrointestinal assessment sounds. Percussion of dull sounds over the right upper quadrant is assessment of the liver.

A nurse is performing auscultation. The nurse would use the bell of the stethoscope to auscultate which sounds?

Bruits The bell of the stethoscope is used to detect low-pitched sounds such as abnormal heart sounds and bruits. The diaphragm is use to detect high-pitched sounds such as breath sounds, normal heart sounds and bowel sounds.

Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply.

Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Gastrointestinal: abdominal pain with rebound tenderness in RLQ

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Document normal breath sounds.

The nurse testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing? Select all that apply.

III: Oculomotor (OAT) IV: Trochlear VI: Abducens The oculomotor, trochlear, and abducens nerves control the motor function of the eye structures, which can be assessed through movement of the eyes through the six cardinal positions of gaze. The optic nerve controls the sense of vision. The trigeminal nerve controls the jaw movements of chewing and mastication (motor), and sensation on the face and neck (sensory). The facial nerve controls the muscles of the face (motor) and the sense of taste on the tongue (sensory).

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first?

Inspect the area of itchy skin Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

Inspection, auscultation, percussion, palpation

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

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

The nurse examines the skin of a 29-year-old Irish woman who is reporting swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?

Maculopapular A maculopapular rash is characterized by macules (distorted but nonelevated spots on the skin) and papules (small, circumscribed, superficial, solid elevations of the skin). The term bullae refers to the presence of large vesicles (usually 2 cm or more in diameter). A papulovesicular rash is characterized by superficial, small, circumscribed, and solid elevations of the skin and vesicles, or blisters. A pustular rash contains visible pus within or beneath the epidermis.

A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen (pale gray) appearance. Which nursing action is the priority intervention?

Measure the pulse oximetry. The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.

The nurse is palpating a client's precordium. What is an expected clinical finding?

Palpable pulsation over the mitral area A palpable pulsation over the mitral area is a normal finding (apical impulse). Normal findings include no pulsation palpable over the aortic and pulmonic areas, with a palpable apical impulse. Abnormal findings include precordial thrills, which are fine, palpable, rushing vibrations over the right or left second intercostal space, and lifts or heaves, which involve a rise along the border of the sternum with each heartbeat.

Sanjay Patel is a 10-year-old boy from India with mahogany-colored skin. He arrives at the school nurse's office and tells the nurse that he was stung by a wasp on the arm yesterday, and he thinks it might be infected. The nurse performs which action in order to assess the wasp sting site for inflammation?

Palpate the area with the back of the hand for increased warmth, then touch the other arm for comparison.

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

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

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.

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

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

Stop lifting the client and reassure him The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.

Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply.

The client answers questions in a barely audible voice. The client bites her fingernails. The client eats 25% of her meals. The client sleeps a lot.

The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator?

Translators may need additional explanations of medical terms. When using a translator it is important to remember that the client still comes first. This means that all information is directed at them and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when an emotional topic is being discussed. Talking loudly not only inhibits better understanding, but it can also come across as hostile and rude. It is true that even professional translators don't understand all medical terms and may need some clarification at times.

Which piece of equipment is used to perform the Weber test and Rinne test?

Tuning fork A tuning fork is used during the Weber and Rinne tests. A reflex hammer is used to test reflexes; a cotton-tipped applictor has several purposes but is not a primary instrument in the Weber and Rinne tests; a laryngeal mirror is used to examine the throat and mouth.

A nurse is percussing a client's abdomen. Which finding would the nurse document as normal?

Tympany Characteristically, percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, the liver is dull, and bone is flat.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

Verify that the procedural consent form is signed. Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

A nurse performs a general survey on a client who is being admitted to the hospital for Chronic Obstructive Pulmonary Disease (COPD). Which components of this type of assessment will be a focus for the nurse? Select all that apply.

Vital signs Gait Behavior Body mass index (BMI) Breathing pattern

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope. Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.

A nurse is caring for a post-operative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? (Select all that apply.)

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills, or acts that involve collecting data, which include interviewing, observing, and examining the client. Inspecting the incision, taking a blood pressure, and reviewing lab results are all examples of data collection. Assisting a client in a chair and performing ADLs are caring interventions.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

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