Fundamentals PrepU Chapter 25: Health Assessment

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

Which framework is used during the focused assessment?

Body systems framework -Body systems approach is used during the focused assessment of an acutely or critically ill client to determine function of a particular body system.

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).

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

Density and location of the lungs

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 -Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description

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. -Assess the thyroid gland with the neck slightly hyperextended. Observe the lower portion of the neck overlying the thyroid gland. Assess for symmetry and visible masses.

A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint?

Prone -In the prone position, the client lies flat on the abdomen with the head turned to one side, which enables the nurse to assess the hip joint and posterior thorax.

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

Liver -The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.

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

Look at a close object, then at a distant object

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

S3 is considered normal in children and young adults and abnormal in middle-age and older adults.

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 community nurse is participating in a health promotion fair and has been asked by a middle-aged woman about the necessity of breast self-examination(BSE). How should the nurse respond to the woman's inquiry?

"Breast self-examination is a valuable tool and should be done once a month.

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.

To obtain data about an adult client's sexuality and reproductive pattern, what question is best for the nurse to ask?

"Has anything changed your sexual performance?" -The sexual assessment is not meant to illuminate nonexistent problems. Rather, the client is, in effect, given permission and encouragement to present sexually related questions.

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).

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

"What brings you here today?" -The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern."

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.

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.

- Client informs the nurse there is a floater in the left eye - Reports of abdominal pain of 4 on a 0 to 10 point scale - The client states, "I feel nauseated." -Subjective data includes any reports or information that the client gives.

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 - 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.

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.

-Complete set of vital signs -Functional ability evaluation -Collection of subjective data

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

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.

-Skin: warm and dry -Cardiovascular: radial pulses 90, bounding and equal -Gastrointestinal: abdominal pain with rebound tenderness in RLQ -Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body

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

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 sleeps a lot -The client bites her fingernails -The client eats 25% of her meals -Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all her food, sleeps a lot, and bites her fingernails is a means of attaining objective findings.

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 wheal is an irregular, superficial area of localized skin edema that is characteristic of hives and mosquito bites.

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

1. Inspection 2.Auscultation 3.Percussion 4.Palpation

A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed.

1. Position the client supine and drape appropriately 2. Inspect the skin of thorax and abdomen 3. Palpate the thorax 4.Auscultate the thorax 5.Auscultate the abdomen 6. Palpate the abdomen

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

10%

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

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+ pittind edema noted on bilateral lower extremities -Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour.

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 kg -1 kg=2.2 lbs

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 -Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert.

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 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

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 -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 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. -The nurse should ask the client to tell her more about the pain because an open-ended question would elicit more assessment information about the nature of the pain than a question that calls for a yes or no answer.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

Asks the client what promotes sleep -The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

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 nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

Assess the client for dehydration -Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly.

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

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation -Auscultation refers to the assessment technique of listening with a stethoscope to sounds produced in the body, such as bowel sounds.

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

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.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should:

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

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

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 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.

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

Comprehensive assessment -A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting.

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

Cranial Nerve I -Cranial nerve I is the olfactory nerve and is used for smelling

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

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

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 -Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output),

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 -Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields.

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. -Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields.

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

A nurse 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. -Inspection and palpation of the supraclavicular area can detect enlarged lymph nodes.

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.

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. -Inspection is the initial step in peripheral vascular assessment of the extremities.

The nurse is preparing to perform an examination of the abdomen of a 23-year-old male client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client?

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.

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

Oriented to person, place, and time

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).

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. -Local inflammation like that sustained from an insect sting presents with redness (erythema), swelling (edema), tenderness, and heat. Because erythema is not observable on a person with dark brown skin, it is necessary to palpate the skin for increased warmth and taut or tightly pulled surfaces that may be indicative of edema. To assess skin for increased warmth, use the back of the hand to palpate the area and compare bilaterally.

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.

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

Palpation -The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic.

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?

Penlight or flashlight -A penlight or flashlight is necessary to gauge pupillary response and to visualize the client's mouth.

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.

Which respiratory sound indicates an upper airway obstruction?

Stridor -Stridor is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction.

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.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature?

The dorsum -The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great.

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 best location to observe for jaundice in this population is 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 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 - It is true that even professional translators don't understand all medical terms and may need some clarification at times.

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.

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.

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.

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 -Wheezing is an abnormal breath sound that is commonly seen with allergic reactions.

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 -The best location to observe for jaundice in this population is the sclera of the eye.

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

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

A nurse uses observation to examine a client's skin. The nurse would document cyanosis for the client:

whose skin is a dusky, bluish color. -Lack of oxygenated blood to a body part produces cyanosis, which exhibits as a dusky, bluish color.