Health Assessment Coursepoint 26

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? Assist the client to a sitting position. Uncover the client to expose the chest and abdomen. Palpate the abdomen before auscultating. Warm the diaphragm of the stethoscope.

Warm the diaphragm of the stethoscope.

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, situation, and time oriented to hospital, person, and date oriented to person, place, and time oriented to person, place, and situation

oriented to person, place, and time

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: subjective data. objective data. baseline data. comprehensive data.

objective data.

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, situation, and time oriented to hospital, person, and date oriented to person, place, and time oriented to persooriented to person, place, and timen, place, and situation

oriented to person, place, and time

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 fine crackles pleural friction rub stertorous breathing

wheezes

During a health assessment, the nurse uses deep palpation to assess a client's: skin turgor. finger nodules. perspiration. liver.

liver.

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response? "Your physician will decide when it is best for you to begin having mammograms based on your family history." "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

"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 preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client? "Let me explain what I am going to do and how you can help." "I am going to examine your abdomen." "I need to report what is going on to your health care provider. Can I look at your abdomen?" "Open your shirt, I need to look at your abdomen."

"Let me explain what I am going to do and how you can help."

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? "You need to sign up for the clinic's stop smoking program." "You should decrease your intake of fried foods." "It is important for you to do 30 minutes of exercise three times a week." "Take your blood pressure medications exactly as your doctor prescribed them."

"Take your blood pressure medications exactly as your doctor prescribed them."

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory? "What did you eat for dinner last night?" "What are the three objects I told you earlier?" "What is meant by 'an ounce of prevention is worth a pound of cure'?" "What are the month, date, and the year of your birth?"

"What are the month, date, and the year of your birth?"

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? "What brings you here today?" "Are you having any pain?" "What medications do you normally use?" "Do you have any allergies?"

"What brings you here today?"

What percentage of weight change in 6 months is considered abnormal? 1% 2% 5% 10%

10%

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury? A circular red, scaly area that itches on the top of the forearm arm. An intact faded purple area on the shoulder blades, with a yellowish tint. An intact red area on the buttocks. An area of swollen, pale red bumps on the front of the neck.

An intact red area on the buttocks. An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. 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 feels dizzy. Ask the client if she has noted any blood in her stools lately. Ask the client if her gums bled this morning when she brushed her teeth. Nothing. The nurse shouldn't alarm her unnecessarily.

Ask the client if she has noted any blood in her stools lately.

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? Warm the equipment. Ask the client to empty her bladder. Place the client in a semi-Fowler's position. Measure height and weight.

Ask the client to empty her bladder.

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? Document a normal skin finding on the client chart. Assess the client for cardiovascular disorders. Report the finding as a positive sign for cystic fibrosis. Assess the client for dehydration.

Assess the client for dehydration.

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

Auscultation

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider? Auscultation of a bruit Auscultation of bowel sounds every 30 seconds Auscultation of gurgles and clicks Umbilicus centrally located

Auscultation of a bruit

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. Neurologic: 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

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

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? Ask the client if he left his earplugs in his ears. Check the client's ear canals for cerumen. Use facial expressions and sign language to communicate. Speak to the older adult client in a high-frequency tone of voice.

Check the client's ear canals for cerumen.

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." Client describes shortness of breath and increased sputum production. Client reports breathlessness and productive cough. Client reports respiratory distress and frequent spitting.

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

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

Crepitus

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? Suspect an inflamed pleura rubbing against the chest wall. Document normal breath sounds. Recommend testing for pneumonia. Assess for asthma.

Document normal breath sounds.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition? Hepatitis Appendicitis Diverticulitis Cellulitis

Hepatitis

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? Check her chart for allergy information. Inspect the area of itchy skin. Review her medical history. Review her medication record.

Inspect the area of itchy skin.

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. Lightly palpate the left leg, assessing for edema. Assess for pain by deeply palpating the left leg. Palpate the popliteal and posterior tibial pulses of both legs.

Inspect the left lower leg for areas of redness.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. Symmetrical shape Irregular edges Single color Larger than 1/4 inch in diameter Change in the mole

Irregular edges Larger than 1/4 inch in diameter Change in the mole

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 appearance. Which nursing action is the priority intervention? Assess capillary refill. Measure the pulse oximetry. Assess fluid intake. Limit the client's activity.

Measure the pulse oximetry.

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene? Palpation of both carotid arteries at the same time Warming of a stethoscope before assessing a client's breath sounds Placing a tongue blade at the side of the tongue while the client pushes it to the left and right Occlusion of one of the client's nostrils while the client breathes through the nose

Palpation of both carotid arteries at the same time

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: front of the ear. mastoid process. top of the head. affected ear.

mastoid process.

The nurse is palpating a client's precordium. Which result is an expected clinical finding? Palpable pulsation over the mitral area Palpable thrill over the aortic area Palpable heave over the pulmonic area Palpable vibration over the right sternal border

Palpable pulsation over the mitral area

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? Auscultation Inspection Palpation Percussion

Palpation

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

Palpation

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. Early bowel obstruction Paralytic ileus Peritonitis Duodenal ulcer Salpingitis Food poisoning

Paralytic ileus Peritonitis

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? Pink labia lesions Coarse brown hair Whitish vaginal discharge Dark pink vulva

Pink labia lesions

The nurse must weigh a client using a bed scale. Place the following steps in the correct order. Use all options. 1Place a cover over the sling of the bed scale. 2Attach the sling to the bed scale. 3Balance the scale so that weight reads 0.0. 4Roll client back over the sling and onto other side. 5Gradually elevate the sling so that the client is lifted up off of the bed. 6Note weight reading on the scale

Place a cover over the sling of the bed scale. Attach the sling to the bed scale. Balance the scale so that weight reads 0.0. Roll client back over the sling and onto other side. Gradually elevate the sling so that the client is lifted up off of the bed. Note weight reading on the scale.

Which components are included in the integumentary system? Select all that apply. Skin Hair Nails Sweat glands Arteries Muscles

Skin Sweat glands Hair Nails

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? The skin is less elastic with aging. The client is dehydrated. The skin has normal turgor. The client is overhydrated.

The client is dehydrated.

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. The client reports thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia.

The client makes noises when he breathes.

When percussing the liver, the sound should be: resonant. hyperresonant. dull. flat.

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

A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. The palate and pharynx move as the client says "ah." The client's tongue remains midline when it protrudes from the mouth. The client is able to turn the head to the side and shrug the shoulders against resistance.

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.

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 ear canal is rough and pinkish. The tympanic membrane is reddish. The ear canal is smooth and white.

The tympanic membrane is translucent, shiny, and gray. The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

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.

To convert the client's weight in pounds to kilograms, the nurse would divide 186 by 2.2 to arrive at a weight of 84.5 kg.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse? Erythema at sting site Heart rate of 100 Wheezing on auscultation Crying with burning pain

Wheezing on auscultation

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 a client in the Intensive Care Unit after having a stroke yesterday a client recovering from brain surgery for repair of an aneurysm a client with a brain tumor who is in the hospital because of respiratory depression

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

The nurse should use the bell of the stethoscope during auscultation of: a client's heart murmur. a client's apical heart rate. a client's breath sounds. a client's bowel sounds.

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

To obtain subjective data about a newly admitted client's sleep pattern, the nurse: inspects the client's eyes for redness. asks the client what promotes sleep. documents the client's affect and yawning. determines how frequently the client naps.

asks the client what promotes sleep.

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

auscultation

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 palpation of muscle symmetry over the posterior thorax an anteroposterior to lateral ratio of 1:2 blowing, hollow sounds auscultated over the larynx

auscultation of short, high-pitched popping sounds during inspiration

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. have the client turn from side to side and assess pain. have the client lay on his right side, then palpate the area. elevate the legs, bending at the knee while the client is supine.

avoid a position change that requires turning.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: clear. blurred. clouded. 20/20.

blurred

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? circumoral cyanosis when the client is at rest a blue-black macular area over the sacral area the anterior fontanel bulging when the client cries the abdomen appearing large in relation to the pelvis

circumoral cyanosis when the client is at rest

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: erosion. ulcer. fissure. crust.

fissure.