Health Assessment Exam 4 Study

To evaluate the client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?"

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

"Do you take painkillers like aspirin on a regular basis?"

A nurse observes silvery, white striae on the abdomen of a middle-aged female client during the examination of the abdomen. What is an appropriate question to ask this client in regard to this finding?

"Have you been pregnant?"

Which statement made by the client indicates an understanding of how the nurse will perform the Romberg test?

"You want me to stand with my feet together and eyes closed for a short time."

A 19- year-old male fell 6 feet from a tree. He is awake, open his eyesspontaneously, and able to move all his extremities. When you ask what happened,he tells you that he fell, then he talked to you about a soccer game. Using theGlasgow Coma scale, his score is 15. How does the nurse document the results?

Document that Glasgow Coma Score results are normal

A nurse is performing passive range-of-motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so that the toes are pointed toward the ceiling?

Dorsal flexion

Which of the following people need to be vaccinated for hepatitis A and B?

Food-service workers

A nurse observes the abdomen of a client and notices it to be distended below the umbilicus. The nurse recognizes this can be caused by which of these conditions? Select all that apply.

Full bladder Uterine enlargement Ovarian tumor Impacted colon

When the median nerve is compressed, symptoms can include numbness, tingling,and weakness in the hand and arm. The test to assess the Carpal tunnel syndromeis known as

Phalen Test - flex the wrists and hold the backs of the hands x 60 seconds

Stomach

Site for both mechanical and chemical digestion

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

Spleen

The correct position in which to place a healthy adult patient to examine the rectum and prostate is

Standing and leaning over the examination table with chest and shoulders resting on the table.

The nurse auscultate the bowel sounds and document hypoactive bowel sounds.What this finding means

indicates low motility

When performing an abdominal assessment, what is the correct sequence

inspection, auscultate, palpation, percussion

What is the correct order for the abdominal assessment?

inspection, auscultation, percussion, palpation

When percussing the abdomen, the nurse notices a dullness at the anterior right costal margin at the right MCL. Which organ is most likely involved?

liver

Pancreas

located in the left upper quadrant secretes insulin and regulates blood glucose level

a 21-year-old male is extremely intoxicated. when you attempt to insert a nasal airway he slaps your hand away, curses at you, and then sits up. when you remove the airway, he lies down on the stretcher. What is the Glasgow Coma Score?

12 (Eye - 2, Verbal 5, Motor 5)

A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. All options are used. A. ask the client to urinate. B. auscultate the client's abdomen C. percuss the client's abdomen. d. perform light palpation.

1a, 2b, 3c, 4d

The nurse is assessing a client's testes. Which finding indicates the testes are normal?

egg-shaped

If performing a rectal examination of a client, which techniques are important to include?

every step of the process, utilize lubrication and gloves, and to allow the anal sphincter to relax as much as possible prior to inserting the gloved finger

colonoscopy

examination of the colon using a flexible colonoscope

The nurse is assessing the client's bowel sounds. The nurse should:

expect to hear about 5 to 35 sounds in 1 minute for normal bowel sounds.

If a male client is uncircumcised, the glans of the penis is covered by the:

foreskin

A 62 -year-old patient is concern about the epigastric pain and the coffee ground emesis he is presenting in the last two days. The patient is asking what can cause it?

gastric ulcers

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding?

high pitched gurgling noises in four abdominal quadrants

The nurse is preparing the patient for a genital examination. What position will the nurse assist the patient into for a comfortable genital examination?

Semi-lithotomy

Which assessment is not common to monitoring both urine and stool?

Shape

A client is experiencing parietal abdominal pain. The nurse would expect the client to describe the pain as which type of sensation?

Steady

You are inspecting the groin of an older adult male who lives in a long-term care facility. Which of the following is an expected finding that you will document?

Smegma under the foreskin

Moving a part of the body away from the midline is called?

Abduction

Liver

Located in the Right Upper Quad produces and secretes bile

Duodenum

The primary site of chemical digestion in humans.

Which of the following would you recognize as an unexpected finding while examining the male genitalia?

You note an impulse at the tip of your finger during hernia examination

The nurse is interviewing an adult client in the clinic. The client asks about actions that can reduce the future risk of a stroke. What health promotion activity should the nurse prioritize?

Smoking cessation

The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?

Speech therapist

Which of the following would be most appropriate if a nurse palpates the abdomen and feels a prominent, nontender, pulsating 6-cm mass above the umbilicus?

Stop palpating and get medical assistance.

The ambulance brings the client with a head injury to the emergency department. The client responds to painful stimuli by opening the eyes, muttering, and pulling away from the nurse. How would the nurse rate this client on the Glasgow Coma Scale?

9 The nurse would rate at an 9: 2 for the opening of the eyes, 3 for verbal response, and 4 for motor response.

The nurse practitioner is assessing a patient with frequent candidiasis. The test that the nurse will order for this patient is

A blood test for glucose

A group of students is reviewing information about the locations of various organs within the abdomen. The students demonstrate understanding of the material when they identify which organ as being found in the left upper quadrant?

Spleen

A patient with a tympanic abdomen complains of pain in the RUQ. Which sign would the nurse expect to be positive?

A. Murphy sign. Rationale: The Murphy sign tests for gallbladder pain. The other signs test for peritoneal irritation in the lower quadrants.

The nurse is performing inspection on a physical assessment. Which finding indicates a normal abdominal inspection?

Abdomen slightly rounded with even skin tone and no visible scarring.

Large intestines

Absorbs the remaining water and salt from digested food Absorbs Vitamin K

Which is the most therapeutic exercise that can be done by a client confined to a bed?

Active range-of-motion exercise

A 27-year-old woman comes to the emergency department reporting severe right lower quadrant pain. Her temperature is 101.5°F (38.6°C), BP 122/80 mm Hg, pulse 95 beats/min, and respirations 22 breaths/min. What might the nurse suspect the client has?

Acute appendicitis

Bladder

Aids in removal of waste products from the body in urine form

Which finding obtained during the abdominal assessment in an older adult client should prompt the nurse to perform an additional assessment to determine the cause?

An enlarged liver felt during palpation

The nurse is performing a focused gastrointestinal assessment and asks the client about appetite. Which term refers to the loss of appetite?

Anorexia

During an abdominal assessment of a client admitted with abdominal pain, the nurse founds pain in the RLQ with coughing, as well as pain in the area with palpation. For what condition would the nurse further assess for and notify the primary health care provider of?

Appendicitis

During Mrs. Milly White's visit, she shared that her loyal dog died a month ago. She is not eating enough and lost three (3) pounds. What factor is influencing her weight to drop?

Appetite changes

A nurse is assessing a client's orientation times three. Which nursing intervention should be included in this assessment? Select all that apply.

Ascertain if the client knows the current environment. Have the client state the time of day. Ask the client's name.

You are at Universal and saw a park visitor that looks weak and asking for help.According to the F-A-S-T scale, how you assess the face to noticed any changes?

Ask the person to smile.

The clinic nurse is interviewing a 20-year-old male. The client states, "I am fairly sure I have another STD. This is, like, the 4th one this year!" What action would be most appropriate for this client?

Assess the client's understanding of safe sexual practice.

When examining the scrotum of an adult male, a normal finding is

Asymmetrical sac with left side lower than right side

Before palpating the abdomen during an assessment, the nurse should perform which of the following actions?

Auscultate bowel sounds.

The nurse suspects the male patient has a hernia. Which of the following should be included in the physical examination for scrotal hernia?

Auscultation of the scrotum.

A 70-year-old male presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition?

BPH

When you ask the patient to walk o tiptoes, heels, heel to toe manner (tandem walking) and backward, you are assessing

Balance

A normal sound obtained after abdomen percussion is?

Dullness heard in right upper quadrant over the liver

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?

Borborygmus

One of the guests at a health promotion fair asks the nurse, "What is the greatest killer of females?" The nurse knows by current evidence that it is

Cardiovascular disease

A Pap smear is recommended to screen for what condition?

Cervical cancer

A newer nurse is assessing a client who has been on the unit for the last week. The nurse notes that one of the client's pupils is larger than the other. What would the nurse do in response to this finding?

Check the client's baseline data.

The client is admitted with diarrhea. When auscultating bowel sounds, what should the nurse expect to assess?

Increased bowel sounds

Which of the following organisms is associated with salpingitis?

Chlamydia trachomatis

Upon inspection, the nurse sees flesh-colored lesions surrounding the anal area. These lesions most likely indicate

Condyloma acuminatum infection

A college student presents to the health care clinic with reports of no bowel movement for 4 days, bloating, and generalized abdominal discomfort. She states that she has not been eating and drinking correctly and is stressed because she has a final exam in 2 days. A nurse assesses the abdomen and finds positive bowel sounds in all four quadrants and tenderness in the left lower quadrant with a few small, round, firm masses. The Rovsing's sign and Psoas sign are negative. What nursing diagnosis can the nurse confirm for this client?

Constipation related to decrease in fluid intake

In order to examine the ocular mobility of a client who recently experienced a stroke, the nurse should examine which of the following cranial nerves? Select all that apply.

Cranial nerve VI Cranial nerves III and IV

During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated?

Cremasteric reflex

A patient with a history of kidney stones presents with complaints of pain, hematuria, and nausea with vomitting. What assessment will elicit kidney pain?

Indirect percussion for CVA tenderness

The nurse is preparing to assess the size of the aorta. The nurse would palpate at which location?

Deep epigastrium to the left of midline

Hepatitis A (acute)

Direct contact or by fecal-contaminated food or water

The nurse is taking a menstrual history. What would be an appropriate question to ask?

Do you ever skip periods?

Which additional health history question related to the abdominal system is appropriate for people of African American decent?

Do you or your parents have sickle cell disease or trait?

Which sound should the nurse expect to hear when percussing a distended bladder?

Dullness

Which assessment a finding over the stomach the nurse most accurately identifys the region as t

Epigastric

Decerebrate posturing is characterized by which of the following?

Extension of the extremities and pronation of the arms.

The nurse needs to perform a quick assessment in order to assess level of consciousness. What scale would the nurse utilize?

GCS or Glasgow Coma Scale has a score ranging from 3-15 that can give a quick overview on a client's neurologic status.

What is the correct procedure to assess for scoliosis in children and adolescents?

Have the child stand and bend forward at the waist while viewing the spine.

To assess the status of the median nerve, which of the following does the nurse perform?

Have the client grasp the nurse's hand while noting the client's strength of the first and second fingers.

After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led the nurse to this conclusion?

Heavier than usual menstrual periods

A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?

Helicobacter pylori

Which STI presents with painful red superficial vesicles along the penis or on the glans?

Herpes simplex virus 2 (HSV-2).

A group of students is preparing for their clinical experience, for which they are required to demonstrate the techniques for examining the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Inspect, auscultate, percuss, palpate

A client presents to the emergency department with reports of new onset of abdominal pain for the past three (3) days. The client states there is also a pulling feeling on the right side. Upon examination the nurse notices a 5cm transverse scar in the right lower quadrant. The nurse recognizes that this client may be experiencing what type of process?

Internal adhesions from previous surgery

The nurse performs the technique shown when assessing a client. For what is this nurse assessing?

Kidney tenderness

A nurse is assessing a 76 -year-old female abdomen for tenderness. Which technique is the nurse using?

Light palpation

The nurse is assessing an older adult client for severe malnutrition. Which of the following factors increases this client's risk for malnutrition?

Limited access to a grocery store

A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?

Listen for a total of 5 minutes

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Listen for five minutes before documenting an absence of bowel sounds.

Gallbladder

Located in the Right Upper Quad stores and concentrates bile

An exaggerated inward curve of the spine that typically affects the lower back is

Lordosis

While walking, a client becomes weak and the knees begin to buckle. Which should the nurse do?

Lower the client to the floor carefully.

What defines a positive (Abnormal) Romberg test?

Moderate swaying with eyes open and closed

An 82 -year-old patient reported that he is unable to smell. Which nerve is affected?

Nerve 1 Olfactory

A nurse performs percussion beginning along the left midaxillary line and progressing downward until the sound changes from lung resonance to splenic dullness. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

Spleen

The nurse is assessing the gait of a client recently admitted after a cerebrovascular event. What are potential abnormalities the nurse may note in the client's gait? Select all that apply.

Staggering Foot scraping Persistent toe walking

A 20-year-old White male complains of a mass in their left testicle. In addition to their age and race, what else is a risk factor for testicular cancer?

Personal history of cryptorchidism-undescended testicle at birth

To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method?

Place a tongue blade lightly on the posterior aspect of the pharynx.

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following?

Positive Rovsing's sign

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

Positive Rovsing's sign

A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.

Small intestine

Propels contents by worm like movements know as peristalsis. Responsible for absorption of nutrients 5.5-.6.1 meters in length (18-20ft)

Which of the following is consistent with obturator sign?

Right hypogastric pain with the right hip and knee flexed, and the hip internally rotated

When auscultating the abdomen, the nurse hears a bruit to the right of the midline slightly below the umbilicus. The nurse documents this finding as bruit of which of the following?

Right iliac artery. Rationale: The iliac arteries are located to the left and right of the midline of the abdomen, below the umbilicus. The aorta is midline, the renal artery is above the umbilicus, and the femoral artery is located in the groin.

As part of an abdominal assessment, the nurse must palpate a client's liver. In which quadrant is this organ located?

Right upper quadrant

The nurse is caring for a patient in the emergency department with complaints ofacute abdominal pain, nausea, and vomiting. When the nurse palpates thepatient's left lower abdominal quadrant, the patient complains of pain in the rightlower quadrant. The nurse will document this as which of the following diagnosticsigns of appendicitis?

Rovsing Sign

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

Supine with arms at sides or folded across chest

Aorta

Supplies oxygenated blood to the cells and organs of the lower half of the body

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

Suprapubic

The nurse is assessing a child in the community clinic and notes that there are several webbed fingers. What is the term the nurse would document for this condition?

Syndactyly

A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following?

Teach TSE

A 20-year-old patient presents with scrotal pain. A suspected diagnosis that requires immediate referral is

Testicular torsion

The nurse is caring for an elderly client who has an indwelling urinary catheter. Which data warrant further investigation?

The client has become confused and irritable.

A client reports severe pain in the left lower quadrant of 3 days' duration. How should the nurse conduct palpation of the abdomen due to this history?

The left lower quadrant is palpated last

Hepatitis C (HCV)

The most widespread chronic blood-bourne illness in the US. No Vaccine available

The practitioner has decided to place a patient on isotretinoin for acne problems. The nurse is preparing to counsel the patient. What is the most important information the nurse needs to tell the patient?

The patient needs to use two forms of birth control or abstain from penile-vaginal intercourse 1 month before, during, and 1 month after taking this medication

When assessing a client's mental status, which of the following would be key areas to include? Select all that apply.

The presence of absence of suicidal thoughts/ideations. The client's judgment and recent (short-term) memory. The client's appearance, facial expressions, mood, and affect.

What happens to older adults?

The productions of saliva and stomach acid is reduced

A nurse is testing the function of a client's vestibulocochlear nerve (CN VIII). The nurse would gather which of the following items to perform the test?

Tuning fork and audiometer

When palpating the bladder of an adult client, a nurse would identify which finding as normal?

a nonpalpable bladder

The nurse is using the rating scale for muscle strength on a recently admitted client. The nurse notes that the client is able to have complete range of motion against gravity and resistance in the upper extremities. In the lower extremities, the client only has complete range of motion when the knees and hips are supported and is unable to perform range of motion again gravity. How would the nurse rate the bilateral upper extremity strength versus the lower extremity strength?

Upper 5/5, lower 2/5

A patient complains of a soft, irregular mass on the left side of the scrotum they noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition?

Varicocele

The nurse is inspecting the urethra and the Skene glands. These are a part of what area?

Vestibule

jejunum and ileum

the part of the small intestine between the duodenum and ileum. absorbs water,nutrients, and electrolytes

A patient reports changes in bowel pattern.Which is the best question to determine normal bowel habits?

What was your bowel pattern before you noticed the change?

A nurse suspects a client has peritonitis. Which assessment finding would the nurse expect to find?

abdominal wall rigidity

endoscopic retrograde cholangiopancreatography (ERCP)

assess the duct draining the liver and pancreas to identify and remove gallstones in the common bile duct and to diagnose pancreatic cancer

The nurse is planning to assess a client's abdomen. Which assessment technique should the nurse use after inspecting the area?

auscultation

The nurse is caring for a client experiencing acute abdominal pain. What is the first action by the nurse?

auscultation of all four quadrants using a stethoscope

The nurse must assess for the Prescence of bowel sounds in a postoperative client. The nurse should auscultate the client's abdomen:

before palpation.

kidneys

control red blood cell production and elevate blood pressure

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client?

palpation

Esophagus

propels food into the stomach and it is controlled by the cardiac sphincter -One way valve

The nurse working in a clinic is assessing a 33-year-old male client. Click to highlight the findings that will require follow-up. The client reports recent increase in lethargy, and shortness of breath with activity . The nurse performs a comprehensive assessment. Findings reveal pale, cool skin; weak pulses bilaterally ; and delayed capillary refill time . Vital signs include: temperature, 97.7°F (36.5°C); heart rate, 95 beats/min; blood pressure, 110/65 mm Hg; respiratory rate, 16 breaths/min ; oxygen saturation, 93% on room air . The client denies difficulty voiding but reports dark, tarry stools for the past month .

recent increase in lethargy, and shortness of breath with activity pale, cool skin; weak pulses bilaterally delayed capillary refill time oxygen saturation, 93% on room air dark, tarry stools for the past month

When percussing a client's chest, what should the nurse expect to hear?

resonance

What are the 9 regions of the abdomen?

right hypochondriac, epigastric, left hypochondriac right lumbar, umbilical, left lumbar, right iliac, hypogastric left iliac

A 32-year-old female client diagnosed with an ovarian cyst is complaining of acute pain. Which area of the abdomen should the nurse expect the client to be experiencing pain?

right lower quadrant

What are the 4 quadrants of the abdomen?

right upper, left upper, right lower, left lower

barium enema

series of radiographic images taken of the large intestine after the contrast agent barium has been administered rectally

The nurse assesses function of cranial nerve XII (hypoglossal nerve) by asking the client to:

stick out the tongue and move it side to side.

What percussion sound is heard over most of the abdomen?

tympany

Hepatitis B Virus (HBV)

virus that causes inflammation of the liver; transmitted through any body fluid, including vaginal secretions, semen, and blood

endoscopy

visual examination of a body cavity or canal using a specialized lighted instrument called an endoscope