Health assessment

How many pairs of cranial nerves exit from the brain?

12

The nurse has completed the inspection of a patient's abdomen during the physical examination. Which technique will the nurse use next during this

Ausculation

What is the rationale for asking the client whether he or she has noticed any new or changed moles?

Changes in existing moles or the appearance of new moles can indicate melanoma.

When caring for a patient with shortness of breath, fatigue is often an issue. How might the nurse limit fatigue and still gather assessment information needed for daily care?

Cluster care during times when the patient is more rested

A patient , with a family history of melanoma, wants to have specific body moles assessed. When performing the assessment, the nurse will use what equipment?

Examination table, natural lighting, gloves

In which order will the nurse document findings from the physical examination of the head and neck?

Head, neck, lymph nodes

During the musculoskeletal physical examination, a patient demonstrates difficulty during the weight-bearing stance phase of walking. On which body area will the nurse focus the examination?

Hips

The nurse is observing the abdominal respiratory movements of a patient who is lying supine in bed. Why is the nurse using this method to assess breathing in the patient?

In the supine position, the thoracic movements are slight.

During the examination of the breasts, a young adult patient's nipples becomes erect and the areolas pucker. The nurse explains to the patient that these findings indicate:

Intact tactile stimulation of the area

The nurse asks a patient to flex and extend the right elbow as part of which screening neurologic examination?

Motor system

An older patient asks the nurse what can be done to help with urinary incontinence. What can the nurse respond to this patient

Practice pelvic muscle exercises

patient asks, "What does SPF 15 mean for a sunscreen?" What should the nurse respond to this patient?

SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays."

During a physical assessment of the abdomen, the nurse palpates a small mass above a patient's symphysis pubis. What should the nurse do at this time?

Stop the examination

Which of the following synovial joints would be an example of a condylar joint? a) Intervertebral joint

Temporomandibular joint

Which is an example of subjective data from a primary source?

The patient states, "My chest hurts and my left arm feels numb."

An older patient with a change in mental status is clenching the jaw closed to avoid taking a prescribed oral medication. The patient is demonstrating the motor function of which cranial nerve?

Trigeminal

During an assessment of the cranial nerves, a patient tells the nurse of not being able to taste sweet or salty foods. The nurse should focus additional assessment on which cranial nerve?

VII

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

abduction

Learning that an older patient lives alone and is unable to drive, the nurse identifies this information as impacting which assessment area within the nutritional history?

acessibility

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination?

adult caring for children under 5 adult patient with COPD older adult in daycare

On assessment of a client, the nurse finds that the client has difficulty in producing and understanding language. How should the nurse document this finding in the client's record?

aphasia

The nurse auscultates 20 clicks and gurgles over 1 minute when examining a patient's abdomen. How should the nurse document this finding?

bowel sounds normal

The nurse is preparing to conduct a health assessment with a patient. What will be the nurse's initial role when caring for this patient?

collecting data

A client has sustained an injury to the cerebellum. Which area would be the primary area for assessment?

coordination

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

crepitus

A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?

depth of respirations

A patient recovering from a burn injury is told by the health care provider that hair will no longer grow on the body part that was burned. The nurse realizes that this patient's burn extended into which skin layer?

dermis

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls?

environmental

A nursing student is preparing to demonstrate how to test the range of motion for the elbow. Which of the following would the student include? Select all that apply.

extension supination flexion

Which movement should the nurse instruct the client to perform to assess range of motion for the knee?

flexion

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the patient's head?

hair color

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?

lordosis

A teenage client with cancer asks the nurse what hair is made of. What would be the nurse's best answer?

mostly protein

A 15-year-old high school freshman with chronic diarrhea is brought to the clinic by his mother. The mother states that for the past few years her son has had diarrhea after many meals. The client states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. Examination shows a relaxed young man breathing comfortably. Vital signs are normal, as are head, eyes, ears, throat, neck, cardiac, and pulmonary examinations. His abdomen is soft and nondistended. His bowel sounds are active, and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. A stool sample is collected for further study. What is the most likely explanation for this client's chronic diarrhea?

osmotic diarhhea

Which of the following patients will have an increased metabolic rate and require nutritional interventions?

patient with serious infection and fever

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?

posterior cervical

. A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this?

primary prevention

To test flexion and extension of the biceps and triceps muscle at the elbow, the nurse tells the patient to

pull and push against the examiner's hand

The nurse is having difficulty auscultating a patient's bowel sounds during a physical examination of the abdomen. What can the nurse do to improve hearing the patient's sounds of this body area?

reduce all the environment noise

When visualizing the structures of the abdominal cavity, which of the following would the nurse expect to be in the right upper quadrant?

right kidney, ascending colon, and liver

The nurse is admitting a new client to the unit. While reviewing old records of the client, the nurse knows that the data being gathered are what kind of data?

secondary

An instructor is teaching a group of students about culture. Which of the following would the instructor use to best define the term "culture"?

shared norms for behavior, values and beliefs

After completing an assessment, the nurse is generating the patient's problem list. Which problem would have the highest priority for the patient?

shoulder pain

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation.

shuffling on feet

A nurse is describing viscera to a group of nursing students in the clinical area, differentiating solid viscera from hollow viscera. Which of the following would the nurse describe as hollow viscera?

small intestine gallbladder urinary bladder stomach

During the health history of the urinary system, a patient tells the nurse about "leaking" urine when coughing or laughing. The nurse should focus additional questions to address which health problem?

stress continence

A client's bladder is found to be distended. At which location would the nurse begin palpating?

symphysis pubis

While conducting the health assessment, the nurse instructs the patient about secondary prevention activities. What did the nurse most likely teach this patient?

the need for annual mammograms

A client tells the nurse about her experience with prolonged therapy for her breast cancer. The nurse responds, "That must have been a very trying time for you." What is this an example of?

validation

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?

venous insufficency

The nurse is preparing to auscultate the lung sounds of a young adult. Which sound will the nurse expect to hear over most of the patient's lungs?

vesicular