Jensen's Health Assessment 3rd Ed. | Chapter 30

A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse determines that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?

3+ pitting edema

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame?

30 minutes

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test?

"With your eyes closed, identify the object I place in your hand."

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?

After assessing the motor function of the lower extremities

A nurse plans to assess the client's epitrochlear lymph nodes. The nurse should combine this with examination of which area?

Arms

The nurse is documenting findings of a comprehensive assessment. Which statement would be categorized as part of the general survey?

Client alert and cooperative; sitting comfortably on chair with hands in lap

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to do which of the following?

Close eyes and assess for smell

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away?

Complete blood count

When conducting a complete head-to-toe assessment on an adult client, which of the following factors is most likely to require adaptations by the nurse?

Cultural considerations

A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, the client states, "I'm really having a good deal of pain in my hip now." What would be most appropriate for the nurse to do?

Delay the full exam until the client's pain has been addressed.

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with?

Developmental stage

A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply.

Explain that the client will need to change into a gown Acquire the client's permission to ask personal questions Discuss the purpose and importance of the health history with the client Explain your respect for the client's privacy and for confidentiality

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII?

Head and face

When discussing health assessment, the nursing instructor would tell the students that potential or actual problems are identified in order to focus on areas requiring what?

Health teaching

A 43-year-old man comes to the ED with new onset of chest pain. Which of the following questions is a priority at the time of admission?

On a scale of 1 to 10, how do you rate your pain?

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed. Rationale: PERRLA stands for pupils equal, round, reactive to light, and accomodate. L 6-4, R 6-4 indicates the pupil sizes of both eyes changed from 6 mm to 4 mm when testing pupil reaction. These results are normal for an adult. There is no indication or need for an opthamologist consult, Weber test (hearing), or Romberg test (balance) based on these results.

During the physical assessment of a client, the nurse uses the head-to-toe approach. What are the advantages of this approach? Select all that apply.

Reduces the number of position changes required of the client. Takes less time because the nurse doesn't have to constantly move around the client.

The nurse is completing an abbreviated head-to-toe assessment of a client. What would the nurse perform when assessing the client's eyes?

Test the client's pupillary response to light.

The nurse is preparing to gather equipment prior to a client's head-to-toe assessment. The nurse's selection of equipment should be based primarily on what variable?

The client's health needs

The nurse is using a mnemonic device during the client's head-to-toe assessment. This tool will allow the nurse to address what component of assessment?

The client's present health concern

It is appropriate to tell a client the findings of the physical examination.

True

During the eye assessment, a nurse performs part of the neurologic examination for which cranial nerve?

VII

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound?

Vesicular

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.)

Wearing client identification bracelet Correct tubes and drains intact Call bell within reach Correct intravenous lines and fluids

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination.

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response?

cranial nerve VIII is intact

When should the nurse assess a client's lymph nodes?

during the assessment of the associated body area

When obtaining subjective data from a new client, you focus primarily on

evaluating risk factors Rationale: Complete subjective data are usually collected once and include information related to the client's history and risk factors.

During a physical examination the nurse assesses a client's anterior neck, carotid arteries, heart and lung sounds, and breasts before assisting the client to a seated position to examine the back. What is the best explanation for using this approach?

it limits the number of times the client had to change position

The nurse is planning to examine a client's thyroid. What additional body area can be assessed at this time?

posterior thorax