N400, PrepU for Ch 25 (Health Assessment)

A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the following assessment techniques in the ORDER in which they should be performed. - Position the client supine and drape appropriately. - Inspect the skin of thorax and abdomen. - Palpate the thorax. - Auscultate the thorax. - Auscultate the abdomen. - Palpate the abdomen.

(already in the right order :) Position the client supine and drape appropriately. Inspect the skin of thorax and abdomen. Palpate the thorax. Auscultate the thorax. Auscultate the abdomen. Palpate the abdomen. Explanation: A head-to-toe approach means assessing the client from the top of the body to the feet; the thorax before the abdomen. The nurse should wash his or her hands before and after every physical patient encounter. This assessment is done while the client is supine. To provide modesty, the client should be covered with a drape. Inspection is completed first, followed by palpation and then auscultation, with the exception of the abdomen. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.

A nurse's assessment of a community-dwelling adult reveals the presence of bilateral pitting edema to the patient's lower legs and feet. Which of the following systems assessments should the nurse consequently prioritize? a) Cardiovascular assessment b) Gastrointestinal assessment c) Musculoskeletal assessment d) Neurological assessment

a) Cardiovascular assessment Explanation: Edema is often associated with cardiovascular dysfunction such as venous insufficiency or congestive heart failure. As a result, a focused cardiovascular assessment is indicated. There is no obvious need to assess the patient's neurological, GI, or musculoskeletal function in patients with edema.

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present? a) Crackles b) Sonorous wheeze c) Sibilant wheeze d) A friction rub

a) Crackles Explanation: Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. A friction rub is a continuous, grating-type sound.

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

a) Crepitus Explanation: Problems with the temporomandibular joint include pain or a grating feeling called 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? a) Document normal breath sounds. b) Assess for asthma. c) Suspect an inflamed pleura rubbing against the chest wall. d) Recommend testing for pneumonia.

a) Document normal breath sounds. Explanation: Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing. Reference:

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? a) Wheezes b) Fine crackles c) Stertorous breathing d) Pleural friction rub

a) Wheezes Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

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

b) "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." Explanation: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse? a) Contact the healthcare provider. b) Complete an assessment. c) Review the client's past medical records. d) Assist the client with activities of daily living.

b) Complete an assessment. Explanation: Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can also use the client's medical record and contact other healthcare providers.

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? a) Interview to obtain the health history b) Evaluate the blood pressure and pulse c) Assess the cause of the client's wound d) Provide a warm, quiet, dimly lit room

b) Evaluate the blood pressure and pulse Explanation: 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.

What assessment technique would the nurse use to assess a client's chest for color, shape, or contour? a) Auscultation b) Inspection c) Palpation d) Percussion

b) Inspection Explanation: Inspection is the process of performing deliberate, purposeful observations in a systematic manner. The nurse closely observes a specific area visually, as using the senses of hearing and smell to gather data throughout the assessment. The color, shape, and contour of the client's chest would be assessed with this method. Neither palpation nor auscultation would not provide the color of the chest; percussion would not provide the color, shape, or contour of the chest.

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? a) Percussion b) Palpation c) Inspection d) Auscultation

b) Palpation Explanation: 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.

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as? a) Ectropion b) Ptosis c) Miosis d) Entropion

b) Ptosis Explanation: Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion, and miosis is constriction of the pupil, which is often caused by medications.

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? a) Enlist the help of another nurse to hold the client steady during the procedure. b) Stop lifting the client and reassess him. c) Administer a sedative to the client and try again when the sedative takes effect. d) Reassure the client that the procedure will only take a few minutes.

b) Stop lifting the client and reassess him. Explanation: The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.

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

b) a client's heart murmur. Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

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

c) "What brings you here today?" Explanation: 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." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

What percentage of weight change in 6 months is considered abnormal? a) 2% b) 5% c) 10% d) 1%

c) 10% Explanation: A 10% change in weight in 6 months is considered abnormal.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment? a) Percussion b) Palpation c) Auscultation d) Inspection

c) Auscultation Explanation: *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. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. *Percussion* is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider? a) Percussion of dull sounds over the right upper quadrant b) Percussion of tympanic sounds over the intestines c) Auscultation of a bruit d) Auscultation of peristalsis sounds

c) Auscultation of a bruit Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis.

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

c) Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to the elderly who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for the elderly.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? a) Heart sounds are caused by the opening of heart valves. b) Each lub-dub is two beats. c) Each lub-dub is one beat. d) The lub-dub sounds occur within 2 seconds of each other.

c) Each lub-dub is one beat. Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

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? a) The client complains of thirst. b) The client is sleepy from the anesthesia. c) The client makes noises when he breathes. d) The client reports pain at the surgical site.

c) The client makes noises when he breathes. Explanation: Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Complaints of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.

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? a) The knuckles b) The fingertips c) The dorsum d) The palm

c) The dorsum Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

A nurse practitioner (NP) is assessing a patient's eyes and has asked the patient to move her eyes in the six cardinal directions of gaze. The NP explains to the student nurse that the patient's eyes moved in a "jerky" manner. The student should assign what significance to this assessment finding? a) A change in the patient's medication regimen may be necessary. b) The patient may need to be assessed for cataracts or glaucoma. c) The patient may have cranial nerve deficits. d) The patient may be nervous or anxious about the health assessment.

c) The patient may have cranial nerve deficits. Explanation: Deficits in the cardinal gazes are associated with lesions in CN III, IV, or VI. This abnormal finding is not suggestive of cataracts, glaucoma, or inappropriate use of medications. Anxiety does not normally cause disruptions in the cardinal gazes.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? a) The ear canal is smooth and white. b) The ear canal is rough and pinkish. c) The tympanic membrane is translucent, shiny, and gray. d) The tympanic membrane is reddish.

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

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: a) objective assessment. b) symptoms. c) chief concern. d) review of systems.

c) chief concern. Explanation: 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.

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

c) liver. Explanation: The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.

To obtain data about an adult client's sexuality and reproductive pattern, the nurse should ask the client: a) "What arouses you when you have intercourse?" b) "How many children do you have, both living and dead?" c) "How often do you have sexual intercourse?" d) "Has anything changed your sexual performance?"

d) "Has anything changed your sexual performance?" Explanation: 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 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? a) Place the client in a semi-Fowler's position. b) Measure height and weight. c) Warm the equipment. d) Ask the client to empty her bladder.

d) Ask the client to empty her bladder. Explanation: Before palpating or percussing the abdomen, the client should empty her bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

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

d) Assess the client for dehydration. Explanation: 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. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.

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? a) Palpate the abdomen. b) Measure abdominal girth. c) Percuss the abdomen. d) Auscultate the abdomen.

d) Auscultate the abdomen. Explanation: 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 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? a) Assess fluid intake. b) Assess capillary refill. c) Limit the client's activity. d) Measure the pulse oximetry.

d) Measure the pulse oximetry. Explanation: The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.

A nursing student is assessing a patient who has a history of peripheral vascular disease and who is being treated for a venous ulcer on his ankle. The student has asked the patient about his symptoms and has carefully inspected the man's lower legs. What action should the student next perform? a) Assess the patient's strength in his lower legs bilaterally. b) Measure the patient's blood pressure at his thighs. c) Assess range of motion in the patient's lower legs. d) Palpate the patient's lower legs and peripheral pulses.

d) Palpate the patient's lower legs and peripheral pulses. Explanation: Palpation normally follows inspection. In a patient with peripheral vascular disease, strength and range of motion are not usual focuses of assessment. There is no need to assess blood pressure in the patient's thighs.

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

d) Palpation Explanation: 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. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

A nursing student is analyzing the results of the assessment of an older adult's neurological function. Which of the following findings should the student attribute to the normal effects of aging? Select all that apply. a) The patient has gaps in his long-term memory. b) Cranial nerve assessment reveals the patient is unable to raise his eyebrows or frown. c) The patient's left side is markedly weaker than his right side. d) The patient has weakened deep tendon reflexes. e) There are pauses between the student's questions and the patient's responses.

d) The patient has weakened deep tendon reflexes. e) There are pauses between the student's questions and the patient's responses. Explanation: Slight weakness in deep tendon reflexes and delays in information processing are considered to be normal effects of aging. Inability to raise the eyebrows or frown is associated with CN VII deficit. Unilateral weakness and deficits in long-term memory are considered pathological in patients of all ages.

A nursing student has assessed a patient's pupils for PERRLA and noted significant asymmetry in their response to light. How should the student best interpret this assessment finding? a) The patient may be fatigued, dehydrated, or fluid overloaded. b) The patient would benefit from detailed assessment of the peripheral nervous system. c) The patient may require vision correction. d) The patient may have a pathology involving CN III.

d) The patient may have a pathology involving CN III. Explanation: Abnormalities in pupil response may be linked to dysfunction with CN III. Visual deficits are linked more closely with CN II. Fatigue or fluid imbalances do not normally cause disruptions in pupillary response. This deficit involves the central nervous system, not the peripheral nervous system.

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require? a) Otoscope b) Ophthalmoscope c) Snellen chart d) Tuning fork

d) Tuning fork Explanation: Weber test and Rinne test are performed in order to assess sound conduction; both require a tuning fork.

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

d) blurred. Explanation: Visual problems with close objects occur more frequently after the age of 40.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should: a) inspect the symmetry of the facial features. b) assess the client's vital signs first. c) interpret the effect of deep palpation. d) observe the client's body language.

d) observe the client's body language. Explanation: 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 is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? a) oriented person, situation, and time b) oriented to person, place, and situation c) oriented to hospital, person, and date d) oriented to person, place, and time

d) oriented to person, place, and time Explanation: Oriented × 3 indicates that the client is oriented to person (one's own name, the names of significant others, or knowing the nurse), place (location, city, or state), and time (time of day, day of week, or date).

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? a) whether they have proper dietary habits b) whether they have home maintenance skills c) whether they have anemia d) whether they have a program of regular physical activity

d) whether they have a program of regular physical activity Explanation: Regular physical activity contributes to a person's physical and psychological well-being.