PrepU Ch.30; Assessment

For which assessment could the neurologic and musculoskeletal systems be combined? a. peripheral vascular b. abdomen c. respiratory d. gait

d. gait

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. 1. Explain that the client will need to change into a gown 2. Explain your respect for the client's privacy and for confidentiality 3. Discuss the purpose and importance of the health history with the client 4. Formulate nursing diagnoses 5. Validate and document assessment findings 6. Acquire the client's permission to ask personal questions

1. Explain that the client will need to change into a gown 2. Explain your respect for the client's privacy and for confidentiality 3. Discuss the purpose and importance of the health history with the client 6. Acquire the client's permission to ask personal questions

The nurse is performing an assessment of a client's nose and sinuses. What should the nurse include in the assessment? Select all that apply. 1. Inspect the mucous membrane, septum, and turbinates. 2. Inspect for symmetry, alignment, and deformity. 3. Palpate the frontal and maxillary sinuses. 4. Palpate for tenderness and patency. 5. Have the client identify one familiar scent.

1. Inspect the mucous membrane, septum, and turbinates. 2. Inspect for symmetry, alignment, and deformity. 3. Palpate the frontal and maxillary sinuses. 4. Palpate for tenderness and patency.

Which of the following equipment will the nurse gather to conduct a physical examination of a client's eyes? Select all that apply. 1. otoscope 2. tuning fork 3. ophthalmoscope 4. Snellen chart 5. thermometer

3. ophthalmoscope 4. Snellen chart

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? a. cranial nerve VIII is intact b. the client understands directions c. cranial nerve XI is intact d. the client knows the difference between left and right

a. cranial nerve VIII is intact

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? a. Delay the full exam until the client's pain has been addressed. b. Provide education on pain control. c. Begin the comprehensive assessment and aim to complete it efficiently. d. Explain the reason for the client's assessment.

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

The nurse has a hand-held Snellen. When in the sequence of assessment should the nurse assess visual acuity? a. Eye assessment b. End of exam c. Beginning of exam d. General assessment

a. Eye assessment

How should a nurse assess graphesthesia as part of the physical assessment of arms, hands, and fingers? a. Write a number in the palm of the client's hand b. Place a quarter or key in the client's hand c. Ask the client to touch finger to nose with eyes closed d. Evaluate sensitivity of position of fingers

a. Write a number in the palm of the client's hand

While performing a head-to-toe assessment, the client reports leg pain. The nurse suspects a lower extremity infection. What sign(s) and symptom(s) would indicate an infection? Select all that apply. a. red and swollen b. weeping drainage c. absent pulses d. fever and increased white blood cells e. intermittent claudication

a. red and swollen b. weeping drainage d. fever and increased white blood cells

A nurse knows that a normal capillary bed refills in how many seconds? a. 5 to 6 b. 1 to 2 c. 3 to 4 d. Less than 1

b. 1 to 2

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client? a. Have the client explain an energy-conservation plan to offset the effects of fatigue b. Collaborate with the physician to treat anemia c. Evaluate urinary patterns d. Evaluate adequacy of exercise

b. Collaborate with the physician to treat anemia

The nurse is unable to palpate a pedal pulse in the right leg of an adult client. What the nurse's best action? a. Notify the healthcare provider. b. Obtain a Doppler to verify absent pulse. c. Elevate the client's right leg. d. Apply sequential compression devices.

b. Obtain a Doppler to verify absent pulse.

It is important for the nurse to apprise the client of what the nurse is doing and what the nurse finds as it does what? a. Instills a friendly feeling toward you in the client b. Opens up teaching/learning moments c. Causes assessment findings to be more accurate d. Speeds up the pace of the assessment

b. Opens up teaching/learning moments

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland? a. Standing behind the client, place fingers at the base of the ears and palpate along the sternomastoid muscle on either side b. Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage c. Standing in front of the client, place the fingers just below and under the mandible d. Standing in front of the client, hook the fingers into the clavicle and press firmly and deeply

b. Standing behind the client, place the fingers on either side of the trachea below the cricoid cartilage

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

b. Tuning fork

After performing a comprehensive head-to-toe assessment on a client, the nurse notes the following: ● The client reports pain in bilateral lower extremities when walking short distances, which is relieved with rest. ● Pulses are weak, barely palpable in bilateral lower extremities. ● Bilateral feet are cool to touch. ● Total cholesterol > 200. ● The client smokes two packs of cigarettes daily for past 20 years. Which step of the nursing process is the nurse performing? a. documentation of subjective assessment findings b. analysis of assessment findings c. development of a problem-based plan c. implementation of interventions

b. analysis of assessment findings

The nurse is planning the comprehensive head-to-toe assessment of a client. What assessment should the nurse usually conduct last? a. assessment of the abdomen b. assessment of the genitalia and rectum c. assessment of the lower extremities d. assessment of the posterior thorax

b. assessment of the genitalia and rectum

The nurse is preparing to conduct a physical examination of an adolescent client as part of a general physical assessment. Which examination approach would be the most appropriate for this client? a. grouping body systems together to limit position changes b. head-to-toe assessment c. beginning with the musculoskeletal assessment of the extremities d. major body systems first approach

b. head-to-toe assessment

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? a. "I have an aunt who had breast cancer." b. "I try not to let the pain affect my life." c. "I haven't had a checkup in over 5 years." d. "I had my appendix removed when I was 14 years old"

c. "I haven't had a checkup in over 5 years."

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best? a. "Keep taking deep breaths; you will be okay." b. "Let's stop and take your vital signs." c. "We can take a break anytime." d. "Let's stop; I have all of the information we need."

c. "We can take a break anytime."

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding? a. Decide whether to alter the process of starting at the head and proceeding to the feet b. Ask if the client wants an observer for the assessment c. Ask for the client's permission to perform the assessment d. Uncover only the part being examined, covering everything else

c. Ask for the client's permission to perform the assessment

The nurse would palpate the axillae during examination of which area? a. Heart b. Neck c. Breasts d. Anterior chest

c. Breasts

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? a. Psychological testing b. Nutritional supplementation c. Health teaching d. Interdisciplinary collaboration

c. Health teaching

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? a. The client's level of participation b. The nurse's time allowance c. The client's health needs d. The nurse's level of expertise

c. The client's health needs

A nurse recognizes that the normal breath sounds that are auscultated over the peripheral lung fields are what type of sound? a. Bronchial b. Tracheal c. Vesicular d. Bronchovesicular

c. Vesicular

The nurse is performing a head-to-toe assessment of a client. What would be an example of information obtained during the review of the client's body systems? a. States her father died of a heart attack at age 70. b. Uses over-the-counter antacid for occasional heartburn. c. Wears dentures; denies problems with eating, chewing, and swallowing. d. Vaginal delivery of two children without complications.

c. Wears dentures; denies problems with eating, chewing, and swallowing.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed? a. after assessing the anterior and posterior thorax b. after assessing cranial nerve function c. after assessing the motor function of the lower extremities d. after assessing the abdomen

c. after assessing the motor function of the lower extremities

When integrating the total physical examination the nurse should a. perform the Mental Status Exam after examining all other body systems. b. integrate the rectal examination with the abdominal examination. c. assess peripheral vascular status when examining the lower extremities. d. assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time.

c. assess peripheral vascular status when examining the lower extremities.

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination? a. light palpation of each quadrant b. auscultation of bowel sounds c. light stroking inward from all quadrants d. percussion for abdominal sounds

c. light stroking inward from all quadrants

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose? a. cotton swab b. ophthalmoscope c. otoscope d. pen light

c. otoscope

The nurse notices that a client has a brilliant smile when asked about children. What should the nurse document about this finding? a. routine dental visits occur b. the client likes children c. the client is pleasant d. cranial nerve VII intact

d. cranial nerve VII intact

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes? a. Anterior chest b. Head and face c. Neck d. Arm, hands, and fingers

d. Arm, hands, and fingers

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey? a. Hair neat clean with white and gray streaks; no scalp lesions noted b. Sclera white; conjunctiva slightly reddened without lesions c. Head symmetrically round; neck nontender with full range of motion d. Client alert and cooperative; sitting comfortably on chair with hands in lap

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

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client? a. Administer a nebulizer treatment b. Order a chest x-ray c. Begin antibiotic therapy through intravenous route d. Encourage turning, coughing, and deep breathing

d. Encourage turning, coughing, and deep breathing

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care? a. Altered nutrition b. Depression c. Decreased activity level d. Fatigue

d. Fatigue

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hyponatremia

d. Hyponatremia

The nurse is performing an abdominal assessment on a client. How should the nurse elicit the client's abdominal reflex? a. Lightly palpate all four quadrants. b. Deeply palpate all four quadrants. c. Palpate for the liver, kidneys, and spleen. d. Lightly stroke inward in all quadrants.

d. Lightly stroke inward in all quadrants.

While performing a head-to-toe assessment on a client admitted 2 days ago, the nurse observes that the pupils are unequal. The nurse reviews the client's chart and notes that pupils are documented as equal, round, and reactive on the comprehensive admission assessment. What is the first action of the nurse? a. Document findings. b. Perform a comprehensive assessment on the client. c. Contact the nurse who performed the admission assessment. d. Perform a focused assessment on the client.

d. Perform a focused assessment on the client.

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction? a. Weber's b. Whisper c. Audiometry d. Rinne

d. Rinne

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? a. Permission maintains the client's confidentiality. b. It ensures that the client will answer personal questions. c. The client's level of comfort will be increased d. The client has the right to refuse.

d. The client has the right to refuse.

During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve? a. IX b. X c. XI d. VII

d. VII

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? a. cranial nerves b. hand grasps c. bowel sounds d. carotid arteries

d. carotid arteries

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time? a. hand grasps b. bowel sounds c. cranial nerves d. carotid arteries

d. carotid arteries

As part of a head-to-toe assessment, a nurse reviews vital signs taken by an unlicensed assistive personnel (UAP). Which client should the nurse see first? a. temperature: 98.06°F (36.7°C), BP 90/60 mm Hg, pulse 98 regular, respirations 24, Sp02 93% 2L nasal cannula b. temperature: 96.8°F (36°C), BP 88/50 mm Hg, pulse 105 regular, respirations 18, Sp02 94% room air c. temperature: 99.8°F (37.67°C), BP 92/52 mm Hg, pulse 60 regular, respirations 20, Sp02 95% 4L NC (nasal cannula) d. temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula)

d. temperature: 101.66°F (38.7°C), BP 88/56 mm Hg, pulse 110 irregular, respirations 22, Sp02 93% 6L NC (nasal cannula)