ch 26- practice questions - Health Assessment PrepU, Fundamentals of Nursing III (Chap 25 Prep U Questions), Chapter 26: Health Assessment

The nurse at the neighborhood family clinic is instructing a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"Take your blood pressure medications exactly as your doctor prescribed them."

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 bruit on auscultation suggests an aneurysm or arterial stenosis.

When a client enters the acute care facility, the nurse should perform a:

A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.

The nurse examines the skin of a 29-year-old Irish woman who is complaining of swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?

A maculopapular rash is characterized by macules (distorted but nonelevated spots on the skin) and papules (small, circumscribed, superficial, solid elevations of the skin).

During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's

A perception of pain

The nurse plans to assess a client's new symptom. Which characteristics will the nurse assess when using the COLDSPA mnemonic?

D Character, onset, location, duration, severity, pattern, associated factors

While assessing a patient, the nurse is asking questions that help the nurse perceive and communicate an understanding of what the patient is feeling. What is this called?

empathy

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use? Fingerpads Ulnar surface Palmar surface Dorsal surface

Doral Surface

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

It is distended.

A patient with a zosteriform rash has a rash that

is distributed along a dermatome

When describing the purpose for obtaining a comprehensive health history to a client, which of the following would the nurse include as primary?

Provides a focus for the physical exam.

What respiratory sound indicates an upper airway obstruction?

Stridor is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction.

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

The client had a recent infestation

The nurse is beginning a physical examination of a client. Which technique should the nurse use for every body part and system? palpation inspection percussion auscultation

inspection

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client?

whether they have a program of regular physical activity

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?

"According to the American Cancer Society, your first mammogram should be done at age 40 and then yearly after that."

A nurse is performing an admission assessment on a new client to the unit. What would be the best way to phrase a question about the client's marital status?

"Do you live alone or with someone?"

A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following?

"Documentation provides a permanent legal record of care given and not given."

The nurse is assessing a client who has been sexually abused by an ex-boyfriend. What would be an example of subjective data from this client? Ecchymosis on the left temple area "He beat me and then raped me." Multiple lacerations and abrasions Tearful crying and shaking

"He beat me and then raped me."

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory?

"What are the month, date, and the year of your birth?"

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

"What brings you here today?" 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.

The nurse is performing an admission assessment with a patient and is questioning the patient about religious preference. The patient says that they have no religious or spiritual preference. What statement by the nurse demonstrates a non-judgmental attitude?

"What provides you strength in dealing with stress or illness in your life?"

An 82-year-old male client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and is being cared for by the nursing assistive personnel (NAP). The NAP comes to the nurse and tells her that her client seems more confused today than yesterday. To assess the client's level of orientation, which of the following questions would the nurse ask?

"What's the name of this hospital?" (ask open-ended questions)

What percentage of weight change in 6 months is considered abnormal?

10%

A nurse assesses a client's nails. What is a normal finding?

160-degree angle of nail attachment

Which of the following scores on the Braden Scale signifies that the patient is not at risk for a pressure sore? 9 or lower 10 to 12 13 to 18 19 to 23

19 to 23

During assessment of the lower extremities, the nurse notes that the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4-mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?

2+ pitting edema noted on bilateral lower extremities

The nurse is preparing a 45-year-old male client for emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the patient goes to the operating room.

To assess a client's visual accommodation, the nurse has the client:

Accommodation can be tested by having the client look at a close object and then look at a distant object.

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

Age

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?

Complete an assessment.

Which of the following terms is used to describe the arrangement of skin lesions? Annular Exposed Localized Generalized

Annular

The nurse is conducting a physical examination on a client with a history of heart problems. Which technique would most likely provide the most information about the client's current cardiac status? palpation inspection percussion auscultation

Auscultation

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

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.

The nurse receives the following report. A patient was admitted for a left hip fracture following a fall at home. The patient was diagnosed with osteoarthritis 7 years ago. The left leg is shorter than right. Ecchymosis noted over left hip and groin areas. Pedal pulses palpable and strong bilaterally. Patient reports a pain rating of 8. An orthopedic case management consult is needed. Which aspect of SBAR does the diagnosis of osteoarthritis 7 years ago represent?

Background

The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of: Batch charting Point-of-care documentation Organized charting Accurate documentation

Batch Charting

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?

Before palpating or percussing the abdomen, the client should empty her bladder to avoid discomfort or pressure during the examination.

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use? Newton scale Head-to-toe assessment Norton scale Braden scale

Braden Scale

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?

Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.

Mr. Sanchez is a 56-year-old Mexican American who 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?

Measure the pulse oximetry.

A nurse is interviewing a client who has recently been diagnosed with terminal disease. In covering the lifestyle and health practices profile, the nurse asks the client, "Are you close to any extended family members in the area?" The client objects to the question and asks why the nurse needs to know that. Which is the best rationale for the nurse posing this question?

C: "I just wanted to see what kind of social support you might have to help care for you during your illness."

Why is it important to collect a thorough and accurate subjective history in regards to a client's nail problems? May affect a person's body image negatively Can be caused by an underlying systemic illness Local irritation can cause damage to the nail bed Abnormalities may be a sign of poor hygiene

Can be caused by an underlying systemic illness

Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. (Select all that apply.)

Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Gastrointestinal: abdominal pain with rebound tenderness in RLQ

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-foot ladder. Which action by the nurse is the most important to take?

Changes in pupillary shape and reactivity to light are early signs of increased intracranial pressure (ICP). The client's orientation to person, place, and time cannot be assessed because he is unconscious.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client.

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for?

Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

Which of the following would be most important for the nurse to do immediately before beginning the physical exam?

Collect necessary equipment essential to the exam.

What intervention should a nurse implement to become culturally competent when assessing a client from another culture?

Collect relevant cultural data of client's health history

Which skin characteristics can a nurse observe by using inspection? Color Temperature Texture Elasticity

Color

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?

Comprehensive assessment A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations.

During a health history, a patient tells the nurse about having pain that has lasted for longer than 6 weeks. What action should the nurse make at this time? Begin high-yield screening questions. Conduct a mental health screening. Document the information. Ask what medication is used for relief.

Conduct a mental health screening

During a home visit an older client asks the nurse to find out what papers the client signed "the other day." What should the nurse do first? Assess for signs of physical abuse Complete a mental health assessment Continue to assess for indications of abuse or neglect Ask the client for the name of the person who had the papers to sign

Continue to assess for indications of abuse or neglect

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?

Crackles

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure.

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

Cranial nerve I

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what? Society Community System Culture

Culture

The nursing instructor is teaching a class on documentation in the medical record. What would be the most important piece of information the instructor would give to the students?

The problem, intervention, evaluation(PIE) system of documentation does not use assessment as part of the PIE note

During the introduction phase of the interview, the patient begins to talk nonstop about health problems, family issues, and fears related to illness. What can the nurse do to control the interview process?

D Courteously interrupt the patient to clarify some information

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

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?

Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing.

What guidelines should the nurse keep in mind while performing auscultation? Eliminate distracting noise from the environment Use good lighting, preferably sunlight Look and observe before touching the client Compare appearance of symmetric body parts

Eliminate distracting noise from the environment

An adult client is brought to the ED after falling 12 feet from a ladder. The client has an obvious deformity to his left lower leg. What kind of assessment is the nurse going to perform?

Emergency

What should a nurse be aware of before effectively assessing for the presence of family violence? Need to create a safe and confidential environment Discuss any legal, mandatory reporting requirements Examine feelings, beliefs, and biases about violence Demonstrate a concerned and nonjudgmental attitude

Examine feelings, beliefs, and biases about violence

A nurse is preparing to assess a client with abdominal pain. What should the nurse do when preparing the client for assessment?

Explain the assessment procedure to the client.

A nurse receives report from the shift nurse that a client has new onset of peripheral cyanosis. Where should the nurse focus the assessment of the skin to detect the presence of this condition?

Fingers and toes

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which kind of lesion?

Fissure

A community health nurse is planning an educational event for the parent-teacher association of the local elementary school. In discussing chickenpox, how would the nurse describe the rash? Fluid-filled lesions greater than 1 cm in diameter Purulent, fluid-filled, raised lesions of any size Raised, reddened, edematous papules or plaques, varying in size and shape Fluid-filled lesions less than 1 cm in diameter

Fluid-filled lesions less than 1 cm in diameter

A group of student nurses is presenting information on Gordon's framework for assessing a client. What type of assessment would they be talking about?

Focused

A nurse is gathering equipment needed for a basic physical assessment. Which supplies will be required? (Select all that apply.)

For a basic physical assessment, the nurse needs: gloves, examination gown, cloth or paper drapes, scale, stethoscope, sphygmomanometer, thermometer, pen light or flashlight, tongue blade, assessment form, and pen. *The nurse does not need cotton balls or an ophthalmoscope.

What is the single most important method of preventing infection transmission by the nurse when coming into contact with a client? Handwashing Wearing latex gloves Using eye protection Gowning

Handwashing

The nurse is beginning the review of systems with a client. Which approach would ensure that all major body systems are included in this assessment?

Head to toe

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects:

Human Violence

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor (Ceclor) 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." What action should the nurse take first?

Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?

Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.

During the review of systems a client states that at times both hands feel numb. In which category should the nurse document this information?

neurologic

A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of vodka daily and that he's had a recent weight gain of 3 pounds in 3 days. Further questioning by the nurse reveals that he was an intravenous drug user in the past but is now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal girth. Which assessment finding supports the nurse's conclusion that the client has liver dysfunction?

Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the blood. It is associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis.

Which of the following assessment findings most likely constitutes a secondary skin lesion?

Keloid formation at the site of an old incision

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use? Light Intermediate Moderate Deep

Light

When documenting that a patient has freckles, the appropriate term to use is macules patches vesicles bullae

Macules

The nurse is assessing the pulse amplitude for a client. Documentation by the nurse states, "Pulses are +1 in the lower left extremity." What amplitude is the nurse assessing?

diminished, weaker than expected

The nurse is preparing to obtain biographical data from a client before initiating a health assessment. Which of the following data should the nurse plan to collect? Select all that apply.

Name Date of birth Gender Occupation

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?

Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention.

The nurse notes that a client has longitudinal ridges in the nails of both thumbs. What should the nurse consider as being the reason for this finding? Hypoxia Recent trauma Iron deficiency Normal finding

Normal Finding

When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention?

Note the client's ability to swallow.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description.

A nurse is examining a young boy who is complaining that he cannot hear as well out of one ear as he used to. The nurse suspects that it is just ear wax that is the problem, but needs to view the ear canal and tympanic membrane to make sure. Which piece of equipment should the nurse use to do this? Stethoscope Otoscope Ophthalmoscope Sphygmomanometer

Otoscope

A client has been reporting persistent headaches. Which is an example of subjective data?

Pain is 4 out of 10 on a pain scale.

The nurse is palpating a client's precordium. Which result is an expected clinical finding?

Palpable pulsation over the mitral area

Sanjay Patel is a 10-year-old boy from India with mahogany-colored skin. He arrives at the school nurse's office and tells the nurse that he was stung by a wasp on the arm yesterday, and he thinks it might be infected. The nurse performs which action in order to assess the wasp sting site for inflammation?

Palpate the area with the back of the hand for increased warmth, then touch the other arm for comparison.

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?

Palpation

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene?

Palpation of both carotid arteries at the same time NOTE: (Palpation of both arteries at once can obstruct blood flow to the brain).

What is the nurse's best defense if a patient alleges nursing negligence? Testimony of other nurses Testimony of expert witnesses Patient's record Patient's family

Patient's record

Your lab instructor explains that physical examination relies on what cardinal assessment technique? Assessment Percussion Organization Communication

Percussion

A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:

Percussion over the lung fields helps identify the density and location of the lungs. Palpation assesses for masses, crepitus, muscle development, and tenderness. Lung auscultation assesses for normal breath sounds and for abnormal (adventitious) breath sounds.

A client reports feeling short of breath. Which area of the body should the nurse inspect for the presence of cyanosis? Perioral Palms Facial Chest

Perioral

While inspecting the skin of an older adult client, the nurse notes multiple small, flat, reddish-purple macules. The nurse should recognize the presence of which of the following?

Petechiae

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as?

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 thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing? Situation Background Assessment Recommendation

Recommendation

The nurse is interviewing a client. The client describes why he is visiting the clinic. The nurse then briefly summarizes what the client has just said. What type of communication is the nurse using?

Reflection

Which statement accurately represents a characteristic of the third or fourth heart sound?

S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-age and older adults. This sound is best heard with the stethoscope bell at the mitral area, with the client lying on the left side. S4 is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults.

A nurse has completed an assessment and is about to document the findings. Which statement best reflects accurate documentation?

Skin pale, warm, and dry without evidence of lesions

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?

Stop lifting the client and reassess him.

A client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is:

Subjective data are those symptoms, feelings, perceptions, preferences, values, and information that only the client can state and validate.

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

The nurse is testing the peripheral vision of a client. Which actions are recommended guidelines for this test? Select all that apply

Tests for peripheral vision (or visual fields) are used to assess retinal function and optic nerve function. The client will stand or sit about 2 feet away, rather than 3 feet away. The client should cover one eye with a hand or an index card and be asked to look directly at the nurse's nose and fix the eyes on that spot. The nurse should cover her own eye opposite the client's closed eye. The nurse holds one arm outstretched to one side (right or left) equidistant from her and the client, and moves the fingers into the visual fields from various peripheral points. The client is asked to tell the nurse when the fingers are first seen. Both the nurse and the client should see the fingers at the same time.

Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? (Select all that apply.)

The client answers questions in a barely audible voice. The client bites her fingernails. The client eats 25% of her meals. The client sleeps a lot.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?

The client's reaction time will likely be slower than that of a younger adult.

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers?

The confidentiality of electronic and printed health information

Ms. Elaine Quan is a 34-year-old Chinese American who has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pains, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client?

The naturally fair skin of Asians has a yellowish undertone, as does the skin of southern Europeans, and some Hispanics and African Americans. The best location to observe for jaundice in this population is the sclera of the eye.

The nurse testing a client's eyes asks the client to focus on a finger from 2 feet away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing? Select all that apply.

The oculomotor, trochlear, and abducens nerves control the motor function of the eye structures, which can be assessed through movement of the eyes through the six cardinal positions of gaze.

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?

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.

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?

The skin over the dorsum (back of hand) of the hand is sensitive to temperature because it is thin and its nerve density is great.

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?

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.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

How should the nurse palpate the skin of a client to assess its texture?

Touch with the palmar surface of the three middle fingers.

The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator?

Translators may need additional explanations of medical terms.

A nurse implements which skin assessment to determine the presence of dehydration in a client? Temperature Texture Turgor Thickness

Turgor

Upon examination of a client, the nurse finds a circumscribed elevated, palpable mass containing serous fluid. How should the nurse properly document this finding?

Vesicle

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require?

Weber test and Rinne test are performed in order to assess sound conduction; both require a tuning fork.

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?

Wheezes

A nurse is implementing appropriate infection control precautions while performing a client's skin assessment. The nurse would wear gloves during which part of the assessment? When palpating the texture of the client's skin When palpating the client's hair When palpating lesions on the client's skin When palpating the client's nail beds for texture and capillary refill

When palpating lesions on the client's skin

What light should the nurse use to inspect a lesion on the thigh of a client for the presence of fungus?

Wood's light

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean?" How should the nurse respond?

You are able to read at 20 feet what a person with normal vision can read at 30 feet." The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur. 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.

It is very important to assess for the quality of someone's respirations as well as describe what is heard with auscultation. Which describes stridor?

a harsh, inspiratory sound that may be compared to crowing

A client from a non-English speaking culture is experiencing a health problem. What should the nurse do to ensure that communication with this client is culturally appropriate? use an interpreter avoid eye contact limit interaction with the client be respectful of the client's culture

be respectful of the client's culture

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:

chief concern.

A female client visits the clinic and complains to the nurse that her skin feels "dry." The nurse should instruct the client that skin elasticity is related to adequate calcium. vitamin D. carbohydrates. fluid intake.

fluid intake

A nurse is performing a patient assessment in an urgent care clinic. The most likely tool being used is the

focused assessment

A client with abdominal pain says that the last time it the pain occurred, over-the-counter laxatives helped. In which part of the assessment should the nurse document this information?

history of present illness

A nurse is caring for a post-operative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? (Select all that apply.)

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results

The nurse is preparing to assess a client's abdomen. What are the steps of the assessment in the correct order.

inspection auscultation percussion palpation

During a comprehensive assessment, the primary technique used by the nurse throughout the examination is palpation. percussion. auscultation. inspection.

inspection.

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ significantly, a finding that suggests which health problem?

peripheral vascular disease

Knowledge of the client's beliefs in the cause of illness can be useful to the nurse in order to encourage new beliefs. dispel religious teachings if they conflict with the nurse's belief system. promote harmony between health and spirituality. raise doubt and point out flaws in one's faith.

promote harmony between health and spirituality.

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

ptosis