Ch 26 Prepu

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 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?

Document normal breath sounds.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Hepatitis Jaundice is a yellow color of the skin resulting from liver or gallbladder disease, some types of anemia, and hemolysis. Hepatitis, inflammation of the liver, is a potential cause of jaundice. Appendicitis and diverticulitis do not typically result in changes in skin color, but will manifest as severe abdominal pain. Cellulitis would not result in yellowing of the skin, but as red and swollen legs.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should:

observe the client's body language.

When percussing the liver, the sound should be:

dull The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:

blurred

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

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 teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response?

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

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?"

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.

Positions for assessment

-standing: posture/gait -sitting: visualization of upper body -dorsal recumbent: used if difficulty supine -sims: rectum/vagina -prone: hip joints/ thorax -lithotomy: female genitalia -knee chest: anus/rectum

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

10%

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury?

An intact red area on the buttocks. An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.

A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next?

Ask the client if she has noted any blood in her stools lately. Any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool. Asking her if she's dizzy is a very broad, closed-ended question that would not elicit information specifically related to the rectal bleeding.

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?

Ask the client to empty her bladder.

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?

Assess the client for dehydration. 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.

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Auscultation of a bruit A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:

mastoid process

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?

Check the client's ear canals for cerumen. Ear wax (cerumen) becomes drier in older adults 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 older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply.

Client informs the nurse there is a floater in the left eye Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated."

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. 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 health care providers.

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

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

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

Warm the diaphragm of the stethoscope.

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?

Ensure that the scale is correctly calibrated and repeat the assessment.

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?

Each lub-dub is one beat.

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?

Evaluate the blood pressure and pulse 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.

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

auscultation of short, high-pitched popping sounds during inspiration

A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?

Inspect and palpate the supraclavicular area. Inspection and palpation of the supraclavicular area can detect enlarged lymph nodes. Palpation of the thyroid gland can reveal thyroid enlargement, tenderness, or nodules. Inspection of the client's ability to move the neck assesses neck range of motion. Inspection and palpation of the left and right carotid arteries evaluates circulation through these arteries.

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 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first?

Inspect the area of itchy skin

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

Inspection Auscultation Percussion Palpation

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.

Irregular edges Larger than 1/4 inch in diameter Change in the mole The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

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 lb (1.35 kg) 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

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?

Measure the pulse oximetry. 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 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?

Palpation

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?

Penlight or flashlight

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?

Risk for Falls Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

The client is dehydrated.

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 client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving?

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation

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.

Palpation

asess temp, turgor, texture, moisture, vibrations

To assess subjective data related to a client's elimination pattern, the nurse:

asks the client about changes in elimination patterns.

Percussion

assessing location, shape, size, and density of tissues

Inspection

assessing size, color, shape, position, and symmetry

Ascultation

assessing sound for pitch, loudness, quality, and duration

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

auscultation

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

density and location of lungs.

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:

fissure

A nurse is caring for a postoperative 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 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, or acts that involve collecting data, which include interviewing, observing, and examining the client. Inspecting the incision, taking blood pressure, and reviewing lab results are all examples of data collection. Assisting a client in a chair and performing ADLs are caring interventions.

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"?

oriented to person, place, and time 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).

Which technique of assessment provides the greatest amount of information about the thyroid gland?

palpation The thyroid gland is assessed by palpation, although it is not normally palpable in some clients. Percussion is a method of tapping on a surface to determine the underlying structure and is used in clinical examinations to assess the condition of the thorax or abdomen. Auscultation of the chest and abdomen is performed for detection of altered respiratory and bowel sounds, rubs, or vascular bruits. Inspection refers to findings on the surface of the body.

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:

peripheral pulses. Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals.

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

ptosis