Chap. 28: putting it all together

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information? apical heart rate respiratory rate edema of the face and limbs presence of cyanosis presence of fluid in the lungs

general survey is 1st part of physical assessment--involves info the nurse can observe and VS respiratory rate edema of the face and limbs presence of cyanosis

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey? facial expression height and weight ambulatory status skin temperature

height and weight

While conducting a physical examination with the client in the seated position, the nurse begins the cardiovascular assessment. In order to listen for aortic insufficiency, the nurse should ask the client to move into which position? standing lean forward supine prone

lean forward Leaning forward brings the ventricular apex and left ventricular outflow closer to the chest wall, enhancing detection of the point of maximal impulse and aortic insufficiency. For much of the cardiovascular examination, the client should be in the supine position; however, it is difficult to assess aortic insufficiency in this way. The three positions required for the cardiovascular assessment are sitting, lying with the head of the bed increased to 30 degrees, and left lateral decubitus.

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? elbow flexion knee extension hip adduction hip abduction

elbow flexion

Two body systems that may be logically integrated and assessed at the same time are the eye and ear exams. ear exam and cranial nerves IV, VI, and VIII. eye exam and cranial nerves II, III, IV, and VI. ear and nose exams.

eye exam and cranial nerves II, III, IV, and VI.

The client has decreased sensation in his legs. What additional assessment should the nurse include? Bloodstream infection Fall Sepsis Surgical site

Fall

What type of assessment would the nurse perform when assessing pain after medicating? Shift Focused Comprehensive Urgent

Focused

A nurse has completed a comprehensive nursing health history of the client and now is beginning the physical assessment. Which assessment should the nurse perform first? Mental status examination Eye assessment General survey Skin assessment

General survey

The nurse is assessing a client's skin. Which additional action should the nurse take while performing this assessment? Identify skeletal abnormalities Analyze cardiovascular status Instruct on preventive measure Assess pulses

Instruct on preventive measure

The nurse is assessing the head and neck areas of an adult client and discovers several abnormal findings. Which assessment finding requires priority nursing care? Immobile, tender lymph nodes. Reduced carotid pulses. Distended jugular veins. Tracheal deviation.

Intervening with a tracheal deviation is priority to protect the airway. Reduces carotid pulses may indicated carotid stenosis which does directly affect airway. Distended jugular veins can indicate heart failure which does not directly affect airway. Immobile and tender lymph nodes are suspicious for malignancy but do not directly affect airway as immediately as a deviated trachea. The deviated trachea is also an indicator of tension pneumothorax which is life threatening if not correctly emergently.

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves? Just before the mouth and throat assessment Just after the mental status examination Just before the rectal assessment Just after the general survey

Just before the mouth and throat assessment

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?

On the mastoid area (behind the ear)

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

Palpation

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this? Popliteal pulses 3-4+ Popliteal pulses 1-2+ Popliteal pulses 4+ Popliteal pulses 2-3+

Popliteal pulses 2-3+

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

VII. CORNEAL reflex tested by touching cornea with cotton.

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

VII. corneal reflex

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? "Let's stop; I have all of the information we need." "We can take a break anytime." "Let's stop and take your vital signs." "Keep taking deep breathes; you will be okay."

"We can take a break anytime." give the client control Taking vital signs would probably show that the client's blood pressure is higher than normal because pain and anxiety can increase blood pressure, heart rate, and respiratory rate. Ana assessment of the vital signs should be complete prior to beginning the physical examination. Stopping the physical examination altogether is not correct because the assessment is largely incomplete and important clinical data that can negatively impact the client's health may be missed.

The nurse is seeing a client with a recent history of exposure to a family member who has influenza. The client reports a throbbing toothache when bending forward. Which assessment should the nurse be sure to include in the physical examination? asking the client to smell coffee beans palpation of the thyroid palpation of the sinuses assessing the heart sounds with the client in a lateral position

A recent exposure to a family member with influenza along with the complaint of a throbbing toothache when the client bends forward should cue the nurse to assess for acute sinusitis. The assessment should include palpation of the sinuses. To determine if there is a loss or change to the sense of smell, the nurse would ask the client to smell something with a strong aroma, like coffee beans. The nurse should palpate the thyroid if the reported symptoms are consistent with a disorder of the thyroid gland such as hoarseness, enlarged thyroid, fatigue, and weight changes. If the client has a history of cardiac issues known to the nurse, assessment of the heart sounds is appropriate. In this case, however, the focus of the assessment should be the sinuses.

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen? Enlargement of the liver Abdominal reflex Irregularities of the spleen Abnormalities of the aorta

Abdominal reflex

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen? Enlargement of the liver Abnormalities of the aorta Abdominal reflex Irregularities of the spleen

Abdominal reflex

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

Arm, hands, and fingers

What would be included in a shift assessment? Select all that apply. Inspection of skin on a client that is not mobile Palpating pulses on a client with PVD Pain relief after medicating Auscultation of lungs on a client with pneumonia Health history assessment

Auscultation of lungs on a client with pneumonia Palpating pulses on a client with PVD Inspection of skin on a client that is not mobile pain relief after meds is considered focused assessment

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? Collaborate with the physician to treat anemia Evaluate urinary patterns Evaluate adequacy of exercise Have the client explain an energy-conservation plan to offset the effects of fatigue

Collaborate with the physician to treat anemia

An adult client complains of dark stools for the past 3 days. Which lab should the nurse review right away? Electrolyte panel Coagulation studies Liver function panel Complete blood count

Complete blood count Dark stool may indicate presence of blood. Therefore the hemoglobin and hematocrit should be assessed to check for blood loss. Loose stools would be a concern for potassium loss. While coagulation studies should be reviewed; the priority is to check for blood loss, then determine a possible cause such as low platelets or other coagulation disorder. A compromised liver can result in bleeding; however, the CBC should be assessed first to determine blood loss and need for immediate intervention such as transfusion.

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. Weber's test does which of the following? Determines the equality or disparity of bone-conducted sound. Measures hearing acuity at various sound frequencies. Compares air versus bone conduction sound. Tests air conduction of sound in the tested ear.

Determines the equality or disparity of bone-conducted sound.

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

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

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client? Refer for opthamologist consult. Conduct the Romberg test. Re-assess as needed. Peform the Weber test.

Re-assess as needed.

A nurse performs the Mini-Mental Status Exam to assess cognitive abilities of a client. What will the nurse assess as a part of the Mini-Mental Status Exam?

Remote memory, NOT LOC

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?

Rinne The nurse should perform Rinne test to compare between bone and air conduction in the client with mild hearing loss. Weber's test and audiometry are done to determine diminished hearing in one ear. The Whisper test is done to evaluate hearing.

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)

Risk factors Common symptoms Family history

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.) Risk factors Common symptoms Visualized signs Family history Auscultated sound

Risk factors Common symptoms Family history Subjective data collection includes health promotion, risk factors, history of present problem, past medical and family histories, personal and social histories, and common symptoms. Auscultated sounds and visualized signs are part of objective data collection.

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time? Pedal pulses Safety Hearing acuity Oxygen saturation

Safety General survey: wash hands; assess the environment for (a) noise, (b) safety, (c) privacy, and (d) lighting

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed? Serous Fibrinous Purulent Sanguineous

Sanguineous

During a shift assessment, the nurse finds the client unable to speak and her face is asymmetrical. What does the nurse suspect? Bell's palsy Stroke Sepsis Myocardial infarction

Stroke This client has neurological deficits as she cannot speak and her face is asymmetrical. Bell's palsy involves facial drooping but speech is intact. Sepsis is due to infection and a myocardial infarction is related to the heart. stroke=mouth drooping; bells palsy=ptosis

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure? Taking vital signs. Identifying risk factors for altered health. Assessing the head and neck. Palpating the integument.

Taking vital signs.

When collecting subjective data, the nurse gives the client time and encouragement to do what? Tell stories about his or her family List common findings Express complaints Tell about the client's concerns

Tell about the client's concerns

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure?

The general survey is the first component of the physical assessment. It includes observing the patient's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the patient's overall health. Palpating the integument and assessing the head and neck are part of the physical assessment and identifying risk factors for altered health occurs in the health history.

A nurse should perform an ongoing assessment of which system throughout the entire examination?

The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesions. General survey and mental status are assessed early in the exam process. The heart is part of the cardiovascular exam.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique? To determine the density of underlying structures. A assess the sounds from the heart, lungs, and abdomen. To observe specific parts for normal or abnormal characteristics. To check the skin temperature and moisture.a

To check the skin temperature and moisture.

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following? Assist client to supine position with head elevated Lower the examination table with client in supine position Have the client stand and face the nurse with gown raised Ask the client to fold the gown to the waist and sit with the arms hanging freely

To evaluate a male client's genitalia, the nurse should have the client stand and face the nurse with gown raised. The nurse should ask the client to fold the gown to the waist and sit with the arms hanging freely when assessing the anterior chest. The client should not be lying supine for this examination.

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

VII The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment. Cranial nerves IX and X are assessed during the mouth and throat assessment. Cranial nerve XI is assessed during the assessment of the arms, hands, and fingers.

Before beginning a physical assessment it is important for the nurse to acquire your client's written permission to perform the physical examination. acquire your client's verbal permission to perform the physical examination. explain to the client in detail how each body system will be assessed. explain to the client the purpose of every physical assessment technique you will be using.

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

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

after assessing the motor function of the lower extremities Although many parts of the assessment can be completed at any time, assessment of the reflexes usually is completed after assessing the lower extremities and serves as a starting point for assessing neurologic functioning.

When should the nurse assess the costovertebral angle for tenderness? after assessing the posterior thorax before palpating the lower pole of the left kidney while assessing range of motion of the spine during percussion of the abdomen

after assessing the posterior thorax

During the general survey a client comments about the extremely cold weather even though the client lives in a major northeastern United States city and the month is July. What action should the nurse take? offer a blanket assess mental status adjust examination room temperature measure body temperature

assess mental status

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

assess peripheral vascular status when examining the lower extremities.

The nurse completes the assessment of a client's heart. What should be assessed next? abdomen breasts lower extremities back

breasts

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

carotid arteries

A client arrives to a healthcare facility for an initial appointment. Which type of assessment should the nurse expect to complete with this client? complete urgent focused evaluative

complete

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

cranial nerve VII intact

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? the client understands directions cranial nerve VIII is intact cranial nerve XI is intact the client knows the difference between left and right

cranial nerve VIII is intact

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

light stroking inward from all quadrants The abdominal reflex is stimulated by stroking around the umbilicus. If reflexes are normal, the nurse should note contraction of the muscles. Auscultating for bowel sounds will not assist the nurse in assessing abdominal reflexes because this would assess the gastrointestinal system rather than the musculoskeletal system. Light palpation should be used to identify masses, tenderness, and the client's face for expressions in response to pain. Percussion of the abdomen helps to listen for sounds that provide information about the liver, kidney, and spleen.

The nurse wants to assess a client's 5th cranial nerve. What approach should be used? palpate the jaw for areas of pain or tenderness ask the client to frown stroke each side of the cheek with a cotton wisp ask the client to puff out the cheeks

stroke each side of the cheek with a cotton wisp

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason? to check the radial pulse to auscultate the lungs to assess jugular venous pressure to assess pedal pulses

to auscultate the lungs