Chapter 26

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

G6PD deficiency

Low NADPH leads to hemolytic anemia (free radicals) with bite cells and heinz bodies Fava beans, sulfonamides, primiquine, dapsone X-linked recessive

he nurse examines the skin of a 29-year-old Irish woman who is reporting 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?

Maculopapular

The nurse weighs the client using a portable bed scale. The obtained weight is 10 lb (4.5 kg) more than the nurse expected. What action does the nurse take next?

Ensure equipment is not hanging into the sling.

Cranial Nerve I

Olfactory (smell)

A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint?

Prone

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

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 performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment? Select all that apply

"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?"

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

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?"

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond?

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

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? *Auscultation *Inspection *Palpation *Percussion

*Palpation

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

*Palpation

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

10%

A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale?

15

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 obtains a client's weight as part of the health history. The client weighs 186 lb. The nurse determines that this client weighs how many kilograms? Please round your answer to the nearest tenth.

84.5

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."

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Ask the client about any usual genital observations.

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.

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.

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-ft (2-m) ladder. Which action by the nurse is the most important to take?

Assess pupil shape and reactivity to light.

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.

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

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 gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply.

Bulge to the left inguinal area Scant yellow discharge

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.

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply.

Collection of subjective data Complete set of vital signs Functional ability evaluation

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Decreased cardiac output

A nurse is performing physical assessments of residents in a long-term care facility. What common head and neck variations in the older adult does the nurse document as a normal finding? Select all that apply.

Decreased color vision and peripheral vision Entropion and ectropion Impaired conductive hearing

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

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 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

cranial nerve II

Optic - vision

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

Palpation

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?

Pink labia lesions

A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III? Select all that apply.

Pupillary reaction to light Ability to open and close eyelids

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.

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

Which components are included in the integumentary system? Select all that apply.

Skin Hair Nails Sweat glands

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 reassure him.

Which respiratory sound indicates an upper airway obstruction?

Stridor

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 closed 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.

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

asks the client about changes in elimination patterns.

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?

The client makes noises when he breathes.

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.

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.

cranial nerve IV

Trochlear

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

Verify that the procedural consent form is signed.

circumoral cyanosis

a bluish discoloration around the mouth

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?

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

Crepitus

a crackling or grating sound usually of bones

fremitus

a palpable vibration from the spoken voice felt over the chest wall

Glasgow Coma Scale (GCS)

a scale used to assess the consciousness of a patient upon physical examination, typically in patients with neurological concerns or complaints

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should:

avoid a position change that requires turning.

bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

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

blurred

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

Peripheral cyanosis and clubbing of the nails are symptoms of:

chronic hypoxia.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

circumoral cyanosis when the client is at rest

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

comprehensive health assessment.

Miosis

constriction of the pupil

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

crepitus

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.

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

ptosis

drooping

Ectropin

eversion or outward turning of the lower eyelid

polyphagia

excessive hunger

Polydyspia

excessive thirst

polyuria

excessive urination

trochlear

eye movement

Cranial Nerve III: Oculomotor

eyelid elevation, pupil constriction and accommodation

Maculopapular

flat to slightly raised colored bumps

Bullae

fluid filled blisters

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

heart murmer

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

entropion

inward turning of the rim of the lower eyelid

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

functional health

level of health defined by one's ability to carry out usual and desired daily activities

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

look at a close object, then at a distant object.

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

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

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

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

palpation

pustular

papule filled with pus

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

ptosis

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

visual acuity

sharpness of vision

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 dorsum

lavage

to wash out a cavity