Chapter 26: Health Assessment

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 testing the function of the spinal cord of a client who presents in the emergency department following a motorcycle accident. What would be the focus of this assessment?

Reflexes

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

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.

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.

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.

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.

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.

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

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.

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?"

A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. The assessment reveals that the client opens the eyes to pain, exhibits abnormal flexion posturing, and produces sounds that are not identifiable. Which score would the nurse assign the client?

6

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.

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

"What brings you here today?"

During a health assessment, the nurse uses deep palpation to assess a client's:

liver

When percussing the liver, the sound should be:

dull

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."

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 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 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next?

Auscultate the abdomen.

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation

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

The nurse is performing a respiratory assessment for a client and hears a high-pitched, harsh "blowing" sound, with sound on expiration being longer than inspiration. How will the nurse document this finding?

Bronchial breath sounds

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response?

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

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.

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 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.

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.

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

Note the client's ability to swallow.

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

Palpation of both carotid arteries at the same time

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

a client's heart murmur.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

asks the client what promotes sleep.

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

inspection, auscultation, percussion, palpation

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 34-year-old client of Asian descent 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 pain, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client?

sclera of the eye

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

subjective data.

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

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

Crepitus

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

Palpation

Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?

Percussion

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

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.

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

auscultation

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

blurred

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

A client is brought to the emergency department after being involved in a motor vehicle accident and sustaining a head injury. The nurse is performing a Full Outline of Un-responsiveness Coma Scale (FOUR) to determine the presence of increased intracranial pressure and client outcomes. What components of the assessment will the nurse document? Select all that apply.

eye response motor response respiration brainstem reflexes Shape

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

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

ptosis