Chpt 26: Health Assessment

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. Explanation: 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.

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

1. Inspection, 2. Auscultation, 3. Percussion, 4. Palpation Explanation: The order of the techniques for the abdominal assessment differs from that for the other systems. This is the preferred approach because performing palpation and percussion before auscultation may alter the sounds heard on auscultation.

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

Cranial nerve I Explanation: Cranial nerve I is important for a person's sense of smell. Cranial nerves II, III, and IV are important for vision.

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

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 Explanation: 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. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Erythema (redness of the skin) is caused by dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is caused by decreased hemoglobin in the circulating blood and causes inadequate oxygenation of the body tissues.

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.

Larger than 1/4 inch in diameter Irregular edges Change in the mole Explanation: 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.

The nurse is preparing to palpate a client's peripheral pulses. The nurse should plan to assess which pulse(s)? Select all that apply.

Popliteal Posterior tibial Dorsalis pedis Brachial Radial Explanation: The radial, brachial, popliteal, posterior tibial, and dorsalis pedis arteries are all located in the extremities and thus are part of the peripheral vascular system.

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. Explanation: S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-aged 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.

Which respiratory sound indicates an upper airway obstruction?

Stridor Explanation: Stridor is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction. Dyspnea is difficult or labored breathing and a term to describe difficulty breathing. Fremitus is a vibration felt on the client's chest during low frequency vocalization. A wheeze is a whistling or rattling sound in the chest as a result of obstruction in the air passages. Wheezing most often is caused by an obstruction (blockage) or narrowing of the small bronchial tubes in the chest.

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 eats 25% of her meals. The client sleeps a lot. The client bites her fingernails. The client answers questions in a barely audible voice. Explanation: Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all her food, sleeps a lot, and bites her fingernails is a means of attaining objective findings. Subjective data are experienced or known only by the client (e.g., pain and nausea) and are gathered by verbal report.

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

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. Explanation: The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern.

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. Explanation: 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.

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

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

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. Explanation: Strike the tuning fork and place its stem firmly against the mastoid process.

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 Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

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." Explanation: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

A nurse is preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client?

"Let me explain what I am going to do and how you can help." Explanation: The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation. Requesting to examine the client's abdomen without any explanation may cause anxiety and increase the client's pain and decrease the chance of cooperation. The results of the assessment should be reported to the health care provider. The nurse does not need to avoid conversation during the assessment.

The nurse at the neighborhood family clinic is teaching 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." Explanation: Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.

The nurse is performing an assessment for a 12-months-old child and observes pronation of the child's feet. The parent asks the nurse what is wrong with the child's feet. What is the best response by the nurse?

"This is an age-related variation for the child and should go away after about 30 months." Explanation: Pronation of the feet in children between 12 and 30 months of age is a common age-related variation. This usually disappears after the 30th month. A referral to the pediatric orthopedic clinic or health care provider is not a necessary intervention at this time. Serial casting is used for children born with clubfoot, which is not the case with this child.

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?" Explanation: Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's abstract reasoning. The nurse needs to ask a question that may be corroborated to confirm a past or remote memory, so asking what the newly admitted client ate at dinner would not be able to be corroborated. The client's birthdate is available in the medical record and can be corroborated. Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses recent memory.

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)." Explanation: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.

The nurse cares for a client with chronic obstructive pulmonary disease. Which explanation does the nurse provide to the client's adult child, who asks, "How will we know if my parent is experiencing chronic hypoxia?"

"Your parent will exhibit clubbing of the nails." Explanation: Clubbing of the nails is a sign of chronic hypoxia. In clubbing, the angle between the nail bed and the finger flattens to 180 degrees or less. Hypoxia of the tissues changes normal, pink-color skin to a grayish or bluish color. A yellowish color of the skin reflects jaundice, a sign of liver impairment. Poor skin turgor is a sign of dehydration, normal aging, or weight loss. Cool skin may indicate poor circulation.

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 Explanation: The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented client.

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

160-degree angle of nail attachment Explanation: Nails are normally convex and the cuticle is pink and intact. The angle of attachment of the nail is 160 degrees; clubbing is present when the angle of the nail base exceeds 180 degrees. Normally, nails are firm and smooth and capillary refill should be brisk—less than 3 seconds.

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 Explanation: Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour. Brawny edema occurs when fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, and there is no pitting, so the tissue palpates as firm or hard, and the skin surface is shiny, warm, and moist.

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant?

An absent popliteal pulse Explanation: Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.

The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which action should the nurse take?

Ask client to move tongue side to side Explanation: The motor function of the glossopharyngeal nerve can be tested eliciting a gag reflex by placing a tongue depressor on the back of the tongue and having the client move the tongue from side to side. Having the client open the mouth against resistance tests motor supply. Lightly touching with different sensations will test the trigeminal nerve (CN V) and observing the uvula tests the vagus nerve.

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. Explanation: 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. Changes in blood pressure (widening pulse pressure) and decreased heart rate are a late sign of ICP. Although carbon dioxide levels will increase intracranial pressure, it is not a test that the nurse can do at the bedside to assess ICP.

An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use?

Auscultation Explanation: Auscultation would reveal if the client's heartbeat is rapid or irregular, and if there are any additional heart sounds such as an S3, which could be an indicator of heart failure. Palpation and inspection may reveal an irregular heartbeat, but they will not disclose extra heart sounds. Percussion is a limited assessment that could be used to outline the cardiac boarder.

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. Explanation: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

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 Explanation: Bronchial breath sounds are heard over the larynx and trachea; they are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are heard over most of the lung fields; they are soft, low-pitched, whispering sounds, with sound on inspiration being longer than expiration. Adventitious breath sounds are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways. These abnormal sounds also result from sudden opening of collapsed alveoli.

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 Explanation: A bulge in the left inguinal area could indicate a hernia and needs further assessment. Yellow discharge could indicate an infection and requires further assessment. Decreased penis and testes size, less firmness of the testes, and decreased pubic hair are normal with aging of the male client's genitalia.

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 Explanation: Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client. The development of the care plan, which includes goals with outcome criteria and client education, are done after the admission assessment.

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 Explanation: 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.

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 Explanation: Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse.Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses.

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. Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

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.

Gastrointestinal: abdominal pain with rebound tenderness in RLQ Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Explanation: Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body. Neurologic assessment findings of awake and alert, respirations of 24 and regular, and musculoskeletal assessment of the client observed sitting up in bed with knees bent are examples of inspection.

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. Explanation: 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.

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?

Inspect the left lower leg for areas of redness. Explanation: 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.

The nurse examines the skin of a 29-year-old woman with light-colored skin who is reporting swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations without blistering on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?

Maculopapular Explanation: A maculopapular rash is characterized by macules (distorted but nonelevated spots on the skin) and papules (small, circumscribed, superficial, solid elevations of the skin). The term bullae refers to the presence of large vesicles (usually 2 cm or more in diameter). A papulovesicular rash is characterized by superficial, small, circumscribed, and solid elevations of the skin and vesicles, or blisters. A pustular rash contains visible pus within or beneath the epidermis.

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. Explanation: 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 nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply.

Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis) Explanation: Newborns and children use abdominal muscles to breath as opposed to adults, who use the thoracic muscles. Increased anteroposterior diameter of the chest is seen in older adults. Kyphosis is seen in older adults. Newborns and children have louder breath sounds and a higher respiratory rate than adults. Older adults have decreased thoracic expansion.

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

Palpable pulsation over the mitral area Explanation: A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

A nurse is assessing the cranial nerves of a client who is recovering from Bell palsy. Which cranial nerves are important for the coordination of facial movement and reflex activity? Select all that apply.

V-Trigemnial VII-Facial IX- Glossopharyngeal Explanation: Cranial nerves V, VII, IX, and XII are important in the coordination of facial movements and reflex activity. Cranial nerve I is important for the sense of smell, whereas cranial nerve VIII is important for hearing. Intact cranial nerve function is important for normal sensory functioning.

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. Explanation: 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 client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

The nurse is caring for a client diagnosed with coronary artery disease after a cardiac angiogram. The client has a sandbag on the right femoral artery. Which assessments should the nurse choose? Select all that apply.

Vital signs Focused peripheral vascular assessment General physical assessment Explanation: A comprehensive assessment with a detailed health history and complete physical examination is conducted when a client enters a health care setting. An ongoing, focused peripheral vascular assessment is conducted at regular intervals during client care after the angiogram. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations, for which there is no indication. A general physical assessment is a systematic bedside assessment and warranted since the client returned from a procedure to determine if there are any health concerns.

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. Explanation: 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. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.

The nurse cares for a client with congestive heart failure (CHF). How does monitoring the client's weight contribute to the provision of effective nursing care?

Weight gain or loss can indicate responses to medical treatment. Explanation: Weight measurement can be done to evaluate fluid status or the response to medical treatment. A client with CHF is often fluid overloaded, as the damaged heart is unable to efficiently pump blood through the kidneys for fluid removal. Diuretics are prescribed to remove fluid and client weight is monitored to evaluate their effectiveness. Increased body weight affects self-concept, puts the client at risk for higher mortality from heart disease, and provides an indication of the nutritional status, but for clients with CHF, this assessment is done to monitor the effectiveness of treatment.

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

a clients heart murmur Explanation: 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.

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. Explanation: Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

A nurse is auscultating the lungs of a client. During the auscultation, the nurse hears high-pitched, harsh, blowing sounds over the larynx and trachea. The nurse identifies these sounds as which type?

bronchial breath sounds Explanation: Normal breath sounds vary over different parts of the lungs. Bronchial breath sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Adventitious breath sounds (added, abnormal sounds) are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways.

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 Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

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

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

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. Explanation: 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. Baseline data is obtained on first contact with the client.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.

soft, low-pitched, whispering sounds heard over most of the lung fields Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly Blowing, hollow sounds auscultated over the larynx and trachea Explanation: Vesicular breath sounds are soft, low-pitched, whispering sounds heard over most of the lung fields, with sound on inspiration being longer than expiration. Bronchovesicular sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Bronchial sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Musical or squeaking sounds describe a sibilant wheeze. Sonorous or coarse sounds with a snoring quality describe a sonorous wheeze. Bubbling, crackling, or popping sounds describe crackles.

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.

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