FN - Unit 2 - Chapter 27: Health Assessment

To obtain data about an adult client's sexuality and reproductive pattern, what question is best for the nurse to ask? "How often do you have sexual intercourse?" "What arouses you when you have intercourse?" "How many children do you have, both living and dead?" "Has anything changed your sexual performance?"

"Has anything changed your sexual performance?" The sexual assessment is not meant to illuminate nonexistent problems. Rather, the client is, in effect, given permission and encouragement to present sexually related questions.

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply. "What seems to make the pain worse?" "Why do you have the pain?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" "Have you taken acetaminophen for the pain?" Intensity

"What seems to make the pain worse?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" Intensity Understanding the location, duration, and aggravating factors may help determine the causative factors. Taking acetaminophen and asking the client why they have the pain are not relevant indicators in the health assessment interview process.

What percentage of weight change in 6 months is considered abnormal? 1% 2% 5% 10%

10% A 10% change in weight in 6 months is considered abnormal.

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? Suspect an inflamed pleura rubbing against the chest wall. Document normal breath sounds. Recommend testing for pneumonia. Assess for asthma.

Document normal breath sounds. Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.

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. Symmetrical shape Irregular edges Single color Larger than 1/4 inch in diameter Change in the mole

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 nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response? "Your health care provider will decide when it is best for you to begin having mammograms based on your family history." "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

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

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?" "Do you smoke, drink alcohol, or use street drugs?" "How do you cope with stressors in your life?" "How do you meet your transportation needs?"

"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?" Performing a functional assessment includes asking about the physical limitations or abilities that a client may experience such as how the client is able to manage transportation, bathing, medication administration, and dressing. Coping with stressors would be included in the psychosocial/lifestyle assessment as well as the use of alcohol, tobacco, and illicit drugs.

The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which action should the nurse take? Elicit a gag reflex Ask the client to open the mouth while applying resistance Lightly touch around the jawline using a piece of cotton wool then a blunt pin Ask the client to open and clench jaws allowing palpation of jaw muscles

Elicit a gag reflex 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 or palpating the jaw muscles while opened and clenched will test the trigeminal nerve (CN V).

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. Lightly palpate the left leg, assessing for edema. Assess for pain by deeply palpating the left leg. Palpate the popliteal and posterior tibial pulses of both legs.

Inspect the left lower leg for areas of redness. 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.

A client has been reporting persistent headaches. Which is an example of subjective data? Temperature is 104.1°F (40.1°C) The client us slow to respond to questions Pain is 4 out of 10 on a pain scale. The client is oriented to person, place, and time.

Pain is 4 out of 10 on a pain scale. Communicating the client's pain level is only something the client can state and validate. Subjective data are those symptoms, feelings, perception, preferences, values, and information that only the client can describe. The rest of the options can be directly observed or measured and are known as objective data.

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

Palpation The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

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? Motor ability Balance and gait Reflexes Sensory abilities

Reflexes This is the initial assessment after a spinal cord injury; therefore, it would be the top priority to help determine the degree of injury by assessing for reflexes. Motor ability and gait cannot be assessed this soon after a spinal cord injury because further injury could result. Sensory abilities are assessed through the sense of smell, taste, hearing, and vision.

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 a blue-black macular area over the sacral area the anterior fontanel bulging when the client cries the abdomen appearing large in relation to the pelvis

circumoral cyanosis when the client is at rest 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: focused health assessment. spiritual health assessment. physical health assessment. comprehensive health assessment.

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

The nurse is preparing to palpate a client's peripheral pulses. The nurse should plan to assess which pulse(s)? Select all that apply. Radial Brachial Popliteal Posterior tibial Dorsalis pedis

Radial Brachial Popliteal Posterior tibial Dorsalis pedis 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.

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, situation, and time oriented to hospital, person, and date oriented to person, place, and time oriented to person, place, and situation

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).

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? Inflammation Arthritis Crepitus or crepitation Fremitus

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

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." "I am going to examine your abdomen." "I need to report what is going on to your health care provider. Can I look at your abdomen?" "Open your shirt, I need to look at your abdomen."

"Let me explain what I am going to do and how you can help." 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 is assessing the skin of a veteran who has returned from deployment overseas. Which response by the nurse reflects the best strategy to gain the cooperation of the client? "May I look at your skin to determine if there are any issues?" "Can you take off your clothes? I need to see your skin." "I need to look at your skin to see if you have any problems." "I am going to look at your skin now."

"May I look at your skin to determine if there are any issues?" Asking permission to look at the client's skin and explaining why prepares the client for the assessment and may gain the client's cooperation. The nurse will need to consider the possibility of posttraumatic stress disorder (PTSD) or other emotional issues related to the client's military service. By directing the client and not explaining the assessment or asking to see the skin without explaining the rationale, the client may resist the nurse.

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? 4 8 12 15

15 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? Concave nails Skin-toned cuticles 160-degree angle of nail attachment Capillary refill of 5 seconds

160-degree angle of nail attachment 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? bilateral lower extremities within normal limits 1+ pitting edema noted on bilateral lower extremities 2+ pitting edema noted on bilateral lower extremities brawny edema noted over bilateral lower extremities

2+ pitting edema noted on bilateral lower extremities 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.

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? 12 9 7 5

7 Based on the assessment findings, the client would receive a score of 2 for eyes opening to pain, a score of 3 for abnormal flexion posturing, and a score of 2 for incomprehensible sounds, for a total score of 7.

A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? A uniform yellow reflex A blurred optic disc Dark-red arteries and light-red veins A reddish retina

A reddish retina Normal findings of the internal eye structures include a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins.

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant? Hairless, shiny legs 2+ edema to lower extremities Thick overgrown toenails An absent popliteal pulse

An absent popliteal pulse 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 conducts a health history on a client who has experienced a 15-pound (7-kilogram) weight loss in the past 3 weeks. Which information would the nurse gather to determine the client's nutrition pattern? Weigh the client and measure the client's height. Ask the client for a 24-hour diet recall. Examine the hygiene of the client's teeth. Inspect the client's abdomen for symmetry.

Ask the client for a 24-hour diet recall. Interview questions that will focus on nutrition might include asking the client to disclose what the individual has eaten in the last 24 hours. Weighing the client would not provide good nutrition information because the nurse already knows the client has experienced a significant weight loss. A 24-hour diet recall would provide better information about the total nutritional pattern than merely examining the client's teeth or inspecting the abdomen for symmetry.

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? Warm the equipment. Ask the client to empty her bladder. Place the client in a semi-Fowler's position. Measure height and weight.

Ask the client to empty her bladder. Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

A 52-year-old male client is admitted to the medical-surgical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He tells the nurse that he hasn't seen any blood in his stool and that he usually drinks a six-pack of beer a day. In trying to pinpoint the cause of the client's pain, which action would the nurse take? Ask the client to compare this pain with the most severe pain he's ever experienced. Rate the client's pain on a scale of 0 to 10, with 10 being the most severe. Ask the client if there was ever a time during those 3 days when he did not have pain. Ask the client to tell her more about the pain.

Ask the client to tell her more about the pain. The nurse should ask the client to tell her more about the pain because an open-ended question would elicit more assessment information about the nature of the pain than a question that calls for a yes or no answer. Asking the client to compare this current pain to past experiences with pain or rating the client's pain level using a pain scale is useful only in determining the intensity of the pain—not the cause of the epigastric pain.

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? Document a normal skin finding on the client chart. Assess the client for cardiovascular disorders. Report the finding as a positive sign for cystic fibrosis. Assess the client for dehydration.

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 nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data would be important for the nurse to collect during the physical examination? Bowel sounds Fatigue level Pain level Symptoms of nausea

Bowel sounds An abdominal assessment includes inspection, auscultation, palpation and percussion. Auscultating for bowel sounds is an objective assessment would be necessary for a physical assessment of the abdomen. Fatigue, pain, and nausea are subjective symptoms. This subjective data would be obtained during the client interview.

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 Decreased penis size Less firmness of the testes Scant amount of pubic hair Scant yellow discharge

Bulge to the left inguinal area Scant yellow discharge 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.

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? Ask the client if he left his earplugs in his ears. Check the client's ear canals for cerumen. Use facial expressions and sign language to communicate. Speak to the older adult client in a high-frequency tone of voice.

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 detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? Hypertension and circulatory overload Decreased cardiac output Impaired kidney function Inflammation of a vein

Decreased cardiac output 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.

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 Increased adaptation to light and dark A blue ring around the cornea Entropion and ectropion Impaired conductive hearing

Decreased color vision and peripheral vision Entropion and ectropion Impaired conductive hearing Older adult common variations include decreased color vision and peripheral vision; decreased adaptation to light and dark; a white ring around the cornea (arcus senilis) and not a blue ring; entropion and ectropion; and impaired conductive hearing. Entropion is a condition in which the eyelid is rolled inward against the eyeball, typically caused by muscle spasm or by inflammation or scarring of the conjunctiva. Ectropion is when the lower eyelid turns or sags outward, away from the eye, exposing the surface of the inner eyelid. This condition can cause eye dryness, excessive tearing, and irritation.

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? Document the weight in the medical record. Notify the health care provider of the abnormal finding. Ensure equipment is not hanging into the sling. Obtain a second scale to verify the measurement.

Ensure equipment is not hanging into the sling. Tubing from IVs, urinary catheters, and wound drains, in addition to other equipment or linens, can add significant weight to a bed scale. The nurse first ensures that the scale is free from items that add weight. The nurse will document after ensuring the weight is accurate. If accurate, the nurse may notify the health care provider. A second scale may not be warranted. Before taking this step, the nurse might lower and remove the client from the scale and zero out the machine again.

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? Encourage the client to increase food and fluid intake. Ensure that the scale is correctly calibrated and repeat the assessment. Report this finding promptly to the client's primary care provider. Increase the frequency of the client's weight assessments.

Ensure that the scale is correctly calibrated and repeat the assessment. If weight varies by more than 1 kg, the nurse should check the scale calibration and the accuracy of the assessment before taking further action, such as reporting to the health care provider or altering the client's diet.

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? Provide a warm, quiet, dimly lit room Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history

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 caring for a client with chronic obstructive pulmonary disease (COPD). What assessment data obtained by the nurse would correlate with this diagnosis? Rhinorrhea Dry cough Expiratory wheezes Fever

Expiratory wheezes Normal inspiration and prolonged expiration are heard to overcome the increased airway resistance of COPD. Wheezes are musical or squeaking, high-pitched, continuous sounds heard as air passes through narrowed airways. Fever may indicate a respiratory infection but is not a symptom of COPD. The cough of a client with COPD is productive and not dry. Rhinorrhea is not a symptom of COPD.

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 Appendicitis Diverticulitis Cellulitis

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.

The nurse testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing? Select all that apply. III: Oculomotor II: Optic V: Trigeminal IV: Trochlear VII: Facial VI: Abducens

III: Oculomotor IV: Trochlear VI: Abducens The oculomotor, trochlear, and abducens nerves control the motor function of the eye structures, which can be assessed through movement of the eyes through the six cardinal positions of gaze. The optic nerve controls the sense of vision. The trigeminal nerve controls the jaw movements of chewing and mastication (motor), and sensation on the face and neck (sensory). The facial nerve controls the muscles of the face (motor) and the sense of taste on the tongue (sensory).

The gerontologic nurse is inspecting the genitalia of an older adult female client. Which assessment findings are of the most concern? Select all that apply. Increased size of the labia unilaterally Smooth skin and slightly drier mucosa Darker pigmentation to vulva Decreased amount of pubic hair Scant red vaginal discharge

Increased size of the labia unilaterally Scant red vaginal discharge Increased size of one of the labia may indicate a tumor or mass. Scant red vaginal discharge requires further assessment, because this could be bleeding or signs of cancer. Smooth skin and slightly drier mucosa, darker pigmentation to vulva, and decreased amount of pubic hair are normal for an older adult female client.

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? Palpate the thyroid gland. Inspect the client's ability to move his neck. Inspect and palpate the left and then the right carotid arteries. Inspect and palpate the supraclavicular area.

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.

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

Inspection Auscultation Percussion Palpation 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.

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? It is normal. It is distended. It is dissecting. It is inflamed.

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

A 56-year-old client has a medium skin tone and 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 breaths/min. The nurse notices that the client is restless and their skin has an ashen appearance. Which nursing action is the priority intervention? Assess capillary refill. Measure the pulse oximetry. Assess fluid intake. Limit the client's activity.

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 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. Children younger than 10 having a slower respiratory rate than an adult 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) Older adults having increased thoracic expansion

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) 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.

A 57-year-old client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. The client denies seeing blood in the stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? auscultation inspection palpation percussion

palpation 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 palpating a client's precordium. Which result is an expected clinical finding? Palpable pulsation over the mitral area Palpable thrill over the aortic area Palpable heave over the pulmonic area Palpable vibration over the right sternal border

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

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority? Movement of lower leg Adequacy of circulation Patency of airway Neurovascular status of the left leg

Patency of airway When performing an assessment after surgery or a traumatic injury, remember the ABCs: Check airway patency first, then breathing, and then circulation. Airway, breathing, and circulation take precedence over neurovascular status.

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? Pink labia lesions Coarse brown hair Whitish vaginal discharge Dark pink vulva

Pink labia lesions Lesions on the labia may be the result of an infection such as herpes or syphilis, which is a concern. Coarse hair is to be expected, although the genitalia may be shaven. Clear or whitish vaginal discharge may be normal. Other signs would need to be present for this finding to be a concern. The vulva has more pigmentation than other skin areas and is often darker pink in color.

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? Dorsal recumbent Sims Supine Prone

Prone In the prone position, the client lies flat on the abdomen with the head turned to one side, which enables the nurse to assess the hip joint and posterior thorax. The Sims position is used to assess the vagina or rectum. The dorsal recumbent position and the supine position are used to assess the head, neck, anterior thorax and lungs, heart, breasts, extremities, and peripheral pulses.

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 Visual acuity Visual fields Blink reflex

Pupillary reaction to light Ability to open and close eyelids Cranial nerve III is the oculomotor nerve. It is a motor nerve that is involved with pupil constriction and raising the eyelids. The nurse would test the pupillary reaction to light and the client's ability to open and close eyelids. Visual field and visual acuity testing would be used to evaluate cranial nerve II or the optic nerve. Blink reflex is not used to test the cranial nerves.

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 Hypoactive bowel sounds in all four quadrants The client states, "I feel nauseated." Peripheral pulses +3 Skin warm and dry 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." Client informs the nurse there is a floater in the left eye Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.

The nurse is examining a client upon admission to the hospital. Which strategy will the nurse use first when completing a comprehensive assessment? Review the client's history prior to introduction to the client. Assess the client for fears and anxiety about the admission. Explain that the interview will be performed after the assessment. Have the family stay in the room to provide emotional support.

Review the client's history prior to introduction to the client. It is possible to obtain some general information about the client by using secondary data sources before introducing oneself. Secondary data sources include sources of data other than the client, such as the history or other health care providers. Such sources help to personalize the interview. Assessing for fears and anxiety will be important to assess during the interview, but obtaining background information from secondary sources should be the first step. The interview is typically performed prior to the head-to-toe assessment and is an opportunity to build rapport with the client and put the client at ease. Having family remain in the room may or may not alleviate anxiety for the client.

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. I- Olfactory V-Trigeminal VII-Facial VIII-Vestibulocochlear IX- Glossopharyngeal

V-Trigeminal VII-Facial IX- Glossopharyngeal 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.

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 will experience lapses in short- and long-term memory. The client will likely have difficulty expressing or understanding abstract concepts. The client's reaction time will likely be slower than that of a younger adult. The client's arm and leg strength will be more asymmetric than that of a younger client.

The client's reaction time will likely be slower than that of a younger adult. Reaction time often decreases with age, even in the absence of pathologic conditions. Each of the other listed findings would be considered abnormal, even in an older adult.

During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique? To assess capillary refill and oxygenation To assess for edema To assess for infection To assess for melanoma

To assess capillary refill and oxygenation Palpation of the nails is done to assess capillary refill and oxygenation. The other answers pertain to assessment of the skin.

A nurse is percussing a client's abdomen. Which finding would the nurse document as normal? Tympany Dull Flat Resonant

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

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? Ensure that the preoperative check list is completed. Document that the preoperative medication was administered. Verify that the procedural consent form is signed. Locate the laboratory test results in the chart.

Verify that the procedural consent form is signed. Although the health care provider 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.

A nurse performs a general survey on a client who is being admitted to the hospital for Chronic Obstructive Pulmonary Disease (COPD). Which components of this type of assessment will be a focus for the nurse? Select all that apply. Vital signs Gait Lab tests Behavior Body mass index (BMI) Breathing pattern

Vital signs Gait Behavior Body mass index (BMI) Breathing pattern The general survey is the first component of the health assessment, beginning at the moment contact is made with the client. Information from the general survey provides clues to the overall health of the client. It includes observing the client's overall physical appearance, body structure, mobility, and behavior; and measuring vital signs, height, weight, and waist circumference; and calculating the client's body mass index (BMI). Laboratory assessments are included in the extended survey of the client.

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 a client in the Intensive Care Unit after having a stroke yesterday a client recovering from brain surgery for repair of an aneurysm a client with a brain tumor who is in the hospital because of respiratory depression

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

The nurse should use the bell of the stethoscope during auscultation of: a client's heart murmur. a client's apical heart rate. a client's breath sounds. a client's bowel sounds.

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.

To assess subjective data related to a client's elimination pattern, the nurse: reviews the latest laboratory report of the urine. asks the client about changes in elimination patterns. notes the frequency, amount, and time the client voids. palpates the abdomen for pain or distention.

asks the client about changes in elimination patterns. The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse: inspects the client's eyes for redness. asks the client what promotes sleep. documents the client's affect and yawning. determines how frequently the client naps.

asks the client what promotes sleep. The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

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

auscultation Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: clear. blurred. clouded. 20/20.

blurred. Visual problems with close objects occur more frequently after the age of 40.

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 bronchovesicular breath sounds vesicular breath sounds adventitious breath sounds

bronchial breath sounds 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.

A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify: masses. muscle tenderness. density and location of lungs. normal breath sounds.

density and location of lungs. 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.

A client has sustained head trauma. The nurse uses the Full Outline of Un-responsiveness (FOUR) coma scale to determine the presence of increased intracranial pressure and client outcomes. What component(s) of the assessment will the nurse document? Select all that apply. heart rate eye response motor response respiration brainstem reflexes Shape

eye response motor response respiration brainstem reflexes The FOUR coma scale combines the most important neurologic signs into an easy-to-use scale with four components. The maximum score in each of these components is 4. The components are not totaled or summed and can be used to detect decreasing consciousness, increasing intracranial pressure, and brain herniation, as well as predict client outcomes. The four components are eye response, brainstem reflexes, respirations, and motor responses.

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 concern for care planning? altered thought processes chronic confusion acute confusion falls risk

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

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: erosion. ulcer. fissure. crust.

fissure. A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.

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. assisting the client to sit up in a chair inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results helping the client to bathe and brush their teeth

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.

The nurse is preparing to perform an examination of the abdomen of a 23-year-old client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client? inspection, auscultation, percussion, palpation percussion, auscultation, palpation, inspection auscultation, inspection, palpation, percussion inspection, palpation, auscultation, percussion

inspection, auscultation, percussion, palpation 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.

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

ptosis. Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.

Which component(s) is included in the integumentary system? Select all that apply. skin hair nails scalp arteries muscles

skin hair nails scalp The integumentary system includes the skin, hair, nails and scalp. Arteries are included in the cardiovascular or peripheral vascular systems, and muscles are included in the musculoskeletal system.

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 the palm the fingertips the knuckles

the dorsum 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.

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 fine crackles pleural friction rub stertorous breathing

wheezes Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

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? "You need to sign up for the clinic's stop smoking program." "You should decrease your intake of fried foods." "It is important for you to do 30 minutes of exercise three times a week." "Take your blood pressure medications exactly as your doctor prescribed them."

"Take your blood pressure medications exactly as your doctor prescribed them." 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." "We will make a referral to the pediatric orthopedic clinic to determine what is wrong with the feet." "Your child may likely have to have serial casting done to correct the deformity of the feet." "It is uncommon for a child to have a deformity of the feet like this. I will call the health care provider."

"This is an age-related variation for the child and should go away after about 30 months." 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 did you eat for dinner last night?" "What are the three objects I told you earlier?" "What is meant by 'an ounce of prevention is worth a pound of cure'?" "What are the month, date, and the year of your birth?"

"What are the month, date, and the year of your birth?" 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? "Your vision is perfect; you can read the entire chart, and you do not need glasses." "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." "Your vision in your right eye is slightly different than that of your left eye." "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)."

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." 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's skin tone will turn yellow." "Your parent's skin turgor will become poor." "Your parent's arms and legs will become cool." "Your parent will exhibit clubbing of the nails."

"Your parent will exhibit clubbing of the nails." 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 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. Assess the client's orientation to person, place, and time. Assess blood pressure and apical heart rate. Assess the client's arterial blood gases level.

Assess pupil shape and reactivity to light. 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.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first? Assess the client's ability to stand or sit. Evaluate the client's level of pain. Monitor for the presence of tubes or lines. Place a cover over the sling of the bed scale.

Assess the client's ability to stand or sit. The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

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? Inspection Palpation Percussion Auscultation

Auscultation 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.

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 Auscultation of bowel sounds every 30 seconds Auscultation of gurgles and clicks Umbilicus centrally located

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.

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. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. 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.

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 Goals with outcome criteria Functional ability evaluation Description of client education

Collection of subjective data Complete set of vital signs Goals with outcome criteria 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.

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. Neurologic: 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

Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Gastrointestinal: abdominal pain with rebound tenderness in RLQ 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.

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." Client describes shortness of breath and increased sputum production. Client reports breathlessness and productive cough. Client reports respiratory distress and frequent spitting.

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." The client's reason for seeking care should always be stated in the client's own words which should be document in quotations. This subjective data is important for all health care providers to review.

The nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse take first? Complete a comprehensive assessment. Contact the health care provider. Review the client's past medical records. Perform a physical assessment.

Complete a comprehensive 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 comprehensive assessment, the nurse can also access the client's medical record for further data, contact other health care providers, and perform the physical 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? Ongoing assessment Comprehensive assessment Emergency assessment Focused assessment

Comprehensive assessment 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.

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

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

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? Check her chart for allergy information. Inspect the area of itchy skin. Review her medical history. Review her medication record.

Inspect the area of itchy skin. Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

The nurse is preparing to conduct a health interview with a client who is hearing impaired. Which considerations will the nurse make for the alteration in the client's hearing? Select all that apply. Sit directly in front of the client Ensure any open windows are closed Determine if hearing aids are required Turn on soft music in the background Dim the lighting in the interview space

Sit directly in front of the client Ensure any open windows are closed Determine if hearing aids are required For clients who are hearing impaired, it is important that the nurse creates an environment in which the client is able to hear the assessment questions accurately. Clients with hearing impairments sometimes rely on being able to see the lips of people they are speaking with and picking up on non-verbal cues from facial expression and body movements. The nurse will sit directly in front of the client to aid visibility as much as possible. Any extraneous noise should be reduced or prevented by shutting any open windows or doors to the room. If hearing aids are used by the client, the nurse will first check with the client that they have these aids with them. Playing music in the background will make it more challenging for the client to hear well. Dimming the lighting in the interview room will make it difficult for the client to see non-verbal expression or read facial cues.

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. Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration 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 Bubbling, crackling, or popping sounds auscultated during inspiration and expiration

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 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 7-year-old child is admitted to the emergency department with a tentative diagnosis of asthma. Which assessment requires a priority intervention by the nurse? Intercostal retractions Snoring sound on inspiration Expiratory wheezing Stridor

Stridor Stridor indicates a narrowing of the upper airway (larynx or trachea) caused by an obstruction or edema and must receive priority of care. Intercostal retractions indicate increased respiratory effort. A snoring sound on inspiration indicates sonorous wheezes and is caused by air passing through or around secretions. Expiratory wheezing is caused by air passing through narrowed lower airways.

Which respiratory sound indicates an upper airway obstruction? Dyspnea Fremitus Stridor Wheeze

Stridor 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.

The client 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 they have been depressed for a long time. The client wants the door closed and the curtains drawn to darken the room. The client refuses visitors, eats only 25% of meals, and tells the nurse that the food makes them nauseous. The nurse observes the client biting their fingernails. The client cries often and sleeps a lot. The nurse documents which client action(s) as objective assessment data? Select all that apply. The client answers questions in a barely audible voice. The client states that they have been depressed for a long time. The client bites their fingernails. The client eats 25% of meals. The client says that the food makes them nauseous. The client sleeps a lot.

The client answers questions in a barely audible voice. The client bites their fingernails. The client eats 25% of meals. The client sleeps a lot. Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all their food, sleeps a lot, and bites their 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 pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? The skin is less elastic with aging. The client is dehydrated. The skin has normal turgor. The client is overhydrated.

The client is dehydrated. The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.

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. The client reports thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia

The client makes noises when he breathes. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.

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. The client reports thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia.

The client makes noises when he breathes. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal? The client's eyes do not converge when the nurse moves a finger toward his nose. The client's pupils are black, equal in size, and round and smooth. An older adult's pupils are pale and cloudy. The client's pupils dilate when looking at a near object and constrict when looking at a distant object.

The client's pupils are black, equal in size, and round and smooth. The pupils should be black, equal in size, and round and smooth. When an object moves towards the client's nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The client's pupils should constrict when looking at a near object and dilate when looking at a distant object.

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. The palate and pharynx move as the client says "ah." The client's tongue remains midline when it protrudes from the mouth. The client is able to turn the head to the side and shrug the shoulders against resistance.

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. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? Assist the client to a sitting position. Uncover the client to expose the chest and abdomen. Palpate the abdomen before auscultating. Warm the diaphragm of the stethoscope.

Warm the diaphragm of the stethoscope. 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? Fluctuations in weight affect a client's self-concept. Obesity puts the client at increased risk for mortality from heart disease. Weight gain is an indication of nutritional status. Weight gain or loss can indicate responses to medical treatment.

Weight gain or loss can indicate responses to medical treatment. 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.

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. have the client turn from side to side and assess pain. have the client lay on his right side, then palpate the area. elevate the legs, bending at the knee while the client is supine.

avoid a position change that requires turning. 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.

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: symptoms. review of systems. chief concern. objective assessment.

chief concern. 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.

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: front of the ear. mastoid process. top of the head. affected ear.

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

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: subjective data. objective data. baseline data. comprehensive data.

objective data. 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.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding requires immediate action by the nurse? erythema at sting site heart rate of 100 beats/min wheezing on auscultation crying with burning pain

wheezing on auscultation Wheezing is an abnormal breath sound that is commonly seen with allergic reactions. Signs of allergic reaction (anaphylaxis) to bee stings are potentially life-threatening and require immediate treatment. Erythema, or redness of the skin, is expected at the sting site. A preschool-aged child has a higher pulse rate (ranging from 80 to 120 beats/min) than an adult. Heart rate also increases when a child is crying. Burning pain is expected after multiple bee stings.