Fundamentals of Nursing - Basic Physical Assessment

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? "Are you having pain in your leg?" "Tell me what you are feeling." "Do you need pain medication?" "Are you feeling all right?"

"Tell me what you are feeling."

A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? "Are you having pain?" "Is the pain constant?" "How does the pain medication make you feel?" "What does the pain feel like?"

"What does the pain feel like?"

As part of a quality improvement team, the nurse uses the plan-do-study-act method to address unit-based alarm fatigue. The team has interviewed stakeholders to identity opportunities for reducing alarms and collaborated with the equipment vendors to gather alarm data. What should the nurse do next? Analyze the patterns to identify which devices account for the most alarms. Conduct a staff training on ways to reduce wave artifact alarms. Prioritize which alarm parameters need visual, audio, or secondary alerts. Revise default alarm parameters for the unit's client population.

Analyze the patterns to identify which devices account for the most alarms.

Which sound should the nurse expect to hear when percussing a distended bladder? Hyperresonance. Tympany. Dullness. Flatness.

Dullness

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? Institute droplet precautions. Obtain the child's vital signs. Ask the parent about medication allergies. Inquire about the health of siblings at home.

Institute droplet precautions.

A client tells the nurse that her bra fits more snugly at certain times of the month and she is concerned this may be a sign of breast cancer. The nurse should give the client which information about this situation? A change in breast size should be checked by her health care provider (HCP). Benign cysts tend to cause the breast to vary in size. It is normal for the breast to increase in size before menstruation begins. A difference in the size of her breasts is related to normal growth and development.

It is normal for the breast to increase in size before menstruation begins.

Why should an infant be quiet and seated in an upright position when the nurse assesses the fontanels? A mother will have less trouble holding a quiet, upright infant. The fontanels may recede, making assessment more difficult. The infant can breathe more easily when sitting up. Lying down and crying can cause the fontanels to bulge.

Lying down and crying can cause the fontanels to bulge.

The client is reporting pain. What objective approach could the nurse use to determine the acuteness of pain? Select all that apply. Measuring intensity of pain individually for each occurrence. Compare past pain experience with present. Medicate using the same pain scale each occurrence. Medicate according to past doses of the medication. Rely on the client to tell you the dose of a medication.

Measuring intensity of pain individually for each occurrence. Medicate using the same pain scale each occurrence.

Which nursing interventions would be appropriate to prevent hyperbilirubinemia and the need for phototherapy? Select all that apply. Monitor intake and output. Supplement feedings with sterile water. Assess for jaundice when vital signs are measured. Perform routine bilirubin checks every 8 to 12 hours. Encourage breastfeeding for a minimum of every 3 hours.

Monitor intake and output. Assess for jaundice when vital signs are measured. Encourage breastfeeding for a minimum of every 3 hours.

The nurse is caring for a client who is post-operative cholecystectomy. When assessing the respiratory status after general anesthesia, which clinical finding would the nurse view as a concern? Select all that apply. respiratory rate of 14 breaths/min while sleeping air entry slightly decreased to the lung bases while sleeping PAO2 of 76 mm Hg ability to speak in complete sentences cyanosis around the mouth and fingertips

PAO2 of 76 mm Hg cyanosis around the mouth and fingertips

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? Initiate hourly intake and output measurement. Request an order to insert a Foley catheter. Palpate for the bladder above the symphysis pubis. Force fluids to encourage voiding.

Palpate for the bladder above the symphysis pubis.

A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method? Place a tongue blade on the front of the tongue and ask the client to say "ah." Place a tongue blade lightly on the posterior aspect of the pharynx. Place a tongue blade on the middle of the tongue and ask the client to cough. Place a tongue blade on the uvula.

Place a tongue blade on the front of the tongue and ask the client to say "ah."

A nurse is assessing a client with pneumonia. The nurse asks the client to say "99." What is the next action by the nurse? Place the fingertips on the chest to detect vibration. Place the ulnar surface of the hand on the chest to detect vibration. Place the dorsal surface of the hand on the chest to detect movement. Place the finger pads on the chest to detect movement.

Place the ulnar surface of the hand on the chest to detect vibration.

The nurse is monitoring a very drowsy client in the immediate postprocedure phase of moderate sedation. The client will open the eyes to repeated verbal stimulation but does not respond verbally. The nurse has an order to give an antiemetic that is known to cause sedation. What assessment tool should the nurse utilize for this client? Face, Legs, Activity, Cry, Consolability (FLACC) scale Richmond Agitation-Sedation Scale (RASS) Critical Care Pain Observation Tool (CPOT) MASCC Antiemesis Tool (MAT)

Richmond Agitation-Sedation Scale (RASS) --> The RASS is a standardized tool that helps assess and chart level of sedation or agitation in clients receiving sedating medications. The RASS can help guide health care providers in determining if the client needs more sedation, if the client should not have any more sedating medications administered, or if the client needs intervention because he or she is too deeply sedated to maintain protective reflexes. The RASS can help prevent over- or undersedation in this manner. The CPOT and FLACC scale are tools to assess pain and do not assess sedation nor help prevent oversedation of this client. The MAT is a tool to assess nausea and vomiting in clients receiving anticancer treatments, and would not be appropriate for this client.

Which statement regarding heart sounds is correct? S1 and S2 sound equally loud over the entire cardiac area. S1 is fainter at the apex, and S2 is loudest at the base. S1 is loudest at the base, and S2 is loudest at the apex. S1 is loudest at the apex, and S2 is loudest at the base.

S1 is loudest at the apex, and S2 is loudest at the base.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? One breast is larger than the other. The lump is firm and non-movable. The lump is round and movable. Nipple retractions are noted.

The lump is round and movable.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected? The client maintains bed rest. There is redness and swelling at the aspiration site. The client requests a strong analgesic for pain. There is no bleeding at the aspiration site.

There is no bleeding at the aspiration site.

Which client should the nurse assess first? a client being treated for chronic stable angina who reports a recent increase in chest pain frequency a client with type 2 diabetes requesting medication refills whose A1C level is 5 mg/dL a client being treated for right side heart failure who has 1+ pitting edema to lower extremities bilaterally and reports a 2 lb (0.9 kg) weight gain in the last week a client with chronic hypertension whose blood pressure today is 182/98 mm Hg

a client being treated for chronic stable angina who reports a recent increase in chest pain frequency

Which client should the nurse assess first? a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain a client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker a client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache a client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria

a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain

The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply. a client with intractable vomiting and diarrhea a client who underwent cholecystectomy today a client with pain related to pancreatitis a client with colon cancer who is receiving chemotherapy a client with suspected tuberculosis (TB)

a client who underwent cholecystectomy today a client with pain related to pancreatitis

The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition? allergies sinusitis ringworm fifth disease

allergies

The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? similarities from one side to the other changes from the normal expected findings appearance of age-related wrinkles skin turgor

changes from the normal expected findings

A client is transferred to the acute stroke unit, and the nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care. The nurse is aware this information indicates what regarding a client's clinical status? alterations in speech and aphasic status quality and rate of pulses, respirations, and blood gas values changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person whether blood pressure is maintained within the lower end of desired parameters

changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate? coughing when drinking liquids muscle flaccidity of the lower extremities bilateral upper extremity weakness tremors in the fingers that increase with purposeful movement

coughing when drinking liquids

Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? a passage of flatus pre- and post-feeding inability of the client to receive a rapid flow of the feeding intermittent epigastric tenderness formula in the client's mouth during the feeding, and increased cough

formula in the client's mouth during the feeding, and increased cough

In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment? breathing patterns, circulation patterns, and responses to hospitalization health habits, family relationships, affect, and thought patterns general survey results, eating habits, and ability to perform activities of daily living rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance

health habits, family relationships, affect, and thought patterns

Which finding would be expected in a client with chest trauma, rib fractures, and respiratory acidosis? Kussmaul respirations due to inability to take deep breaths hypoventilation due to inability to take deep breaths because of pain hyperventilation due to inability to take deep breaths, so short fast breaths are more comfortable a massive diffusion disturbance due to the rib fractures

hypoventilation due to inability to take deep breaths because of pain

The nurse is obtaining a health history from a client of Puerto Rican descent. Which is most likely to be a health problem with a cultural connection for this client? lactose enzyme deficiency tuberculosis sickle-cell anemia suicide

lactose enzyme deficiency

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect pallor and coolness of the left foot with decreased sensation. a decrease in the left dorsalis pedis and posterior tibial pulses. loss of hair on the lower portion of the left leg and foot. left calf circumference 1" (2.5 cm) larger than the right.

left calf circumference 1" (2.5 cm) larger than the right.

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? orthostatic hypotension moist crackles shortness of breath bounding pulse

orthostatic hypotension

A nurse is conducting a physical assessment on a client who has been diagnosed with primary syphilis. Which assessment best supports this diagnosis? rash on palms of hands and soles of feet painless chancre at site of infection dementia with episodes of psychosis mucopurulent vaginal discharge with cervical exudate

painless chancre at site of infection

The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client? auscultation inspection palpation percussion

palpation

After a local factory explodes, a nurse begins to triage the victims. Victim 1 is initially unconscious and not breathing. After the victim's airway is opened, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds, but remains unconscious. What color tag should the nurse use for this victim? green yellow red black

red

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action? visualization of the ossicles through the tympanic membrane fine hairs in the auditory canal with dark brown wax light reflecting off the ear drum surface reddened tympanic membrane without discomfort

reddened tympanic membrane without discomfort

The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response? pulse rate increased by 20 bpm immediately after the activity respiratory rate decreased by 5 breaths/minute diastolic blood pressure increased by 7 mm Hg pulse rate within 6 bpm of resting pulse after 3 minutes of rest

respiratory rate decreased by 5 breaths/minute

A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases? complaints of constipation nausea and vomiting bradypnea tachypnea

tachypnea

Which sign is an early indication that a client has developed hypocalcemia? tingling in the fingers depressed reflexes ventricular dysrhythmias memory changes

tingling in the fingers

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention? a core body temperature of 97.9° F (36.6° C) confusion when listening to explanations of procedures polydipsia urine output of 90 mL over the past 6 hours

urine output of 90 mL over the past 6 hours

A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions? pustules papules plaque vesicles

vesicles