Health assessment

A nurse is caring for a 7-year-old client with Down's syndrome. How will the nurse implement care for the client?

Be mindful of developmental age

Peripheral cyanosis and clubbing of the nails are symptoms of

Chronic hypoxia Hypoxia of the tissues changes normal pink-color skin to a grayish or bluish color.

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?

Comprehensive assessment A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations.

The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment?

Identify baseline data

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

Inspection Auscultation Percussion Palpation

chronic obstructive pulmonary disease (COPD)

permanent, destructive pulmonary disorder that is a combination of chronic bronchitis and emphysema

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

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

A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of vodka daily and that he's had a recent weight gain of 3 lb (1.35 kg) in 3 days. Further questioning by the nurse reveals that he was an intravenous drug user in the past but is now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal girth. Which assessment finding supports the nurse's conclusion that the client has liver dysfunction?

Jaundice

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?

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

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?"

The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed. What would be the nurse's best response?

"Hospitalization is a traumatic experience for children. Regression is common, and it takes time for them to return to their former behavior."

A nurse must perform an integumentary inspection on a client. Which statement most effectively explains why the nurse will be assessing the client's skin?

"I am inspecting your skin to get a baseline of your skin and to check if any conditions require treatment."

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."

The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?

"Take your blood pressure medications exactly as your doctor prescribed them."

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory?

"What are the month, date, and the year of your birth?"

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

"What brings you here today?" The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

What percentage of weight change in 6 months is considered abnormal

10%

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

15 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.

During assessment of the lower extremities, the nurse notes that the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4-mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result?

2+ pitting edema noted on bilateral lower extremities

tympany

A bell-like noise when tapping the abdomen

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 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.

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

Ask the client about any unusual genital observations.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?

Ask the client to empty her bladder

As a component of a head to toe assessment, Nurse G. is preparing to assess convergence of the patient's eyes. How should Nurse G. conduct this assessment?

Ask the patient to follow her finger as she slowly moves it towards the patient's nose. Eye convergence is assessed by holding your finger 6" to 8" from the patient's nose and asking the patient to follow it as it moves closer. A penlight is used to assess pupillary reaction. Visual acuity is assessed with the use of a Snellen chart and following a pencil from side to side is a test for extraocular movements.

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

Auscultation 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.

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

Auscultation 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.

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Auscultation of a patient's heart murmur

When completing an assessment of a healthy adolescent client, which measure would be most appropriate

Gather information from the parents and adolescent; then assess the adolescent in private.

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. A friction rub is a continuous, grating-type sound.

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

Crepitus or crepitation

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

Decreased cardiac output 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 caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis is the highest priority?

Deficient fluid volume Deficient fluid volume (hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Confusion, dizziness, and increased heart rate may be initial symptoms.

A nurse is assessing the lungs of a patient and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Document normal breath sounds

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Document normal breath sounds.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

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

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

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

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

Ensure equipment is not hanging into the sling. 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?

Ensure that the scale is correctly calibrated and repeat the assessment.

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?

Ensure that the scale is correctly calibrated and repeat the assessment. 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.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first?

Examine the fontanels and sutures.

subjective

Existing in the mind or relating to one's own thoughts, opinions, emotions, etc.; personal, individual, based on feelings

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?

Expiratory wheezes

During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. This is a

Focused assessment

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 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 IV: Trochlear VI: Abducens

A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of vodka daily and that he's had a recent weight gain of 3 pounds in 3 days. Further questioning by the nurse reveals that he was an intravenous drug user in the past but is now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal girth. Which assessment finding supports the nurse's conclusion that the client has liver dysfunction?

Jaundice Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the blood. It is associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Erythema, redness of the skin, is caused by dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is caused by decreased hemoglobin in the circulating blood and causes inadequate oxygenation of the body tissues.

A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention?

Measure the pulse oximetry. 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.

Sanjay Patel is a 10-year-old boy from India with mahogany-colored skin. He arrives at the school nurse's office and tells the nurse that he was stung by a wasp on the arm yesterday, and he thinks it might be infected. The nurse performs which action in order to assess the wasp sting site for inflammation?

Palpate the area with the back of the hand for increased warmth, then touch the other arm for comparison.

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

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

Pupillary reaction to light Ability to open and close eyelids

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply.

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

An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse?

Request that the child be screened for myopia.

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?

Risk for Falls

You are preparing to assess a patient's cranial nerves. Which of the following techniques should you use to assess cranial nerve III?

Shine a bright light in the patient's eye and observe for bilateral pupillary response.

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

Stop lifting the client and reassure them

Which respiratory sound indicates an upper airway obstruction?

Stridor

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

Subjective data Subjective data are those symptoms, feelings, perceptions, preferences, values, and information that only the client can state and validate.

Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply.

The client answers questions in a barely audible voice. The client bites her fingernails. The client eats 25% of her meals. The client sleeps a lot.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

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. 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 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 nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?

The client's reaction time will likely be slower than that of a younger adult.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

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

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope. 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.

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes Wheezes are continuous sounds that originate in small air passages that are narrowed by secretions, swelling, or tumors and 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.

A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first?

a 10-year-old child with asthma whose oxygen saturation levels are dropping

myasthenia gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

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

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

ask the client what promotes sleep

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

asks the client about changes in elimination patterns.

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

auscultation

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:

chief concern

COPD

chronic obstructive pulmonary disease

creptius

clicking or grating at a joint

A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:

density and location of lungs.

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:

fissure. 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 child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position?

high Fowler's

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

inspection, auscultation, percussion, palpation In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard.

Ausculation

listening to sounds within the body

orthostatic hypotension

low blood pressure that occurs upon standing up

What finding indicates that a child is receiving too much IV fluid too rapidly?

moist crackles in the lung fields

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

objective

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

oriented to person, place, and time

Which technique of assessment provides the greatest amount of information about the thyroid gland?

palpation

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

palpation The 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.

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's:

peripheral pulses

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:

peripheral pulses.

A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. What is the nurse next action?

prepare to ventilate the child The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child should not lie down. When the child's condition allows, the nurse can notify the parents or guardian.

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

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.

A 34-year-old client of Asian descent has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pain, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client?

sclera of the eye

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

symmetry (comparison of bilateral body parts)

Which of the following can a nurse assess by palpation?

temperature, turgor, moisture

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

accommodation of the eye

the process by which the eye's lens changes shape to focus near or far objects on the retina

palpate

to examine by touch

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

tuning fork

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

tympany

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