Health Assessment Exam 1

A nurse is assessing a client using percussion and identifies a tympanic percussion sound. The nurse understands this sounds is normally heard while percussing

Stomach or intestine

A nurse is caring for a patient postoperatively. Which questions should the nurse ask the patient to appropriately assess the intensity of the pain?

"Can you rate the pain that you have now?"

When assessing the radial pulse of a client, a nurse notes it is irregular. Which of these assessments should the nurse perform next? Assess the

Apical pulse for one minute

A client tells a nurse, "I am very anxious about my physical exam." The best action by the nurse should be

Appear unhurried and confident when examining the client

A nurse is assessing a client using the Percussion technique. The nurse understands the purpose of the percussion technique is to (SELECT ALL THAT APPLY)

-Map out the location of an organ -Detect a superficial abnormal mass -Identify the density of a structure

A nurse understands that the goal of a review of systems during assessment process is to (SELECT All THAT APPLY)

-Assess health promotion practices for a variety of body systems -Evaluate the past and present health state of each body system -Double-check in case any significant data has been omitted.

A client asks a nurse, "What do the numbers in a blood pressure reading mean? "Which of these statements is the best response by the nurse?

"The top # is systolic blood pressure and reflects the pressure on the arteries when the heart contracts"

When assessing the quality of a client's pain, which of these questions would be most important for a nurse to ask?

"What does the pain feel like?"

A nurse understands that an example of Objective information obtained during the physical assessment includes?

2x5 cm scar present on the right lower forearm

A female client does not speak English well and a nurse needs to choose an interpreter. Which of these would be the most appropriate choice to maintain HIPPA policy?

A trained interpreter

When assessing a client with clubbing of the fingernails, the nurse should expect to find

An angle of the nail base 180 degrees or greater with a nail base that feels spongy

A nurse is performing a lymphatic assessment and notices that a client's sub-mental lymph nodes are enlarged. The next action by the nurse should be to assess the

Area proximal to the enlarged nodes

When assessing the skin of a black client who may be experiencing shock, a nurse may expect to assess the skin as

Ashen, gray, or dull

A nurse understands the process is a sequential method of problem-solving that has five phases. These phases include

Assessment, diagnosis, planning, implementation, and evaluation

A newly admitted client reports having acute pain, has not been sleeping well, and having difficulty breathing. In which priority order, should a nurse assess these problems?

Breathing, pain, sleep

A client is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:

Caused by the complete absence of melanin pigment

A nurse understands the difference between a sign and a symptom. Which of these would the nurse record in a client's history and physical as a symptom?

Chest pain

2- A nurse understands that a bluish mottled color that signifies decreased perfusion is?

Cyanosis

When assessing an older adult client with dehydration, a nurse should expect to obtain which of these findings?

Decreased skin turgor under the clavicle

A nurse has just completed the lymph assessment on an older adult client and is unable to palpate any of the lymph nodes. Which of these actions should the nurse take?

Document this as a normal finding

When assessing skin temperature, a nurse should use which part of the hand?

Dorsal surface

A nurse understands intense redness of the skin due to excess blood in the dilated superficial vessels is

Erythema

A client tells a nurse "I'm afraid of what the test will show. I think I have cancer" The nurse replies, "Don't be silly. Of course you don't have cancer." Which of these communication techniques did the nurse use with this client?

False-reassurance

A non-English speaking client appears somewhat uncomfortable about a nurse examining his neck. The client would probably be most comfortable with the nurse examining the thyroid

From the front with the head tilted forward and using the thumbs to palpate

During the interview portion of a health history the nurse collects which of the following categories of information? SELECT ALL THAT APPLY

Functional assessment Reason for seeking care Review of systems Biographical data

When assessing the neck of a client, a nurse gives a client a cup of water to sip. The nurse understands the purpose of this action is to

Observe the thyroid gland as the client swallows

A nursing student understands the purpose of the review of symptoms section in the health history is to

Identify current or past health problem

A nurse is assessing a client who reports fainting episodes that started last week. The nurse should FURTHER assess the client's blood pressure

In the lying, sitting, and standing positions

A nurse is assessing the blood pressure (BP) on a client with hypertension. Which of these techniques is the best for the nurse to use when taking the BP?

Inflate the blood pressure cuff 30mmHG above the point at which the palpated pulse disappeared

A nurse is assessing a client during a routine wellness check at a clinic. Which of the following assessment techniques involve documentation of symmetry, gait, and physical appearance?

Inspection

A nurse is describing the order of a physical assessment to a nursing student. The nurse explains the examination of most body systems is best conducted in which order?

Inspection, Palpation, Percussion, Auscultation

A nurse assesses a client's face, and observes multiple lesions which are light brown in color without elevation or depression of the surface and less than 1 cm in size (freckles). The nurse documents these assessment findings as

Macules

A nurse is assessing a young adult client who states complaints of "sore throat & fever for three days". As part of the exam the lymph nodes are assessed. Which of the following would be considered a normal finding in a WELL client?

Nodes are non-palpable

A nurse is assessing a client using percussion assessment technique. The nurse identifies a resonant sound is normally heard while percussing

Normal lung tissue

A nurse is assessing the vital signs of a young adult marathon runner and documents the following: Temperature-97 F (36.1 C), Pulse -50 beats per minute, Respirations -14 breaths per minute, and Blood Pressure- 104/68 mmHg. The nurse recognizes these findings indicate

Normal vital signs for a healthy, athletic adult

A nursing student asks the instructor to distinguish tenderness from pain. The instructor explains that tenderness

Occurs with palpation

A nurse is assessing a client who has swollen ankles. Which of these assessment techniques should the nurse use to gather more data from this observation?

Palpation

A nurse is assessing a client and finds a solid, elevated, circumscribed lesion that is less 1 cm in diameter. The nurse identifies this finding as a

Papule

A nurse is documenting a physical assessment on a client. Which of these assessment techniques involves palpable vibrations and audible sounds?

Percussion

A nurse is assessing a client's pain. The nurse understands that the most reliable indicator of pain is

The client's statement

A nurse is assessing skin texture, swelling, and pulsation in a client. Which of these parts of the hand should the nurse use with this assessment?

Tips of the fingers

A nurse is assessing a client using auscultation. Which of these actions should the nurse employ when using the stethoscope tool?

Use the diaphragm to listen for high-pitched sounds

A nurse is assessing a client using the bell of the stethoscope. The bell is most effective when it is used to assess

Vascular sounds

A client has an elevated lesion containing serous 1 cm in diameter on the lip. A nurse should identify this lesion as a

Vesicle

A nursing is caring for a patient postoperatively . Which questions should the nurse ask the patient to appropriately assess alleviating factors of the pain? All of the apply?

What makes your pain better? What makes your pain worse?

A nurse understands jaundice is exhibited by a yellow skin color, indicating rising levels of bilirubin in the blood. Which of the following findings is indicative of true jaundice?

Yellow color of the sclera that extends up to the iris

When assessing a client, a nurse notes a linear pattern of lesions along the T4 dermatome. The nurse would document these findings as

Zosteriform lesions extending laterally at the nipple line

A nurse is assessing the radial pulse of a healthy adult client. The nurse should count the pulse

for 30 seconds and multiple by 2 to calculate the pulse rate

A nurse is bathing an older adult client and notices the skin is wrinkled, thin, lax and dry. The nurse understands the underlying cause of these skin changes is increased

loss of elastin and decrease subcutaneous fat in the older adult

A nurse is performing a wellness assessment on a client who visits a clinic for a routine check-up. Following a health history and interview that yielded insignificant results, the nurse should begin the assessment by inspecting the

skin