Health Assessment Exam 5
A nurse is assessing a client's vital signs. While counting the number of respirations, which of the following information should the nurse collect? A. Characteristics of the respirations B. Symmetric expansion of the chest walls C. Shape and alignment of the rib cage D. Intensity of tactile fremitus
A.
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? A. Crackles B. Stridor C. Wheezes D. Friction Rub
A.
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? A. "Insert the earpieces at a downward angle toward your nose." B. "Use the diaphragm to listen to low-pitched sounds." C. "Drape the stethoscope over your neck when not in use." D. "Clean the stethoscope by immersing it in soapy water."
A.
BMI: Obese A. 30-34.9 B. <18.5 C. 18.5-24.9 D. 25-29.9
A.
Blood Pressure: Normal A. <120/<80 B. 120-129/<80 C. 130-139/80-89 D. ≥140/≥90
A.
True or False: Breast cancer treatment can lead to edema of the upper limb. A. True B. False
A.
A nurse in an outpatient setting is performing a head-to-toe assessment on a client. Which of the following should the nurse inspect when performing a general survey of the client? (SATA) A. Nutritional status B. Hygiene C. Lung expansion D. Posture E. Range-of-motion
A. B. D.
A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting. At which of the following times should the nurse plan to collect information about the client's general appearance? (SATA) A. During an interview about the client's health history B. When introducing themselves to the client C. Once the focused assessments have been completed D. While collecting the client's vital signs E. During the discussion of planning for follow-up care
A. B. D.
A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? (SATA) A. Instruct the client to swallow. B. Apply downward pressure and ask the client to shrug their shoulders. C. Tell the client to open their mouth and say "ahhh." D. Test the client's ability to protrude their tongue. E. Request the client move their head forward and backward and then side to side.
A. B. E.
What is gynecomastia?
Abnormal breast enlargement in males
Quadrants of the breast
Axillary Tail of Spence Upper Outer Quadrant Upper Inner Quadrant Lower Outer Quadrant Lower Inner Quadrant
BMI: Underweight A. 30-34.9 B. <18.5 C. 18.5-24.9 D. 25-29.9
B
Pulse: Normal A. 50-120 B. 60-100 C. 70-100 D. 50-150
B
A nurse is preparing to perform a head-to-toe assessment on a client. Which of the following tools should the nurse plan to gather? (SATA) A. Blood glucose meter B. Penlight C. Stethoscope D. Sphygmomanometer E. Sterile gloves
B. C. D.
A nurse is assessing a client's radial pulse rate. Which of the following information should the nurse collect while performing this action? (SATA) A. Depth of pedal pitting edema B. Regularity of the pulse C. Presence of a murmur D. Presence of a bruit E. Strength of the pulse
B. E.
Palpation of areolas and nipples: Unexpected
Bloody, purulent discharge: infection Serous, serosanguineous, bloody drainage: intraductal papilloma. Thick, gray drainage and fixation of nipple: ductal ectasia. Loss of elasticity: underlying malignancy.
At what age should women begin mammogram screening? A. 25 B. 35 C. 40 D. 55
C
BMI: Normal A. 30-34.9 B. <18.5 C. 18.5-24.9 D. 25-29.9
C.
Blood Pressure: Stage 1 HTN A. <120/<80 B. 120-129/<80 C. 130-139/80-89 D. ≥140/≥90
C.
Pulse Strength: Expected A. 4+ B. 3+ C. 2+ D. 1+
C.
Temperature: Hyperthermia A. 98.6-100.4 B. 39°C (102.2ºF) C. >40°C (104ºF) D. <35°C (95ºF)
C.
Inspection of areolas and nipples: Unexpected finding
Change from everted to inverted, or change in direction. Flattened or inverted - shortening of mammary ducts. Discharge. Lesions, erosion, ulceration - pagets disease.
Pulse Ox: Normal A. 80-100 B. 90-100 C. 85-100 D. 95-100
D.
Ideal positioning for head to toe: Heart
High Fowler's (sitting up straight)
Assessing the Abdomen
Inspect, Auscultate, Percuss, Palpate. Inspect = Examine for shape, symmetry, contour, scars, hernia/pulsations. Auscultate = Listen to all 4 ABD quadrants - Begin @ RLQ and work clockwise Percuss = Dullness: Solid Organs, Tympany: Hollow Space Palpate = Lightly in same pattern as when auscultation (Rebound Tenderness).
What is the function of the female breast?
Lactation, Female sexuality.
The remainder of the body is drained into the ______.
Left Subclavian Vein
Female genitourinary and rectal exam position
Lithotomy - feet in stirrups
Pap smear
Pelvic exam every year, pap smear every 3 years while sexually active from age 21-65. Can stop if have hysterectomy with removal of cervix.
Bladder Scanner
Place client in supine position Locate symphysis pubis Apply US gel 2.5 to 4 cm above the area Place scanner head on gel, keeping it pointed down Press and release scan button Normal = 50-100 mL post void volume If greater than 100 mL notify provider.
Ideal positioning for head to toe: Pulses
Sitting straight up; supine, semi-Fowler's
Inspection of breasts: Expected Variations
Surgical scars Gynecomastia (large breasts on men). Visible veins bilaterally in pregnant or obese clients Striae Erythema under the breast
Inspection of areolas and nipples: Expected finding
Symmetrical, round, darker than breast tissue. No masses, lesions, discharge. Symmetrical nipple direction, usually lateral and upward. May be everted, flat, or inverted.
A nurse is inspecting the anterior chest of a client. Which of the following findings should the nurse report to the provider? A. Distended veins in one breast B. Costal margin of 85° C. PMI located to the left of the midclavicular line at the 4th intercostal space D. Symmetrical chest expansion during the inspiratory phase
A.
A nurse is preparing to assess the status of a client's upper extremities. Which of the following actions should the nurse take? (SATA) A. Inspect the condition of each fingernail. B. Apply a pulse oximeter to a finger. C. Compare the amplitude of the radial pulses bilaterally. D. Evaluate blood pressure in an upper extremity. E. Palpate the shoulder, elbow, wrist, and finger joints.
A. C. E.
Auscultating heart sounds
APETM Aortic Pulmonic Erb's point Tricuspid Mitral/ Apical (listen 1 minute)
Respiratory Rate: Normal A. 10-16 B. 12-20 C. 16-24 D. 10-25
B
A nurse is assessing a client's posterior and lateral chest. Which of the following actions should the nurse take? A. Position the client in prone position. B. Observe for the use of accessory muscles during inspiration. C. Begin auscultating at the level of C4. D. Reposition the stethoscope downward at 4 inch (10 cm) intervals.
B.
A nurse is evaluating an older adult client for an alteration in orientation. Which of the following questions should the nurse ask the client? A. "Can you tell me your birthday?" B. "Can you tell me what month it is?" C. "Can you tell me what you had for lunch yesterday?" D. "Can you repeat the four words that I asked you to remember?"
B.
Temperature: Fever A. 98.6-100.4 B. 39°C (102.2ºF) C. >40°C (104ºF) D. <35°C (95ºF)
B.
*What does the lymphatic system do in relation to breast tissue?
Detecting and elimination bacteria and viruses from the body. Lymphatic system drains into the axilla.
Internal hemorrhoid SS
Dilated veins inside the anus. They are painless unless they become irritated or thrombosed. Thrombosed = pain, itchiness, bleeding during bowel movements, can be found on toiletpaper.
External hemorrhoid SS
Dilated veins on the exposed portion of the anus. They appear as tissue flaps that are painless unless they become irritated or thrombosed. Thrombosed = pain, itchiness, bleeding during bowel movements.
Syphilitic chancre
Single silver colored raised patch that develops into a superficial ulcer with yellow serous discharge.
Inspection of Axillae: Expected Finding
Skin smooth and intact. Hair growth appropriate for age and sex
Genital Warts
Small painless fleshy growth that may appear singularly or in clusters.
Equipment needed for Head to Toe
Stethoscope Penlight Tongue Depressor VS Equipment, if needing to verify measurements
Inspection of areolas and nipples: Expected Variation
Supernumerary nipples (extra nipples).
Breast examination position
Supine with pillow Sitting with arms at side Sitting with arms over head Sitting with hands on hip or pushed together Sitting leaning forward
Subjective Breast Data: Identify Present health conditions
Unrelieved soreness. Discharge. Lumps. Erythema. Change in texture. Family history of breast cancer - how far back? Trauma, surgeries, biopsies? When was last check up? Do you perform monthly self-breast exams (SBE), can you self demonstrate? Any abnormal findings? Any history of breast disease?
Epispadias
Urethral opening on top of penis.
Gonorrhea
Yellow or green discharge from meatus along with abdominal or pelvic pain and dysuria.
Prostate specific antigen screening/digital rectal exam (DRE)
average risk starts at 50-70, for high risk its 40-45
Types of contraceptives
o Natural - withdrawal / fertility tracking o Barrier - condoms, diaphragms, sponges. o Pharmacologic methods - oral BC, injectable, vaginal spermicide. o Surgical options - vasectomy, tubal ligation.
PERRLA
pupils equal, round, reactive to light and accommodation
Male Genitourinary Anatomy
· Testes (sex organs) - make sperm · Epididymis (stores sperm) - tube located near each testicle, moves sperm from the testicles · Vas deferens - tube that carries sperm out of scrotal sac, between epididymis and urethra and connects them. · Urethra - urination · Seminal vesicles - sac-like glands that lie behind bladder release fluid that forms a part of semen. · Prostate - size of walnut, surrounds neck of bladder and urethra.
The right lymphatic duct drains the bodies ______ into the ______.
Upper Right Side, Right Subclavian Vein.
A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? A. Posterior tibial B. Popliteal C. Dorsalis pedis D. Femoral
C.
Inspection of breasts: Unexpected Findings
Change in breast symmetry, edema, and orange-peel (peau D orange) skin appearance. Erythema. Dimpling or puckering. Lesions and asymmetrical increased venous pattern.
Temperature: Hypothermia A. 98.6-100.4 B. 39°C (102.2ºF) C. >40°C (104ºF) D. <35°C (95ºF)
D.
Chlamydia
Symptom free or may present with yellow purulent discharge from the meatus and painful frequent urination.
Vaccines
· Human papilloma virus (HPV) - STI correlated with cervical, anal, penile cancers. 3 vaccines over 6 months, recommended administering at age 11 for all genders. Best if administered prior to becoming sexually active. · Hepatitis B virus (HBV) - Spread through infected blood. Recommended for high risk groups, risk of exposure to blood.
A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A. A continuous sensation of vibration felt over the second and third left intercostal spaces. B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum. C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. D. A whooshing or swishing sound over the second intercostal space along the left sternal border.
C.
A nurse is performing a general client survey and finds that the client has a body mass index of 23, which of the following should the nurse document? A. The client has no nutritional issues or deficits. B. The client is at high risk for obesity-related health problems. C. The client will need a referral to a dietitian. D. The client has a BMI within the expected reference range.
D.
A nurse is preparing to care for a group of clients in an acute care setting. Which of the following assessments should the nurse plan to perform on every client? (SATA) A. Lung sounds B. Bowel sounds C. Measurement of abdominal girth D. Pedal pulses E. Mental status
A. B. D. E.
Ideal positioning for head to toe: Lungs
Anterior: High Fowler's Posterior: Orthopneic or High Fowler's
What are you assessing during the general survey?
Appearance Describe facial features such as emotional expressions, eye contact, LOC Inspect Skin color and texture Level of Consciousness LOC - A+Ox3 = Are they alert and oriented x's 3? X3 = Person, place, time. (4th, situation). Behavior Clients speech, Mood & affect personal hygiene Facial expression Dress Body structure and mobility Describe overall posture, build and mobility Identify expected vs unexpected mobility findings and ROM
A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A. Auscultation B. Inspection C. Percussion D. Palpation
B.
Blood Pressure: PreHTN A. <120/<80 B. 120-129/<80 C. 130-139/80-89 D. ≥140/≥90
B.
A nurse is assessing a client's nerves. Which of the following client actions is an indication that cranial nerve I is intact? A. The client can stick their tongue out. B. The client can smile symmetrically. C. The client can hear whispered words. D. The client can identify a minty scent.
D.
A nurse is preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg Test is used to assess which of the following characteristics? A. Gait B. Hearing C. Vision D. Balance
D.
BMI: Overweight A. 30-34.9 B. <18.5 C. 18.5-24.9 D. 25-29.9
D.
Blood Pressure: Stage 2 HTN A. <120/<80 B. 120-129/<80 C. 130-139/80-89 D. ≥140/≥90
D.
Inspection of Axillae: Unexpected Finding
Edema or erythema Rash - infection of sweat glands or irritation Deeply pigmented skin of axillae
Colorectal cancer screening
Every client at age 50. · FOBT - once a year · Sigmoidoscopy and DRE every 5 years · Colonoscopy and DRE every 10 years
What is dorsal recumbent position used for?
Female catheter insertion. Supine position with knees bent.
Inspection of Axillae: Expected Variation
Hx mastectomy: Edema of upper extremity.
Assessing the Anterior, Posterior, and Lateral Chest
Inspect, Palpate, Percuss (advanced provider), Auscultate. Expected: Anteroposterior diameter (AP) is 1/3 to ½ less than transverse diameter; no retractions or use of accessory muscles - AP 2:1 Unexpected: Barrel chest 1:1; spinal deformities, kyphosis, scoliosis Position - Expected: Sitting upright, relaxed Unexpected: tripod, pursed lip breathing controls CO2. LOC - Expected: Relaxed/comfortable. Unexpected: Disoriented Auscultation: Lung sounds - know technique.
Assessing the Head, Face, Neck
Inspect, Palpate. Normocephalic, PERRLA, Conjunctiva, Mucous Membranes, Swallow, Smile, JVD
Assessing Upper and Lower Extremities
Inspection, Palpation. Patient raise up their arms with palms facing them for push/pull assessment. Supine position, you may continue to check for skin turgor, Radial pulses, & capillary refill. Assess the skin for color, temperature and presence of edema.
Inspection of Lymph nodes: Expected
Nonpalpable, non-tender
Genital patient teaching
Practice safe sex - contraceptive, shower after sex, urinate after sex, wipe from front to back, no polyester/synthetic underwear, cotton underwear preferred.
Testicular Self Exam
Should be done with annual exam, but self exam every month. Perform while standing, after warm shower, check for swelling and roll each testicle between the fingers and thumb.
True or False: The left teste can appear lower than the right?
True
Palpation of breast
Vertical strip, pie wedge, concentric circles. Use finger pads, make small circles with light, medium, and deep pressure. Do not lift finger pads.
Inspection of lymph nodes: Unexpected
Visible/palpable, pain/tenderness.
Breast self-examination
a self-care procedure for the early detection of breast cancer Once monthly, 4-7 days after the start of menstrual cycle (or 2-3 days after your period). Examine with raised arm. Use Finger pads with massage oil or shower gel. Examine in the mirror for lumps or skin dimpling, change in skin color or texture, nipple deformation or any leaking. Vertical strip, pie wedge, concentric circles. Use finger pads, make small circles with light, medium, and deep pressure. Do not lift finger pads.
Genital Herpes
groups of small painful fluid filled vesicles that break and become superficial ulcers.
Temperature: Normal A. 98.6-100.4 B. 39°C (102.2ºF) C. >40°C (104ºF) D. <35°C (95ºF)
A.
A nurse is performing an assessment on a client who reports ear pain. Which of the following actions should the nurse take? A. Palpate the temporomandibular joint for pain. B. Palpate the mastoid area for pain. C. Inspect the nasal mucosa for redness. D. Inspect the conjunctival sac for redness.
B.
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? A. Document accurate data B. Develop a plan of care C. Validate previous data D. Evaluate outcomes of care
B.
A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? A. Right Upper Quadrant B. Left Upper Quadrant C. Right Lower Quadrant D. Left Lower Quadrant
C.
Palpation of areolas and nipples: Expected
Elastic, nontender, no discharge or white sebaceous secretion with nipple compression.
Ideal positioning for head to toe: Abdomen
Supine, dorsal recumbent
Inspection of breasts: Expected Findings
Symmetry - lobular, symmetrical, or slightly asymmetrical. Smooth and similar color to surrounding skin
Hypospadias
Urethral opening under the penis
A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? A. Borborygmi B. Rebound tenderness C. Tympany D. Abdominal guarding
B.
A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? A. Lordosis B. Kyphosis C. Ankylosis D. Scoliosis
B.
A nurse is performing an assessment of a client's lower extremities. Which of the following actions should the nurse include in this assessment? A. Palpate the strength of the brachial pulses. B. Observe the client's gait as they walk across a room. C. Use a sharp pin to assess for sensation on the sole of the client's foot. D. Inspect the pattern of hair distribution.
D.
A nurse is planning to complete a physical assessment on a client. Which of the following actions should the nurse plan to include? A. Maintain client modesty by auscultating over the client's clothing. B. Include the nurse's interpretation when recording objective information. C. Perform the assessment in the same order. D. Use quotation marks when documenting client statements.
D.
STI Prevention and screening
· Counseling for adolescent and adults who have increased risk for STI. · Discuss transmission and how to reduce risk with methods that fit client lifestyle. · HIV screening recommended ages 15-75. High risk should be tested annually. Low risk at least one check. · Annual screening for chlamydia and gonorrhea recommended for sexually active younger than 25 and/or multiple sex partners.
BPH (benign prostatic hyperplasia) SS
· Frequency / Urge · Nocturia - waking at night to use restroom · Difficulty starting to urinate · Incomplete bladder emptying · Weak Urine Stream · Dribbling
A nurse is performing an assessment of a client's abdomen. Which of the following actions should the nurse take? A. Palpate client-identified areas of discomfort first. B. Begin auscultation in the left upper quadrant. C. Auscultate bowel sounds prior to palpating. D. Count the number of bowel sounds auscultated over 1 min.
C.