Health Assessment

When asking a client newly admitted to the hospital about diet history, which question by the nurse would be the most important? 1. What time of day do you eat each meal? 2. Do you eat alone or with family members? 3. How often do you eat meals in restaurants? 4. Do you have any dietary restrictions?

4. Do you have any dietary restrictions?

Because of a history of a headache, the examiner uses transillumination to assess for an inflamed sinus. The findings in a healthy individual would be:

A diffuse red glow

The nurse is evaluating a 20-year-old client's gait and balance. The client is unable to walk heel to toe without swaying. The nurse should further evaluate for which problem?

Alcohol intoxication

What does the "A" in the ABCDE of mole assessment stand for?

Asymmetry

The nurse has auscultated the client's lungs and hears bubbling sounds bilaterally in the lower lung fields. The nurse would document which finding in the client's medical record?

Bilateral crackles at the bases

Otorrhea

Drainage of the ears

In an effort to provide a comfortable environment for a client during a physical assessment, the nurse would take which action?

Drape the client prior to beginning the examination

The nurse has used percussion to assess the client's abdomen. The nurse documents which normal characteristic assessed over the liver in the RUQ?

Dullness

In what order would the nurse complete the following components of a respiratory assessment on an assigned client? Percuss the anterior thorax Palpate the anterior thorax Position the client Explain the procedure to the client Auscultate the anterior thorax

Explain the procedure to the client Position the client Palpate the anterior thorax Percuss the anterior thorax Auscultate the anterior thorax

To evaluate the client for anosmia, the nurse would perform what assessment?

Have the client close his eyes and identify a familiar smell

What action would the nurse take to examine the temporomandibular joint?

Have the client open and close the mouth while palpating the joint in front of the tragus

The client is admitted to the hospital reporting inability to sleep because of shortness of breath. The nurse should take which preferred action?

Have the client sleep on two or three pillows

Swimmer's ear

Infection in the ear canal

When performing an assessment of the client presenting with a musculoskeletal problem, which action should the nurse take first?

Inspect the area of pain or inflammation

The nurse is preparing to conduct a physical assessment of a client's chest and will be utilizing all the following steps. Place the techniques in the correct order for use: Percussion, Auscultation, Inspection, Palpation

Inspection, Palpation, Percussion, Auscultation

A client who has been diagnosed with a myocardial infarction (MI = heart attack) presents with a complaint of "awakening in the middle of the night with a feeling of not being able to breathe". What is the appropriate action for the nurse to take?

Instruct the client to sleep in a Semi-Fowler's position because of the paroxysmal nocturnal dyspnea

When assessing your patient's lungs for egophony, you ask him to say "E" but it sounds like "a". This finding may indicate which condition?

Lung consolidation

What data regarding the family history of an adult client is most important for the nurse to obtain during an initial interview?

Major diseases of close family

The nurse has assessed the client's shoulder strength and finds the client has full resistance and ROM. The nurse should document this finding with which of the following ratings?

Normal (5)

The nurse notes during a routine screening examination that the client has a thready pulse. In what other way could this finding be documented?

Pulse is difficult to palpate and obliterates easily

To assess the intensity of a client's pain during a health assessment, the nurse could ask the client to do which of the following?

Rate the pain on a scale of 1-10

In the Rinne test, the 2 to 1 ratio refers to:

The lengths of time until the patient stops hearing the tone by air conduction and by bone conduction

The examiner records "positive consensual light reflex." This is:

The simultaneous constriction of the other pupil when one eye is exposed to bright light

In examining the ear of an adult, the canal is straightened by pulling the auricle:

Up and back

To examine the oculomotor nerve, the nurse would use which assessment technique?

Use a Snellen eye chart

The clinic nurse is conducting a health history. Place in proper sequence the following questions the nurse would ask using the standard format for collecting health history information. Does anyone in your family have diabetes? For what reason did you come to the clinic today? What is your date of birth? Can you tell me about your support system? Have you ever been hospitalized?

What is your date of birth? For what reason did you come to the clinic today? Have you ever been hospitalized? Does anyone in your family have diabetes? Can you tell me about your support system?

Bifid uvula

a common finding in Native Americans

Preauricular

anterior to the tragus

To assess for pallor in a dark-skinned client, the nurse should observe the client's skin for a color that appears

ashen

Which technique is the most effective method for the nurse to use to validate an alert client's level of pain?

ask the client to use a pain scale

Tonsillar

at the angle of the mandible anterior edge of sternomastoid

Occipital

at the posterior base of the skull

Submental

behind the tip of the mandible

Supraclavicular

between clavicles and sternomastoid

rhinorrhea

clear, watery nasal drainage/sign of allergy

When testing the ROM of a client's shoulder, the nurse hears a grating sound. The nurse should document which of the following assessment findings?

crepitus

Skin turgor is assessed by picking up a large fold of skin on the anterior chest under the clavicle. This is done to determine the presence of:

dehydration

Flattening of the angle between the nail and its base is:

described as clubbing

Posterior cervical

in the posterior triangle

Submandibular

medial border of the mandible

Posterior auricular

posterior to the auricle

Leukoplakia

precancerous lesions of the mouth

When performing respiratory assessment of an adult, the nurse notes hyperresonance on percussion. The nurse would conclude that this is due to which condition?

pulmonary disease

While assessing an older client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should?

refer the patient to the physician for further evaluation

Superficial cervical

superficial to the sternomastoid

Visual acuity is assessed with:

the Snellen eye chart

Conductive hearing

transmission of sound through external/middle ear

Sensorineural hearing

transmission of sound waves in the inner ear

Candida albicans

white curdlike patches over the oral mucosa

Deep cervical

within and around the sternomastoid

The client reports shoulder pain without palpation or movement. The nurse should evaluate the client for which health problem?

A cardiac problem

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellow nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge Is most likely due to:

An upper respiratory infection

The nurse is performing a nutritional and physical assessment on an adult client. The nurse documents that the client has yellow subcutaneous fat deposits around the eyes. The nurse should expect which lab test to be ordered?

Cholesterol

A client is admitted for evaluation of upper GI symptoms. The nurse would document which statement as objective data in the client's medical record? Client states, "I have a headache" Client states," I had chickenpox as a child" Client has distended abdomen and active bowel sounds Client states," I feel nauseated after eating"

Client has distended abdomen and active bowel sounds

The nurse is performing a respiratory assessment on a client and finds unequal chest expansion. The nurse would conclude that this may be caused by what factors?

Collapse or obstruction of part of the lung

The client has a history of chronic obstructive pulmonary disease (COPD). The nurse should expect to document which clinical manifestations found on the physical examination? Select all that apply. Increased tactile fremitus Asymmetrical excursion Decreased bilateral excursion Fine crackles A transverse to anteroposterior diameter of 1:1

Decreased bilateral excursion A transverse to anteroposterior diameter of 1:1

Otalgia

Ear pain

The clinical educator on a neurological unit is teaching a new nurse how to elicit deep tendon reflexes. The educator would evaluate the orientee as having appropriate knowledge of a positive triceps reflex if she describes this as which of the following?

Extension of the forearm

Vertigo

Feeling that the room is spinning

The sinuses that are accessible to physical examination are the:

Frontal and maxillary

Presbycusis

Gradual hearing loss of aging

Sensorineural hearing loss may be related to:

Gradual nerve degeneration

To test CN VII, which is the most appropriate assessment for the nurse to conduct?

Have the client smile and clench teeth

The nurse is performing a respiratory assessment on a client who is presenting with an underlying obstructive pulmonary disease. What is the most important question for the nurser to ask the client during the interview to provide information about contributing factors?

Have you ever smoked tobacco products?

When obtaining information about a child's health history, the nurse would include which data?

Past medical history, present medical complaint, review of systems

The nurse is teaching the client about MyPyramid. The nurse can evaluate that the client understands the teaching when the client states that MyPyramid does which of the following?

Reflects an individualized approach to nutrition

Tinnitus

Ringing in the ears

To access for early jaundice, you will access:

Sclera and hard palate

The nurse is testing the client's ability to recognize familiar objects. When the nurse places a coin in the client's hand he correctly identifies the object. How would the nurse document the finding?

Steriognosis

The nurse would plan to do which of the following as a high priority during a routine health assessment?

Teach the client about ways to maintain health and wellness

In a medical record, the tonsils are graded as 4+. The tonsils would be:

Touching each other

The nurse is unable to elicit the patellar reflex. What action should the nurse take next to try to test this reflex?

Use distraction to facilitate relaxation

The nurse plans to do which of the following using the skill of inspection during health assessment on an adult?

Use eyes, ears, and sense of smell to make observations

When you auscultate the lower lobes of a healthy patient's lungs, you would expect to hear:

Vesicular sounds

To evaluate the patellar reflex, the nurse would perform the following assessments in which order? List the numbers in order performed. Use distraction Wash hands Palpate the patella Position the client Strike the patella with a reflex hammer

Wash hands Position the client Palpate the patella Use distraction Strike the patella with a reflex hammer

fissured tongue

a sign of dehydration

When assessing carotid pulses, what action should the nurse avoid?

bilateral compression of the arteries

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before. The nurse should instruct the client that prolonged wearing of contact lenses can lead to:

corneal damage

If the thyroid is enlarged, which of the following next steps is appropriate? Check for tracheal deviation Listen for a bruit over the carotid arteries Listen for a murmur over the aortic area Listen for a bruit over the thyroid lobes

listen for bruit over thyroid lobes

Canker Sore

yellow/white ulcer with red halo, painful

When obtaining a cardiovascular health history the nurse should ask which questions? Select all that apply. Are you able to perform your activities of daily living? Do you have any musculoskeletal aches? Have you had any weight changes? Have you been treated for cardiovascular disease? Do you know your cholesterol and triglyceride levels?

Are you able to perform your activities of daily living? Have you had any weight changes? Do you have any musculoskeletal aches? Have you been treated for cardiovascular disease?

When palpating the carotid arteries it is essential that the nurse do which of the following?

Avoid palpating the arteries simultaneously

When percussing the liver the nurse would expect to document which of the following findings?

Dullness

When obtaining information about appetite from a client who reports not feeling hungry in the last few weeks, the nurse should ask the client which questions? Select all that apply. Has your weight changed? Can you complete a dietary recall? Have you had any changes in your elimination patterns? When did you notice your appetite change? Are you experiencing any additional symptoms associated with the weight change?

Has your weight changed? Can you complete a dietary recall? When did you notice your appetite change? Are you experiencing any additional symptoms associated with the weight change?

The nurse sis examining the spine of a client who is experiencing extreme curvature of the lumbar spine. How should the nurse document this finding?

Lordosis

Using the otoscope, the tympanic membrane is visualized. The color of a normal membrane is:

Pearly grey

During a cardiovascular assessment the nurse notes that the client has a heart rhythm with a pause after each beat and a skip every third beat. What is the appropriate interpretation of this finding?

Regularly irregular

The nurse inspects the client's abdomen and observes a concave shape. The nurse should document this using which of the following descriptions?

Scaphoid

The nurse performing a physical assessment is unable to palpate a pulse. What is the best first action for the nurse to take?

The nurse should use a Doppler to listen for the pulse that is not palpable.

While palpating the client's abdomen the nurse notes the client wince in pain and assesses involuntary contraction of the abdominal muscles. The nurse would document which of these findings?

guarding

When assessing the abdomen, the nurse would expect to auscultate which sounds?

high-pitched gurgling

What approach would the nurse use to elicit the cooperation of a school-age child during a cardiovascular examination?

permit the child to listen to their parent's chest with the stethoscope

An elderly female client is admitted to the ED after falling on ice and sustaining a fractured hip. The client's daughter pulls the nurse aside and says, "Watch my mother carefully - she has an unbelievable tolerance for pain." If this information is accurate, the nurse will anticipate which client need? Select all that apply 1. The client will be able to endure a great deal of pain 2. The client will experience discomfort with the slightest movement 3. The client will probably not experience significant pain 4. The client will ask for pain medication more often than prescribed 5.The client will not ask for pain medication and may need to be assessed more frequently for comfort

1. The client will be able to endure a great deal of pain 5.The client will not ask for pain medication and may need to be assessed more frequently for comfort

The nurse is obtaining a 24 hour diet recall from a client who is losing approximately 1-1.5 pounds per week. What are the most appropriate questions for the nurse to ask this client about the diet consumed? Select all that apply. 1. When was the first time you ate yesterday? 2. How much water did you drink yesterday? 3. What nutritional supplements did you take yesterday? 4, What did you have for breakfast? 5. What was the first thing you ate yesterday?

1. When was the first time you ate yesterday? 3. What nutritional supplements did you take yesterday? 4. What did you have breakfast? 5. What was the first thing you ate yesterday?

The nurse is obtaining a health assessment on a client who reports leg pain and inability to perform ADLs. The nurse would ask which questions to obtain information about the client's ability to carry out ADL's? Select all that apply. Can you tell me how the pain is affecting your life? Do you know what is causing the problem? Does anyone in your family have any musculoskeletal problems? Can you describe how your activity level has changed? Can you tell me about your hobbies?

Can you tell me how the pain is affecting your life? Can you describe how your activity level has changed?

The client tells the nurse during the health history, "I feel jumpy all over since using my new respiratory inhaler." Which question would be most appropriate for the nurse to ask next?

Can you tell me what you mean by jumpy?

The nurse finds ascites during assessment of the abdomen. The nurse would conclude that this is most likely associated with which of the following health problems?

Cirrhosis

The nurse palpates and accumulation of fluid in the abdomen and documents this as ascites. THE nurse should assess the client for which health problems as possible etiological causes? Select all that apply. Chronic obstructive disease Cirrhosis Congestive heart failure Renal failure Appendicitis

Cirrhosis CHF Renal Failure

The nurse caring for a client experiencing chest discomfort should obtain which assessment data from the client? Presence of a fever Description of the pain and its location Recent weight gain Whether the client smokes

Description of the pain and its location

What question should the nurse include in the assessment of a 50-year-old postmenopausal woman's musculoskeletal system?

Do you take any calcium supplements?

To determine alleviating factors for symptoms of a musculoskeletal injury, it is essential that the nurse ask the client which question?

Have you used over the counter medications?

An adult client tells the nurse that she has had a sudden change in her vision. For which of the following should the nurse assess the patient? Diabetes Hypertension Head trauma The normal effect of the aging process

Head trauma

When assessing the abdomen, the nurse performs the following examination techniques. In which sequence should the nurse complete the assessment? Place the answers in the correct order. Auscultation Palpation Inspection Percussion

Inspection Auscultation Palpation Percussion

A 30 year-old client arrives at the clinic for a diagnostic workup related to chronic right hip pain. The nurse teaching the client about the chronic pain would include which of the following items? 1. It is an unusual occurrence in young adults 2. It lasts longer than 12 months duration 3. It can be difficult to treat effectively 4. It is often associated with nerve damage

It can be difficult to treat effectively

The adult client presents to the ambulatory care center with reports of not being able to chew and swallow easily. The nurse should evaluate the client for which possible contributing factor?

Missing teeth or ill-fitting dentures

To assess whether a client is having symptoms of abdominal problems, the nurse would ask him or her about which of the following? Select all that apply. Nausea Indigestion Vomiting Fever Dietary intake

Nausea Indigestion Vomiting

When evaluating a client's circulation, the nurse should apply which assessments? Select all that apply. Palpation of pulses Skin temperature of bilateral extremities Skin color Skin dryness Hair on the legs and feet

Palpation of pulses Skin temperatures of bilateral extremities Skin color Hair on the legs and feet

While the nurse is performing an admission assessment on a client, the client states "I am very unsteady on my feet." What assessment would the nurse perform to evaluate the client's statement?

Perform assessments to evaluate cerebellar function

The client has been slowly losing weight for the past several months. The client states, "I have always been of normal weight up til now." The nurse determines that it is essential to gather information about which of the following?

Poor dentition, swallowing and chewing difficulties, and functional and physical decline

When auscultating the apical pulse the nurse should assess for which characteristics? Select all that apply. Rate Intensity Temperature Regularity Rhythm

Rate Intensity Regularity Rhythm

After the nurse gathers health assessment data on a client admitted with pneumonia, the nurse would take which action?

Review the information gathered to analyze the data

The nurse is examining an elderly client who is unable to stand with his eyes closed, feet together, arms at his sides. The man leans from side to side during this part of the exam. The nurse would conclude that this is a positive finding for which assessment?

Romberg test

Which of the following is not used to assess extraoccular muscle strength? Cover test Corneal light reflex test Positions test Rosenbaum test

Rosenbaum test

Which of the following is not an area patient's commonly develop pressure ulcers Shin Coccyx Heels Hip

Shin

The nurse is performing a cardiovascular assessment. To evaluate the client for pulmonary edema the nurse would assess the client for which manifestation?

Shortness of breath

During inspection of the abdomen, the nurse notes silvery, shiny stretch marks. The nurse would document this finding as which of the following?

Striae

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to:

Strike a tuning fork and place it on the center of the client's head or forehead

When assessing the client's abdomen, the nurse should position the client in which of the following positions?

Supine with a pillow under knees and head

During physical assessment, the nurse would palpate the skin for which characteristics? Select all that apply. 1. Temperature 2. Texture 3. Pigmentation 4. Moisture 5. Elasticity

Temperature, texture, moisture, elasticity

Prior to beginning a physical examination of a client, the nurse would carry out which activities?

Wash hands, provide privacy for the client, explain the procedure to the client, and position the client comfortably.

The nurse palpates a round, fluid filled cyst on the dorsum of the wrist. The nurse interprets this finding as consistent with what?

a ganglion

The nurse is assessing a child and notes a protruding umbilicus. How would she document this finding?

a hernia

During a cardiovascular assessment the nurse finds a bluish tinge on the client's lips, fingers and toes. What is the appropriate documentation of this finding?

central and peripheral cyanosis

During inspection of the carotid arteries the nurse assesses a bounding pulse. The nurse should evaluate the client for which additional finding?

fever

Which of the following conditions could explain a finding of diaphoresis when assessing the skin:

hyperthyroidism

When assessing the ROM of a client's ankle, the nurse would place the client through which movements?

inversion, eversion, adduction, abduction, plantar flexion, dorsal flexion

Which of the following is true of cluster headaches? May be precipitated by alcohol Usual occurrence is two per month, each lasting 1-3 days Characterized as throbbing Tend to be supraorbital, retro-orbital or frontotemporal

may be precipitated by alcohol

In preparing to perform a cardiovascular assessment the nurse should initially place the client in which position?

sitting upright

When obtaining a dietary health history on a client with a cardiovascular history, the nurse should obtain information related to which item?

sodium intake

The client has a history of aortic stenosis and an S3murmur. What action would the nurse take to auscultate this murmur?

use the bell of the stethoscope