N2 ch.27 Health Assessment

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? 4 8 12 15

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.

The nurse is performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment? Select all that apply "Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "Do you smoke, drink alcohol, or use street drugs?" "How do you cope with stressors in your life?" "How do you meet your transportation needs?"

"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?" Performing a functional assessment includes asking about the physical limitations or abilities that a client may experience such as how the client is able to manage transportation, bathing, medication administration, and dressing. Coping with stressors would be included in the psychosocial/lifestyle assessment as well as the use of alcohol, tobacco, and illicit drugs.

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." "I am going to examine your abdomen." "I need to report what is going on to your health care provider. Can I look at your abdomen?" "Open your shirt, I need to look at your abdomen."

"Let me explain what I am going to do and how you can help." The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation. Requesting to examine the client's abdomen without any explanation may cause anxiety and increase the client's pain and decrease the chance of cooperation. The results of the assessment should be reported to the health care provider. The nurse does not need to avoid conversation during the assessment.

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? "You need to sign up for the clinic's stop smoking program." "You should decrease your intake of fried foods." "It is important for you to do 30 minutes of exercise three times a week." "Take your blood pressure medications exactly as your doctor prescribed them."

"Take your blood pressure medications exactly as your doctor prescribed them." Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.

The nurse is performing an assessment for a 12-months-old child and observes pronation of the child's feet. The parent asks the nurse what is wrong with the child's feet. What is the best response by the nurse? "This is an age-related variation for the child and should go away after about 30 months." "We will make a referral to the pediatric orthopedic clinic to determine what is wrong with the feet." "Your child may likely have to have serial casting done to correct the deformity of the feet." "It is uncommon for a child to have a deformity of the feet like this. I will call the health care provider."

"This is an age-related variation for the child and should go away after about 30 months." Pronation of the feet in children between 12 and 30 months of age is a common age-related variation. This usually disappears after the 30th month. A referral to the pediatric orthopedic clinic or health care provider is not a necessary intervention at this time. Serial casting is used for children born with clubfoot, which is not the case with this child.

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 did you eat for dinner last night?" "What are the three objects I told you earlier?" "What is meant by 'an ounce of prevention is worth a pound of cure'?" "What are the month, date, and the year of your birth?"

"What are the month, date, and the year of your birth?" Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's abstract reasoning. The nurse needs to ask a question that may be corroborated to confirm a past or remote memory, so asking what the newly admitted client ate at dinner would not be able to be corroborated. The client's birthdate is available in the medical record and can be corroborated. Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses recent memory.

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? "What brings you here today?" "Are you having any pain?" "What medications do you normally use?" "Do you have any allergies?"

"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.

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply. "What seems to make the pain worse?" "Why do you have the pain?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" "Have you taken acetaminophen for the pain?" Intensity

"What seems to make the pain worse?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" Intensity Understanding the location, duration, and aggravating factors may help determine the causative factors. Taking acetaminophen and asking the client why they have the pain are not relevant indicators in the health assessment interview process.

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? "Your health care provider will decide when it is best for you to begin having mammograms based on your family history." "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

"Your health care provider will decide when it is best for you to begin having mammograms based on your family history." Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

What percentage of weight change in 6 months is considered abnormal? 1% 2% 5% 10%

10% A 10% change in weight in 6 months is considered abnormal.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply. 1. Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration 2. Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration 3. Soft, low-pitched, whispering sounds heard over most of the lung fields 4. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly 5.Blowing, hollow sounds auscultated over the larynx/ trachea 6. Bubbling, crackling, or popping sounds auscultated during inspiration and expiration

3.Soft, low-pitched, whispering sounds heard over most of the lung fields 4. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly 5. Blowing, hollow sounds auscultated over the larynx/ trachea Vesicular breath sounds are soft, low-pitched, whispering sounds heard over most of the lung fields, with sound on inspiration being longer than expiration. Bronchovesicular sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Bronchial sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Musical or squeaking sounds describe a sibilant wheeze. Sonorous or coarse sounds with a snoring quality describe a sonorous wheeze. Bubbling, crackling, or popping sounds describe crackles.

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 Auscultation of bowel sounds every 30 seconds Auscultation of gurgles and clicks Umbilicus centrally located

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 will be caring for a client entering the acute care facility for the first time. Which of the following actions is most appropriate? Do a focused health assessment. Prioritize subjective data over objective data Avoiding reading the client's history until the nurse has completed their own assessment Conduct a comprehensive health assessment.

A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living and should be completed with new clients. A focused assessment hones in on particular findings from the comprehensive assessment. Subjective and objective data are both valid and important. The nurse should learn as much as possible about the client before assessing.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first? Assess the client's ability to stand or sit. Evaluate the client's level of pain. Monitor for the presence of tubes or lines. Place a cover over the sling of the bed scale.

Assess the client's ability to stand or sit. The nurse must first assess the client's ability to sit, stand, or lie still to identify the appropriate type of scale to use. Evaluating pain or presence of lines would be done after identifying the type of scale to use. If a portable bed scale is indicated, the nurse would place a cover over the sling of the bed scale.

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? Inspection Palpation Percussion Auscultation

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.

The nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data should the nurse prioritize during the objective assessment? Bowel sounds Fatigue level Pain quality Symptoms of nausea

Bowel sounds An abdominal assessment includes inspection, auscultation, palpation and percussion. Auscultating for bowel sounds is an objective assessment would be necessary for a physical assessment of the abdomen. Fatigue, pain, and nausea are subjective symptoms.

Which technique should the nurse use to assess the pupillary light reflex on a client? Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply. Neurologic: awake and alert Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Respirations: 24 and regular Gastrointestinal: abdominal pain with rebound tenderness in RLQ Musculoskeletal: sitting up in bed with knees bent

Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Respirations: 24 and regular Gastrointestinal: abdominal pain with rebound tenderness in RLQ Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body. Neurologic assessment findings of awake and alert, respirations of 24 and regular, and musculoskeletal assessment of the client observed sitting up in bed with knees bent are examples of inspection.

The Romberg test assesses balance; an unsuccessful test constitutes a likely falls risk. This test does not relate to the client's cognition. Ask the client if he left his earplugs in his ears. Check the client's ear canals for cerumen. Use facial expressions and sign language to communicate. Speak to the older adult client in a high-frequency tone of voice.

Check the client's ear canals for cerumen. Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Client describes shortness of breath and increased sputum production. Client reports breathlessness and productive cough. Client reports respiratory distress and frequent spitting.

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." The client's reason for seeking care should always be stated in the client's own words which should be document in quotations. This subjective data is important for all health care providers to review.

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply. Collection of subjective data Complete set of vital signs Goals with outcome criteria Functional ability evaluation Description of client education

Collection of subjective data Complete set of vital signs Functional ability evaluation Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client. The development of the care plan, which includes goals with outcome criteria and client education, are done after the admission assessment.

The nurse is admitting a new client to the hospital and needs to determine the client's needs and current problems. Which action will the nurse take first? Complete a comprehensive assessment. Contact the health care provider. Review the client's past medical records. Perform a physical assessment.

Complete a comprehensive assessment. Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client and, in some cases, the client's family. Following the comprehensive assessment, the nurse can also access the client's medical record for further data, contact other health care providers, and perform the physical assessment.

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? Ongoing assessment Comprehensive assessment Emergency assessment Focused 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 is assessing a newly admitted client. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. How does the nurse document this finding? crackles friction rub sonorous wheeze sibilant wheeze

Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. Sibilant wheezes are high-pitched and shrill-sounding breath sounds that occur when the airway becomes narrowed. They often have a musical quality to them. These are the typical wheezes heard when listening to an asthmatic client. A sonorous wheeze is an added sound with a musical pitch occurring during inspiration or expiration, heard on auscultation of the chest and caused by air passing through bronchi that are narrowed by inflammation, spasm of smooth muscle, or presence of mucus in the lumen. A friction rub is a continuous, grating-type sound.

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? Hypertension and circulatory overload Decreased cardiac output Impaired kidney function Inflammation of a vein

Decreased cardiac output

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply. Decreased near vision Decreased facial hair Increased gag reflex Increased systolic and diastolic blood pressure Decreased tissue elasticity Increased mental confusion

Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging. Decreased facial hair, increased gag reflex, and increased mental confusion are not normal signs of aging.

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first? Provide a warm, quiet, dimly lit room Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history

Evaluate the blood pressure and pulse In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.

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? Rhinorrhea Dry cough Expiratory wheezes Fever

Expiratory wheezes Normal inspiration and prolonged expiration are heard to overcome the increased airway resistance of COPD. Wheezes are musical or squeaking, high-pitched, continuous sounds heard as air passes through narrowed airways. Fever may indicate a respiratory infection but is not a symptom of COPD. The cough of a client with COPD is productive and not dry. Rhinorrhea is not a symptom of COPD.

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first? Check her chart for allergy information. Inspect the area of itchy skin. Review her medical history. Review her medication record.

Inspect the area of itchy skin. Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? Inspect the left lower leg for areas of redness. Lightly palpate the left leg, assessing for edema. Assess for pain by deeply palpating the left leg. Palpate the popliteal and posterior tibial pulses of both legs.

Inspect the left lower leg for areas of redness. Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.

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? Warm the equipment. Ask the client to empty her bladder. Place the client in a semi-Fowler's position. Measure height and weight.

Place the client in a semi-Fowler's position. Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint? Dorsal recumbent Sims Supine Prone

Prone In the prone position, the client lies flat on the abdomen with the head turned to one side, which enables the nurse to assess the hip joint and posterior thorax. The Sims position is used to assess the vagina or rectum. The dorsal recumbent position and the supine position are used to assess the head, neck, anterior thorax and lungs, heart, breasts, extremities, and peripheral pulses.

A nurse is testing the function of the spinal cord of a client who presents in the emergency department following a motorcycle accident. What would be the focus of this assessment? Motor ability Balance and gait Reflexes Sensory abilities

Reflexes This is the initial assessment after a spinal cord injury; therefore, it would be the top priority to help determine the degree of injury by assessing for reflexes. Motor ability and gait cannot be assessed this soon after a spinal cord injury because further injury could result. Sensory abilities are assessed through the sense of smell, taste, hearing, and vision.

A gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply. Bulge to the left inguinal area Decreased penis size Less firmness of the testes Scant amount of pubic hair Scant yellow discharge

Scant yellow discharge Bulge to the left inguinal area

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? supine prone Sims' Fowler's

Sims'Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

Which respiratory sound indicates an upper airway obstruction? Dyspnea Fremitus Stridor Wheeze

Stridor is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction. Dyspnea is difficult or labored breathing and a term to describe difficulty breathing. Fremitus is a vibration felt on the client's chest during low frequency vocalization. A wheeze is a whistling or rattling sound in the chest as a result of obstruction in the air passages. Wheezing most often is caused by an obstruction (blockage) or narrowing of the small bronchial tubes in the chest.

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. The client reports thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia.

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 client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving? The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. The palate and pharynx move as the client says "ah." The client's tongue remains midline when it protrudes from the mouth. The client is able to turn the head to the side and shrug the shoulders against resistance.

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? Palpation Inspection Percussion Auscultation

The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action? Ensure that the preoperative check list is completed. Document that the preoperative medication was administered. Verify that the procedural consent form is signed. Locate the laboratory test results in the chart.

Verify that the procedural consent form is signed. Although the health care provider is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

A nurse performs a general survey on a client who is being admitted to the hospital for Chronic Obstructive Pulmonary Disease (COPD). Which components of this type of assessment will be a focus for the nurse? Select all that apply. Vital signs Gait Lab tests Behavior Body mass index (BMI) Breathing pattern

Vital signs Gait Behavior Body mass index (BMI) Breathing pattern The general survey is the first component of the health assessment, beginning at the moment contact is made with the client. Information from the general survey provides clues to the overall health of the client. It includes observing the client's overall physical appearance, body structure, mobility, and behavior; and measuring vital signs, height, weight, and waist circumference; and calculating the client's body mass index (BMI). Laboratory assessments are included in the extended survey of the client.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse? Assist the client to a sitting position. Uncover the client to expose the chest and abdomen. Palpate the abdomen before auscultating. Warm the diaphragm of the stethoscope.

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.

The nurse cares for a client with heart failure (HF). How does daily monitoring the client's weight most contribute to the provision of effective nursing care? Fluctuations in weight affect a client's body image and identity Obesity puts the client at increased risk for mortality from heart disease. Weight gain is an indication of nutritional status. Weight gain or loss can indicate responses to medical treatment.

Weight gain or loss can indicate responses to medical treatment. Weight measurement can be done to evaluate fluid status or the response to medical treatment. A client with CHF is often fluid overloaded, as the damaged heart is unable to efficiently pump blood through the kidneys for fluid removal. Diuretics are prescribed to remove fluid and client weight is monitored to evaluate their effectiveness. Increased body weight affects self-concept, puts the client at risk for higher mortality from heart disease, and provides an indication of the nutritional status, but for clients with CHF, this assessment is done to monitor the effectiveness of treatment. Obesity is not normally assessed through frequent (daily) measurements.

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 a client in the Intensive Care Unit after having a stroke yesterday a client recovering from brain surgery for repair of an aneurysm a client with a brain tumor who is in the hospital because of respiratory depression

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time

a client sitting in a chair who slides down

The nurse should use the bell of the stethoscope during auscultation of: a client's heart murmur. a client's apical heart rate. a client's breath sounds. a client's bowel sounds.

a client's heart murmur. The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

A client states during the interview that they have pain in their lower back. The client rates the pain as 10/10 when asked to turn. What is the nurse's most appropriate action? avoid a position change that requires turning. have the client turn from side to side and assess pain. have the client lay on his right side, then palpate the area. elevate the legs, bending at the knee while the client is supine.

avoid a position change that requires turning.

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: symptoms. review of systems. chief concern. objective assessment.

chief concern. The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern. This is subjective, not objective, data. It does not address or review a number of body systems.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? circumoral cyanosis when the client is at rest a blue-black macular area over the sacral area the anterior fontanel bulging when the client cries the abdomen appearing large in relation to the pelvis

circumoral cyanosis when the client is at rest Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. A slate grey nevus is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

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 concern for care planning? altered thought processes chronic confusion acute confusion falls risk

falls risk The Romberg test assesses balance; an unsuccessful test constitutes a likely falls risk. This test does not relate to the client's cognition.

A nurse is caring for a postoperative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? Select all that apply. assisting the client to sit up in a chair inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results helping the client to bathe and brush their teeth

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? contacting the primary health care provider placing a small towel under the neck administering a muscle relaxer positioning the client on the stomach

placing a small towel under the neck Kyphotic changes can cause pressure on cervical vertebrae when someone is in a supine position. Effects of this can be minimized by placing a small towel or cervical pillow under the neck. Placing the client on the stomach is incorrect, and a muscle relaxer will not help reduce the pressure caused by the kyphosis. Contacting the health care provider is unnecessary.

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

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.

The client, after undergoing an appendectomy for a ruptured appendix, has an open drain left in the wound. The health care provider prescribes removal of 2 in (5 cm) of drain every day. Which action will the nurse take? reposition the safety pin or clip on the drain apply extra dressing to absorb continued drainage weigh the soiled dressing to determine approximate drainage document only this action and client response

reposition the safety pin or clip on the drain A drain is left in the wound to assist with capillary drainage of fluids, especially after a ruptured appendix. A safety pin or clip is placed on the drain to prevent it from slipping into the wound. As the nurse withdraws the drain, the safety pin or clip must be relocated to keep the drain at the correct location. There should be no need to apply extra dressing as the drainage is usually decreased by this time, which is part of the rationale to slowly remove it. There is no need to weigh the soiled dressing. The nurse should document and record the response of the client after all interactions, not just this technique.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation secondary intention tertiary intention

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

Which component(s) is included in the integumentary system? Select all that apply. skin hair nails scalp arteries muscles

skin hair nails scalp

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 the palm the fingertips the knuckles

the dorsum The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

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 fine crackles pleural friction rub stertorous breathing

wheezes Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; 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.