Physical Assessment: Assignment 2A

During auscultation of the heart, where would the RN expect the first heart sound (S1) to be the loudest? O Left lateral border. O Right lateral border. O Base of the heart. O Apex of the heart.

Apex of the heart. The apex -along the 5th intercostal space and the midclavicular line- of the heart (the bottom) is where S1 is the loudest.

Which physical assessment technique involves listening to the sounds of the body? O Percussion. O Palpation. O Auscultation. O Inspection.

Auscultation. Defined by the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis.

During an assessment, the RN shines a light into the client's eyes & observes that the pupil remains dilated. Which cranial nerve (CN) would the RN suspect to be affected? O CN VIII. O CN VII. O CN V. O CN III.

CN III CN I: Olfactory-Smell CN II: Optic-Vision CN III: Oculomotor-Eye movement, Pupil reflex. CN IV: Trochlear-Eye movement. CN V: Trigeminal-Face sensation & movement. CN VI: Abducens-Eye movement. CN VII: Facial-Face movement, Taste. CN VIII: Vestibulocochlear-Hearing, Balance. CN IX: Glossopharyngeal-Throat sensation, Taste, Swallowing. CN X: Vagus-Movement, Sensation, Abd organs. CN XI: Accessory-Neck movement. CN XII: Hypoglossal-Movement, Sensation, Abd organs.

The RN assess an older adult client with a diagnosis of dehydration. Which finding is an early sign of dehydration? O Dry, flaky skin. O Decreased bowel sounds (hypoactive). O Change in mental status. O Sunken eyes.

Change in mental status. In an older client diagnosed with dehydration, the most common early sign is confusion, altered LOC.

Which urine characteristic is consistent with a urinary tract infection? O Yellow-brown. O Cloudy. O Orange-amber. O Smoky.

Cloudy. Cellular debris, WBC, bacteria, & pus can cause the urine to look "cloudy". "Dark", "smoky" urine usually suggests hematuria. "Orange-amber" color may indicate concentrated urine; also, it can be caused by phenazopyridine or foods such as beets. "Yellow-brown" to "dark" color indicates increased bilirubin.

Which nursing intervention is correct for a client with venous insufficiency? O Elevate the client's legs above heart level. O Remove compression stockings for pt ambulation. O Keep the upper extremities elevated. O Apply abdominal girdle PRN.

Elevate the client's legs above heart level. Venous insufficiency: when vascular damage impedes the body's ability to move blood from legs toward heart. This causes blood to pool in the legs, causing swelling; pain; (sometimes >) leaking fluid in the skin or ulcers. Elevating the legs above heart level uses gravitational force to drain blood through the veins toward the heart. Pts shouldn't wear tight restrictive pants & avoid wearing a girdle/garter -> impede venous return. Compression stockings prevent blood pooling. Elevating upper extremities will not decrease edema in the lower extremities.

A client complains of difficulty breathing. The RN auscultates wheezing in the anterior bilateral upper lobes. Which could be the possible reason for this sound? O High velocity airflow through an obstructed airway. O Inflammation of the pleura. O Muscular spasms in the larger airways. O Sudden reinflation of groups of alveoli.

High velocity airflow through an obstructed airway. Inflammation of the pleura -> pleural friction rubs. Muscular spasms in larger airways/Any new growth causing turbulence: rhonchi -> loud & low-pitched sound. Sudden reinflation of groups of alveoli -> crackling sounds.

The RN is preparing to assess the abd quadrants of a client who c/o stomach pain. When would the RN assess the symptomatic quadrant? O Third. O First. O Second. O Last.

Last. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere c̅ the assessment.

Which action of the RN would be MOST important to convey interest in starting a conversation with a client who has hearing loss? O Smiling while seeing the client. O Making eye contact with the client. O Nodding head in front of the client. O Leaning forward towards the client.

Making eye contact with the client. Eye contact ensures the client that you are listening to them and that you are attentive in the conversation.

The RN's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the PRIORITY nursing intervention? O Assess the client's oxygen saturation level. O Obtain chest x-ray film immediately. O Notify the primary health provider. O Place client in a high-fowler position.

Place client in a high-fowler position. Placing pt in high-fowler position promotes lung expansion & GE; decreases venous return & cardiac workload. Notifying the PCP is necessary, but should be done second because position change will have an immediate effect. An chest x-ray can be ordered, but after breathing is supported. Assessing the pt's O2 Sat is important, but the priority is for the RN to improve the pt's respiratory status.

In which age group is scoliosis usually determined? O Adolescence. O Preadolescence. O Middle-school years. O Early-school years.

Preadolescence. Scoliosis may occur at any age, but idiopathic scoliosis, the most common type, tends to become evident during the preadolescent growth spurt.

A client is admitted to the emergency department with a stab wound of the chest. Which is a PRIORITY nursing assessment? O Amount of serosanguinous drainage. O Blood pressure and pupillary response. O Level of pain. O Quality and depth of respirations.

Quality and depth of respirations. In an emergency assessment the ABCs are to be followed. Airway, Breathing, Circulation. Based on the answer choices, establishing the respiratory effort takes care of the B in the ABCs of an emergency assessment.

A client is admitted with an acute onset of RLQ pain at McBurney's point. Appendicitis is suspected. For which clinical indicator would the RN assess the client to determine if the pain is secondary to appendicitis? O Gastric hyperacidity. O Increased lower bowel motility. O Urinary retention. O Rebound tenderness.

Rebound tenderness. Rebound/Referred tenderness is abd pain immediately after removal of RN's hand post-depression of abd area. It is a difficult skill for beginner RN to master. It's most common error is removal of hand too quickly, c̅ an exaggerated motion that surprises pt. Observe pt for pain: facial grimace, or abd wall spasm during palpation. Both tenderness & rebound tenderness can be elicited by palpation in opposite/different quadrant. Ex: palpation of LLQ may produce tenderness & rebound tenderness in the RLQ in appendicitis. Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute LRQ pain. There generally is decreased bowel motility distal to an inflamed appendix.

The nursing student under the supervision of the RN is performing a pulse assessment. While preparing to assess the client, the RN asks the student to check the apical pulse after assessing the radial pulse. Which would be the reason behind this change? O The client may have peripheral artery disease. O The client may have a dysrhythmia. O The client underwent surgery earlier in the day. O The client may have physiologic shock.

The client may have a dysrhythmia. A pt c̅ dysrhythmia may have an intermittent or abnormal radial pulse. For this, the RN would advise the student to assess the apical pulse because it is more accurate. If the pt is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is used to assess a pt c̅ peripheral artery disease.

When assessing a client for the dorsalis pedis pulse, the nurse documents the reading as +1. Which can be inferred from this finding? O The pulse strength is normal. O The pulse strength is bounding. O The pulse strength is barely palpable. O There is absence of a pulse.

The pulse strength is barely palpable. 0 = No pulse. +1 = Thready, weak. +2 = As expected. +3 = Bounding.

Which action would the RN take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? O Count the pulse at another site. O Lower the legs to increase blood flow. O Verify the pulse by using a doppler. O Notify the primary health care provider.

Verify the pulse by using a doppler. You still have to verify the extremity pulses. Lowering the legs will cause the condition to worsen. First you should verify the pulse via doppler, then you document how the pulse was assessed and why. It is likely the HCP knows the condition, but if not, notify.

While assessing a client's range of motion, the RN explains adduction to the nursing student. Which statement made by the student indicates effective learning? O "I will ask the client to move his or her arm toward the body." O "I will ask the client to bend his or her limb by decreasing the angle." O "I will ask the client to move his or her head beyond its normal resting extended position." O "I will ask the client to move his or her hand so that the ventral surfaces faces downward."

"I will ask the client to move his or her arm toward the body." This is the only answer choice that shows adduction. #2 demonstrates flexion. #3 demonstrates hyperextension. #4 demonstrates pronation.

Which statement made by the RN indicates the need for further teaching when assessing clients with darker skin? O "I will look for any changes in skin color darker than surrounding skin." O "I will touch the skin to feel its consistency." O "I will use a fluorescent light source to assess the skin color." O "I will place my hand on the skin to assess the temperature."

"I will use a fluorescent light source to assess the skin color." Use a natural or halogen light source, fluorescent light can cast a blue hue-making for a difficult assessment.

Which actions would the RN take to obtain subjective data about a client's respiratory status? Select all that apply. O Ask the client about color and quantity of sputum. O Palpate the chest and back for masses. O Check the hematocrit and hemoglobin values. O Question the client about shortness of breath. O Inspect the skin and nails for integrity and color.

- Ask the client about color and quantity of sputum. - Question the client about shortness of breath. The color and amount of sputum can say whether the pt has an infection or blood in the lungs. SOB is an indicator of a mass or possibly a viral infection that is occluding the lungs, like pneumonia.

Which assessment findings would help the RN support the diagnosis of the condition of orthostatic hypotension? Select all that apply. O Light headedness. O Weakness. O Headache. O Fainting. O Shortness of breath.

- Light headedness. - Weakness. - Fainting. These are sx of orthostatic HoTN. H/A and SOB are not typical sx of HoTN. They can be sx of HTN and MI/HF.