Physical assessment final review PrepU

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones

A 30-year-old client arrives at the community healthcare center complaining of dizziness and a feeling of the room spinning. Based on the client's symptoms, which condition best describes what the client most likely experiencing?

Vertigo

The nurse takes a patient's family history to identify diseases for which she is at risk. A common tool used by nurses to understand family patterns is what?

genogram

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding?

"Right carotid bruit auscultated"

A nurse recognizes that which of these are possible health risks for a client who is obese? Select all that apply.

-Diabetes -Hypertension -Sleep apnea

The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following?

3+

A client presents to the health care clinic with reports of two-day history of sore throat pain, ear pressure, fever, and stiff neck. The client states they have taken Tylenol and lozenges without relief. Which nursing diagnosis can be confirmed by this data?

Acute Pain related to sore throat

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

Angina

An adult client has been diagnosed with carpal tunnel syndrome. What type of working conditions may have contributed to this diagnosis?

Frequent repetitive movements

A nurse is assessing the effect of a client's chronic back pain on his affective dimension. Which question should the nurse ask for this assessment?

How does the pain influence your overall mood?

A patient comes to the Emergency Department with bruises on her upper and lower body and appears to be withdrawn. The injuries do not appear consistent with the explanations for them. The patient's boyfriend refuses to leave the examination room and is overly protective of her. The nurse suspects:

Human violence

Mary started a job 2 weeks ago that requires carrying heavy buckets. She presents with elbow pain worse on the right. On examination, it hurts her elbows to dorsiflex her hands against resistance when her palms face the floor. What condition does she have?

Lateral epicondylitis (tennis elbow)

A nurse in the emergency department assesses a client's pupillary reaction and observes pinpoint pupils. The nurse interprets this finding as suggesting which of the following?

Narcotic use

The nurse is reviewing the following vital signs of a client who is lying in bed. Which of the following would the nurse identify as being abnormal?

Respirations 28 breaths/minute

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

Tenting indicates dehydration

After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect?

The head is midline and aligned with the spine

When percussing the anterior chest for tone, a nurse should anticipate what tone over the majority of the lung fields?

Resonance

A 38-year-old woman presents with multiple small joints that are symmetrically involved with pain, swelling, and stiffness. Which of the following is the most likely explanation?

Rheumatoid arthritis

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client?

Smoking increases the heart's workload and contributes to atherosclerosis.

A patient recovering from abdominal surgery is complaining of pain. The nurse realizes that the patient is most likely experiencing which type of pain?

Somatic

An elderly female client is accompanied by her daughter on a visit to the health care facility. The nurse observes that the client is doing quite well, except for the use of a hearing aid. How can the nurse best facilitate the interview process with this client?

Speak slowly and clearly, using straightforward language

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

Spleen

A 17-year-old high school senior presents to the clinic in acute respiratory distress. Between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke, but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honour student and on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. Examination shows a tall, thin young man in obvious distress. He is diaphoretic and breathing at a rate of 35 breaths per minute. Auscultation reveals no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms?

Spontaneous pneumothorax

A client reports severe pain in the left lower quadrant of three (3) days duration. How should the nurse conduct palpation of the abdomen due to this history?

The left lower quadrant is palpated last

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

asthma

The nurse is conducting a nutrition history with a young adult with signs and symptoms of an eating disorder. Which question exemplifies the most effective way for the nurse to ask about body image?

"What would you change about your body, if you could?"

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.)

-Asked the client to open and close the mouth -Asked the client to jut the jaw forward -Asked the client to rock the jaw laterally

The nurse explains to the client that smoking has what effect on the body? Select all that apply.

-Hypertension -Vasoconstriction -Peripheral vascular disease

A 26-year-old sports store manager comes to the clinic with severe right-sided abdominal pain for 12 hours. He began having a stomach ache yesterday with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 38.8° and his heart rate is 170. His bowel sounds are decreased, and he has rebound and involuntary guarding at one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain?

Acute appendicitis

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

Acute otitis media

The student nurse is studying therapeutic communication and realizes that it is an important aspect of collecting a health history. When gathering information about the patient's current illness, the student nurse understands that she should use which technique?

Asking open-ended questions

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Chronic obstructive pulmonary disease (COPD)

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

Heart attacks in his father and siblings

A nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmur

A patient presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition?

Herpes simplex

The nurse is assessing the seven attributes of a client's symptom using the mnemonic OLD CART. In which section of the comprehensive health history will the nurse document this information?

History of present illness

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?

Impaired Physical Mobility

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

Impaired swallowing

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage

A patient recovering from a stroke complains of pain. The nurse suspects this patient is most likely experiencing which type of pain?

Neuropathic

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?

Red, swollen, with purulent discharge

When crackles, wheezes, or rhonchi clear with a cough, which of the following is a likely etiology?

Bronchitis

A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?

Consensual reaction

A 50-year-old realtor comes to the office for evaluation of neck pain. She was in a motor vehicle collision 2 days ago and was assessed by the emergency medical technicians on site, but she didn't think that she needed to go to the emergency room at that time. Now, she has severe pain and stiffness in her neck. On physical examination, the nurse notes pain and spasm over the paraspinous muscles on the left side of the neck, and pain when the client does active range of motion of the cervical spine. What is the most likely cause of this neck pain?

Cervical sprain

What is the rationale for asking the client whether he or she has noticed any new or changed moles?

Changes in existing moles or the appearance of new moles can indicate melanoma.

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?

Check the insertion site for redness.

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

A patient has been taught relaxation exercises before beginning a painful procedure. What chemicals are believed to be released in the body during relaxation to relieve pain?

Endorphins

Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45. This finding indicates the patient is which of the following?

Extremely obese

The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?

Fifth intercostal space, left midclavicular line

The nurse asks the client to perform the action shown. What is the nurse assessing?

Flexion

Which movement should the nurse instruct the client to perform to assess range of motion for the knee?

Flexion

A nurse at a long-term care facility is completing the nutrition assessment of a man who has just moved to the facility. After determining the client's venous filling and emptying each take approximately 10 seconds, the nurse would perform further assessments related to what health problem?

Fluid volume deficit

What would the nurse expect to hear when auscultating the lungs of a client diagnosed with pleuritis?

Friction rub

A nurse is admitting a client, having completed the health history, and is now doing a physical assessment. The physical assessment will provide what type of data?

Objective

How can a nurse best assess a client's dietary habits?

Obtain a 24 hour dietary recall of all foods and fluids consumed

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation

On a health history, a client reports no visual disturbances, last eye exam two years ago, and does not wear glasses. The nurse notices that the client squints when signing the consent for treatment form and holds the paper close to the face. What should the nurse do next?

Perform both the distant and near visual acuity tests

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath

In partnership with the client, the nurse identifies a priority health goal for this client is smoking cessation. The nurse and client discuss possible interventions to assist the client in achieving this goal. In which phase of the nursing process are the nurse and patient participating?

Planning

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Pneumonia

A nurse educator is leading a group of nurses in exercises aimed at improving cultural competence. Which of the following would the educator use to best describe an aspect of the term "culture"?

It is shared through norms for behaviors, values, and beliefs.

The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?

Kyphosis

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

The nurse recognizes that a barrier to successful pain management for the patient with opioid tolerance is:

The patient does not experience pain relief with usual doses of opioids.

The nurse is admitting a 79-year-old man for outpatient surgery. The patient has bruises in various stages of healing all over his body. Why is it important for the nurse to promptly document and report these findings?

The patient may have been abused.

Which is an example of subjective data from a primary source?

The patient states, "My chest hurts and my left arm feels numb."

The nurse is asking the patient about the health of her parents, siblings, and grandparents. This is part of the health history and is done for what reason?

To identify diseases for which the patient may be at risk

A nurse is providing care for a patient who has a history of alcoholism. What would be appropriate to include in this patient's discharge teaching?

To increase fruit and vegetable intake

A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding?

Toes point out

Mrs. Anderson presents with an itchy raised rash that appears and disappears in various locations. Each lesion lasts for many minutes. Which most likely accounts for this rash?

Urticaria or hives

What is the most common measurement used to determine abdominal visceral fat?

Waist circumference.

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

a foreign body obstruction

When answering questions about health during a presentation at a women's club luncheon, the nurse emphasizes that prevention of disease is multifaceted but is connected directly to

a healthy lifestyle

A new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad that an easy way is to think about the anagram

ADPIE

The nurse suspects an abdominal aortic aneurysm when what is assessed?

Abdominal bruit

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?

Acromegaly

The patient arrives to the emergency room reporting severe abdominal pain that started 3 hours ago. He rates the pain as an 8 on a scale of 1 to 10. After tests are performed, the patient is diagnosed with appendicitis. This is an example of which of the following types of pain?

Acute

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

Before completing the physical examination, the nurse determines that the patient is awake, alert, and oriented. This information would be important for which part of the general survey?

Level of consciousness

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible

The nurse is caring for a client who has an elevated cholesterol level. To reduce the mean total blood cholesterol and low-density lipoprotein (LDL) cholesterol levels, what diet should the nurse discuss with the client?

Low-fat, low-cholesterol meals

The nurse has completed the physical examination of a hospitalized client who is lying in a supine position in the bed. The nurse puts the bed rails in the upright position. In order to ensure client safety, what is the most important thing the nurse should do prior to leaving the room?

Lower the bed height.

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding

What would the nurse interpret as a positive response to the Phalen test for a client suspected of having carpal tunnel syndrome?

Numbness

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following?

Otitis externa

To promote relaxation of the abdominal muscles, which of the following would be most appropriate for the nurse to do?

Place a pillow under both of the client's knees.

During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect?

Presbyopia

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea

A young Hispanic woman brings her baby into the clinic for immunizations. What type of disease-prevention strategy is this?

Primary prevention

When testing the near reaction, an expected finding includes which of the following?

Pupillary constriction on near gaze; dilation on distant gaze

Joints may be classified as cartilaginous, synovial, or

fibrous.

A client has uneven height of the shoulders and hips. What should the nurse suspect this client is demonstrating?

scoliosis

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing

venous insufficiency

A nurse is preparing to conduct an initial interview on a patient from a different culture. Which of the following is important for the nurse to consider before beginning the interview?

verbal and nonverbal communication

When assessing muscle tone and strength, the nurse would document expected findings as

"upper and lower extremity muscle strength is 5/5 bilaterally"

The nurse is reviewing a client's health history and physical examination. Which of the following would the nurse identify as subjective data? Select all that apply.

-"I feel so tired sometimes" -Client complains of a headache -"My father died of a heart attack"

The nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. Which members would benefit from receiving this vaccination? (Select all that apply.)

-Adult patient with chronic obstructive pulmonary disease -Adult patient caring for children under age 5 -Older adult attending adult day care

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? Select all that apply.

-Assess the client's apical pulse for a full minute. -Assess the client's S1 and S2 sounds for regularity.

When considering eye safety, what instructions should the nurse provide to a patient newly prescribed contact lenses? (Select all that apply.)

-Do not share lenses. -Keep the lenses clean. -Wash hands before inserting or removing the lenses. -Discard unused portions of contact solutions at the expiration date.

A nurse is preparing a class for a local community group on coronary heart disease. Which of the following recommendations would the nurse include as appropriate for reducing a person's risk? Select all that apply.

-Eat foods low in sodium. -Walk for at least 30 minutes/day. -Use relaxation techniques to manage stress.

Which of the following techniques are used in a physical assessment? Select all that apply.

-Inspection -Palpation -Auscultation

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

-Smoking -Overweight -Lack of exercise

When recording the client's chief concerns during the health history, it is recommended that the interviewer do which of the following?

Quote the client's words.

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole?

S1

When inspecting a client's abdominal contour, the nurse observes the abdomen to be sunken with the lower edges of the ribs visible. The nurse documents this as which of the following?

Scaphoid

Which of the following is a symptom of the eye?

Scotomas

The experienced nurse understands that active listening is the key element when interviewing a patient.

True

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve?

Turning the palm of the hand upward

What should a nurse do if a posterior tibial pulse cannot be obtained on a client with edema of the feet?

Use a Doppler to assess for the presence of the pulse.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

The nurse is performing a health history on a patient with mild chest pain who came to the Emergency Department. When asked about his allergies, the patient states that he is allergic to codeine for pain. The nurse asks if that is the only allergy and then proceeds with the rest of the assessment. What other information should the nurse obtain when a patient states an allergy?

What type of reaction did the patient experience?

Although the assessment phase of the nursing process precedes the other phases, the assessment phase is

continuous.

During palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. The nurse is performing

deep palpation.

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of

fissures.

An older adult client visits the clinic and tells the nurse that she has had shooting pain in both of her legs. The nurse should assess the client for signs and symptoms of

herniated intervertebral disc.

Articulation between the head of the femur and the acetabulum is in the

hip joint.

Care that considers the patient's body, mind, and spirit is which type of nursing care?

holistic care

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is enlarged and everted. The nurse should refer the client to a physician for possible

umbilical hernia.

Which joint movement is a nurse testing when asking a client to move an extremity towards the body?

Adduction

What pulse is located in the groove between the medial malleolus and the Achilles tendon?

Posterior tibial

A nursing assistant working in a small rural hospital, states to the charge nurse, "The Jewish patient in room 124 says that they are not able to eat the food because it is not kosher. That is ridiculous. There is nothing wrong with this food, I eat it!" What is the best response by the nurse?

"It is important that we are culturally sensitive to other beliefs. Let's see how we can accommodate the patient's food preferences."

A nurse assesses the radial pulse of a client. Which pulse rate would the nurse document as bradycardia?

56 beats/minute

Which of the following client situations would the nurse interpret as requiring an emergency assessment?

A client who took a drug overdose

A student states that a client has palpable rushing vibration in the area of the pulmonic valve. What should the instructor explain that the student is feeling?

A thrill

A male client comes to the clinic complaining of a persistent cough. Further questioning reveals that he was just recently diagnosed with hypertension. Which of the following would the nurse do next?

Ask about any medications being used for hypertension.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions.

A new nurse on the long-term care unit is learning how to assess a patient's risk for skin breakdown. What would be the most likely instrument this nurse would use?

Braden scale

To assess abduction of the shoulders and arms, a nurse should ask a client to do which of the following?

Bring both hands together overhead starting with the arms at the sides

A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?

Chronic obstructive pulmonary disease

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder?

Chronic obstructive pulmonary disease

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe

A client comes to the clinic and reports a sore knee. The nurse notes popping and cracking noises when the client attempts to bend the knee. The client exhibits signs of pain by facial expression. The nurse knows that the popping and cracking noises should be charted as what?

Crepitus

The nurse is using a goniometer while conducting the physical examination of a client's musculoskeletal status. What will the nurse use this device to measure?

Degree of joint motion

While performing the physical examination of a client, the nurse lightly taps certain parts of the body to produce sound waves. What is the purpose of this method of assessment?

Determine if a structure is filled with air or fluid or is a solid structure

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

Gallbladder

A client presents to the health care clinic with reports of a swollen, tender, reddened joint in the left big toe. The nurse recognizes this finding as an indication of what inflammatory process?

Gouty arthritis

During the physical exam, the nurse notes a very tender and painful, reddened, hot, and swollen metatarsophalangeal joint of the client's great toe. What would the nurse suspect?

Gouty arthritis

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first?

Have the client cough, then listen again

When assessing a client for possible varicose veins, which of the following would the nurse do?

Have the client stand for the exam

The nurse is assessing a client's gait. Which finding would alert the nurse to the need for a referral for further evaluation.

Shuffling of feet

A 33-year-old mother of three has visited the clinic seeking a solution to the fact that when she laughs hard or coughs she experiences an involuntary and embarrassing discharge of urine. Which of the following health problems most likely underlies her complaint?

Stress incontinence

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor

Which of the following is an important function of the skin?

Synthesis of vitamin D

The functional reflex that allows the eyes to focus on near objects is termed

accommodation

While conducting a physical examination, the nurse notices the client's mucous membranes are pale in color. Which nutritional deficiency is most likely for this client?

anemia

The nurse is assessing an older adult client who has lost 2.27 kg (5 lb) since her last visit 1 year ago. The client tells the nurse that her husband died 2 months ago. The nurse should further assess the client for

appetite changes.

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing

arterial insufficiency.

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for

lymphedema.

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

migraine

The nurse is completing a physical examination of a client who reports ear pain. In order to determine if the tympanic membrane is still intact, which instrument is required?

otoscope

The nurse is taking a health history on a newly admitted patient. When the nurse asks, "How would you describe yourself?" the nurse is assessing which of the following?

self-perception/self-concept

A patient has had consecutive blood pressure readings in the 140s/90s for the last week of evaluation. This would be classified as

stage 1 hypertension