PrepU - #2 Health Assessment

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

Cranial nerve I

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus

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?

Evaluate the blood pressure and pulse

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

Objective data.

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

Ptosis.

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 diagnosis?

Risk for Falls

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

Stop lifting the client and reassure him.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

The client is dehydrated.

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.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

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

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 nurse is preparing to begin a health assessment with a new client. Which nursing consideration will help to establish a safe and appropriate environment for conducting the health assessment?

The room is private, quiet, warm, and has adequate light.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray.

The client has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator?

Translators may need additional explanations of medical terms.

A nurse is percussing a client's abdomen. Which finding would the nurse document as normal?

Tympany

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?

Verify that the procedural consent form is signed.

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 are the month, date, and the year of your birth?"

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 - Scant yellow discharge

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply.

- Client informs the nurse there is a floater in the left eye - The client states, "I feel nauseated." - Reports of abdominal pain of 4 on a 0 to 10 point scale

A client has sustained head trauma. The nurse uses the Full Outline of Un-responsiveness (FOUR) coma scale to determine the presence of increased intracranial pressure and client outcomes. What component(s) of the assessment will the nurse document? Select all that apply.

- Eye response - Motor response - Respiration - Brainstem reflexes

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope.

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

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client?

Whether they have a program of regular physical activity

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?

Ask the client to empty her bladder.

To assess subjective data related to a client's elimination pattern, the nurse:

Asks the client about changes in elimination patterns.

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

Assess the client for dehydration.

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation

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

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?"

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."

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?

"Take your blood pressure medications exactly as your doctor prescribed them."

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."

The nurse is testing the peripheral vision of a client. Which actions are recommended guidelines for this test? Select all that apply.

- Have the client cover one eye with a hand or index card. - The nurse should cover an eye opposite the client's closed eye. - Hold one arm outstretched to the side equidistant from the nurse and client, and move fingers into the visual fields from various peripheral points.

Which components are included in the integumentary system? Select all that apply.

- Skin - Hair - Nails - Sweat glands

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.

- Skin: warm and dry - Gastrointestinal: abdominal pain with rebound tenderness in RLQ - Cardiovascular: radial pulses 90, bounding, and equal

Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply.

- The client answers questions in a barely audible voice. - The client bites her fingernails. - The client eats 25% of her meals. - The client sleeps a lot.

What percentage of weight change in 6 months is considered abnormal?

10%

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."

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

The nurse should use the bell of the stethoscope during auscultation of:

A client's heart murmur.

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury?

An intact red area on the buttocks.

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Ask the client about any usual genital observations.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:

Blurred.

A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse?

Complete an assessment.

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.

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?

Crackles

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?

Check the client's ear canals for cerumen.

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

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Decreased cardiac output

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

Document normal breath sounds.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Hepatitis

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?

Inspect the area of itchy skin.

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

Inspection, auscultation, percussion, palpation

The nurse examines the skin of a 29-year-old woman with light-colored skin who is reporting swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations without blistering on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?

Maculopapular

A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention?

Measure the pulse oximetry.

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?

Oriented to person, place, and time

The nurse is palpating a client's precordium. Which result is an expected clinical finding?

Palpable pulsation over the mitral area

A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

Palpation

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

Palpation

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?

Palpation

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?

Pink labia lesions