(PrepU) Chapter 26: Health Assessment
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." 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.
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?
"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." 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.
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?" Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?
"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.
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. An intact reddened area of the skin in an area that comes in contact with a wheelchair may be a stage I pressure injury. The shoulder blades would be another area of contact for the wheelchair, but a faded purple area indicates a resolving bruise. The neck and forearm are not pressure areas for a paraplegic. Pale red bumps indicate urticaria (hives), while circular red scaly area indicates ringworm.
A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next?
Ask the client if she has noted any blood in her stools lately. Any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool. Asking her if she's dizzy is a very broad, closed-ended question that would not elicit information specifically related to the rectal bleeding.
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. 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.
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. Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.
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 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 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. 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 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 Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated." Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.
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 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 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. 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 assessment, the nurse can also use the client's medical record and contact other health care providers.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?
Crepitus Problems with the temporomandibular joint include pain or a grating feeling called crepitus.
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 Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse (which may indicate a decreased cardiac output), a forceful or bounding pulse (seen in hypertension and circulatory fluid overload), and an asymmetric pulse (related to impaired circulation). Inflammation of a vein would not result in a weak or thready pulse. Impaired kidney function would not be related to the decrease in amplitude of peripheral pulses.
The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?
Each lub-dub is one beat. Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.
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 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?
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?
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 preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order.
Inspection Auscultation Percussion Palpation The order of the techniques for the abdominal assessment differs from that for the other systems. This is the preferred approach because performing palpation and percussion before auscultation may alter the sounds heard on auscultation.
A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.
Irregular edges Larger than 1/4 inch in diameter Change in the mole The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.
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 sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.
A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?
Penlight or flashlight A penlight or flashlight is necessary to gauge pupillary response and to visualize the client's mouth. Doppler ultrasound, a bladder scanner and a syringe are not necessary in order to perform a basic physical assessment.
A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?
Pink labia lesions Lesions on the labia may be the result of an infection such as herpes or syphilis, which is a concern. Coarse hair is to be expected, although the genitalia may be shaven. Clear or whitish vaginal discharge may be normal. Other signs would need to be present for this finding to be a concern. The vulva has more pigmentation than other skin areas and is often darker pink in color.
A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed. All options must be used.
Position the client supine and drape appropriately. Inspect the skin of thorax and abdomen. Palpate the thorax. Auscultate the thorax. Auscultate the abdomen. Palpate the abdomen. A head-to-toe approach means assessing the client from the top of the body to the feet, so the thorax before the abdomen. The nurse should wash the hands before and after every physical client encounter. This assessment is done while the client is supine. To provide modesty, the client should be covered with a drape. Inspection is completed first, followed by palpation and then auscultation, with the exception of the abdomen. 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.
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. 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 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. 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 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 Wheezing is an abnormal breath sound that is commonly seen with allergic reactions. Signs of allergic reaction (anaphylaxis) to bee stings are potentially life threatening and require immediate treatment. Erythema or redness of skin is expected at the sting site. Preschool children have a higher pulse rate (ranging from 80 to 120 beats/min) than do adults. Heart rate also increases when a child is crying. Burning pain would be expected after a bee sting.
The nurse should use the bell of the stethoscope during auscultation of:
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.
To assess subjective data related to a client's elimination pattern, the nurse:
asks the client about changes in elimination patterns. The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.
A nurse assesses a client for blood pressure. Which technique would be used for this assessment?
auscultation Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.
The nurse is assessing the bowel sounds of a client who has Crohn disease. What assessment technique does the nurse use?
auscultation Auscultation refers to the assessment technique of listening with a stethoscope to sounds produced in the body, such as bowel sounds. Palpation uses the sense of touch, such as pulse rate; percussion is the act of striking one object against another to produce sound, such as with the abdomen; and inspection refers to observing, such as appearance or behavior.
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 Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. The other findings are normal.
When a client enters the acute care facility, the nurse should perform a:
comprehensive health assessment. A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.
A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:
density and location of lungs. Percussion over the lung fields helps identify the density and location of the lungs. Palpation assesses for masses, crepitus, muscle development, and tenderness. Lung auscultation assesses for normal breath sounds and for abnormal (adventitious) breath sounds.
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 The FOUR coma scale combines the most important neurologic signs into an easy-to-use scale with four components. The maximum score in each of these components is 4. The components are not totaled or summed and can be used to detect decreasing consciousness, increasing intracranial pressure, and brain herniation, as well as predict client outcomes. The four components are eye response, brainstem reflexes, respirations, and motor responses.
The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:
fissure A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.
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.
inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results 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, or acts that involve collecting data, which include interviewing, observing, and examining the client. Inspecting the incision, taking blood pressure, and reviewing lab results are all examples of data collection. Assisting a client in a chair and performing ADLs are caring interventions.
To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:
mastoid process. Strike the tuning fork and place its stem firmly against the mastoid process.
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. Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description. Baseline data is obtained on first contact with the client.
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 Oriented ×3 indicates that the client is oriented to person (one's own name, the names of significant others, or knowing the nurse), place (location, city, or state), and time (time of day, day of week, or date).
Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:
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.
A nurse is using the assistance of an interpreter. When interviewing a client who does not speak English, the nurse should:
observe the client's body language. When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.
What percentage of weight change in 6 months is considered abnormal?
10% A 10% change in weight in 6 months is considered abnormal.
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. Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.
The nurse weighs the client using a portable bed scale. The obtained weight is 10 lb (4.5 kg) more than the nurse expected. What action does the nurse take next?
Ensure equipment is not hanging into the sling. Tubing from IVs, urinary catheters, and wound drains, in addition to other equipment or linens, can add significant weight to a bed scale. The nurse first ensures that the scale is free from items that add weight. The nurse will document after ensuring the weight is accurate. If accurate, the nurse may notify the health care provider. A second scale may not be warranted. Before taking this step, the nurse might lower and remove the client from the scale and zero out the machine again.
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. Tests for peripheral vision (or visual fields) are used to assess retinal function and optic nerve function. The client will stand or sit about 60 cm away, rather than 1 meter away. The client should cover one eye with a hand or an index card and be asked to look directly at the nurse's nose and fix the eyes on that spot. The nurse should cover her own eye opposite the client's closed eye. The nurse holds one arm outstretched to one side (right or left) equidistant from her and the client, and moves the fingers into the visual fields from various peripheral points. The client is asked to tell the nurse when the fingers are first seen. Both the nurse and the client should see the fingers at the same time.
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 Jaundice is a yellow color of the skin resulting from liver or gallbladder disease, some types of anemia, and hemolysis. Hepatitis, inflammation of the liver, is a potential cause of jaundice. Appendicitis and diverticulitis do not typically result in changes in skin color, but will manifest as severe abdominal pain. Cellulitis would not result in yellowing of the skin, but as red and swollen legs.
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?
The client is dehydrated. The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.
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. The pupils should be black, equal in size, and round and smooth. When an object moves towards the client's nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The client's pupils should constrict when looking at a near object and dilate when looking at a distant object.
A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?
The client's reaction time will likely be slower than that of a younger adult. Reaction time often decreases with age, even in the absence of pathologic conditions. Each of the other listed findings would be considered abnormal, even in an older adult.
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. 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.
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:
blurred Visual problems with close objects occur more frequently after the age of 40.
Which technique of assessment provides the greatest amount of information about the thyroid gland?
palpation The thyroid gland is assessed by palpation, although it is not normally palpable in some clients. Percussion is a method of tapping on a surface to determine the underlying structure and is used in clinical examinations to assess the condition of the thorax or abdomen. Auscultation of the chest and abdomen is performed for detection of altered respiratory and bowel sounds, rubs, or vascular bruits. Inspection refers to findings on the surface of the body.
A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?
tuning fork Rinne and Weber tests are performed in order to assess sound conduction; both require a tuning fork. A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. The nurse strikes a tuning fork and places it on the mastoid bone behind one ear. When the client can no longer hear the sound, they signal to the nurse. The nurse then moves the tuning fork to the ear canal. When the client can no longer hear that sound, they once again signal the nurse. The nurse records the length of time the client hears each sound. In the Weber test, the nurse strikes a tuning fork and places it on the middle of the client's head, and the client indicates where the sound is best heard: the left ear, the right ear, or both equally. A Snellen chart is an eye chart that can be used to measure visual acuity. An otoscope is an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses. An ophthalmoscope is an instrument for inspecting the retina and other parts of the eye.
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 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.
When percussing the liver, the sound should be:
dull The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.
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 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.
A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?
Ensure that the scale is correctly calibrated and repeat the assessment. If weight varies by more than 1 kg, the nurse should check the scale calibration and the accuracy of the assessment before taking further action, such as reporting to the health care provider or altering the client's diet.
A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?
Inspect and palpate the supraclavicular area. Inspection and palpation of the supraclavicular area can detect enlarged lymph nodes. Palpation of the thyroid gland can reveal thyroid enlargement, tenderness, or nodules. Inspection of the client's ability to move the neck assesses neck range of motion. Inspection and palpation of the left and right carotid arteries evaluates circulation through these arteries.
A 30-year-old janitor from Russia tells the nurse in the clinic that he drinks a fifth of vodka daily and that he's had a recent weight gain of 3 lb (1.35 kg) in 3 days. Further questioning by the nurse reveals that he was an intravenous drug user in the past but is now "clean." His sclerae and skin have a yellowish tinge, and he has a large abdominal girth. Which assessment finding supports the nurse's conclusion that the client has liver dysfunction?
Jaundice Jaundice is a yellow color of the skin resulting from elevated amounts of bilirubin in the blood. It is associated with liver and gallbladder disease, some types of anemia, and excessive hemolysis. Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Erythema (redness of the skin) is caused by dilation of superficial blood vessels. It is associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is caused by decreased hemoglobin in the circulating blood and causes inadequate oxygenation of the body tissues.
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. The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.
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 Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.
A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:
peripheral pulses. Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals.
