Quiz 2 Chapter 13 Physical Assessment

The nurse is examining a patient with cirrhosis of the liver for edema of the lower extremities. The nurse notes that the indentation remains for several seconds, deep pitting (6mm), swelling is obvious on general inspection. How should the nurse quantify the severity of this finding? a) 2+ pitting edema of the lower extremities noted from the knees to the feet b) 5+ pitting edema of the lower extremities from the knees to the feet c) 3+ pitting edema of the lower extremities from the knees to the feet d) 1+ pitting edema of the lower extremities noted from the knees to the feet

3+ pitting edema of the lower extremities from the knees to the feet

During the assessment, the nurse observes that the client has yellow discoloration of the skin. What is the next step in the assessment for the nurse? a) Assess oxygen levels b) Auscultate the lungs c) Inspect the sclera and mucous membranes (hard palate) d) Observe for cyanosis or eccychomosis

Inspect the sclera and mucous membranes (hard palate)

When inspecting the neck it is important to assess the following: (Select all that apply.) *Lymph Notes *Thyroid *Range of Motion of the head and neck *Tracheal Position *Carotid Arteries *Breath sounds

Lymph nodes Thyroid Range of motion of the head and neck Tracheal position Carotid arteries

During assessment of a child who has sustained injuries in a bicycle accident, the nurse notes an area on his left knee that has been rubbed away by friction resulting in erythema, against the pavement. How should the nurse document this finding? a) Abrasion b) Laceration c) Scar d) Wound

abrasion

Rubbing of the skin due to friction against another surface

abrasion

When assessing the right lower quadrant of the abdomen, the nurse knows that the following structure is located in the RLQ. a) Liver b) Appendix c) Spleen d) Sigmoid Colon

appendix

A nurse greets a new client and asks the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's: a) Judgement and insight b) Abdominal girth c) Balance and gait d) Coping skills

balance and gait

Which technique should the nurse use to assess pupillary light reflex (pupils dilating and constricting)? a) Bring a narrow beam of light from the temple toward the eye, observing for pupillary constriction. b) Ask the client to follow the penlight in 6 different positions c) Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye d) Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose for pupil constriction

bring a narrow beam of light from the temple toward the eye, observing for pupillary constriction.

Abnormal sound heard as blood flows through the carotid artery

bruit

During the assessment of the auditory canal, the nurses notes that she cannot examine the tympanic membrane. The nurse knows that this might be due to excess: a) Sebum b) Cerumen c) Cilia (Fine Hairs) d) Keratin

cerumen

The nurse is performing assessment of extraocular eye movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe? a) Nystagmus in all positions b) Convergence of the eyes c) Constriction of the pupils d) Coordinated movement of both eyes in 6 different positions

coordinated movement of both eyes in 6 different positions

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes intermittent, high pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings? a) Gurgling is occurring in the posterior lower lobes. b) Bronchovesicular breath sounds are audible in the posterior lobes c) Pleural friction rub is heard in the posterior middle lobes d) Crackles are audible in the posterior lower lobes bilaterally

crackles are audible in the posterior lower lobes bilaterally

A client has been admitted to your unit. The nurse notes that the client's oral mucous membranes are dry and that skin on the chest just below the clavicle remains "tented" when gently pinched. What is the assessment revealing to the nurse? a) Fluid volume overload b) Dehydration c) Poor oral hygiene d) Poor skin condition

dehydration

The nurse is evaluating the client's nailbeds for capillary refill which is an indicator of the percentage of oxygen within the tissues. The nurses knows that the following is the correct procedure to check capillary refill. a) Normal capillary refill time is 5 minutes b) Press the nailbed and hold for a minute. Note blood return to the nailbed. c) Normal capillary refill time is >2- 3 seconds or less d) Depress the nailbed, displacing capillary blood, release the pressure.

depress the nailbed, displacing capillary blood, release the pressure.

The nurse is assessing a client who seems to have developed a hearing impairment after working in construction for a few months. The nurse is using the Weber test to assess hearing acuity. What is the purpose of this test? a) Compares bone conduction to air conduction b) Test air conduction of sound in the tested ear c) Measures hearing acuity at various sound frequencies d) Determines the equality or disparity of bone-conducted sound by placing the tuning fork in the middle of the forehead or scalp

determines the equality or disparity of bone-conducted sound by placing the tuning fork in the middle of the forehead or scalp

During the assessment, the nurse uses percussion to evaluate the following: a) Moisture of the skin b) Determines the size, location, and density of underlying structures c) Skin temperature d) Unusual vibrations

determines the size, location, and density of underlying structures

A bruise

ecchymosis

A nurse is preparing for a skin care certification course and needs to identify various lesions that may be seen on the skin. Which definition is correct? a) Abrasion is a jagged wound b) Vesicle is a round area filled with pus c) Wheal is a a slightly elevated area, possibly due to a rash also called hives d) Cyst is an elevated lesion filled with serous fluid

wheal is a a slightly elevated area, possibly due to a rash also called hives

The nurse is assessing a client after being diagnosed with a Cerebrovascular Accident (CVA or Stroke) which has the potential to affect neurological status. The patient is coherent. During the assessment the nurse will evaluate the following pertaining to the client's diagnosis. (Select all that apply) *Lymph Node Enlargement *Bilateral hand grips/strength *Pupil reaction *Orientation x 3

Bilateral hand grips/strength Pupil reaction Orientation x 3

Selected the correct order of assessment techniques. a) Palpation, Inspection, Auscultation, Percussion b) Inspection, Percussion, Palpation, Auscultation (note Auscultate bowel sounds prior to palpation) c) Inspection, Percussion, Auscultation, Palpation d) Inspection, Palpation, Percussion, Auscultation

Inspection, Percussion, Palpation, Auscultation (note Auscultate bowel sounds prior to palpation)

When assessing lung sounds, the nurse places the diaphragm of the stethoscope to the client's upper back, but avoids placing in over the scapulae or ribs. How does this intervention help in the assessment? a) It ensures friction with hair avoiding the distortion of air sounds b) It facilitates hearing sounds in the upper and lower lobes c) It reduces sound from air turbulence that would distort findings d) It helps to clear the air passages and open the alveoli

It facilitates hearing sounds in the upper and lower lobes

A patient has been admitted to the medical surgical unit with end-stage liver disease. It is noted that the patient has ascites and the physician has ordered the nursing staff to measure abdominal girth every day. The nurse knows that the following is important so that the measurements are accurate. (Select all that apply.) *Measure at the same location, indicated by guide marks on the abdomen *Position the client in the supine position *Use a tape measure *Measure just below the ribs

Measure at the same location, indicated by guide marks on the abdomen Position the client in the supine position Use a tape measure

When documenting the client's pupillary assessment, the nurse uses which of the following abbreviations? a) PEARL b) PEARLA c) PEARRA d) PERRLA

PERRLA

A nurse is completing vital signs on a client who was brought the the ED by ambulance. The following values are recorded. Which assessment findings require immediate attention? (Select all that apply.) *Respiratory rate is 32 *Oxygen saturation rate is 90% *Temperature is 101.4 (38.6 C) *Pain (lung area) is an 8 on a scale of 1-10 *Heart rate is 130 *Blood Pressure is 130/78

Respiratory rate is 32 Oxygen saturation rate is 90% Temperature is 101.4 (38.6 C) Pain (lung area) is an 8 on a scale of 1-10 Heart rate is 130

The nurse is assessing lung sounds of client with respiratory disorders. How is a normal bronchial air sound described? a) Soft and muffled, equal in length during inspiration and expiration, with no noticeable pause b) Soft and muffled, longer on inspiration than expiration, with no noticeable pause c) Harsh and loud, shorter on inspiration than expiration, with a pause between them d) Harsh and loud, equal in length during inspiration and expiration, separated by a pause

harsh and loud, shorter on inspiration than expiration, with a pause between them

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as a part of the nutritional assessment? a) Calorie Count b) Vital Signs c) Pulse oximeter reading d) Height and Weight

height and weight

The nurse is performing an assessment of an older adult female client. The nurse documents scoliosis as a part of the spinal assessment. How is scoliosis described? a) an exaggerated lumbar curvature b) is a pronounced lateral curvature of the spine c) a gentle concave and convex curve of the spine d) increased curvature of the thoracic spine

is a pronounced lateral curvature of the spine

The client is having difficulty reading information that is within 12 inches of his visual field. Which item listed below will assist the nurse to evaluate near visual acuity? a) Jaeger Chart b) Ophthalmoscope c) Otoscope d) Snellen Chart

jaeger chart

A jagged wound

laceration

When assessing the client's abdomen, the nurse knows that within the right upper quadrant (RUQ) is the following structure. a) Sigmoid Colon b) Appendix c) Spleen d) Liver

liver

A flat discoloration found on the skin

macule

A nurse is caring for a client reporting low back pain. The nurse uses the body systems approach to assess the client. What are the advantages of using this type of approach? a) Prevents overlooking of certain data collection b) Makes problems more identifiable, as findings tend to be clustered according to body system c) Reduces the number of position changes for the client d) Takes less time, as the nurse is not constantly moving around the client

makes problems more identifiable, as findings tend to be clustered according to body system

Elevated, solid, mass deeper and firmer than a papule, example is an enlarged lymph node

nodule

When assessing the client's auditory meatus and tympanic membrane, it is important to use the following instrument. a) Ophthalmascope b) Otoscope c) Tuning Fork d) Snellen Chart

otoscope

A nurse is assessing a client and observes jaundice of the skin, hard palate and of the sclera bilaterally. What is the next step that is appropriate for the nurse to take during the assessment? a) Percuss the spleen b) Assess the client's temperature c) Auscultate the lungs d) Palpate the liver for enlargement

palpate the liver for enlargment

The nurse is assessing the carotid arteries. What is the correct technique? a) Palpate both arteries at the same time b) Percuss the arteries c) Do not palpate the arteries d) Palpating the artery one at a time to avoid any potential disruption in blood flow

palpating the artery one at a time to avoid any potential disruption in blood flow

An elevated, palpable area such as a wart

papule

A nurse is assessing the skin of a client who has been on a hiking trip and has developed inflamed red patches on his hands and face in response to a possible allergic reaction. How should the nurse document this finding? a) Skin on face and hands demonstrates pallor b) Macular areas noted on hands and face c) Bruising noted on hands and face d) Patches of erythema noted on hands and face

patches of erythema noted on hands and face

A nurse is listening to the lung sounds of client. The nurse hears a sound that is described as grating or abrasive. What type of adventitious sound is this? a) Wheezes b) Crackles (Rales) c) Pleural friction rub d) Gurgles (Rhonchi)

pleural friction rib

The nurse is examining the anus of a client with a history of chronic constipation. What is indicative (signs that suggest) of chronic constipation? a) Area is moist and hairless b) Absence of rectal fissures c) Presence of rectal fissures d) Pigmentation is greater than other areas of the body

presence of rectal fissures

When assessing the adult client's ear canal, the nurse will do the following to ensure visual assessment of the auditory canal and tympanic membrane. a) Pull the pinna up and back b) Pull the lobe straight down c) Pull the pinna down and back d) Pull the pinna straight back

pull the pinna up and back

A raised area in which is pus is seen

pustule

When assessing sensory perception of a client, the nurse strokes the skin with a cotton ball at various places on both sides of the upper and lower extremities of the body. What information does the nurse obtain from this assessment? a) Sensory for fine touch b) Sensory for dull touch c) Sensory for temperature change d) Sensory for vibration

sensory for fine touch

The nurse is conducting the hearing acuity of a patient using audiometric tests. The decibel range at which the client can hear is recorded at 78 dB. What is the hearing level of this client? a) Severely impaired b) Profoundly impaired c) No hearing difficulty noted d) Moderately impaired

severely impaired

When assessing the left lower quadrant of the abdomen, the nurse knows that the following structure is located in the LLQ. a) Spleen b) Liver c) Sigmoid colon d) Stomach

sigmoid colon

A nurse is assessing bowel sounds of a client with abdominal pain. The nurse describes the client's bowel sounds as hypoactive if: a) no sound is heard after listening for 3-5 minutes b) sounds occur after a long interval c) sounds occur 30-34 times a minute d) sounds occur frequently

sounds occur after a long interval

When assessing the left upper quadrant of the abdomen, the nurse knows that the following structure is located in the LUQ. a) Liver b) Spermatic cord c) Appendix d) Spleen

spleen

When auscultating lung sounds, the nurse notes that a rub is present. The nurse knows that this is due to: a) S1 sound b) S2 sound c) The rubbing of the pleural membranes. d) The rubbing of pericardial membranes

the rubbing of the pleural membranes.

A nurse is performing a physical assessment for a client using the technique of palpation. What is the purpose of using this technique? a) To check the skin temperature by feeling the surface of the skin b) To assess the sounds from the heart, lungs, and abdomen c) To determine the density and location of structures underlying the skin's surface d) To inspect specific structures for normal or abnormal characteristics

to check the skin temperature by feeling the surface of the skin

A nurse has explained the purpose and procedure for a comprehensive assessment and has directed the client to an appropriate position on the bed. The nurse has also provided a drape to cover the patient. What is the primary purpose of a drape during the assessment process? a) To provide a barrier during palpation and percussion to ensure objective interpretation of findings b) To provide the client with modesty and integrity during the assessment c) To keep the patient's skin dry during the assessment d) The keep the client warm during the assessment

to provide the client with modesty and integrity during the assessment

An elevated, round area, filled with serum such as a blister

vesicle

It is important for a client to be comfortable during the assessment. The nurse uses empathy that assists him to make adjustments in his method during the exam. One adjustment might include: a) Dim the lighting in the exam room b) Keeping accessible doors open to the exam room c) Warming any equipment prior to touching the patient d) Assist the client to walk down the hall to the bathroom in his gown but with a blanket

warming any equipment prior to touching the patient

A nurse is completing a vision exam with the Snellen chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean?" How should the nurse respond? a) Your vision is better than average, you can read at 30 feet what a person with normal vision can read at 20 feet. b) Your vision in your right eye is slightly different that your left eye. c) You are able to read at 20 feet what a person with normal vision can read at 30 feet d) Your vision is perfect; you can read the entire chart and you do not need glasses

you are able to read at 20 feet what a person with normal vision can read at 30 feet