312- health assessment

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?" page 389

The nurse is preparing to interview a client with a documented history of mental illness. Which question should the nurse use to begin this interview?

"Have you ever had a problem with mental or emotional illness?"

During a health history, the nurse recommends using a genogram. The client asks the nurse to explain the purpose of a genogram. How should the nurse respond?

"It helps the nurse organize data on the client's family history."

A clinic nurse has reviewed a new client's available health record and will now begin taking the client's health history. Which of the following questions should the nurse ask first when obtaining the health history?

"What is your major health concern at this time?"

Which of the following questions is most useful in the assessment of a client's diabetes management?

"What is your routine for checking your blood sugar these days?"

The nurse is caring for an older adult client with a blood pressure of 186/98 mm Hg. The client asks, "What is happening to me?" Which of the following is the best response by the nurse?

"Your blood pressure is elevated, so we should talk more after I complete your assessment."

A nurse is discussing factors affecting blood pressure with an assistive personnel. Which of the following factors should the nurse identify as potential causes for an increase in a client's blood pressure?

1. Anxiety 2.Fear 3.Use of nicotine 4.Obesity

Identify the direction of blood flow through the heart after it enters the right atrium.

1. Blood passes through the tricuspid valve 2.Blood collects in the Right ventricle 3. Blood passes through the pulmonary artery 4.Blood enters the LEFT atrium 5.Blood passes through the mitral valve 6.Blood collects in the Left ventricle 7. Blood passes through the aorta

A nurse is reviewing the medical records for a group of clients. Which of the following clients should the nurse identify as being at risk for experiencing tachycardia?

38-year-old client who has a fever due to an infection

The spinous process termed the vertebra prominens is in which cervical vertebra

7th

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea

The nurse understands that the preferred method of hand hygiene when hands are not visibly soiled is what?

Alcohol-based rub

Which description of exterior landmarks indicates normal positioning of the lungs?

Anteriorly, the lower border of the lung crosses the 6th rib at the midclavicular line.

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes?

Arm, hands, and fingers

A nurse hears adventitious lung sounds while auscultating a client's lung fields. What action should the nurse take?

Ask the client to cough. page 400

When interviewing a client, the nurse inquires about the presence of pain. The client states that she is in a great deal of pain. Which of the following should the nurse do next?

Ask the client to rate the pain on a scale from 0 to 10

The nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?

Asymmetrical smile

The nurse is conducting an abdominal assessment with a client. What should the nurse do prior to documenting that a client's bowel sounds are absent?

Auscultate the abdomen for 5 minutes

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Auscultation of a client's heart murmur.

A nurse is caring for a client who reports dizziness when standing up. The client's blood pressure after lying supine for 15 minutes is 136/86 mm Hg in the left arm. Which of the following findings would indicate the client is experiencing orthostatic hypotension?

B/P 114/72 mm Hg left arm immediately after standing

A nurse is interviewing a client who complains of dyspnea of sudden onset. Based on this finding, the nurse should suspect which of the following causes?

Bacterial infection page 387

A health care provider is performing a comprehensive physical examination of a 51-year-old man. After performing a digital-rectal exam for prostate enlargement and tenderness, the nurse checks the fecal material on the gloved finger for the presence of which of the following?

Blood

Universal precautions are primarily designed to protect the health care worker from what?

Blood-borne pathogens

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough. PAGE 384

What is COLDSPA?

C-character-- What does this pain feel like? O- onset-- When did the pain start? L- location-- Show me exactly where the pain is. D-duration -- How long has this been going on? S- severity -- How would you rate your pain? P- Pattern-- Does your pain come and go? A- Associated factors-- Any symptoms that accompany the pain?

What us subjective date?

CC History of present illness Allergies Med list PMH/PSH Social History Family History What the PT is saying to YOU

The hospitalized client is at risk for ineffective tissue perfusion. What should the nurse assess to identify ineffective tissue perfusion?

Capillary refill

A client experiences increasing difficulty taking in a deep breath. For which health problem should the nurse focus when assessing this client?

Chronic obstructive lung disease 406

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles

The nurse is conducting a physical examination of a client. After completing the examination, the nurse realizes that part of the examination was omitted by mistake. How should the nurse proceed?

Complete the forgotten portion of the exam out of sequence.

What type of assessment would a nurse perform on a client being admitted to the hospital?

Comprehensive

A nurse on an oncology unit enters a client's room to auscultate bowel sounds. What should the nurse do before auscultating?

Disinfect the stethoscope before touching the client

A nurse is caring for an adult client who has bradycardia. Which of the following physical manifestations of bradycardia should the nurse expect?

Dizziness

The nurse would use what part of the hand when assessing temperature during palpation?

Dorsal surface

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

Dyspnea

A nurse is preparing to perform auscultation on a client. Which guideline is most important for the nurse to keep in mind while performing this technique?

Eliminate distracting noises from the environment.

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client?

Encourage turning, coughing, and deep breathing

The client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, and has been placed on O2. What priority assessment would the nurse include?

Evaluate changes in respiratory pattern and rate. page 385

A nurse is preparing to examine a 45-year-old female client with a family history of breast cancer. The nurse explains that she will be performing a routine clinical breast examination of the client today. The client objects to having her breasts examined. How should the nurse respond?

Explain the importance of the examination and the risks of breast cancer

A client has just been admitted to the postsurgical unit from postanesthetic recovery, and the nurse is in the introductory phase of the client interview. Which of the following activities should the nurse perform first?

Explain the purpose of the interview

A female client is reporting burning during urination. The client refuses to allow the nurse to perform a vaginal assessment. What is the best action of the nurse?

Explain to the client why the assessment is important and the possibility of missing important findings.

A 54-year-old man is found to be anemic. Which of the following nursing diagnoses is most likely to be recorded in his plan of care?

Fatigue

closed-ended questions

Gain information and stay focused

What do we assess?

General Appearance Speech, Cognition Physical Examination Vital Signs Safety, Hazards Equipment/ Medical Device Sites Situation Re-Assess to evaluate interventions

A nurse is performing an assessment on a client who has been smoking cigarettes for the past 30 years. The nurse uses the DRIVE4COPD questionnaire to determine the client's risk for chronic obstructive pulmonary disease (COPD). The client scores a 9 on the questionnaire. How should the nurse document the client's risk for developing COPD?

HIGH

The nurse is preparing for a physical examination of a client. What should the nurse do first?

Hand hygiene

What should be the nurse's initial intervention when adventitious sounds are heard during auscultation of a client's lungs?

Have the client cough and then listen again page 400

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

The nurse would use the tuning fork to assess for what?

Hearing loss

The thoracic cavity contains which of the following organs? Select all that apply.

Heart Lungs Most of the esophagus page 384

A nurse is beginning the physical examination of an elderly man with chronic obstructive pulmonary disease. In which order should the nurse implement the four physical assessment techniques with this client?

Inspection, palpation, percussion, auscultation

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully

A nurse is reviewing a client's medical record to identify risk factors for hypertension. Identify the following findings as intrinsic (nonmodifiable) risk factors or extrinsic (modifiable) risk factors.

Intrinsic- 1. Age 2. Hormones 3. Race 4. Genetics Extrinsic 1. Exercise 2.Smoking 3. Caffine Intake 4. Sodium Intake

What is ADPIE (definition and the acronym)- The Five stages for the Nursing Process

It is the process for basic nursing care. Assess, diagnose, plan, implement and evaluate

The nurse is assessing a client with unexplained lesions noted on the client's back. The nurse is going to palpate the area of the lesions. What type of palpation should the nurse use?

Light

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

Which action by a nurse demonstrates the proper sequence for auscultation of the lung fields?

Listen at each site for at least one complete respiratory cycle page 399

You should use the bell of the stethoscope when auscultating what type of sounds?

Low-frequency sounds

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 PAGE 389

When to take vital signs

On admission( Baseline) Standards of care (Routine) Client has a CHANGE in status or report Before and after SX ( Pre-op & Post-op) Before & after admin of meds Before & after nursing interventions (walking) Severity of illness Procedure related

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?

On the mastoid area.

When assessing the abdomen, which assessment technique is used last?

Palpation

Seven Dimension of Pain

Physical- Where is it located? Sensory- What does it feel like? Behavioral- Physical signs of pain Sociocultural- cultural influences on how to handle pain Cognitive-How does it affect your lifestyle Spiritual- How does your spiritual beliefs influence your response to pain

A nurse is performing percussion on a client's back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. Which of the following describes this finding?

Resonance

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields 398

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

Rinne

A nurse is admitting a new client. The client is lying in bed. Where should the nurse be positioned?

Seated in a chair at eye level with the client

What is SBAR?

Situation Background Assessment Recommendation

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration. page 395

During an interview, the client begins to talk about the frequency of being abused by a spouse. What can the nurse do at this time to acknowledge the sensitivity of the information the client is providing?

Stop documenting in order to maintain eye contact with the client.

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

Stridor page 405

What is an appropriate action by a nurse when providing care for an 18-year-old with respiratory problems caused by excessive smoking?

Suggest methods and provide resources to assist with smoking cessation

In palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. The nurse recognizes this landmark as which of the following?

Suprasternal notch 382

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath.

Which describes the nurse using the technique of percussion?

The nurse notes resonance over the individual's thorax.

A client asks why gloves are being worn during the physical examination. What should the nurse respond to this client?

They make sure that any microorganisms on my hands do not touch your skin."

What is a physical examination?

Vital signs BP Pulse Rate Respiratory rate Temp. O2 saturation Pain assessment The more information the better off you are.

Which action by a nurse demonstrates the correct application of the principles of standard precautions?

Wearing gloves when palpating the tongue, lips, & gums

open-ended questions

Who, What, When, Where, How

During the interview process, the nurse uses both open-ended and closed-ended questions. During what phase of the interview process does the nurse use these specific types of questions?

Working

The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?

Works in the service industry

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 page 384

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination.

The nurse is preparing to assess a client's reflexes. At which point during the assessment should this be completed?

after assessing the motor function of the lower extremities

A bony ridge located at the point where the manubrium articulates with the body of the sternum is termed the sternal

angle

The apex of each lung is located at the

area slightly above the clavicle.

After auscultating bowel sounds the nurse lightly strokes each side of the client's abdomen. What is the purpose of this technique?

assess abdominal reflex

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities.

The nurse observes a student nurse performing a focused assessment on a client with a suspected heart murmur. The nurse determines accurate assessment technique is used when which of the following is observed?

auscultation of the heart with the stethoscope bell

The nurse is preparing to interview a client with a history of sexual abuse. What technique should the nurse use when conducting this interview?

be nonjudgmental

A client is supine with the head of the examination table at a 30-degree angle. What should the nurse assess at this time?

carotid arteries

What is CC?

chief complaint- Why the patient is here

The nurse learns that a client is unable to sleep because of high anxiety. On which category of health patterns should the nurse focus?

coping-stress-tolerance

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response?

cranial nerve VIII is intact

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis.

While examining a client, the nurse plans to palpate temperature of the skin by using the

dorsal surface of the hand.

Two body systems that may be logically integrated and assessed at the same time are the

eye exam and cranial nerves II, III, IV, and VI.

The client has decreased sensation in his legs. What additional assessment should the nurse include?

fall

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

funnel chest

The nurse is preparing to conduct a physical examination of an adolescent client as part of a general physical assessment. Which examination approach would be the most appropriate for this client?

head-to-toe assessment

The client reports severe pain when breathing in deeply. The description suggests to the nurse that the client is experiencing which respiratory condition?

inflammation of the parietal pleura page 393

A nurse is palpating the sternum of a client. If the client is healthy, which of the following would characterize his costal angle?

less than 90 degrees

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose?

otoscope

The nurse assesses an adult client's thoracic area and observes a markedly sunken sternum and adjacent cartilages. The nurse should document the client's

pectus excavatum.

A nurse in a clinic performs a head-to-toe assessment on a 62-year-old male client. The assessment reveals the following: alert and cooperative, lungs diminished in the bases, increased secretions in the larger airway, respirations 22 breaths/min, pulses 1+, capillary refill greater than 3 seconds, abdomen soft and nontender, skin warm and dry with cool lower extremities, and client moves all extremities well with full range of motion.

respiratory function cardiovascular system

What is ROS?

review of systems- Anything related to the patient

At the beginning of the exam the nurse performs a general survey. What would the nurse assess at this time?

safety

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

skin

The nurse documents vesicular lung sounds upon auscultation. The nurse heard what type of sound?

sound heard throughout inspiration and two thirds of expiration 394

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason?

to auscultate the lungs

A client with congestive heart failure presents with edema of the ankles. When conducting a physical examination of this client, the nurse requires a stethoscope for which purpose?

to auscultate the lungs

The nurse collects equipment prior to conducting a physical examination for a new client. For which body area should the nurse use a gauze pad during the assessment?

tongue

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

tuberculosis.

The nurse documents information about a client's activity-exercise health pattern. Which information did the nurse most likely document?

unable to go to the gym since having back surgery

Which terms are used to identify the lobes of the right lung? Select all that apply.

upper lobe middle lobe lower lobe

What is objective data?

what YOU observe- VS General HEENT CV Resp GI GU Neuro/Msk Skin Labs/Test

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 8 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea Page 406

Why do we have to breath

Cellular respiration

The nurse is performing the technique shown. What is the nurse assessing?

Chest expansion 397

Upon inspection of a client's chest, a nurse observes an increase in the ratio of anteroposterior to transverse diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease

Is this finding within the expected reference range? Does this value require nursing intervention? Why or why not?

Mr. Ricci's blood pressure of 116/74 mm Hg is within the expected reference range of less than 120/80 mm Hg for an adult. This finding does not require nursing intervention. You should continue to monitor Mr. Ricci's blood pressure to assist in identifying whether he is experiencing a change in his health status.

During the physical examination of your client you auscultate the sound of the client's breathing. What area of the client are you assessing?

Lungs

A client admitted to the health care facility for new onset of abdominal pain expresses to the nurse that she was treated for gastroesophageal reflux disease in the past. In which section of the comprehensive health assessment should the nurse document this information?

Personal health history

A nurse is discussing tachycardia with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as exhibiting tachycardia?

Preschooler who has a pulse of 142/min

When you obtained Mr. Ricci's initial vital signs, his temperature via temporal scan was 39° C (102.2° F). His skin was warm to palpation and he was visibly shivering. What are some nursing interventions you can implement to address his fever?

Remove blankets, hats, and clothing except for a single light layer. Encourage Mr. Ricci to drink cool fluids or eat ice chips frequently. Administer an antipyretic medication. Sponge Mr. Ricci's skin with tepid water. Enhance heat loss via convection by placing a fan near Mr. Ricci. Administer antibiotics. Administer IV fluids. Decrease the temperature of the room.

A client plays doubles tennis every Saturday and golfs on Wednesday afternoons. In which part of the comprehensive health history is this information utilized?

health patterns

Light palpation is most appropriate to assess the

inflamed areas of skin

How does O2 & CO2 move around the body?

1. Oxygen from lungs 2. Oxygen bonds to hemoglobin ( Hemoglobin- Iron (Fe +) is required to do this) 3. Oxygen released to tissues

Classification of pain

1. nociceptive-injury tissue Ex: Skin, muscles, joints, tendons(Somatic) or Internal organs ( Visceral) ( Acute Pain) 2. neuropathic- Nerve, tingling, spinal, phantom, limb (Chronic Pain) 3. Inflammatory- Chronic Pain Tissue inflammatory Rheumatoid Arthritis, IBS

Name the four stages of hypertension, including the blood pressure values that define each stage.

1.Elevated: when the systolic pressure is 120 to 129 mm Hg and the diastolic pressure is less than 80 mm Hg Stage I 2.Hypertension: when the systolic pressure is 130 to 139 mm Hg, or the diastolic pressure is 80 to 89 mm Hg Stage II 3.Hypertension: when the systolic pressure is 140 mm Hg or greater or the diastolic pressure is 90 mm Hg or greater 4. Hypertensive crisis: when the systolic pressure is greater than 180 mm Hg and/or the diastolic pressure is greater than 120 mm Hg

components of vital signs

1.respirations-- gas exchange ( O2 & CO2 Movement) 2. BP--- gas exchange ( O2 & CO2 Movement) 3. Pulse--- gas exchange ( O2 & CO2 Movement) 4. Temp 5. Pain (Can affect the above)

A school nurse is reviewing the health records for a group of students who recently had a physical examination. Which of the following students should the nurse identify as having a pulse rate outside of the expected reference range

15-year-old who has a pulse rate of 40/min 10-year-old who has a pulse rate of 118/min

The nurse is focusing an interview on a client's respiratory status. Which question should the nurse ask first to begin this interview?

Describe how you breathe for me?

A nurse is interviewing a man complaining of a pain in his shoulder. The nurse asks him where exactly the pain is, and he points to a spot on the lateral, posterior upper arm. The nurse has seen similar cases in other clients and recognizes that is likely from prolonged work at a computer, particularly using a mouse. Which of the following is the most effective use of inferring that the nurse might implement in this situation?

Do you perform any sustained or continually repetitive motions with that arm?"

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

Why are vital signs important?

Establish a baseline, monitor a patient's condition, identify problems, and evaluate responses to interventions Foundation Nursing Assessment Measuring and monitoring the most basic and important body functions A-Airway B- Breathing C- Circulation Signals the body is compensating for something to maintain homeostasis

A nurse is providing an inservice training for a group of newly hired assistive personnel about certain factors that can affect accuracy when measuring blood pressure. Identify whether each of the following factors can result in a falsely high measurement or a falsely low measurement.

Falsely High- BP Cuff to tight & Obtaining after someone has smoked Falsely Low- 1. unsupported arm 2. large cuff 3.small cuff 4.cuff to loose

A graduate nurse working on a medical-surgical unit is admitting a client who does not speak English. No interpreters are available. The client's spouse is present and speaks English. What should the nurse remember about the use of interpreters when communicating with clients?

Friends and family who are unfamiliar with medical terminology may misinterpret information

assessment techniques

Inspection-- Looking at what you are assessing Palpation-- feeling what you are assessing Percussion-- tapping on what you are assessing Auscultation-- listening to what you are assessing

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Observe the client's respiratory rate and pattern

During a comprehensive physical assessment at a home visit, a client reports chest discomfort. What is the first action of the nurse?

Perform a focused assessment. page 387

A client scheduled for surgery tells the nurse that he is very anxious about the surgery. What is an appropriate action by the nurse when interacting with this client?

Provide simple and organized information.

Palpation is a necessary skill in nursing. Many of the body's structures, even though they are not visible, can be assessed through palpation. Which structures would be included in assessment by palpation?

Thyroid gland

The nurse is caring for the client who is receiving heparin. The nurse plans to:

Wear clean gloves when administering heparin to the client

Types of Physical Assessments

comprehensive- head to toe Focused- in depth body system assessment shift- Basic Physical assessment emergent- new-onset

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

fluid in the alveoli

What does the general survey assess?

physical appearance body structure mobility behavior Coloring of the skin pain