Assessment 3306

One extremity cooler than the other indicates venous insufficiency.

false

Which formula will the nurse use to calculate cardiac output?

heart rate x stroke volume

A client comes to the clinic reporting pain in her legs while walking. the client states the pain is goes away when resting. The nurse suspects the client is experiencing what?

intermittent claudication

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

melanoma

A 62 year old client visits the clinic and tells the nurse that she feels chest pain and pain down her left arm. The nurse should refer the client to a physician for possible

myocardial infraction

The nurse is caring for a client with a sudden onset of chest pain. Which assessment is highest priority?

obtain pulse and bp

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

posterior tibial

What is the most important lifestyle changes a client can make to improve cardiovascular health?

quit smoking

A nurse notes a bruit when auscultating over the right carotid artery. The nurse determines the abnormal sound is a bruit because a _________ sound is heard.

swishing

The sternal angle at the right 2nd rib space is also known as what?

the aortic area

The nurse assessing a clients skin identifies an ulcer. What would indicate to the nurse it is an arterial ulcer?

the ulcer is necrotic

S1 results from closure of the mitral and tricuspid valves true flase

true

The nurse should recognize that the presence of a wheeze can result from air passing through constricted passageways. true false

true

The nurse is preparing to palpate the breasts of a female client. Which technique would be most appropriate?

use the flat pads of three fingers

During the assessment, the nurse identifies warm thick skin that is swollen and reddish-blue. The nurse also notes an ulcer at the ankle that The client describes pain at the ulcer site as achy. The nurse suspects the client may have what?

venous insufficiency

While performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 6-mm depression. How would the nurse document this?

3+ pitting edema

The point of maximum impulse is most often found where?

5th intercostal space (ICS), left midclavicular line (MCL)

A nurse is inspecting a client's nipples. Which of the following findings should the nurse regard as a cause for concern?

A recently retracted nipple that was previously everted

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

Chronic obstructive pulmonary disease

What techniques can be performed when palpating the breasts? Select all that apply.

Circular pattern Wedge vertical

A client tells a nurse about a raised lesion on the client's leg. What is the nurse's first nursing action? A. Inspect the area B. Palpate the area C. Move to the next body system D. Document the statement

Inspect?

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

Listen to the lungs starting in the apices.

Six P's

Pallor Pain Parasthesia Poikilothermia Pulselessness Paralysis (late sign)

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique?

Palpating carotid pulses simultaneously

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about the lump? size, symmetry, nipple size, size

Size

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

Tenting indicates dehydration

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

The right lung has three lobes, while the left lung has two lobes.

A client in the ED tells a nurse that she feels short of breath. The nurse would document this finding as dyspnea. true false

True

Maintaining fluid balance is one function of the lymphatic system

True

Nurses assess ability to perform self-care activities, also called activities of daily living. T/F

True

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

angina

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

braden scale

When assessing the lower extremities, it is critical that the examiner

compare side to side

What characteristic nail color should the nurse recognize as an indication of hypoxia?

cyanotic

A client reports to the ER complaining of pain in their left calf. Upon assessment a nurse notes the reported area is edematous, red, and warm to the touch. The nurse suspects the client may have what?

deep vein thrombosis

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis