CH 26 - Health Assesment - PREP U

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? "Your physician will decide when it is best for you to begin having mammograms based on your family history." "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?" "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s."

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

To obtain data about an adult client's sexuality and reproductive pattern, what question is best for the nurse to ask? "How often do you have sexual intercourse?" "What arouses you when you have intercourse?" "How many children do you have, both living and dead?" "Has anything changed your sexual performance?"

"Has anything changed your sexual performance?" Explanation: The sexual assessment is not meant to illuminate nonexistent problems. Rather, the client is, in effect, given permission and encouragement to present sexually related questions.

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? "I need to report what is going on to your health care provider. Can I look at your abdomen?" "Let me explain what I am going to do and how you can help." "Open your shirt, I need to look at your abdomen." "I am going to examine your abdomen."

"Let me explain what I am going to do and how you can help." Explanation: The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation. Requesting to examine the client's abdomen without any explanation may cause anxiety and increase the client's pain and decrease the chance of cooperation. The results of the assessment should be reported to the health care provider. The nurse does not need to avoid conversation during the assessment.

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? "You should decrease your intake of fried foods." "You need to sign up for the clinic's stop smoking program." "Take your blood pressure medications exactly as your doctor prescribed them." "It is important for you to do 30 minutes of exercise three times a week."

"Take your blood pressure medications exactly as your doctor prescribed them." Explanation: Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease. Reference:

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?" "What are the three objects I told you earlier?" "What did you eat for dinner last night?" "What is meant by 'an ounce of prevention is worth a pound of cure'?"

"What are the month, date, and the year of your birth?" Explanation: Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's abstract reasoning. The nurse needs to ask a question that may be corroborated to confirm a past or remote memory, so asking what the newly admitted client ate at dinner would not be able to be corroborated. The client's birthdate is available in the medical record and can be corroborated. Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses recent memory.

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? "Are you having any pain?" "What brings you here today?" "Do you have any allergies?" "What medications do you normally use?"

"What brings you here today?" Explanation: 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 completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond? "Your vision in your right eye is slightly different than that of your left eye." "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." "Your vision is perfect; you can read the entire chart, and you do not need glasses." "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)."

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." Explanation: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average. Reference:

What percentage of weight change in 6 months is considered abnormal? 5% 10% 1% 2%

10%

During assessment of the lower extremities, the nurse notes that the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4-mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result? brawny edema noted over bilateral lower extremities 1+ pitting edema noted on bilateral lower extremities bilateral lower extremities within normal limits 2+ pitting edema noted on bilateral lower extremities

2+ pitting edema noted on bilateral lower extremities Explanation: Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour. Brawny edema occurs when fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, and there is no pitting, so the tissue palpates as firm or hard, and the skin surface is shiny, warm, and moist.

A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding? A uniform yellow reflex Dark-red arteries and light-red veins A blurred optic disc A reddish retina

A reddish retina Explanation: Normal findings of the internal eye structures include a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins. Reference:

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take? Request a prostate-specific antigen diagnostic blood test. Ask the client about any unusual genital observations. Call the health care provider and request diagnostic testing. Insert an indwelling urinary catheter to ensure urine flow.

Ask the client about any unusual genital observations. Explanation: The nurse finds abnormal physical assessment data and asks the client for subjective information. This helps the nurse know if this is a pre-existing issue, a chronic condition, or an acute finding. Unless the client exhibits acute symptoms, there is no need to contact the health care provider for testing. A prostate-specific antigen test assesses for prostate cancer and does not offer diagnostic information about abnormal scrotal contents. There is no indication the client has difficulty voiding.

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? Nothing. The nurse shouldn't alarm her unnecessarily. Ask the client if she feels dizzy. Ask the client if she has noted any blood in her stools lately. Ask the client if her gums bled this morning when she brushed her teeth.

Ask the client if she has noted any blood in her stools lately. Explanation: 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.

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-ft (2-m) ladder. Which action by the nurse is the most important to take?

Assess pupil shape and reactivity to light. Explanation: Changes in pupillary shape and reactivity to light are early signs of increased intracranial pressure (ICP). The client's orientation to person, place, and time cannot be assessed because he is unconscious. Changes in blood pressure (widening pulse pressure) and decreased heart rate are a late sign of ICP. Although carbon dioxide levels will increase intracranial pressure, it is not a test that the nurse can do at the bedside to assess ICP.

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? Report the finding as a positive sign for cystic fibrosis. Assess the client for cardiovascular disorders. Assess the client for dehydration. Document a normal skin finding on the client chart.

Assess the client for dehydration. Explanation: 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.

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

Auscultation Explanation: 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, percussion is the act of striking one object against another to produce sound, and inspection refers to observing.

An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use?

Auscultation Explanation: Auscultation would reveal if the client's heartbeat is rapid or irregular, and if there are any additional heart sounds such as an S3, which could be an indicator of heart failure. Palpation and inspection may reveal an irregular heartbeat, but they will not disclose extra heart sounds. Percussion is a limited assessment that could be used to outline the cardiac boarder.

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 bowel sounds every 30 seconds Umbilicus centrally located Auscultation of gurgles and clicks Auscultation of a bruit

Auscultation of a bruit Explanation: 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.

Which technique should the nurse use to assess the pupillary light reflex on a client? 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 and observe for pupil constriction. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction.

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Explanation: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.

A nurse is performing auscultation. The nurse would use the bell of the stethoscope to auscultate which sounds?

Bruits Explanation: The bell of the stethoscope is used to detect low-pitched sounds such as abnormal heart sounds and bruits. The diaphragm is use to detect high-pitched sounds such as breath sounds, normal heart sounds and bowel sounds.

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. Less firmness of the testes Scant amount of pubic hair Scant yellow discharge Decreased penis size Bulge to the left inguinal area

Bulge to the left inguinal area Scant yellow discharge Explanation: A bulge in the left inguinal area could indicate a hernia and needs further assessment. Yellow discharge could indicate an infection and requires further assessment. Decreased penis and testes size, less firmness of the testes, and decreased pubic hair are normal with aging of the male client's genitalia.

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. Gastrointestinal: abdominal pain with rebound tenderness in RLQ Cardiovascular: radial pulses 90, bounding, and equal Respirations: 24 and regular Musculoskeletal: sitting up in bed with knees bent Neurologic: awake and alert Skin: warm and dry

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

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? Ask the client if he left his earplugs in his ears. Speak to the older adult client in a high-frequency tone of voice. Use facial expressions and sign language to communicate. Check the client's ear canals for cerumen.

Check the client's ear canals for cerumen. Explanation: 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 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 describes shortness of breath and increased sputum production. Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Client reports breathlessness and productive cough. Client reports respiratory distress and frequent spitting.

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Explanation: 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 new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply. Complete set of vital signs Goals with outcome criteria Functional ability evaluation Collection of subjective data Description of client education

Collection of subjective data Complete set of vital signs Functional ability evaluation

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

Cranial nerve I Explanation: Cranial nerve I is important for a person's sense of smell. Cranial nerves II, III, and IV are important for vision.

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? Arthritis Crepitus or crepitation Fremitus Inflammation

Crepitus or crepitation Explanation: 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? Impaired kidney function Hypertension and circulatory overload Decreased cardiac output Inflammation of a vein

Decreased cardiac output Explanation: 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.

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? Assess for asthma. Document normal breath sounds. Recommend testing for pneumonia. Suspect an inflamed pleura rubbing against the chest wall.

Document normal breath sounds. Explanation: 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 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? The lub-dub sounds occur within 2 seconds of each other. Each lub-dub is one beat. Each lub-dub is two beats. Heart sounds are caused by the opening of heart valves.

Each lub-dub is one beat. Explanation: 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.

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? Notify the health care provider of the abnormal finding. Obtain a second scale to verify the measurement. Document the weight in the medical record. Ensure equipment is not hanging into the sling.

Ensure equipment is not hanging into the sling. Explanation: 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.

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? Report this finding promptly to the client's primary care provider. Increase the frequency of the client's weight assessments. Encourage the client to increase food and fluid intake. Ensure that the scale is correctly calibrated and repeat the assessment.

Ensure that the scale is correctly calibrated and repeat the assessment. Explanation: 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 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? Provide a warm, quiet, dimly lit room Evaluate the blood pressure and pulse Assess the cause of the client's wound Interview to obtain the health history

Evaluate the blood pressure and pulse Explanation: 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 testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing? Select all that apply. V: Trigeminal IV: Trochlear VII: Facial III: Oculomotor II: Optic VI: Abducens

III: Oculomotor IV: Trochlear VI: Abducens Explanation: The oculomotor, trochlear, and abducens nerves control the motor function of the eye structures, which can be assessed through movement of the eyes through the six cardinal positions of gaze. The optic nerve controls the sense of vision. The trigeminal nerve controls the jaw movements of chewing and mastication (motor), and sensation on the face and neck (sensory). The facial nerve controls the muscles of the face (motor) and the sense of taste on the tongue (sensory).

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? Check her chart for allergy information. Inspect the area of itchy skin. Review her medication record. Review her medical history.

Inspect the area of itchy skin. Explanation: 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 caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? Palpate the popliteal and posterior tibial pulses of both legs. Lightly palpate the left leg, assessing for edema. Assess for pain by deeply palpating the left leg. Inspect the left lower leg for areas of redness.

Inspect the left lower leg for areas of redness. Explanation: Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.

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. Single color Irregular edges Symmetrical shape Larger than 1/4 inch in diameter Change in the mole

Irregular edges Larger than 1/4 inch in diameter Change in the mole

A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean? It is normal. It is dissecting. It is inflamed. It is distended.

It is distended. Explanation: Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.

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? Ensure that the preoperative check list is completed. Document that the preoperative medication was administered. Verify that the procedural consent form is signed. Locate the laboratory test results in the chart.

Palpable pulsation over the mitral area Explanation: A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

Sanjay Patel is a 10-year-old boy from India with mahogany-colored skin. He arrives at the school nurse's office and tells the nurse that he was stung by a wasp on the arm yesterday, and he thinks it might be infected. The nurse performs which action in order to assess the wasp sting site for inflammation?

Palpate the area with the back of the hand for increased warmth, then touch the other arm for comparison. Explanation: Local inflammation like that sustained from an insect sting presents with redness (erythema), swelling (edema), tenderness, and heat. Because erythema is not observable on a person with dark brown skin, it is necessary to palpate the skin for increased warmth and taut or tightly pulled surfaces that may be indicative of edema. To assess skin for increased warmth, use the back of the hand to palpate the area and compare bilaterally. Taking the child's temperature would not indicate the presence of a local inflammation.

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

Palpation Explanation: The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene? Warming of a stethoscope before assessing a client's breath sounds Palpation of both carotid arteries at the same time Occlusion of one of the client's nostrils while the client breathes through the nose Placing a tongue blade at the side of the tongue while the client pushes it to the left and right

Palpation of both carotid arteries at the same time Explanation: Palpation of both carotid arteries at once can obstruct blood flow to the brain, potentially causing dizziness or loss of consciousness. The other assessments are correct as described.

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority? Neurovascular status of the left leg Adequacy of circulation Movement of lower leg Patency of airway

Patency of airway Explanation: When performing an assessment after surgery or a traumatic injury, remember the ABCs: Check airway patency first, then breathing, and then circulation. Airway, breathing, and circulation take precedence over neurovascular status.

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? Pink labia lesions Coarse brown hair Whitish vaginal discharge Dark pink vulva

Pink labia lesions Explanation: 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.

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? Chronic Confusion Acute Confusion Disturbed Thought Processes Risk for Falls

Risk for Falls Explanation: Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.

Which statement accurately represents a characteristic of the third or fourth heart sound? S3 is considered normal in children and young adults and abnormal in middle-aged and older adults. S4 is considered normal in children and adults but abnormal in older adults. S4 is the fourth heart sound, represented by "lub-dub-dee." S3 is best heard with the stethoscope bell at the mitral area, with the client lying on the right side. SUBMIT ANSWER

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults. Explanation: S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-aged and older adults. This sound is best heard with the stethoscope bell at the mitral area, with the client lying on the left side. S4 is represented by "dee-lub-dub" and is considered normal in older adults but abnormal in children and adults.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply. Blowing, hollow sounds auscultated over the larynx and trachea Sonorous or coarse sounds with a snoring quality auscultated during inspiration and expiration Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly Musical or squeaking sounds, or high-pitched continuous sounds auscultated during inspiration and expiration Bubbling, crackling, or popping sounds auscultated during inspiration and expiration Soft, low-pitched, whispering sounds heard over most of the lung fields

Soft, low-pitched, whispering sounds heard over most of the lung fields Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly Blowing, hollow sounds auscultated over the larynx and trachea

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? Reassure the client that the procedure will only take a few minutes. Administer a sedative to the client and try again when the sedative takes effect. Enlist the help of another nurse to hold the client steady during the procedure. Stop lifting the client and reassure him.

Stop lifting the client and reassure him. Explanation: The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.

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 bites her fingernails. The client sleeps a lot. The client answers questions in a barely audible voice. The client states that she has been depressed for a long time. The client says that the food makes her nauseous. The client eats 25% of her meals.

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.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment? The skin has normal turgor. The skin is less elastic with aging. The client is overhydrated. The client is dehydrated.

The client is dehydrated. Explanation: 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 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 reports pain at the surgical site. The client makes noises when he breathes. The client reports thirst. The client is sleepy from the anesthesia.

The client makes noises when he breathes. Explanation: 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 performing eye assessments at a community clinic. Which assessment would the nurse document as normal? The client's pupils dilate when looking at a near object and constrict when looking at a distant object. The client's eyes do not converge when the nurse moves a finger toward his nose. An older adult's pupils are pale and cloudy. The client's pupils are black, equal in size, and round and smooth.

The client's pupils are black, equal in size, and round and smooth. Explanation: 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. Explanation: 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 client's tongue remains midline when it protrudes from the mouth. The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. The palate and pharynx move as the client says "ah." The client is able to turn the head to the side and shrug the shoulders against resistance.

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Explanation: 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.

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 ear canal is rough and pinkish. The ear canal is smooth and white. The tympanic membrane is reddish. The tympanic membrane is translucent, shiny, and gray.

The tympanic membrane is translucent, shiny, and gray. Explanation: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

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. Talking directly to the translator facilitates the transfer of information. Talking loudly helps the translator and the client understand the information better. It is always okay to not use a translator if a family member can do it.

Translators may need additional explanations of medical terms. Explanation: When using a translator, it is important to remember that the client still comes first. This means that all information is directed at the client and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when an emotional topic is being discussed. Talking loudly not only inhibits better understanding, but it can also come across as hostile and rude. It is true that even professional translators do not understand all medical terms and may need some clarification at times.

A nurse is assessing the cranial nerves of a client who is recovering from Bell palsy. Which cranial nerves are important for the coordination of facial movement and reflex activity? Select all that apply.

V-Trigeminal VII-Facial IX- Glossopharyngeal Cranial nerves V, VII, IX, and XII are important in the coordination of facial movements and reflex activity. Cranial nerve I is important for the sense of smell, whereas cranial nerve VIII is important for hearing. Intact cranial nerve function is important for normal sensory functioning.

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. Explanation: Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.

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. Uncover the client to expose the chest and abdomen. Palpate the abdomen before auscultating. Assist the client to a sitting position.

Warm the diaphragm of the stethoscope.

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. Palpate the abdomen before auscultating. Uncover the client to expose the chest and abdomen. Assist the client to a sitting position.

Warm the diaphragm of the stethoscope. Explanation: 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? Heart rate of 100 Wheezing on auscultation Crying with burning pain Erythema at sting site

Wheezing on auscultation Explanation: 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 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 a client recovering from brain surgery for repair of an aneurysm a client with a brain tumor who is in the hospital because of respiratory depression a client in the Intensive Care Unit after having a stroke yesterday

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications Explanation: Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

To assess subjective data related to a client's elimination pattern, the nurse: palpates the abdomen for pain or distention. notes the frequency, amount, and time the client voids. asks the client about changes in elimination patterns. reviews the latest laboratory report of the urine.

asks the client about changes in elimination patterns. Explanation: The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.

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.

A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should: avoid a position change that requires turning. elevate the legs, bending at the knee while the client is supine. have the client lay on his right side, then palpate the area. have the client turn from side to side and assess pain.

avoid a position change that requires turning. Explanation: Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client.

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: 20/20. clouded. blurred. clear.

blurred. Explanation: Visual problems with close objects occur more frequently after the age of 40.

A nurse is auscultating the lungs of a client. During the auscultation, the nurse hears high-pitched, harsh, blowing sounds over the larynx and trachea. The nurse identifies these sounds as which type?

bronchial breath sounds Explanation: Normal breath sounds vary over different parts of the lungs. Bronchial breath sounds heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus and are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are soft, low-pitched, whispering sounds, heard over most of the lung fields, with sound on inspiration being longer than expiration. Adventitious breath sounds (added, abnormal sounds) are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways.

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's: review of systems. chief concern. symptoms. objective assessment.

chief concern. Explanation: The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern.

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? the anterior fontanel bulging when the client cries circumoral cyanosis when the client is at rest a blue-black macular area over the sacral area the abdomen appearing large in relation to the pelvis

circumoral cyanosis when the client is at rest Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

When a client enters the acute care facility, the nurse should perform a:

comprehensive health assessment. Explanation: 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. normal breath sounds. muscle tenderness. masses.

density and location of lungs. Explanation: 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.

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: crust. ulcer. erosion. fissure.

fissure. Explanation: 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. helping the client to bathe and brush their teeth assisting the client to sit up in a chair reviewing morning lab results inspecting the abdominal incision taking the client's blood pressure

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results

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

inspection, auscultation, percussion, palpation Explanation: In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard.

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. Explanation: Strike the tuning fork and place its stem firmly against the mastoid process.

A nurse is using the assistance of an interpreter. When interviewing a client who does not speak the dominant language, the nurse should: assess the client's vital signs first. observe the client's body language. interpret the effect of deep palpation. inspect the symmetry of the facial features.

observe the client's body language. Explanation: When using an interpreter, the nurse should observe the cues the client expresses with body language, and listen to the tone of voice.

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 hospital, person, and date oriented to person, place, and time oriented to person, place, and situation oriented to person, situation, and time

oriented to person, place, and time Explanation: 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).

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

palpation Explanation: 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 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. lymph nodes. liver.

peripheral pulses. Explanation: 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

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

ptosis. Explanation: 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 34-year-old client of Asian descent has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pain, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client? neck and chest sclera of the eye mucous membranes of the mouth face and hands

sclera of the eye Explanation: Jaundice can be observed in the face and body of people with very fair beige-colored skin with pinkish undertones, as is often seen in northern Europeans. The naturally fair skin of Asians has a yellowish undertone, as does the skin of southern Europeans, and some Hispanics and Black Americans. The best location to observe for jaundice in this population is the sclera of the eye. Jaundice in people with light brown skin with reddish undertones, such as Native Americans/First Nations, some Hispanics and Blacks, North Africans, and Arabians is best observed in the sclera. People with very dark brown skin with purplish undertones, such as sub-Saharan Africans, some Blacks, South Asians, and Native Australians often have normal yellow subconjunctival fatty deposits in the outer sclera. Do not confuse this with scleral jaundice. The best location to observe jaundice in this population is the junction of the hard and soft palate in the mouth, viewed with a non-LED flashlight. LED flashlights have an ultra-bright, bluish-white light that can alter color perception. The mucous membranes of the mouth is the location to observe for cyanosis.

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 fingertips the knuckles the dorsum the palm

the dorsum Explanation: 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 has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require? ophthalmoscope otoscope tuning fork Snellen chart

tuning fork Explanation: 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.

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? Report the finding as a positive sign for cystic fibrosis. Assess the client for cardiovascular disorders. Assess the client for dehydration. Document a normal skin finding on the client chart.

xplanation: 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.