CH 5
Which of the following statements made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history?
"How has the stroke affected your ability to perform your daily activities?" Explanation: An emphasis on functional assessment is viewed as being more holistic than the traditional health or medical history. A patient's functional status is the ability of the patient to function normally and perform his or her usual physical, mental, and social activities. Questions related to blood pressure readings, family history, and medication regimen indicate a traditional or medical model versus a holistic health assessment
A nurse is assessing a patient's sexuality. Which of the following would be MOST appropriate for the nurse to use first when addressing this topic?
"I would like to ask you some questions about your sexual health." Explanation: When approaching a sensitive issue such as sexuality, the nurse would first use an orienting statement or question, such as "I would like to ask you about your sexual health and practices." This then opens the door for further discussion. Beginning the assessment by asking about the patient's sex life, number of sexual partners, or being divorced is inappropriate and nontherapeutic.
A graduate nurse is completing her first health history questionnaire with a client. She needs to assess the client's sexual history at the end of the interaction. Which opening remark for this topic would be most appropriate?
"Lastly, I need to ask about your sexual health and practices." Explanation: Obtaining the sexual history provides an opportunity to discuss sexual matters openly. This questioning should begin with an orienting sentence that will lead to a discussion of sexuality. Introducing the subject of sexuality indicates to the client that a discussion of sexual concerns is acceptable and necessary.
A nurse is documenting a patient's chief complaint/reason for seeking care in the medical record. Which of the following would be MOST appropriate?
"My head feels like it is about to explode." Explanation: When documenting a patient's chief complaint or reason for seeking care, the nurse should record the patient's exact words. Additional information, such as location and duration, would then follow as the nurse continues the interview
During the health history, the nurse asks the client about the health status of siblings and grandparents. The client asks why the nurse is asking about her family members. Which response from the nurse is most appropriate?
"Often the health status of family members helps to identify genetic diseases." Explanation: Questions about family history help to identify diseases that may be genetic, communicable, or possibly environmental in orgin. The nurse asks about the health status of first-order and second-order relatives
Which of the following observations made by the nurse reflects the first fundamental technique used in physical examination?
"Patient appears older than stated age." Explanation: The first fundamental technique is inspection or observation. General inspection begins with the first contact with the patient. Percussion translates the application of physical force into sound. Light and deep palpation can be used on the abdomen. Auscultation is the skill of listening to sounds produced within the body created by the movement of air or fluid.
Two nursing students are role-playing a patient assessment situation. One of the students is acting as the nurse, and the other student is acting as the patient. The task is to focus on assessing the patient's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask? lth.
"What do you usually do for fun?" Explanation: Assessing a patient's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of ilicit drugs, alcohol, and caffeine. The question about what the patient does for fun reflects activities. The question about where the patient lives provides information about the physical environment; the question about where the patient's parents came from provides information about culture, which is also part of the environment. The question about the patient's childhood provides information about the patient's past life events related to hea
While undergoing a health history and physical assessment, a patient states, "I'm really afraid this pain in my belly is cancer." Which response by the nurse would be MOST appropriate?
"You seem upset about the pain. Tell me what's happening." Explanation: During the interview, it is essential that the nurse establish rapport, put the patient at ease, and listen to the patient carefully. The nurse's statement about the patient seeming upset is most consistent with these goals. Telling the patient not to worry now dismisses the patient's concerns. Questioning the patient about cancer focuses on the diagnosis, not the patient's current feelings and concerns. Although telling the patient that more testing is necessary can be helpful, the response does not address the patient's feelings and concern
A nurse is conducting a health history with a patient and has obtained the necessary biographical information. The nurse then collects data from the patient in the following categories. Place the categories in the proper sequence for data collection.
1.Chief complaint (reason for seeking care) 2.Present health concern 3.Past health history 4.Family history 5.Review of systems Explanation: After obtaining biographical data, the nurse would then collect information about the patient in the following sequence: chief complaint/reason for seeking care, present health concern or illness, past health history, family history, and finally a review of systems.
When preparing to perform a physical assessment of a patient, the nurse performs the steps below. Place the steps in the order in which they most typically are completed.
1.Inspection 2.Palpation 3.Percussion 4.Auscultation Explanation: The traditional sequence of steps for the physical examination is inspection, palpation, percussion, and auscultation, except in the case of the abdominal examination, when auscultation is performed before palpation and percussion to avoid altering bowel sounds.
Investigation of lifestyle should also include questions about complementary and alternative therapies. How many types of complementary and alternative therapies are estimated?
1,800 Explanation: It is estimated that there are more than 1,800 types of complementary and alternative therapies, including special diets, prayer, visualization or guided imagery, massage, meditation, herbal products, and many others. Marijuana is used to manage symptoms, especially pain, in a number of chronic conditions.
During an assessment a client reports tightness in his chest and frequent coughing. Order from step 1 to step 5 the assessment sequence that the nurse will most likely perform. Use all the options.
1.Ask, "When do you most frequently cough?" 2.Obtain the respiratory rate 3.Inspect the anterior chest wall 4.Percuss the anterior chest wall 5.Auscultate the posterior lung field Explanation: Physical assessment is an integral part of the nursing assessment. The nurse should ask the client about health concerns in order to gather as much information as possible. Vital signs are preformed as a first physical contact and are an important part of the examination. The traditional sequence in a focused portion of the examination is inspection, palpation, percussion, and then auscultation, except in the case of the abdominal assessment.
To calculate the ideal body weight for a woman, the nurse allows for which of the following?
100 pounds for 5 feet of height Explanation: To calculate a woman's ideal body weight, the nurse allows 100 pounds for 5 feet of height and adds 5 pounds for each additional inch over 5 feet. The nurse allows 106 pounds for 5 feet of height in calculating the ideal body weight for a man. The nurse adds 6 pounds for each additional inch over 5 feet in calculating the ideal body weight for a man. Eighty pounds for 5 feet of height is too little.
A female patient comes to the clinic for evaluation. As part of the assessment, the nurse determines the patient's ideal body weight. The patient is 5' 5" tall and has an average frame. What would be her ideal body weight in lbs? Enter the correct number only.
125 Explanation: To calculate the ideal body weight for a woman, allow 100 lb for 5 feet of height and then add 5 lb for each additional inch over 5 feet. In this situation, the calculation would be 100 lb + 5(5) = 125 lbs
What is the ideal body weight (IBW) of a woman with a large frame who is 5 feet, 4 inches tall? Enter the correct number ONLY.
132 Explanation: The formula for IBW for women is to allow 100 lbs for 5 feet of height, then to add 5 lbs for each additional inch over 5 feet. Lastly, subtract 10% of that total for a small frame; add 10% for a large frame. So 100 + 20 = 120. 120 X 10%= 12. 120 + 12 = 132.
Within which body mass index (BMI) range are patients considered to have increased risk for problems associated with poor nutritional status?
18.5 to 20 Explanation: People who have a BMI lower than 18.5 (or who are 80% or less of their desirable body weight for height) are at increased risk for problems associated with poor nutritional status. Additionally, higher mortality rates in hospitalized patients and community-dwelling elderly are associated with individuals who have low BMI. People who have a BMI of 25 to 29 are considered overweight. People who have a BMI of 30 to 39 are considered obese. People who have a BMI above 40 are considered morbidly obese.
A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk?
23 Explanation: Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.
People are at increased risk for problems related to poor nutritional status if they have a BMI lower than
24 Explanation: People who have a BMI lower than 24 (or who are 80% or less of their desirable body weight for height) are at risk for problems associated with poor nutritional status.
What is the body mass index (BMI) of a client who weighs 195 lbs and is 6 feet tall? Round to the nearest whole number, and enter the correct number ONLY.
26 Explanation: This client's BMI is 26.4, which rounds to 26 and indicates that the client is slightly over weight. BMI is a ratio based on body weight and height. The value obtained is compared to established standards and is highly correlated with body fat. The BMI score is at the intersection of height and weight. A BMI of 25 or more is considered overweight, and a BMI of 30 or more is considered obese.
A nurse is preparing a teaching plan based on MyPyramid recommendations to promote healthy nutrition for an adult. The nurse would recommend a daily milk intake of how many cups?
3 Explanation: According to MyPyramid, an adult should have 3 cups of dairy or milk products each day. If the patient were a child, 2 cups per day would be recommended.
An individual is considered obese when his or her BMI is which of the following?
30 to 39 Explanation: Those persons with a BMI of 30 to 39 are considered obese. Persons with a BMI of less than 24 are at risk for problems associated with poor nutritional status. Persons with a BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered morbidly obese.
An individual is considered obese when his or her BMI is
30 to 39. Explanation: Those persons with a BMI of 30 to 39 are considered obese. Persons with a BMI of less than 24 are at risk for problems associated with poor nutritional status. Persons with a BMI of 25 to 29 are considered overweight. Those with a BMI of greater than 40 are considered extremely obese.
A waist circumference of greater than which of the following is indicative of excess abdominal fat in men?
40 inches Explanation: A waist circumference greater than 40 inches for men or 35 inches for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.
A nurse determines that a male patient has an increased risk for diabetes, heart disease, and hypertension based on the patient's waist circumference. Which waist circumference measurement would lead the nurse to suspect this?
41 inches Explanation: In men, a waist circumference greater than 40 inches indicates excess abdominal fat and places the patient at risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation.
When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet?
5 Explanation: When calculating ideal body weight for women, add 5 pounds for each additional inch of height over 5 feet. The other numerical values are incorrect
A client who has lost weight asks a nurse about how much physical activity is needed to prevent regaining the weight. Which of the following would the nurse recommend?
60 minutes per day Explanation: According to MyPyramid, an individual should engage in 60 minutes of physical activity each day to prevent weight gain. Routinely, a person should engage in 30 minutes of physical activity each day to maintain health and 60 to 90 minutes per day to sustain weight loss.
A patient comes to the clinic at 8 a.m. for a scheduled visit. The nurse obtains the patient's temperature orally. Which finding would the nurse interpret as a potential indicator of a problem?
99.6 degrees F Explanation: A diurnal variation of 1 or 2 degrees in body temperature is normal throughout the day. Temperature is usually lowest in the morning and increases during the day to betweeen 99 to 99.5 degrees F and then decreases during the night. Therefore, an early morning temperature of 99.6 degrees would suggest a potential problem, because this temperature would then increase as the day goes on. Early morning temperatures of 97.2 degrees, 98.0 degrees, and 98.4 degrees would not be a cause for concern.
A new patient walking in to the health care center displays symptoms of wheezing and recurrent flare-ups. During the interview, the patient says that she may be allergic to certain foods. Based on this information, what nutritional assessment method is appropriate?
A 3- to 7 day food record Explanation: Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in combination to determine a patient's nutritional status, but information obtained through these assessments will not help determine the possibility of allergies to food. The food record is used most often in nutritional status studies. A 3- to 7-day food record can be used to associate allergic reactions with specific food intake.
A nursing student is learning to complete a focused abdominal assessment. She understands the necessity for altering the assessment skill sequence when examining this body region. Therefore, she will complete which skill after inspection?
Auscultation Explanation: The traditional sequence in the focused portion of the examination is inspection, palpation, percussion, and auscultation, except in the case of the abdomen. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.
The nurse working in a culturally diverse neighborhood knows that providing culturally sensitive materials during nutritional counseling will increase patient understanding of the nutritional information. What is the best way for the nurse to prepare materials for the patient to provide culturally appropriate teaching?
Access a government-sponsored Website that provides culturally appropriate food guides. Explanation: Culturally sensitive materials are available for making appropriate dietary recommendations. Providing extra time for the patient will not increase the likelihood that the patient will adhere or understand nutritional counseling. Food records are used to determine individual eating patterns and do not take cultural preferences into consideration. Specific nutrients may need to be added on an individual and culturally acceptable basis, but only as a result of an in-depth nutritional assessment.
A nurse is preparing a presentation for a group of adolescent girls about nutritional risks at this life stage. When developing this presentation, the nurse integrates knowledge about which of the following?
Adolescent girls usually do not consume enough foods that are high in iron. Explanation: Adolescent girls are at a particular nutritional risk because iron, folate, and calcium intakes are below recommended levels and they are a less physically active group compared to adolescent boys. Over the past 20 years, the rate of obesity in adolescents (boys and girls) has increased at an alarming rate
A nurse is conducting a physical assessment of a patient with a cardiac murmur. Which technique would the nurse most likely use to assess the murmur?
Auscultation Explanation: Auscultation would be used to assess the sounds created by a cardiac murmur. Inspection is used to assess skin color, symmetry, pulsations, lesions, and body movements. Palpation is used to assess body structures not visible, such as the liver, bladder, and spleen. Percussion is used to assess the density of underlying organs and tissues.
A nurse determines that a patient has poor nutrition based on which assessment finding?
Beefy-red tongue Explanation: Signs of poor nutrition include a beefy-red tongue, palpable thyroid gland, pale eye membranes, and flaccid, poorly toned, wasted, or underdeveloped muscles.
A patient arrives at the clinic for an evaluation. This is the first time the patient is being seen. Which information would the nurse need to obtain first? .
Biographical data Explanation: Since this is the first visit for the patient, the nurse needs to obtain biographical infomration to hlep put the patient's health history into context. Once this information obtained, then the nurse would go on to gather information about the patient's chief complaint, present health concern, and past health history
Which one the following areas for assessing the patient profile should be addressed after the others?
Body image Explanation: The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal. Educational level is relatively impersonal and readily revealed by the patient. Occupation is relatively impersonal and readily revealed by the patient. Housing, religion, and language are relatively impersonal and readily revealed by the patient
Which is the last area to be addressed when assessing the patient profile?
Body image Explanation: The patient is often less anxious when the interview progresses from information that is less personal to information that is more personal. Educational level, occupation, housing, religion, and language are relatively impersonal and readily revealed by the patient
A nurse is preparing to conduct a health assessment with a 78-year-old man who wears a hearing aid in his left ear. The patient is accompanied by his wife. Which of the following would be most appropriate?
Check to make sure that the patient has his hearing aid turned on and in place in his left ear. Explanation: When obtaining information from an older adult with a hearing deficit, the nurse should make sure that the patient's hearing aid is turned on and in place in the appropriate ear. The patient should be positioned so that he can read lips and facial expressions to augment verbal communication. Distracting noises should be kept to a minimum. Keeping the door open would increase the chances of distracting noises and could violate privacy. There is no need to direct the interview to the patient's wife just because the patient has a hearing deficit.
A nurse is obtaining family history from a patient. Which of the following would be LEAST helpful to use when documenting this information?
Checklist Explanation: When recording the family history, family trees, genograms, and pedigrees are most helpful. Checklists are helpful when documenting a review of systems.
While collecting the client profile information, the client admits to crying everyday after working 8 hours in a factory. This finding reflects what part of the profile?
Coping strategies Explanation: Present coping strategies are included in a profile category of stress and coping responses collected during the client interview. The profile is important to the chief complaint and the client's ability to deal with healthcare issues and how a client may response to health problems
During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches. Based on this finding, which of the following is a priorty intervention?
Educate the client regarding her increased risk for hypertension and diabetes. Explanation: A waist circumference greater than 35 inches for a woman indicates excess abdominal fat. Those with an increased waist circumference are at risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation. It is necessary at this time to educate the client about her risks for such health deviations.
Which of the following is important for the nurse to consider during the preinterview period with an adult?
Establish rapport with the patient and family members Explanation: The pre interview period determines the direction of the interview process. The nurse should start by establishing rapport with the patient and family members and ensuring that the client is comfortable. During the introduction, the nurse should address the patient by his or her surname. The nurse should avoid tiring older patients by allowing rest periods during the physical examination and should also keep the room warm and free from drafts.
Nursing students are reviewing information about the MyPyramid recommendations for food intake. The students demonstrate a need for additional review when they identify which of the following as one of the five major food groups?
Fats Explanation: MyPyramid divides foods into five major groups: grains, vegetables, fruits, milk products, and meat and beans. Fats and oils are not one of the five groups but the MyPyramid does address the need for moderation in eating them
Which of the following is the reason for the nurse to be empathetic when caring for a patient? ups.
Helps become effective while remaining detached Explanation: Empathy helps the nurse become effective in providing for the patient's needs while remaining detached. In the role as an educator, the nurse avoids giving advice, reserves the right of each person to make his or her own choices, shares information on potential alternatives, and supports the patient's ultimate decision. Typically, the nurses have all the information about health services available in the community. Such information empowers patients to become involved with self-help gro
Which of the following is the reason for the nurse to be empathetic when caring for a patient?
Helps become effective while remaining detached Explanation: Empathy helps the nurse become effective in providing for the patient's needs while remaining detached. In the role as an educator, the nurse avoids giving advice, reserves the right of each person to make his or her own choices, shares information on potential alternatives, and supports the patient's ultimate decision. Typically, the nurses have all the information about health services available in the community. Such information empowers patients to become involved with self-help groups.
A diagnostic finding that is unrelated to nutritional deficiency is which of the following?
High serum albumin Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. A lower than normal 24-hour urine creatinine may indicate loss of lean body mass and protein malnutrition. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding
A student nurse walks into a patient's room and observes the patient chanting and holding his rosary. The patient pauses and asks the student nurse to join hands while he prays. What is the best action for the student nurse to take?
Join hands with the patient and remain at the bedside until the patient finishes the prayer. Explanation: It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. Leaving the room based on the nurse's spiritual beliefs does not convey respect for the patient. It is within the scope of the nurse to support the patient's request for prayer and conveys respect for the patient's spirituality. The patient needs to remain in control of the prayer, speaking it as he or she is accustomed to doing it.
A nurse is conducting a health assessment and interviewing a patient. Which of the following would be MOST appropriate for the nurse to do?
Listen carefully to the patient's responses. Explanation: When communicating with a patient during a health history, it is important for the nurse to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient's responses. Technical terms should be avoided. The health history involves asking questions about sensitive issues such as sexuality. As such, the nurse needs to develop trust and rapport with the patient and approach the topic with sensitivity, using an orienting question or statement to begin the discussion.
While assessing a client's abdomen, the nurse percusses a dull sound, not the expected tympany. Upon further reflection, the nurse realizes she has assessed what?
Liver Explanation: The assessment technique of percussion produces sounds based on the density of the underlying structure. Certain densities produce sounds as percussion notes. Percussion of the liver produces a dull sound, while percussion over the air-filled stomach produces tympany.
Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?
Liver Explanation: There are two palpation techniques: light and deep. In light palpation, the examiner uses one hand to feel superficial contents. An examiner uses both hands for deep palpation to examine the liver or kidneys
A client has monthly laboratory tests done. The nurse notes a decrease in the albumin level. What condition in the client's history could alter the albumin level?
Liver disease Explanation: Albumin levels are used as measures of protein in adults. Albumin systhesis depends on normal liver function. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss.
While reviewing a client's records, the nurse notes a reduction in weight of 15 pounds over the last month without dieting. What factor may be associated with this possible nutritional deficit?
Losing a spouse and only child in an accident 2 months ago Explanation: Depression can cause loss of appetite as well as desire for social interaction. Clients experiencing life changing events such as the death of loved ones often experience depression and loss the desire to eat or cook, which can lead to weight loss.
Which nursing measure should be considered when performing a physical examination on a patient using the inspection technique? .
Maintain standard precautions Explanation: The nurse should ensure adequate lighting and provide a warm room for the examination and should maintain standard precautions. It is not essential for the patient's family member to be present during the physical examination. The nurse should also maintain the patient's privacy
A nurse identifies a nursing diagnosis of "Anxiety related to hospitalization and uncertainity about diagnostic test results." Which of the following actions by the nurse will be an attempt to decrease client anxiety?
Maintaining eye contact and carefully listening to client responses and concerns Explanation: Clients seeking health care are often anxious. The nurse can reduce anxiety by attempting to establish rapport through honest communication, making eye contact, and listening carefully.
A nurse is percussing a patient's abdomen. The nurse understands that which sound indicates tissue with the LEAST density?
Tympany Explanation: Percussion sounds reflect tissue density. The sequence of sounds proceeding from least to most dense are tympany, hyperresonance, resonance, dullness, and flatness.
Hyperresonance is audible when which area is percussed?
Over-inflated lung tissue Explanation: Hyperresonance is audible when over inflated lung tissue is percussed, such as in a person with emphysema. Percussion over the liver produces a dull sound. Percussion of the thigh produces a flat sound. Tympany is the drumlike sound produced by percussing the air-filled stomach.
Which of the following is considered the "fifth vital sign"?
Pain Explanation: The "fifth vital sign" is considered pain. Speech, strength, and posture are important assessment parameters, but none of these is considered the fifth vital sign.
When taking a health history, which of the following would most likely be the primary source of information?
Patient Explanation: In most instances, the patient is the informant unless the patient is developmentally delayed, mentally impaired, disoriented, confused, unconscious, or comatose. In these cases, another individual close to the patient would provide the necessary information. The nurse could collect additional data from the referring physician and the medical record, but these would not be the primary sources of information
A male client in a wheelchair comes in for his yearly physical examination. He is unable to stand. The nurse retrives the wheelchair scale to obtain an accurate weight. The nurse understands the importance of this assessment with this client. What is the nurse's reasoning for obtaining an accurate weight?
People with disabilities have an increased incidence of obesity. Explanation: Many clients with disabilities report that they have not been weighed for years because they cannot stand during weighing. Alternative methods such as use of a wheelchair scale is important, because there is an increased incidence of obesity in clients with disabilities.
While performing the physical examination, the nurse determines that a patient has an area of consolidation in the lungs suggesting pneumonia. Which technique would the nurse most likely have used to obtain this finding?
Percussion Explanation: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. It also can be used to locate a consolidated area caused by pneumonia. Inspection reveals characteristics such as color, lesions, edema, symmetry, and pulsations. Palpation is used to examine body structures not visible. Auscultation reveals sounds created by the movement of air or fluid. With pneumonia, lung sounds may be altered as the air moves through the consolidated area
While performing the physical examination, the nurse determines that a patient has an area of consolidation in the lungs suggesting pneumonia. Which technique would the nurse most likely have used to obtain this finding? .
Percussion Explanation: Percussion allows the examiner to assess normal anatomic details such as the borders of the heart and the movement of the diaphragm during inspiration. It also can be used to locate a consolidated area caused by pneumonia. Inspection reveals characteristics such as color, lesions, edema, symmetry, and pulsations. Palpation is used to examine body structures not visible. Auscultation reveals sounds created by the movement of air or fluid. With pneumonia, lung sounds may be altered as the air moves through the consolidated area
Which method of physical examination refers to the translation of physical force into sound? .
Percussion Explanation: Percussion translates the application of physical force into sound. Palpation refers to examination by nonforceful touching. Auscultation refers to the skill of listening to sounds produced within the body created by movement of air or fluid. Manipulation refers to the use of the hands to determine motion of a body part
Which method of physical examination refers to the translation of physical force into sound?
Percussion Explanation: Percussion translates the application of physical force into sound. Palpation refers to examination by nonforceful touching. Auscultation refers to the skill of listening to sounds produced within the body created by movement of air or fluid. Manipulation refers to the use of the hands to determine motion of a body part.
During a physical examination, the nurse finds that a client has thin, dry hair with flaky skin, recessed gums, and ridged, brittle nails. The nurse can conclude what from these data?
Poor nutritional status Explanation: The state of nutrition is often reflected in a person's appearance. Hair, teeth, nails, and skin can serve as indicators of general nutritional status and intake of specific nutrients. Indicators of good nutrition in the hair include that it is shiny and firm, not dry and thin. Flaky skin can be a sign of poor nutrition. Nails indicating good nutrition are firm and pink, not brittle and ridged. Recessed gums are seen with poor nutrition.
The emergency department (ED) nurse conducting an abdominal assessment demonstrates the proper abdominal assessment in which of the following scenarios?
Protects patient privacy while visually inspecting the abdomen, warms the stethoscope prior to listening for bowel sounds, using the fingertips lightly palpates the four abdominal quadrants, and taps the four abdominal quadrants. Explanation: The proper sequence for the abdominal assessment is inspection, auscultation, palpation, and percussion. When the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering bowel sounds.
The nurse using the assessment technique depicted in the accompanying image realizes that the following factor most strongly influences the success of the results:
Quick striking Explanation: Percussion translates the application of physical force into sound. The principle is to set the client's body into vibration by striking it with a firm object. The examiner uses the middle finger of one hand to strike the terminal phalanx of the middle finger of the other hand, which he or she places firmly against the client's body. The action is to be sharp and brief to produce a resonant tone.
During the health history, a client is making conflicting statements and has difficulty focusing. Which nursing action would be most appropriate? spouse.
Redirect the questions of concern to the client's spouse for clarification. Explanation: The informant providing the health history may not always be the client. Examples include mentally impaired, disoriented, confused, or developmently delayed clients. The nurse must make a clinical judgement about the reliability of the information from the client. If the information is conflicting and the client cannot focus during the health history, the nurse must gather the information from another reliable source, such as a
A patient with chronic obstructive pulmonary disease (COPD) visits the health care center with breathing difficulties. It is observed that during coughing bouts, the patient sits up in a tripod position to breathe. During inspection, the nurse notes that the patient has developed a barrel-shaped chest. Which part of the patient profile relates to the patient's view of himself or herself and the impact of COPD? on's overall ability to handle stress.
Self-concept Explanation: Self-concept, a person's view of himself or herself, is an image that develops over many years. Self-concept can be threatened very easily by changes in physical function or appearance related to the impact of certain medical conditions such as COPD. Biographical information includes the person's name, address, age, gender, marital status, occupation, and ethnic origins. The chief complaint is the issue that caused the patient to seek the care of the health care provider but does not address the patient's view of himself or herself. Past coping patterns and perceptions of current stresses and anticipated outcomes are explored to identify the pers
The nurse is preparing the patient file for a female patient with HIV who does not exhibit any chronic signs or symptoms. Her infection is in the second, or asymptotic, stage at present. The nurse knows it is the professional and clinical responsibility of the nurse to discuss issues of sexuality with the patient as part of the patient profile. Which of the following scenarios demonstrates that the nurse understands what the best method is to obtain information related to sexuality?
State near the end of the interview, "Some patients with HIV are worried about future sexual relationships." Explanation: Collecting written information is important; however obtaining the verbal sexual history provides an opportunity to discuss sexual matters openly and gives the patient permission to express sexual concerns to an informed professional. Interviewers are frequently uncomfortable with such questions and ignore this area of the patient profile or conduct a very cursory interview about this subject. The nurse needs to assure the sexuality assessment is addressed. It is within the scope of nursing to obtain the sexual history. Sexual assessment can be approached at the end of the interview, at the time interpersonal or lifestyle factors are assessed. Direct questions are usually less threatening when prefaced with introductory statements.
A client being discharged from the healthcare facility will be receiving home care services. The home care nurse will assess the incision and complete a dressing change. What other aspects of assessment will be necessary for the home care nurse to perform?
Steps in the house and the client's support system Explanation: During the home visit, assessment is not limited to physical assessment of the client. Other aspects of assessment are related to the home environment and support systems.
A client presents with intense back pain, rating it an "11" on the 0-to-10 scale. He is hunched over and reports that the pain is running down his legs. What information will the nurse inquire about while obtaining the history of the present health concern?
The client's activity just prior to the onset of pain Explanation: The history of the present problem includes such information as the date and manner in which the problem occurred, the setting in which the problem occurred, and the manifestations of the problem. Such information will help to define the problem further and determine the client's needs.
The nurse is preparing the patient file for an 8-year-old child. The child's mother informs that her daughter has difficulty breathing at night, and makes a whistling sound while sleeping. Due to Sara's age, her mother continues to provide Sara's health history to the nurse. Which of the following actions by the nurse demonstrates that the nurse understands the importance of collecting a patient's health history?
The nurse continues to collect information from Sara's mother knowing the informant will not always be the patient. Explanation: The informant, or the person providing the health history, may not always be the patient. The nurse assesses the reliability of the mother and the usefulness of the information provided. It is within the scope of the nurse to collect the health history.
The nurse observes that a patient's medical report indicates that the patient has Cushing's syndrome. During inspection, the nurse notes that his BMI is 31, his waist circumference is 40 inches, and there are localized fat pads around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the patient's care?
The nurse recognizes that the patient's obesity may be specifically related to his endocrine disorder. The nurse performs a thorough nutritional assessment. Explanation: Food records, 24-hour diet recall, and dietary education directed at weight loss do not account for the patient's medical condition as a factor in the patient's weight or nutritional status, although each method helps estimate whether or not food intake is adequate and appropriate. Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these symptoms should be studied further.
In which of the following situations is the nurse most likely to use the assessment technique, which translates the application of physical force into sound, when performing a physical examination on a patient?
The patient who presents with a respiratory rate of 22 and a productive cough and reports shortness of breath with stair climbing Explanation: The assessment technique of percussion is most beneficial in patients suspected of disease processes in the chest and abdomen. The technique of percussion translates the application of physical force into sound. It is a skill requiring practice that yields much information about disease processes in the chest and abdomen. A patient with a rash and fever is likely to be experiencing a disease process of the integumentary system; the nurse is most likely to rely on the assessment technique of inspection in this situation. Percussion is not the primary assessment technique in a musculoskeletal assessment. The symptoms of dry skin and thinning hair could be indicative of thyroid disease
During the initial physical examination, a client's pulse rate was 71 beats per minute (bpm). Four hours later on reassessment, the pulse rate was 40 bpm. How should the nurse proceed?
Thoroughly assess the client; then notify the physician. Explanation: The ability to assess a client accurately is an integral nursing skill. The nurse will use appropriate assessment skills to identify psychological problems. Unexpected changes and values that deviate from a client's normal value are to be brought to the attention of the physician.
A positive nitrogen balance indicates which of the following conditions?
Tissue growth Explanation: A positive nitrogen balance exists when nitrogen intake exceeds nitrogen output and indicates tissue growth. A negative nitrogen balance exists with fever, starvation, and burn injury.
When examining a patient's abdomen, the nurse percusses over the stomach. Which of the following would the nurse expect to elicit?
Tympany Explanation: Percussion of the stomach, an air-filled structure, would elicit tympany. Hyperresonance would be noted over an inflated lung in a patient with emphysema. Resonance would be noted when percussing over the normally air-filled lungs. Dullness would be noted when percussing the liver.
A nurse is percussing a patient's abdomen. The nurse understands that which sound indicates tissue with the LEAST density? .
Tympany Explanation: Percussion sounds reflect tissue density. The sequence of sounds proceeding from least to most dense are tympany, hyperresonance, resonance, dullness, and flatness
Which of the following questions would identify a client's chief complaint?
What brought you to the emergency department? Explanation: A chief complaint is the issue that causes the client to seek health care. It is the reason why the person comes to the health care provider.
A diagnostic finding that is unrelated to nutritional deficiency is .
high serum albumin. Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. A lower than normal 24-hour urine creatinine may indicate loss of lean body mass and protein malnutrition. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding
The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis?
low serum albumin levels Explanation: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. In addition, transferrin levels decrease in response to protein depletion. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding.
A client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination. When percussing the client's chest wall, the nurse expects to elicit:
resonant sounds. Explanation: When percussing the chest wall of a client with allergy-induced asthma, the nurse should expect to elicit resonant sounds — low-pitched, hollow sounds heard over normal lung tissue. Hyperresonant sounds indicate increased air in the lungs or pleural space; they're louder and lower pitched than resonant sounds. Although hyperresonant sounds occur in such disorders as emphysema and pneumothorax, they may be normal in children and very thin adults. Dull sounds, normally heard only over the liver and heart, may occur over dense lung tissue, such as from consolidation or a tumor. Dull sounds are thudlike and of medium pitch. Flat sounds, soft and high-pitched, are heard over airless tissue and can be replicated by percussing the thigh or a bony structure.
The nurse determines the client's temperature, utilizing palpation by
using the back of the hand. Explanation: When palpating, the nurse uses the fingertips to detect pulsations or to differentiate surfaces, the surface of the palm to sense vibrations, and the back of the hand to determine the temperature. Percussion means tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures.
When obtaining a patient profile for a patient newly diagnosed with diabetes, which of the following assessments are essential components of the genetics aspects of the health assessment? Select all that apply.
• Ask the patient to list three complications of diabetes. • Offer appropriate genetics information and resources. • Assess the patient's children for signs/symptoms of diabetes. • Obtain history of known diseases or disorders from both maternal and paternal family members. Explanation: Listing three complications of diabetes allows the nurse to assess the patient's understanding of the disease process. Offering appropriate genetics information and resources is indicated in this situation. Referral for risk assessment when a hereditary disease or disorder is present so the family can discuss inheritance risk with other family members is appropriate. Information should be obtained about both maternal and paternal sides of family for three generations. Nutritional counseling is dependent on an individualized nutritional assessment
Assessment of a female client reveals a waist circumference of 37 inches. Based on this finding, the nurse develops a teaching plan for the client to reduce her risk for which of the following? Select all that apply.
• Cardiovascular disease • Hypertension • Diabetes Explanation: A waist circumference greater than 35 inches in a woman indicates excess abdominal fat, placing her at increased risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation. Risks for chronic lung and Parkinson's diseases are not associated with increased waist circumference.
A community health nurse goes on a first home visit to complete a home safety assessment. Which of the following components will be part of the nurse's home safety assessment? Select all that apply.
• Hard wood floors in the dining room • Motion light on the porch • ABC fire extinguisher in the kitchen pantry Explanation: The home nurse would check the exterior and interior physical facilities and identify any safety hazards (eg, lighting and flooring concerns) and check for safety measures (eg, fire extinguisher). The nurse would not focus on the type of milk the client uses and would not be concerned about exercise equipment.
During a health history, a new nurse wants to make sure to include all components. Which of the following components should the nurse include? Select all that apply.
• Marital status • Childhood illnesses • Current medications Explanation: The health history is a series of questions used to provide an overview of the current health status of the client. Components include biographical data, chief complaint, past health history (including current medications), family history, and past life events that relate to health.
A nurse is performing a physical assessment of a patient. When conducting the initial observations, which of the following would the nurse be LEAST likely to include? Select all that apply.
• Percussion of the lungs • Palpation of the abdomen Explanation: When performing initial observations, the nurse would assess posture, body movements (for abnormalities and asymmetry), nutritional status, speech pattern and vital signs, including auscultation of blood pressure. Lung percussion and abdominal palpation are done later in the assessment.
When assessing a client who has a draining wound, the nurse would be alert for which of the following nutritional consequences? Select all that apply.
• Protein loss • Electrolyte loss • Mineral loss • Inadequate fat intake Explanation: A client with a draining wound would be at risk for losses of protein, electrolytes, and minerals. Caloric and fat intakes would not necessarily be affected
A very thin woman seeks medical care. During assessment of this client, the nurse determines the need for a nutritional assessment. Which of the following components will the nurse include in this assessment? Select all that apply.
• Ratio of body weight and height • Oral mucosa • Thyroid gland Explanation: Nutritional state is often reflected in a client's appearance. Assessment of nutritional status provides information about weight loss, malnutrition, and nutrient deficiencies. Components of the nutritional assessment include body mass index (ratio of body weight and height), biochemical assessment, and physical examination of hair, teeth, oral cavity, thyroid gland, skeletal muscles, and abdomen.
The Health Insurance Portability and Accountability Act (HIPAA), passed in 1996, established national standards to protect individuals' medical records and other personal health information; it applies to health plans, health care clearinghouses, and health care providers who conduct certain health care transactions electronically. Which of the following actions demonstrates an understanding of HIPAA? Select all that apply.
• The nurse informs the patient that the therapist will have access to his EMR. • The hospital provides a copy of the medical record to the patient. • The nurse allows the patient to view his or her electronic medical record (EMR) at the bedside. • The patient requests a correction to the medical record on file. Explanation: HIPAA includes the rights of patients to obtain and examine a copy of their health records, and to request corrections. HIPPA provides the patient the right to know why requested information is sought and how it will be used. The act requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information. Sharing patient information with the patient's son or daughter or sharing computer passwords is a violation of this privacy.
