Chapter 25: Health Assessment
A nurse is teaching a young female client about breast cancer prevention. The client asks at what age does she need 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." "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." "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." 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.
A community nurse is participating in a health promotion fair and has been asked by a middle-aged woman about the necessity of breast self-examination BSE. How should the nurse respond to the woman's inquiry? "Breast self-examination is the single most valuable tool in the fight against breast cancer." "Breast self-examination is a useful practice, but it is only recommended for women 65 years and older." "Breast self-examination used to be recommended for all adult women, but new recommendations limit it to women of childbearing age." "Breast self-examination may have some benefit, but it is no longer a recommended screening activity."
"Breast self-examination may have some benefit, but it is no longer a recommended screening activity." In November 2009, the U.S. Preventive Services Task Force made the controversial recommendation that teaching BSE is unnecessary because there is no net benefit.
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? "What brings you here today?" "Are you having any pain?" "What medications do you normally use?" "Do you have any allergies?"
"What brings you here today?" 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 is perfect; you can read the entire chart and you do not need glasses." "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 in your right eye is slightly different than that of your left eye." "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)." The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see. 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.
The nursing student is assessing a patient who is recovering in hospital from a stroke. The nurse determines that the patient opens his eyes when she speaks to him and that he obeys the student's commands and follows her cues. The patient identifies himself by name and knows where he is but does not know the month or the year. The student would document what score on the Glasgow Coma Scale (GCS)? 9 11 13 15
13 Eye opening to voice is worth 3 points on the GCS and obeying commands is worth 6 points. Incorrect knowledge of the month and/or year constitutes a confused verbal response and 4 points.
During assessment of the lower extremities, the nurse notes 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? bilateral lower extremities within normal limits 1+ pitting edema noted on bilateral lower extremities 2+ pitting edema noted on bilateral lower extremities brawny edema noted over bilateral lower extremities
2+ pitting edema noted on bilateral lower extremities 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.
What percentage of weight change in 6 months is considered abnormal? 1% 2% 5% 10%
A 10% change in weight in 6 months is considered abnormal.
A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol abuse. 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? 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. Nothing. The nurse shouldn't alarm her unnecessarily.
Ask the client if she has noted any blood in her stools lately. 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 that would not elicit information specifically related to the rectal bleeding.
The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment? Warm the equipment. Ask the client to empty her bladder. Place the client in a semi-Fowler's position. Measure height and weight.
Ask the client to empty her bladder. Before palpating or percussing the abdomen, the client should empty her bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.
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? Document a normal skin finding on the client chart. Assess the client for cardiovascular disorders. Report the finding as a positive sign for cystic fibrosis. Assess the client for dehydration.
Assess the client for dehydration. 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 nursing student is conducting a patient's focused cardiovascular assessment and notes that the patient's jugular venous pressure is 4.5 cm at the sternal angle. What is the student's most appropriate response? Document this expected finding. Reposition the patient and reassess in 15 minutes. Assess the patient for other signs of fluid overload. Assess the patient for chest pain or peripheral cyanosis.
Assess the patient for other signs of fluid overload. JVP of 4.5 cm is an unexpected finding and is suggestive of right-sided heart failure and consequent fluid overload. Reassessment is not normally necessary, and fluid overload is not closely associated with chest pain.
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next? Palpate the abdomen. Auscultate the abdomen. Measure abdominal girth. Percuss the abdomen.
Auscultate the abdomen. 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 is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use? Auscultation Palpation Percussion Inspection
Auscultation 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 INSPECTION refers to observing.
Assessment of a client's bowel sounds is best obtained by performing which assessment technique? Auscultation Inspection Palpation Percussion
Auscultation Auscultation is the act of listening with a stethoscope to sounds produced within the body, and will provide the nurse with assessment data related to bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner using visual, auditory, and olfactory senses. Palpation is an assessment technique that uses the sense of touch. Percussion is the act of striking one object against another to produce a sound.
A nurse assesses a client for blood pressure. Which technique would be used for this assessment? Inspection Palpation Percussion Auscultation
Auscultation Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.
The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider? Auscultation of a bruit Percussion of tympanic sounds over the intestines Auscultation of peristalsis sounds Percussion of dull sounds over the right upper quadrant
Auscultation of a bruit A bruit on auscultation suggests an aneurysm or arterial stenosis. Auscultation- the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis. Percussion is a method of tapping on a surface to determine the underlying structure, and is used in clinical examinations to assess the condition of the thorax or abdomen. four types of percussion sounds: resonant, hyper-resonant, stony dull or dull
Which framework is used during the focused assessment? Functional health assessment Head-to-toe framework Conceptual framework Body systems framework
Body systems framework Body systems approach is used during the focused assessment of an acutely or critically ill client to determine function of a particular body system.
A nurse's assessment of a community-dwelling adult reveals the presence of bilateral pitting edema to the patient's lower legs and feet. Which of the following systems assessments should the nurse consequently prioritize? Cardiovascular assessment Neurological assessment Musculoskeletal assessment Gastrointestinal assessment
Cardiovascular assessment Edema is often associated with cardiovascular dysfunction such as venous insufficiency or congestive heart failure. As a result, a focused cardiovascular assessment is indicated. There is no obvious need to assess the patient's neurological, GI, or musculoskeletal function in patients with edema.
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. Check the client's ear canals for cerumen. Use facial expressions and sign language to communicate. Speak to the elderly client in a high-frequency tone of voice.
Check the client's ear canals for cerumen. Ear wax (cerumen) becomes drier in the elderly 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 the elderly who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for the elderly.
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 states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Client describes shortness of breath and increased sputum production. 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." The client's reason for seeking care should always be stated in the client's own words.
A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse? Complete an assessment. Contact the healthcare provider. Review the client's past medical records. Assist the client with activities of daily living.
Complete an assessment. Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection, which include interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can also use the client's medical record and contact other healthcare providers.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? Inflammation Arthritis Crepitus Fremitus
Crepitus Problems with the temporomandibular joint include pain or a grating feeling called crepitus. Fremitus is a vibration transmitted through the body.
A nurse performs an integumentary assessment of a client and documents the following: 5/27/16: Examined skin of Mr. Williams. Client is a white, 56-year-old male who reports a history of emphysema. Skin coloring is bluish gray. What is the term for this change in skin color? Jaundice Erythema Pallor Cyanosis
Cyanosis Cyanosis is a bluish or grayish tinge caused by inadequate oxygenation. Jaundice is a yellow color resulting from liver and gallbladder disease. Erythema is a reddish color associated with sunburn, inflammation, allergies, trauma, and fever. Pallor is a white color caused by inadequate circulation of the blood.
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? Suspect an inflamed pleura rubbing against the chest wall. Document normal breath sounds. Recommend testing for pneumonia. Assess for asthma.
Document normal breath sounds. 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? Each lub-dub is one beat. Each lub-dub is two beats. Heart sounds are caused by the opening of heart valves. The lub-dub sounds occur within 2 seconds of each other.
Each lub-dub is one beat. 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.
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 Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history
Evaluate the blood pressure and pulse 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 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 which of the following? Erosion Ulcer Fissure Crust
Fissure 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.
During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this? Focused assessment Spiritual assessment Social assessment Comprehensive assessment
Focused assessment Often, nurses must select the most important interviewing questions or assessment techniques to use, and perform a focused health assessment based on the client's problem.
A nursing student is caring for an older adult who has a diagnosis of kidney failure. Recognizing the patient's risk for fluid overload, the nurse student weighs the patient and measures her abdominal girth to compare the values to those recorded yesterday. This student is most clearly demonstrating what type of assessment? Emergency Problem-centered Follow-up Comprehensive
Follow-up The follow-up assessment allows the nurse to compare the patient's current state to his or her previous health status. The fact that the student made a comparison to preexisting data categorizes this as a follow-up assessment, despite the fact that it was focused on a specific problem. A comprehensive assessment has a much broader scope, and an emergency assessment addresses an acute and immediate threat to health.
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 Percussion, auscultation, inspection, palpation Inspection, auscultation, percussion, palpation Inspection, percussion, auscultation, palpation
Inspection, auscultation, percussion, palpation 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.
A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention? Assess capillary refill. Measure the pulse oximetry. Assess fluid intake. Limit the client's activity.
Measure the pulse oximetry. The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.
A client has been reporting persistent headaches. Which is an example of subjective data? Temperature is 104.1°F (40.05°C) The client appears lethargic. Pain is 4 out of 10 on a pain scale. The client is alert and oriented to person, place, and time.
Pain is 4 out of 10 on a pain scale. Communicating the client's pain level is only something the client can state and validate. Subjective data are those symptoms, feelings, perception, preferences, values, and information that only the client can describe. The rest of the options can be directly observed or measured and are known as objective data.
A nursing student is assessing a patient who has a history of peripheral vascular disease and who is being treated for a venous ulcer on his ankle. The student has asked the patient about his symptoms and has carefully inspected the man's lower legs. What action should the student next perform? Assess range of motion in the patient's lower legs. Assess the patient's strength in his lower legs bilaterally. Palpate the patient's lower legs and peripheral pulses. Measure the patient's blood pressure at his thighs.
Palpate the patient's lower legs and peripheral pulses. Palpation normally follows inspection. In a patient with peripheral vascular disease, strength and range of motion are not usual focuses of assessment. There is no need to assess blood pressure in the patient's thighs.
A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? Auscultation Inspection Palpation Percussion
Palpation 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.
The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? Palpation Percussion Auscultation Inspection
Palpation The thyroid gland is assessed by palpation, although it is not normally palpable in some clients.
The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? Palpation Inspection Percussion Auscultation
Palpation 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 of the following actions, if observed, would require the charge nurse to intervene? Palpation of both carotid arteries at the same time Insertion of an otoscope into the client's ear canal Assessment of the red reflex using an ophthalmoscope Occlusion of one of the client's nares while the client breathes through the nose
Palpation of both carotid arteries at the same time Palpation of both arteries at once can obstruct blood flow to the brain.
Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as? Ptosis Entropion Ectropion Miosis
Ptosis 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 EXTROPION MIOSIS is constriction of the pupil, which is often caused by medications.
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. Stop lifting the client and reassess him. 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 reassess him. 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.
A nursing student is conducting an older adult patient's musculoskeletal assessment and it becomes newly apparent that the patient has impaired balance. What is the student's best response to this assessment finding? Reassure the patient that this is an expected age-related physiological change. Stop the assessment and report this finding to the primary care provider. Provide the patient with a snack and a drink and then reassess. Immediately place the patient on enforced bed rest.
Stop the assessment and report this finding to the primary care provider. Lack of balance should be reported to other members of the care team, especially if this is a new finding. This is not necessarily an age-related change, especially if it has a new onset. It is beyond the student's scope of practice to determine that a patient requires bed rest.
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 makes noises when he breathes. The client complains of thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia.
The client makes noises when he breathes. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Complaints 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 eyes do not converge when the nurse moves a finger toward his nose. The client's pupils are black, equal in size, and round and smooth. An older adult's pupils are pale and cloudy. The client's pupils dilate when looking at a near object and constrict when looking at a distant object.
The client's pupils are black, equal in size, and round and smooth. 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.
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 dorsum The palm The fingertips The knuckles
The dorsum 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 is performing a comprehensive assessment of a patient who has recently been admitted to the health-care facility. Which of the following statements describes the appropriate use of equipment during the assessment? The nurse uses the diaphragm of the stethoscope to auscultate for bruits over the aorta, renal arteries, and iliac arteries. The nurse uses a penlight to visualize the patient's middle and inner ear. The nurse uses the bell of the stethoscope to auscultate the patient's heart sounds. The nurse uses the stethoscope to gauge the strength of peripheral pulses.
The nurse uses the bell of the stethoscope to auscultate the patient's heart sounds. The bell part of the stethoscope is used to hear low-pitched tones such as vascular sounds (e.g., heart sounds and murmurs). Bruits are also heard better with the bell of the stethoscope than the diaphragm. Peripheral pulses are gauged by palpation, not by auscultation.
A nurse practitioner (NP) is assessing a patient's eyes and has asked the patient to move her eyes in the six cardinal directions of gaze. The NP explains to the student nurse that the patient's eyes moved in a "jerky" manner. The student should assign what significance to this assessment finding? The patient may be nervous or anxious about the health assessment. A change in the patient's medication regimen may be necessary. The patient may need to be assessed for cataracts or glaucoma. The patient may have cranial nerve deficits.
The patient may have cranial nerve deficits. Deficits in the cardinal gazes are associated with lesions in CN III, IV, or VI. This abnormal finding is not suggestive of cataracts, glaucoma, or inappropriate use of medications. Anxiety does not normally cause disruptions in the cardinal gazes.
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 tympanic membrane is translucent, shiny, and gray. The ear canal is rough and pinkish. The tympanic membrane is reddish. The ear canal is smooth and white.
The tympanic membrane is translucent, shiny, and gray. The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.
A nursing student on a medical-surgical unit is beginning a shift by performing a head-to-toe assessment of a patient who is being treated for kidney failure. What is the primary purpose of the student's assessment? To allocate time and resources efficiently and effectively To enhance the student's understanding of the patient's health To identify the patient's health needs and act on them appropriately To facilitate the patient's participation in his or her care
To identify the patient's health needs and act on them appropriately The overarching goal of assessment is to identify a patient's particular health needs and to allow the care team to address these needs appropriately. Allocation of time and resources are secondary goals. Assessment will enhance the student's understanding of the patient, but this is not the primary goal of assessment. Similarly, it is beneficial to have patients participate in their care, but this is not the main goal of the assessment process.
The client, Mrs. Rodrigquez, 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? 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.
Translators may need additional explanations of medical terms. When using a translator it is important to remember that the client still comes first. This means that all information is directed at them 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 don't understand all medical terms and may need some clarification at times.
A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require? Tuning fork Snellen chart Otoscope Ophthalmoscope
Tuning fork Weber test and Rinne test are performed in order to assess sound conduction; both require a tuning fork.
Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? Wheezes Fine crackles Pleural friction rub Stertorous breathing
Wheezes 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.
The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse? Erythema at sting site Heart rate of 100 Wheezing on auscultation Crying with burning pain
Wheezing on auscultation 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 nurse should use the bell of the stethoscope during auscultation of: a client's heart murmur. a client's apical heart rate. a client's breath sounds. a client's bowel sounds.
a client's heart murmur. The bell of the stethoscope is used to listen to LOW-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to HIGH-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.
To gather subjective data on a client's nutrition and metabolic pattern, the nurse should: weigh the client and measure his height. ask the client for a 24-hour diet recall. examine the hygiene of the client's teeth. inspect the client's abdomen for symmetry.
ask the client for a 24-hour diet recall. Interview questions that will focus a nutrition-metabolism assessment might include asking the client to disclose what he has eaten in the last 24 hours.
To assess subjective data related to a client's elimination pattern, the nurse: reviews the latest laboratory report of the urine. asks the client about changes in elimination patterns. notes the frequency, amount, and time the client voids. palpates the abdomen for pain or distention.
asks the client about changes in elimination patterns. The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.
To obtain subjective data about a newly admitted client's sleep pattern, the nurse: inspects the client's eyes for redness. asks the client what promotes sleep. documents the client's affect and yawning. determines how frequently the client naps.
asks the client what promotes sleep. The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.
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 palpation of tactile fremitus over the posterior thorax an anteroposterior to lateral ratio of 1:2 percussion of loud, hollow sounds over the lateral lung fields
auscultation of short, high-pitched popping sounds during inspiration Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure.
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. have the client turn from side to side and assess pain. have the client lay on his right side, then palpate the area. elevate the legs, bending at the knee while the client is supine.
avoid a position change that requires turning. 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: clear. blurred. clouded. 20/20.
blurred. Visual problems with close objects occur more frequently after the age of 40.
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: symptoms. review of systems. chief concern. objective assessment.
chief concern. 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.
When percussing the liver, the sound should be: resonant hyperresonant dull flat
dull The percussion of the LIVER is DULL Percussion of the ABDOMEN is TYMPANIC HYPER INFLATED lung TISSUE is hyper RESONANT NORMAL lung tissue is RESONANT bone is flat.
When percussing the liver, the sound should be: resonant hyperresonant dull flat
dull The percussion of the liver is dull. Percussion of the abdomen is tympanic hyperinflated lung tissue is hyper resonant normal lung tissue is resonant, and bone is flat.
When performing a cranial nerve assessment on an adult client, the nurse assesses the trigeminal nerve by: asking the client to smile. eliciting the client's gag reflex. having the client turn his head. eliciting the client's blink reflex.
eliciting the client's blink reflex. To assess the trigeminal or cranial nerve V, the nurse should elicit the blink reflex with a cotton swab.
During a health assessment, the nurse uses deep palpation to assess a client's: skin turgor. finger nodules. perspiration. liver.
liver. The purpose of deep palpation is to locate organs, determine their size, and detect abnormal masses.
To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the: front of the ear. mastoid process. top of the head. affected ear.
mastoid process. 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 English, the nurse should: assess the client's vital signs first. interpret the effect of deep palpation. inspect the symmetry of the facial features. observe the client's body language.
observe the client's body language. 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 person, situation, and time oriented to hospital, person, and date oriented to person, place, and time oriented to person, place, and situation
oriented to person, place, and time 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 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. liver. lymph nodes. thyroid gland.
peripheral pulses. 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.
An intensive care unit nurse reports the client's condition to the nurse on the medical unit. This is a(an): primary source. secondary source. general report. informational report.
secondary source. Secondary data sources include sources of data other than the client, such as the chart or other health care providers.
A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? whether they have anemia whether they have a program of regular physical activity whether they have proper dietary habits whether they have home maintenance skills
whether they have a program of regular physical activity Regular physical activity contributes to a person's physical and psychological well-being.