Chapter 28 Health Assessment

The nurse wants to assess a client's 5th cranial nerve. What approach should be used? palpate the jaw for areas of pain or tenderness stroke each side of the cheek with a cotton wisp ask the client to puff out the cheeks ask the client to frown

stroke each side of the cheek with a cotton wisp

Prior to conducting a mental status exam with a client who has a diagnosis of depression, the nurse can obtain which information by observing the client? perceptions grooming posture affect orientation

grooming affect posture

The nurse is beginning a complete assessment of a client. What should be included as part of the general survey? facial expression ambulatory status height and weight skin temperature

height and weight

Two body systems that may be logically integrated and assessed at the same time are the eye and ear exams. ear and nose exams. ear exam and cranial nerves IV, VI, and VIII. eye exam and cranial nerves II, III, IV, and VI.

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

What type of assessment would the nurse perform when assessing pain after medicating? Focused Shift Comprehensive Urgent

Focused

A nurse has completed a comprehensive nursing health history of the client and now is beginning the physical assessment. Which assessment should the nurse perform first? General survey Eye assessment Skin assessment Mental status examination

General survey

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes? Head and face Neck Anterior chest Arm, hands, and fingers

Arm, hands, and fingers

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen? Enlargement of the liver Irregularities of the spleen Abdominal reflex Abnormalities of the aorta

Abdominal reflex

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding? Ask for the client's permission to perform the assessment Uncover only the part being examined, covering everything else Decide whether to alter the process of starting at the head and proceeding to the feet Ask if the client wants an observer for the assessment

Ask for the client's permission to perform the assessment

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.) Call bell within reach Bed at mid-level, locked position Correct tubes and drains intact Correct intravenous lines and fluids Wearing client identification bracelet

Call bell within reach Correct tubes and drains intact Correct intravenous lines and fluids Wearing client identification bracelet

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.) Common symptoms Family history Visualized signs Auscultated sounds Risk factors

Common symptoms Family history Risk factors

The client has decreased sensation in his legs. What additional assessment should the nurse include? Fall Sepsis Bloodstream infection Surgical site

Fall

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. Weber's test does which of the following? Measures hearing acuity at various sound frequencies. Tests air conduction of sound in the tested ear. Compares air versus bone conduction sound. Determines the equality or disparity of bone-conducted sound.

Determines the equality or disparity of bone-conducted sound

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's: Judgement and insight Health maintenance Level of consciousness Coping skills

Level of consciousness

The nurse identifies during assessment that the client is at risk for the development of pressure ulcers. What findings did the nurse identify? Select all that apply. Pain Moisture Altered sensory perception Warmth Poor nutrition

Moisture Poor nutrition Altered sensory perception

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? Center of the head. On the mastoid area. Near the ear canal. Behind the client's head.

On the mastoid area

When assessing the abdomen, which assessment technique is used last? Inspection Percussion Auscultation Palpation

Palpation

A nurse is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment? Bladder scanner Syringe Doppler ultrasound Pen light or flashlight

Pen light or flashlight

When doing a shift assessment on a new client, the nurse notes that the popliteal pulses are within normal limits (WNL). How would the nurse chart this? Popliteal pulses 1-2+ Popliteal pulses 2-3+ Popliteal pulses 4+ Popliteal pulses 3-4+

Popliteal pulses 2-3+

The nurse is assessing the upper extremities of the client. What pulses should be assessed? Select all that apply. Pedal Femoral Radial Brachial Popliteal

Radial Brachial

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client? Peform the Weber test. Conduct the Romberg test. Re-assess as needed. Refer for opthamologist consult.

Re-assess as needed

During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment? Stand behind the patient and palpate the sides of the trachea. Auscultate over the patient's trachea while asking the patient to hold his or her own breath. Observe the midline of the patient's neck while asking him or her to bear down. Lightly percuss slightly off midline over the patient's trachea.

Stand behind the patient and palpate the sides of the trachea

When collecting subjective data, the nurse gives the client time and encouragement to do what? Tell stories about his or her family Express complaints Tell about the client's concerns List common findings

Tell about the client's concerns

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique? A assess the sounds from the heart, lungs, and abdomen. To check the skin temperature and moisture. To observe specific parts for normal or abnormal characteristics. To determine the density of underlying structures.

To check the skin temperature and moisture

Before beginning a physical assessment it is important for the nurse to explain to the client the purpose of every physical assessment technique you will be using. explain to the client in detail how each body system will be assessed. acquire your client's verbal permission to perform the physical examination. acquire your client's written permission to perform the physical examination.

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

When should the nurse assess the costovertebral angle for tenderness? during percussion of the abdomen after assessing the posterior thorax while assessing range of motion of the spine before palpating the lower pole of the left kidney

after assessing the posterior thorax

The nurse is conducting a cephalic to caudal assessment with a newly admitted client. Why should the nurse compare findings from side to side? identify problems compare with the medical record determine symmetry validate findings

determine symmetry

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information? apical heart rate presence of cyanosis respiratory rate edema of the face and limbs

edema of the face and limbs presence of cyanosis respiratory rate

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position? elbow flexion hip adduction knee extension hip abduction

elbow flexion

While conducting a physical examination with the client in the seated position, the nurse begins the cardiovascular assessment. In order to listen for aortic insufficiency, the nurse should ask the client to move into which position? prone lean forward standing supine

lean forward

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination? percussion for abdominal sounds light palpation of each quadrant auscultation of bowel sounds light stroking inward from all quadrants

light stroking inward from all quadrants

The nurse is seeing a client with a recent history of exposure to a family member who has influenza. The client reports a throbbing toothache when bending forward. Which assessment should the nurse be sure to include in the physical examination? asking the client to smell coffee beans palpation of the thyroid palpation of the sinuses assessing the heart sounds with the client in a lateral position

palpation of the sinuses

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves? Just after the general survey Just before the rectal assessment Just before the mouth and throat assessment Just after the mental status examination

Just before the mouth and throat assessment

When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that apply.) Stick out tongue Smile Frown Close eyes Raise eyebrows

Raise eyebrows Frown Smile Close eyes

A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply. Discuss the purpose and importance of the health history with the client Explain that the client will need to change into a gown Acquire the client's permission to ask personal questions Validate and document assessment findings Formulate nursing diagnoses Explain your respect for the client's privacy and for confidentiality

Discuss the purpose and importance of the health history with the client Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and for confidentiality Explain that the client will need to change into a gown

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed? State's nurse practice act Hospital policy Supervising physician Federal law

State's nurse practice act

The client has a Foley catheter. What should be assessed related to catheter that may alert the nurse to an infection? Select all that apply Odor Pain In place greater than 2 days Temperature Color

Temperature Odor Color Pain

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply. Blood pressure 124/72 Documented or suspected infection Respiratory rate 36 breaths per minute Temperature greater than 102 °F (38.9 °C) Heart rate 75 beats per minute Altered mental state

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

The nurse has palpated a patient's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted? The patient shows no signs of a circulatory health problem. The patient has increased radial pulses that may result from hypertension. The patient has normal peripheral pulses. The patient's weak pulses may be indicative of cardiovascular disease.

The patient's weak pulses may be indicative of cardiovascular disease

The nurse is assessing the head and neck areas of an adult client and discovers several abnormal findings. Which assessment finding requires priority nursing care? Distended jugular veins. Tracheal deviation. Immobile, tender lymph nodes. Reduced carotid pulses.

Tracheal deviation

The nurse suspects that a client has an infection of the lower leg. What skin assessment finding caused the nurse to make this clinical determination? Select all that apply. Pallor Warmth Increased tenting Erythema Jaundice

Warmth Erythema

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the hand rails of the bed. Which response by the nurse is best? "We can take a break anytime." "Let's stop and take your vital signs." "Let's stop; I have all of the information we need." "Keep taking deep breathes; you will be okay."

We can take a break anytime

During the general survey a client comments about the extremely cold weather even though the client lives in a major northeastern United States city and the month is July. What action should the nurse take? adjust examination room temperature measure body temperature offer a blanket assess mental status

assess mental status

When integrating the total physical examination the nurse should assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. perform the Mental Status Exam after examining all other body systems. integrate the rectal examination with the abdominal examination. assess peripheral vascular status when examining the lower extremities.

assess peripheral vascular status when examining the lower extremities

The nurse is preparing to assess a client's anterior thorax. In which position should the client be placed to assess the heart? standing sitting supine right lateral

sitting