Expected findings
Breath Sounds: Bronchovesicular + vesicular
- Bronchovesicular: Esp on the right- have moderate intensity + pitch. Inspiration + expiration duration are equal -Vesicular: more intense + loud airflow in the upper anterior lobes. Softer intensity w/low pitch throughout the other lobes. Sounds like wind blowing through trees. Inspiratory sounds last longer than expiration sounds
Which of the following would be an appropriate question to collect subjective data about a client's past health history?
- Have you had any previous abdominal surgeries
Which of the following subjective questions assesses the need for STI evaluation and education?
-"How many sexual partners have you had over the past 3 months?"
Which of the following instructions should you include while teaching a client about actions to promote the health of their head and neck?
-"Use ear protection when attending a loud event" -Wear eye protection when cutting the grass" -"Wear a bike helmet if you are going to participate in a bike race" -"Limit music volume when using headphones"
Which of the following questions should ask the client when assessing for an orientation deficit?
-"What is your birthday" -"Do you know why you are here" -"Who is the president?" -"Where are you?"
For which of the following client ages would the human papilloma virus (HPV) vaccine be recommended?
-12 years old
At what age should the client who is considered to have an average risk for colorectal cancer begin screenings?
-45 years old
Which of the following is an unexpected finding that should be documented and reported to the provider?
-Abdominal distension
Which of the following are nursing interventions for chest pain?
-Apply oxygen -Provide continuous ECG monitoring -Obtain IV access
Which of the following are the risk factors for heart disease?
-BMI greater than 30 -Smoking tobacco -Family history of hypertension -Type 2 diabetes
Pupils expected findings
-Black and round
When assessing the ear, which of the following is an emergency and requires immediately contacting the provider?
-Bloody drainage from the ear following head tramuma
Which of the following assessment findings are expected when auscultating the abdomen?
-Borborygmi
For which of the following findings should you contact the provider?
-Clear one-sided nasal drainage in a client who fell down the stairs
Assess level of consciousness
-Client should look relaxed and comfortable
Which of the following are functions of the gastrointestinal tract?
-Digestion of food -Elimination of waste
Rectum + Genitourinary MON PUBIS expected findings
-Distribution of pubic hair varies. After puberty, hair should have even dis. Inverted triangle pattern, smooth, clear skin w/even color -Labia majora + labia minora will be darker than overall skin color -Client that hasn't had a vaginal delivery will appear full symmetrical w/labia meeting in midline -After vaginal delivery labia will have a open + wrinkly appearance
You are teaching a client about recommendation to prevent the occurrence of colorectal cancer. Which of the following should be included in the teaching?
-Engage in moderate exercise for 30 min per day -Achieve + maintain a weight within the recommended BMI
Which of the following conditions present w/manifestations of genital lesions?
-Genital herpes -Syphilis -Human papillomavirus (HPV)
Which of the following are expected findings during a genitourinary assessment of a male client?
-Glans visible at the tip of the penis -Scrotal skin darker than surrounding skin -Visible vein along the shaft of the penis
Which of the following conditions is associated w/jugular venous distention?
-Heart failure
Which of the following client reports indicates a medical emergency
-I have a tight feeling in my chest
A nurse is preparing education material for a client to maintain a healthy respiratory status. Which of the following information should the nurse include in the material? (Select all that apply)
-Instruct and encourage the client to obtain the influenza vaccine -Counsel the client about smoking cessation -Educate the client that hand hygiene is the first line of defense to prevent illness
Which of the following organs filters liquid waste products from the blood?
-Kidney
Mouth expected findings
-Lips should be symmetrical + smooth lips -Lips can range from pink to plum colored and typically deeper in color than the surrounding facial skin
Urethral meatus
-Loc. midline in the center of the glans. The meatus + the surrounding area should be smooth + similar in color + texture to the glans w/o any redness, swelling or discharge
Which of the following are unexpected findings during a genitourinary assessment?
-Malodorous vaginal discharge and itching near the vulva -Cervix that appears at the vaginal opening -Red, fluid-filled pocket on the inner labia
Sclera expected findings
-Moist,glossy + clear -Lighter skin = white -Darker skin tones = slightly yellow
Cardiovascular NECK expected findings
-Neck: Jugular veins will be w/o distention + observe visible pulsations in the carotid artery -Palpate neck: carotid artery pulse strength to be moderate + equal bilaterally
Neck expected findings
-No lumps or swelling visible or palpable in the neck -Skin should be the same pigmentation as other skin areas and the area should be free of contusions or lesions -Move neck freely w/o pain -Be able to swallow w/o difficulty or choking
-Ears expected findings
-Outer ear should appear symmetrical in size + placement -Color of clients ear should be the same as the client face -Skin should be intact w/ no lumps or lesions or edema
A nurse is caring for a client who is hyperventilating. The nurse should identify that which of the following circumstances can contribute to hyperventilation?
-Pain -Anxiety -Fear
Which of the following abdominal organs releases insulin to regulate blood sugar?
-Pancreas
Eye expected findings
-Parallel to another on the face + aligned in the socket w/no protrusion or sunken appearance
Rectum + Genitourinary MALE
-Penis: skin appear slightly wrinkled pubic hair can presented around genital areas -Penis will be hairless -Large dorsal vein should be noticeable on the bottom side of the shaft of penis, other vasculture can be present -Glans should be smooth
Which of the following tools are used in an assessment of the head and neck?
-Penlight -Examination gloves
Conjunctiva expected findings
-Pink + clear w/o lesions or edema, numerous small blood vessels will be visible
A nurse is assessing a client and notes minimal air movement w/the client inspirations. Which of the following should the nurse recognize as a contributing factor?
-Pneuomina -Chest trauma
cardiovascular EXTREMITIES + PERIPHERAL PULSES expected findings
-Pulses: should be symmetrical in size bilaterally w/ intact skin -Even color consistent w/body -Nail surface should be smooth + intact w/slight curve of 160* -Nail color consistent w/ skin -Hair can be think + sparse or thick + diffuse
Respiratory expected findings
-Relaxed posture either standing or sitting -No difficulty w/ respirations
Which of the following is an extra or unexpected heart sound?
-S3 -S4 -Murmur
Scrotum + Testes
-Scrotal skin usually darker than the rest of the body. The left testicle can appear lower than the right due to the longer length of the left spermatic cord. The testes should be equal in size bilaterally + free moveable
Which of the following areas should the technique of palpation be used as part of the assessment?
-Sinus cavities
abdomen SKIN TONE + APPERANCE expected findings
-Skin: smooth, dry,, even skin tone or lighter than client face or extremities due to lack of sun exp
Head expected findings:
-Skull generally round w/prominences in the frontal area anteriorly + the occipital area posteriorly -Expected protrusions found on the side of each parietal bone + the mastoid process behind each ear -Head should be proportional in relation to the body + is typically help upright + midline to the truck -Facial features: should be symmetrical , relaxed expression -Skin on face + scalp: should be in uniform in color + smooth w/ no lesions or edema present
Eyelids expected findings
-Smooth + same color as the surrounding skin w/o the presence of edema -Margins should be pink
Which of the following assessment findings are unexpected when inspecting abdomen?
-Soft protrusion of the umbilicus -Prominent veins
Which of the following are unexpected findings of the eye?
-Subconjunctival hemorrhage -Ptosis -Conjunctivitis -Entropion
Eyebrows expected finding
-Symmetrical + extended over the width of the eye
Inguinal + femoral areas:
-Symmetrical + flat
Noses + sinuses expected findings
-Symmetrical + midline in relation to the clients other facial features -Skin on nose should match the color on their face + free from lesions or lumps -Nares mucosa: smooth moist surface that is a deeper color than the oral mucosa -Mucosa should be free from any swelling,discharge, bleeding or foregin bodies
abdomen SYMMETRY + MASSES expected findings
-Symmetry of mov. associated w/breathing w/o any bulges or masses
cardiovascular SKIN TEMP + PULSE expected findings
-Temp consistent + bilateral -Smooth + dry w/ rapid recoil -NO EDEMA -Cap refill less than 2 seconds -Pulses should be palpable, regular equal bilaterally + normal 2+ amplitude
A nurse is inspecting a client and documents that the spine is straight and movement upon inspiration is symmetrical. Which of the following describes the location that the nurse is documenting?
-The posterior chest
Breath sounds: tracheal + bronchial
-Tracheal: loud intensity. Both inspiration + expiration durations sounds are equal -Bronchial: loud intensity + high pitch inspiration is shorter duration than the expiration
A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?
-Tripod position
Which of the following are signs of peripheral arterial disease?
-Ulcer on the toes -Leg pain that occurs w/activity -Decreased or absent pulses
Which of the following can be used to prevent STIs?
-Vaccine -Condom
What expected breath sounds are heard over the largest portions of the lungs and are soft-sounding like wind blowing through trees?
-Vesicular
Which of the following should the nurse include when documenting objective findings?
-Vital signs -Inspection results
Which of the following is an expected finding when palpating the abdomen?
-Voluntary gurading
Anal + perianal area
-anal + perianal skin should be intact w/o noticeable protrusions or lesions -Anal skin will be coarse + more darkly pigmented than the overall skin tone -Area will appear moist + hairless the anus should remain closed when the client is relaxed
Mucosa expected findings
-appear glistening, smooth, moist -Clients w/ darker skin tones can have darkly pigmented mucosa w/areas of hyperpigmentation -Clients w/lighter skin will have pink mucosa
Tongue expected findings
-appear moist, slightly rough on the top surface -Medium-red in color -Smooth along the lateral margins -The ventral surface should be smooth and pink w/large veins between the frenulum
Aussculate expected findings
-bowel sounds usually high-pitch + gurgling w/a freq of occurrence 5 - 34x per min
Hard palate expected findings
-dome shaped and whitish in color -Soft palate should be smooth and light pink
abdomen SHAPE + CONTOUR expected findings
-flat, slightly convex, or rounded
Gums expected findings
-gums should fit tightly around each tooth appear smooth and moist -Client w/darker skin tones have patchy pigmentation and dark pink to brown gums -Client who have lighter skin tones will have pink gums
Umbilicus expected findings
-loc. at body midline + inverted
Tonsils expected findings
-present as pink, smooth tissue -small blood vessels and the presence of small irregular spots of lymphatic tissue
Teeth expected findings
-smooth and skiny w/varying degrees of whiteness
What is the correlating scale rating for mild pitting edema that is barely noticeable?
1+
Place the steps of the female genitourinary assessment in order
1. Gather the needed equipment 2.Help the client to assume the lithotomy position 3.Inspect the mon pubis and outer aspect of the labia majora 4.Separate the labia for inspection 5.Inspect the urethral meatus, vaginal introitus and perineum
Place the following steps in the correct order to perform an assessment of a client's pupillary reaction to light?
1. Have the client sit facing you at eye level 2.Observe the pupils for size 3.Darken the room 4.Instruct the client to look at a distant object 5.Move your penlight in from the side to shine on one pupil 6.Observe the pupillary response in both eyes
Place the steps of the assessment of the anal and perianal area in order
1. Position the client 2. Separate the client buttocks 3.Inspect the anal and perianal area 4.Ask the client to bear down 5.Inspect for the presence of hemorrhoids, fissures, polyps, tumors, or rectal prolapse
Place the steps of abdominal assessment in the correct order
1. Review the client's health history 2.Visually inspect the abdominal area 3.Auscultate for bowel sounds 4.Palpate the abdominal area 5.Document findings
In what order does the blood flow through the heart valves?
1. Tricuspid valve 2. Pulmonic valve 3. Mitral valve 4. Aortic valve
Which of the following ratings should you assign to to a bounding carotid pulse?
4+
Cardiovascular ANTERIOR CHEST expected findings
Anterior chest: Symmetrical chest movements w/visible gentle pulsations in the PMI area -Heart sounds: S1: dull, low pitch sound "LUB" S2: Higher pitch sound or "DUB" Systole: silent period between S1 + S2 Diastole: silent period between S2 + the next S1
Anterior chest
Clients w/fair skin: will have pinkish hue to their cheeks -Clients w/darker skin can have reddish-purple tone to their nail beds and mucous membrane -Skin should be dry and warm to touch
Palpation of chest
Symmetrical movement
The nurse is inspecting a client's anterior chest. Which of the following findings should the nurse expect?
The ribs are sloping downward at an angle