Health Assesment Ch.25

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?

"According to the American Cancer Society, your first mammogram should be done at age 40 and then yearly after that." Explanation: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society 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 nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding?

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

The acute care nurse is assessing a newly admitted patient's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

Auscultation of a bruit

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 Explanation: A bruit on auscultation suggests an aneurysm or arterial stenosis.

You are assessing a patient's thorax and lungs. Which of the following findings would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

______ occurs when the artery is partially obstructed or distended

Bruits

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?

Check the client's ear canals for cerumen. Explanation: 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 providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment finding that should be documented and reported to the physician?

Decreased heart rate

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?

Document normal breath sounds. Explanation: Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.

A nurse uses percussion to assess a patient's liver. What is the normal tone that should be heard in this situation?

Dull

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

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

A nurse auscultates the right carotid artery in an elderly client and identifies a bruit. What does this assessment finding mean?

It is distended (increased in size)

The nurse assesses the client's lung sounds following the client's period of coughing. This is a(an) example of

Objective data

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as?

Ptosis Explanation: Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion, and miosis is constriction of the pupil, which is often caused by medications.

The nurse is conducting an assessment of a 74-year-old patient's integumentary system. Which of the following findings should the nurse document as an anomaly that may warrant follow-up?

The patient states that a mole on his forehead has become larger in recent months.

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

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require?

Tuning fork Explanation: Weber test and Rinne test are performed in order to assess sound conduction; both require a tuning fork.

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes

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 Explanation: 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 should use the bell of the stethoscope during auscultation of:

a client's heart murmur. Explanation: 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.

A nurse examining the lungs of a patient percusses over the anterior thorax using the proper sequence. This technique helps to identify:

density & location of lungs

During a health assessment, the nurse uses deep palpation to assess a client's

liver

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each patient prior to the patient's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a patient's:

peripheral pulses.

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. Explanation: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals.

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?

"What brings you here today?" Explanation: The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean?" How should the nurse respond?

"You are able to read at 20 feet what a person with normal vision can read at 30 feet." Explanation: 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.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment?

Auscultation Explanation: 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.

When percussing the liver, the sound should be

Dull

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. Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

A nurse is percussing a client's abdomen. Which of the following would the nurse identify as a normal finding?

Tympany

A nurse asks a client to raise her eyebrows, smile and show her teeth, and puff out her cheeks. This nurse is most likely assessing which cranial nerve?

Facial (VII) Explanation: Cranial nerve VII controls the muscles of the face. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.

A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor (Ceclor) 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." What action should the nurse take first?

Inspect the area of itchy skin. Explanation: Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem. Checking the chart for known allergies and reviewing the medical history and medication record may provide helpful information, but assessing the skin gives firsthand information about the problem.

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

Inspection, auscultation, percussion, palpation

Mr. Sanchez is a 56-year-old Mexican American who 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?

Measure the pulse oximetry. Explanation: 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.

The charge nurse is observing a new nurse perform an assessment of a patient'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

A 7-year-old child is admitted to the emergency department with a tentative diagnosis of asthma. Which observation requires a priority intervention by the nurse?

Stridor Explanation: Stridor indicates a narrowing of the upper airway (larynx or trachea) caused by an obstruction or edema and must receive priority of care. Intercostal retractions indicate increased respiratory effort. A snoring sound on inspiration indicates sonorous wheezes and is caused by air passing through or around secretions. Expiratory wheezing is caused by air passing through narrowed lower airways.

Percussion sounds: -abdomen -hyper-inflated lung tissue -normal lung tissue -liver -bone

abdomen: tympanic hyper-inflated lung tissue: hyper-resonant normal lung tissue: resonant liver: dull bone: flat

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 Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.