N5451 Skills Lab > Video Quizzes > Module 3. Assessment

The nurse is to assess the cranial nerves of a client admitted with a suspected tumor of the sternocleidomastoid muscle. When assessing the motor function of the spinal accessory nerve, what is the nurse evaluating?

Ability to rotate the head

The nurse is performing a quick assessment at the beginning of the shift. During auscultation of the client's lungs, decreased breath sounds, prolonged expiration, and expiratory wheezes bilaterally are auscultated. What would the nurse suspect?

An acute asthmatic exacerbation is occurring Decreased breath sounds, prolonged expiration, and expiratory wheezes bilaterally are most consistent with asthma. With an obstructive mass in the right bronchial region, decreased breath sounds and stridor would be expected. With pneumonia and areas of infection, crackles would be expected. Right sided congestive heart failure would present with fatigue, shortness of breath, and crackles.

The nurse is assessing the client's hair, skin, and nails during the health assessment. The nurse uses which action to assess capillary refill?

Applies pressure to the nail beds. Capillary refill is assessed by pressing on the client's nail beds. Color should return briskly within 1 to 2 seconds. Palpating the skin surfaces, feeling the top of the skull, and touching the forehead with the back of the hand are other components of the hair, skin, and nail assessment.

The nurse is performing a general survey on a client who is being admitted to the medical unit with abdominal pain. Which components would the nurse assess during the general survey? Select all that apply.

Ask client for today's date and time Observe the client's gait Assess the client's vital signs The general survey is a precursor to any in‑depth focused physical assessment. The general survey provides initial information about the client's overall demeanor, orientation, vital signs, appearance, gait, and behavior and can indicate the need for further targeted assessments. Evaluating the client's bowel pattern and palpating the entire abdomen would fall under the targeted abdominal assessment.

The nurse is admitting a client with diabetes and a stage II wound to the right heel. When assessing the client's skin, what would the nurse do first?

Inspect overall skin color. Inspection should always be done first. Assess whether overall color is consistent with ethnicity. The nurse could then palpate for skin temperature, compare the texture of the arms, and measure the length, width, and depth of any existing wound present.

The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first?

Inspect the skin, bones, and muscles of the entire posterior thorax. Inspection is always done first and provides the nurse information about lung expansion, as well as use of accessory muscles, color of the skin, rashes, masses or client distress. All other assessment components would be completed after inspection.

The nurse is reviewing the lab work of a client who has a serum bilirubin level of 0.3 mg/dL (5.13 μmol/L). What assessment findings would the nurse expect when conducting a focused skin assessment of this client? Select all that apply.

Jaundice of the sclera Generalized pruritus Jaundice to the skin, sclera, and palate, as well as pruritus would be observed in the client with an elevated serum bilirubin. The other findings are not observed with an elevated serum bilirubin or liver issues.

The emergency room nurse is conducting a focused thorax and lung assessment on a client reporting chest pain, cough, and dyspnea. Which assessment findings indicate the need for further assessment? Select all that apply.

Observed the client have a moist cough with production of yellow sputum Auscultated low pitched, bubbling sounds during inspiration in right upper lobe High pitched popping sounds (crackles) and a productive cough for yellow sputum require further assessment to determine a possible pneumonia. All other findings are normal and do not need further assessment.

The nurse is completing head and neck assessments on four different older adult clients in a long‑term care facility. Which findings would the nurse promptly report to the health care provider for further testing? Select all that apply.

Obvious turbulence upon auscultation of the bilateral carotid arteries New, mild, left sided facial droop upon inspection of the client's face Right pupil that is slightly misshapen and is not constricting with light Obvious turbulence upon auscultation indicates a bilateral bruit and carotid stenosis. New one‑sided facial droop may indicate a recent cerebrovascular accident, and a right pupil that is slightly misshapen and is not constricting with light may indicate a cataract or other neurological issue. All require further testing. A small, nontender, soft, moveable node on the right the neck upon palpation as well as a symmetrical and mobile skull with no nodules or enlargement on palpation are normal findings.

The nurse on a telemetry unit is performing morning assessments on the clients. Upon auscultation of an adult client's heart sounds, the nurse notes a scratchy, high‑pitched sandpaper sound. How should the nurse document this sound?

Pericardial friction rub Pericardial friction rub is a high pitched, scratchy sound usually found with an inflamed pericardium. Midsystolic click is an extra heart sound usually found with mitral valve prolapsed not associated with a scratchy noise. Inspiratory stridor is not a heart sound and is associated with an obstructed airway and often with respiratory infections such as croup. Benign murmur is a swooshing sound that is usually developmental and outgrown with aging.

A nurse is preparing to perform a focused hair and scalp assessment on an 8‑year‑old client who reports, "my head has been itchy for the past couple days." What should the nurse do first?

Put on a pair of gloves. Because the client is reporting itching to the scalp for the past couple days, there is a possibility of infestation. The nurse needs to put on gloves before starting the rest of the assessment. The nurse would use a flashlight to examine hair for any lice or nits. The nurse may ask the client to describe or rate the itching, but the priority would be to put on gloves and then assess the hair and scalp.

When performing a general survey assessment, how would the nurse assess the client's orientation? Select all that apply.

Request the client states his or her name. Query about today's date and season. Question where the client is now. When assessing for the client's orientation, the nurse should assess the client for person, place, time, and situation. Asking about allergies and medications are not included in orientation.

The nurse is planning to assess an older adult client admitted with abdominal pain. Which special considerations are important to contemplate when assessing the older adult client? Select all that apply.

Short term memory may diminish with age; Presence of heart sound S4 is considered normal; Older adults take longer to perform certain actions

A nurse is preparing to perform a general survey of a client. What equipment would the nurse require to perform this assessment? Select all that apply.

Sphygmomanometer Stethoscope Tape measure Standing scale The general survey should include vital signs, which require a sphygmomanometer, as well as a height, weight, and BMI, which require a standing scale and a tape measure. A glucometer is not necessary to perform a general survey, it but could be used later during the physical assessment. A Doppler is not indicated unless the nurse was unable to palpate a pulse in a normal manner.

The nurse is performing a focused assessment of the skin, hair, and nails. Which assessment findings would require immediate intervention? Select all that apply.

Tenderness and edema to the left calf Blue tinge to all of the nail beds Tenderness and edema to one calf may indicate a deep vein thrombosis (DVT), and blue color to the nail beds may be cyanosis and indicate hypoxia. Both of these findings require immediate action and further assessments. Generalized pallor may be normal or indicate anemia, inflamed red itchy patches are usually eczema, and complete absence of pigmentation is albinism. None of these conditions require immediate attention.

The nurse is conducting an initial cranial nerve assessment of a client with meningioma of the sphenoid ridge. Which actions should the nurse perform to assess cranial nerve I? Select all that apply.

Test each nostril independently. Examine the client's ability to smell.

The medical‑surgical nurse is caring for a client admitted with gastroenteritis. Which assessment finding would indicate that the nurse should contact the health care provider?

Whooshing sound at the top of the abdomen near the aorta Whooshing sound at the top of the abdomen near the aorta may indicate an aneurysm or arterial stenosis and needs further assessment by the health care provider Loud gurgling in all four quadrants is normal with the expected increased motility of gastroenteritis and is called Borborygmi. The liver spans for about 6 to 12 cm and would be percussed as dull sounds at the right midclavicular line. Diffuse abdominal tenderness on palpation and cramping is common with gastroenteritis.

The nurse is conducting a focused musculoskeletal and peripheral vascular assessment on a client. What should the nurse do first?

Examine range of motion

The telemetry nurse is conducting an initial cardiac assessment on a client admitted with chest pain and coronary artery disease (CAD). What should the nurse do first?

Examine the client's chest for any visible pulsations. The initial step in any assessment is inspection, so the nurse should examine the client's chest for any visible pulsations. The other actions are all part of the cardiac assessment, but they should be performed after inspection.

The nurse is completing a quick head-to-toe assessment on a client admitted with right-sided heart failure. Which body parts should be examined for peripheral edema? Select all that apply.

Hands, Sacrum, Feet

A nurse is conducting a peripheral vascular assessment on a client admitted with congestive heart failure. The nurse notes an 8-mm deep depression in the skin after pressing that remains for a prolonged period on both legs. How should the nurse document this finding?

4+ pitting edema

An emergency room nurse is conducting a quick head-to-toe assessment of a client reporting flu-like symptoms. What pulse grade would the nurse document if the client's radial pulses were "full, easy to palpate, and cannot be obliterated"?

+1 pulse

A client with a history of congestive heart failure comes to the cardiac wellness clinic reporting "frequent awakening from sleep due to shortness of breath." Which action by the nurse is most appropriate?

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is awakening from sleep with dyspnea (shortness of breath) and needing to be upright to achieve comfort. There is no assessment indication for nor a prescription for orthostatic vital signs. The nurse should not tell the client to take a sleeping pill nor tell that the dyspnea will subside in a few days; further assessment would be needed.

The emergency room nurse is caring for a client reporting severe right lower quadrant pain that had started as milder pain near the umbilicus. Vital signs include a fever of 38.6°C (101.5°F), pulse 92 bpm, respirations 24 breath/min, and blood pressure 136/80 mm Hg. What should the nurse do next? Select all that apply.

Begin an OR checklist Keep the client NPO Cleanse the abdomen with chlorhexidine The nurse would suspect acute appendicitis due to the pain location and vital signs. Thus, the client wound need to remain NPO and be immediately prepared for surgery, which includes applying the chlorhexidine cleanser to the abdomen and beginning an OR checklist. There is no need for a tap water enema or an antiemetic, because nausea or constipation are not mentioned in the assessment findings.

The nurse is to assess the cranial nerves of a client admitted with a recent cerebral vascular accident. What is the nurse evaluating when assessing the motor function of the glossopharyngeal nerve?

Capability to swallow. The motor function of the glossopharyngeal nerve is swallowing motion. Presence of a gag reflex is tested in motor function of the vagus nerve. Ability to taste is the sensory function of the glossopharyngeal nerve. Lateral jaw movements are the motor function of the trigeminal nerve.

The nurse is preparing to conduct a 10-minute head-to-toe assessment on a client admitted with pneumonia. What should the nurse do first?

Complete a general inspection.

The gerontologic nurse is assessing the muscles of an older adult client. Which muscle components are the most important for the nurse to assess with this client? Select all that apply.

Contour, pain, range of motion, and symmetry; tone strength, size, and tenderness

The emergency room nurse is caring for a client reporting dizziness and headache with identified nystagmus. Which cranial nerves would the nurse plan to assess? Select all that apply.

Cranial nerve III, Cranial nerve IV, Cranial nerve VI

The nurse is beginning a general survey on a client who is being admitted to the hospital for abdominal pain. After identifying the client, which components would the nurse include in the general survey? Select all that apply.

Does the person's body structure match the stated age? Are there any tubes, lines, or drains? Does the client appear to be alert? Is the client's color appropriate for ethnicity? After identifying the client, a general survey is completed by observing general appearance including whether the client is wearing oxygen, has an IV or other lines, the demeanor and behavior, body structure, BMI, and vital signs. This is then followed by a brief, generalized assessment from head to toe with the addition of in depth targeted assessments as needed, based on the client.

A 40‑year‑old female client reports dull pain in the left breast. Before examining the client's breasts, using the wedge method, the nurse places the client in which position?

Dorsal recumbent with the arm of the side being examined above the head The dorsal recumbent position is used to assess the head, neck, anterior thorax, lungs, heart, breasts, and extremities. When examining the breasts using the wedge, circular or vertical strip method, the arm of the side being examined is placed above the head. Prone position is used to assess the hips and posterior thorax. Left protective Sim's is the position used to give an enema, where the client lies on the left side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. Both knees are flexed, with the upper leg more acutely flexed. It is used to assess the rectum or vagina. Supine could be used, but both hands would not be in together in the client's lap.

The nurse is caring for a client who is being admitted to the intensive care unit with bilateral pulmonary emboli. The client is reporting anxiety and apprehension. What would the nurse do? Select all that apply.

Encourage client to express and acknowledge feelings. Modify procedures as much as possible to limit stress. Note cultural influences that may influence individual response. With bilateral pulmonary embolism, the client would be working hard to breathe, which would create anxiety and apprehension. The nurse would encourage client to express and acknowledge feelings to deal with them. It is also important to note cultural influences that may influence individual response to treatment or perception of the situation. It would be wrong for the nurse to reassure the client that it will be alright, because prognosis may not be good. It is wrong to not allow the behavior to be only the client's and could lead to a nontherapeutic response.

The nurse is conducting an initial assessment of the abdomen. When checking for vascular sounds in the abdomen, what should the nurse do? Select all that apply.

Evaluate the aortic region of the abdomen first. Expose only the region of the client being assessed. Assess the lower region of the abdomen last. When assessing the abdomen for vascular sounds, the nurse should use the bell, not the diaphragm of the stethoscope, expose only the region being assessed, and go from top to bottom in the artery areas. Listening for growling sounds would be assessing for Borborygmi, which is a bowel, not vascular sound.

The nurse working on the rehabilitation unit is examining the shoulder of a client during a detailed muscloskeletal assessment. Which four motions should be included during this examination?

Forward flexion, internal rotation, abduction, and external rotation

An intensive care nurse is caring for a client who sustained a head injury from a motor vehicle accident. During the morning assessment, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 3 mm and reacts to light. What is the nurse's priority action?

Notify the health care provider immediately Decreased or absent pupillary response and uneven pupil dilation indicate blindness or increased cranial pressure and serious brain damage. The nurse would notify the health care provider immediately, because this is a critical change in condition. The nurse should not wait for 1 hour to reassess, because the client's condition will continue to deteriorate and brain damage could increase. Monitoring the client's breathing is important, but not the nurse's priority concern. Repositioning the client will not help to reduce the cranial pressure.

The nurse is caring for a client who was recently admitted to the cardiac care unit after open‑heart surgery. The current assessment by the nurse reveals +0 pedal pulse on the left foot and +2 pedal pulse on the right foot. What should the nurse do first?

Notify the health care provider of this abnormal finding. An absent pulse after cardiac surgery is not normal. This finding needs to be reported to the health care provider, because it could indicate a thromboembolic obstruction. Elevating the right leg is not necessary, because there is a normal pulse in the right leg. It would not be appropriate to reassess in one hour, and absent pulse is not normal. Applying heat will not solve the problem of an absent pedal pulse.

A nurse is caring for a client who has a right femur fracture that is currently in traction. The client has a prescription for hourly circulatory assessment. Which nursing assessment findings should be reported to the health care provider? Select all that apply.

Numbness and tingling to the right leg Edema and coolness to the right calf Right capillary refill of 4 seconds The nurse should report any neurovascular or circulatory compromise immediately to the health care provider. Reportable findings would include coolness, paleness, diminished pulse, impaired sensation such as numbness or tingling, muscle paralysis or extreme pain to the affected extremity. Pink color and warmth to the right calf is a normal finding and does not need reported to the health care provider. Pedal pulses +2 bilaterally is a normal pulse and does not need reported to the health care provider.

The nurse is about to begin a focused abdominal assessment on a client that is scheduled for surgery tomorrow. What primary nursing action should be done prior to the physical assessment?

Request that the client try to empty the bladder. The nurse should ask the client to empty the bladder prior to assessment to avoid discomfort or pressure during the physical examination. Auscultating for bowel sounds is part of the actual physical assessment. The ileocecal valve is the area where bowel sounds are most often heard. The client should be placed in a supine position for physical assessment of the abdomen, lateral Sims is used for enema insertion. A drape or blanket should not be removed but be used to cover all parts not being assessed to provide as much privacy as possible.

The nurse is performing a cranial nerve assessment on a client admitted with head trauma who is alert and oriented. Which actions should the nurse perform to assess cranial nerve V? Select all that apply.

Touch a cotton ball to the client's forehead, cheek, and jaw bilaterally. Palpate the masseter and temporal muscles with the client's teeth clenched. When assessing cranial nerve V, touching the face with a cotton ball assesses facial sensory function, and palpating the masseter and temporal muscles assesses motor function. Asking the client to raise eyebrows, puff out cheeks, and smile; or taste foods is assessing cranial nerve VII. The corneal reflex should only be assessed in an unconscious client.

The nurse is caring for a client who is reporting throat pain, fever, and difficulty swallowing. Which technique should the nurse use to palpate the client's lymph nodes for enlargement or tenderness?

Use gentle pressure, a circular manner, and palpate with bilateral finger pads to compare both sides. The nurse should use the finger pads, in slow circular motions, comparing both sides to feel for any enlargement, tenderness, and mobility. The nurse should never use firm pressure nor pinch each node, because these cause discomfort to the client. The nurse should always compare both sides to look for asymmetry or differences.

The nurse is performing morning assessments on the medical‑surgical unit. Which clients are most likely to have palpable lymph nodes in the neck? Select all that apply.

Woman, 62, with chronic bronchitis Man, 67, with aspiration pneumonia Lymph nodes are usually palpable due to acute or frequent infection. Lymph nodes are not usually palpable with disease or pathology like dehydration, heart failure, or anemia.