PREPU CH 26 HEALTH ASSESSMENT

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

"These brown spots are senile lentigines and are common when you get older."

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

"What brings you here today?"

After testing a 4-year-old child's vision using the Snellen chart, the nurse tells the parent that the vision is 20/30 (6/9). Which statement by the nurse explains what this means to the parent?

"Your child has normal vision."

The nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data would be important for the nurse to collect during the physical examination?

Bowel sounds

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.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?

Wheezing on auscultation

Which component(s) is included in the integumentary system?

skin hair nails scalp

A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response?

"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."

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 no longer a recommended screening activity."

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"Can you tell me where you are right now?"

The nurse is performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment?

"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?"

A 17-year-old client is brought into the emergency department following a sporting accident. The client's eyes open upon hearing the nurse's voice, but the client does not answer appropriately upon questioning. When assessing the motor response of the client, the client withdraws from painful stimuli. Select the appropriate score for each corresponding component on the Glasgow Coma Scale for this client.

Eye Opening - 3 Verbal Response - 3 Motor Response - 4

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic?

Irregular edges Larger than 1/4 inch in diameter Change in the mole

The nurse is examining the client's skin to determine whether the delivery of oxygenated blood is sufficient. Which body area(s) will the nurse assess for color change?

Nail beds Tongue Lips

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?

Palpation

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene?

Palpation of both carotid arteries at the same time

Which respiratory sound indicates an upper airway obstruction?

Stridor

A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving?

The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

Verify that the procedural consent form is signed.

The nurse is caring for a client diagnosed with coronary artery disease after a cardiac angiogram. The client has a sandbag on the right femoral artery. Which assessments should the nurse choose?

Vital signs Focused peripheral vascular assessment General physical assessment

A nurse performs a general survey on a client who is being admitted to the hospital for Chronic Obstructive Pulmonary Disease (COPD). Which components of this type of assessment will be a focus for the nurse?

Vital signs Gait Behavior Body mass index (BMI) Breathing pattern

The nurse is performing a focused respiratory assessment on a client who was admitted for exacerbation of asthma. When performing the assessment, which action(s) will the nurse take?

Warm the diaphragm of the stethoscope between the palms. Instruct the client to breathe deeply and slowly in and out through the mouth.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope.

The nurse cares for a client with congestive heart failure (CHF). How does monitoring the client's weight contribute to the provision of effective nursing care?

Weight gain or loss can indicate responses to medical treatment.

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain?

"What seems to make the pain worse?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" Intensity

The nurse is asking questions about the client's pain experience during the interview. Which questions are important to address when assessing pain? Select all that apply.

"What seems to make the pain worse?" "How long does the pain last?" "Where is the pain located and does it move anywhere else?" Intensity

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?

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)."

The nurse cares for a client with chronic obstructive pulmonary disease. Which explanation does the nurse provide to the client's adult child, who asks, "How will we know if my parent is experiencing chronic hypoxia?"

"Your parent will exhibit clubbing of the nails."

What percentage of weight change in 6 months is considered abnormal?

10%

A nurse assesses a client's nails. What is a normal finding?

160-degree angle of nail attachment

During assessment of the lower extremities, the nurse notes that 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?

2+ pitting edema noted on bilateral lower extremities

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). What assessment data obtained by the nurse would correlate with this diagnosis?

Expiratory wheezes

The nurse is testing the peripheral vision of a client. Which actions are recommended guidelines for this test?

Have the client cover one eye with a hand or index card. The nurse should cover an eye opposite the client's closed eye. Hold one arm outstretched to the side equidistant from the nurse and client, and move fingers into the visual fields from various peripheral points.

Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?

Hepatitis

The nurse testing a client's eyes asks the client to focus on a finger from 60 cm away and moves the client's eyes through the six cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing?

III: Oculomotor IV: Trochlear VI: Abducens

The gerontologic nurse is inspecting the genitalia of an older adult female client. Which assessment findings are of the most concern?

Increased size of the labia unilaterally Scant red vaginal discharge

A nurse is performing a head and neck assessment of a client suspected of having leukemia. How would the nurse detect enlarged lymph nodes commonly associated with this disease?

Inspect and palpate the supraclavicular area.

What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?

Inspection

A nurse is assessing the abdomen of a newly admitted client. Place in order the steps of assessing the abdomen.

Inspection Auscultation Percussion Palpation

A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity.

Pallor - circulation Paralysis - motor function Numbness - sensation Pain - motor function Temperature - circulation

A client reports severe abdominal pain that started about an hour after eating lunch. Assessment reveals absent bowel sounds and rebound tenderness in the right lower quadrant. What does the nurse suspect these findings may indicate?

Paralytic ileus Peritonitis

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority?

Patency of airway

The nurse must weigh a client using a bed scale. Place the following steps in the correct order

Place a cover over the sling of the bed scale. Attach the sling to the bed scale. Balance the scale so that weight reads 0.0. Roll client back over the sling and onto other side. Gradually elevate the sling so that the client is lifted up off of the bed. Note weight reading on the scale.

The nurse must weigh a client using a bed scale. Place the following steps in the correct order.

Place a cover over the sling of the bed scale. Attach the sling to the bed scale. Balance the scale so that weight reads 0.0. Roll client back over the sling and onto other side. Gradually elevate the sling so that the client is lifted up off of the bed. Note weight reading on the scale.

A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III?

Pupillary reaction to light Ability to open and close eyelids

A nurse is examining a client and is testing the client's cranial nerves. Which action would the nurse use to evaluate cranial nerve III? Select all that apply.

Pupillary reaction to light Ability to open and close eyelids

A nurse is testing the function of the spinal cord of a client who presents in the emergency department following a motorcycle accident. What would be the focus of this assessment?

Reflexes

The nurse is examining a client upon admission to the hospital. Which strategy will the nurse use first when completing a comprehensive assessment?

Review the client's history prior to introduction to the client.

The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?

Risk for Falls

Which statement accurately represents a characteristic of the third or fourth heart sound?

S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.

The nurse is preparing to conduct a health interview with a client who is hearing impaired. Which considerations will the nurse make for the alteration in the client's hearing?

Sit directly in front of the client Ensure any open windows are closed Determine if hearing aids are required

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal?

Soft, low-pitched, whispering sounds heard over most of the lung fields. Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly. Blowing, hollow sounds auscultated over the larynx and trachea

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?

Stop lifting the client and reassure him.

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

Stridor

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

The client is dehydrated.

A nurse is assessing the cranial nerves of a client who is recovering from Bell palsy. Which cranial nerves are important for the coordination of facial movement and reflex activity?

V-Trigeminal VII-Facial IX- Glossopharyngeal

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

A 52-year-old male client is admitted to the medical-surgical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He tells the nurse that he hasn't seen any blood in his stool and that he usually drinks a six-pack of beer a day. In trying to pinpoint the cause of the client's pain, which action would the nurse take?

Ask the client to tell her more about the pain.

A 44-year-old male client arrives unconscious to the emergency department with a head injury sustained in a fall from a 6-ft (2-m) ladder. Which action by the nurse is the most important to take?

Assess pupil shape and reactivity to light.

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?

Assess the client for dehydration.

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?

Auscultation

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Auscultation of a bruit

Which technique should the nurse use to assess the pupillary light reflex on a client?

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

The nurse is performing a respiratory assessment for a client and hears a high-pitched, harsh "blowing" sound, with sound on expiration being longer than inspiration. How will the nurse document this finding?

Bronchial breath sounds

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.

The health care provider asks the nurse to perform a Weber test for a client with suspected conduction hearing loss. Which finding should be reported?

Client hears vibrations in the affected ear.

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."

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment?

Collection of subjective data Complete set of vital signs Functional ability evaluation

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

Crepitus or crepitation

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?

Decreased cardiac output

A nurse is performing physical assessments of residents in a long-term care facility. What common head and neck variations in the older adult does the nurse document as a normal finding?

Decreased color vision and peripheral vision. Entropion and ectropion. Impaired conductive hearing.

The nurse enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging?

Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity

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.

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.

The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which action should the nurse take?

Elicit a gag reflex

A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?

Ensure that the scale is correctly calibrated and repeat the assessment.

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?

Evaluate the blood pressure and pulse

A client has sustained head trauma. The nurse uses the Full Outline of Un-responsiveness (FOUR) coma scale to determine the presence of increased intracranial pressure and client outcomes. What component(s) of the assessment will the nurse document?

eye response motor response respiration brainstem reflexes

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:

fissure

A nurse is caring for a postoperative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment?

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results

A nurse is caring for a postoperative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? Select all that apply.

inspecting the abdominal incision taking the client's blood pressure reviewing morning lab results

The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding?

jaundice

To assess a client's visual accommodation, the nurse has the client:

look at a close object, then at a distant object.

To assess an adult client's hearing, the nurse performs the Rinne test by activating the tuning fork and placing it first at the:

mastoid process.

A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:

objective data.

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 to person, place, and time

Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?

percussion

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

ptosis

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

tuning fork

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Ask the client about any unusual genital observations.

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?

Ask the client to empty her bladder.

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?

Measure the pulse oximetry.

The nurse is caring for a client diagnosed with emphysema and COPD. Which nursing intervention would the nurse include in the nursing care plan?

Monitor arterial blood gases (ABGs) Encourage a healthy weight Administer influenza and pneumococcal vaccines as needed Check the client's capillary refill

A nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations?

Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis)

A nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations?

Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis)

A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed.

Position the client supine and drape appropriately. Inspect the skin of thorax and abdomen. Palpate the thorax. Auscultate the thorax. Auscultate the abdomen. Palpate the abdomen.

A nurse is performing a physical assessment for an older adult client who recently had a hip replacement. In what position would the nurse place this client to examine the hip joint?

Prone

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The client's pupils are black, equal in size, and round and smooth.

A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?

The client's reaction time will likely be slower than that of a younger adult.

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?

crackles

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for?

a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

asks the client what promotes sleep.

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

auscultation

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

auscultation of high-pitched continuous sounds during inspiration

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

circumoral cyanosis when the client is at rest