Basic Physical Assessment
When evaluating a client's preoperative cognitive-perceptual pattern, which question should the nurse ask the client?
"Do you wear glasses?"
To evaluate a client's cerebellar function, a nurse should ask
"Do you have any problems with balance?"
The charge nurse is notified that a client has fallen while ambulating to the bathroom. The client has been evaluated by the health care provider, and no injuries were found. What information should the charge nurse include in the post-fall assessment? Select all that apply.
-eye-witness reports of the fall -an inspection of the client's room for fall hazards -a review of medications that may have contributed to the fall -an assessment for gait disturbances or improper mobility equipment use
Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which would be the best response by the nurse?
"You will need to have your blood pressure reassessed before a diagnosis can be made."
What should the nurse include in the teaching plan for the family of a newborn receiving home phototherapy? Select all that apply.
-"The lights should be 12 to 30 inches (30 to 76 cm) above your newborn." -"Record your newborn's temperature, weight, and fluid intake daily." -"Make sure your newborn's eyes are covered well when under the lights."
The nurse is asked to assess urine output for a client. Which statements would be expected outcomes of adequate output? Select all that apply.
-Daily early morning weight helps to identify retention of fluids. -Urine output is increased with diuretic administration.
Which sound should the nurse expect to hear when percussing a distended bladder?
Dullness
The nurse is assessing a client who has had hoarseness for more than 2 weeks. What action should the nurse take?
Assess the client for dysphagia.
A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?
Assess the client's level of pain, and administer prescribed analgesics.
The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?
Assess the client's temperature.
A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?
Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). What should the nurse do next?
Encourage the client to increase fluid intake.
The nurse prepares to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes. Which action would be most important for the nurse to do?
Ensure that the room is kept warm.
The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions?
Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.
A nurse is examining the abdomen of a client with suspected peritonitis. How does the nurse elicit rebound tenderness?
Press the affected area firmly with one hand, release pressure quickly, and note any increased tenderness on release.
A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?
Respect the adolescent's wishes and maintain her confidentiality.
After suctioning a client with a tracheotomy tube, the nurse performs an assessment to determine the effectiveness of the suctioning. Which findings indicate that no further interventions are needed?
Respiratory rate drops from 24 breaths/minute to 16 breaths/minute.
The nurse is providing care to a client who was brought to the emergency department by family. The client has full-thickness (third-degree) burns to the face and upper body and is having difficulty speaking. Place these nursing interventions in order the nurse will perform them. All options must be used.
Secure a patent airway Insert a large-bore intravenous cannula Start fluid resuscitation Administer intravenous pain medication Gently cleanse the burns with sterile water Provide psychosocial support to the client and family
Which is a priority nursing assessment of a reddened heel in a bed-ridden client?
Test for blanching to the affected area.
A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?
The client exhibits signs of adequate GI perfusion with normal bowel sounds.
The nurse is not able to palpate the left pedal pulses of a client with peripheral artery disease. What should the nurse do first?
Use a Doppler ultrasound device.
The nurse receives morning lab work after shift hand-off. Based on the analysis of lab values, which client would the nurse assess first?
a client diagnosed with renal disease and a serum potassium level of 6.1 mEq/dL (6.1 mmol/L) who has limited output
The nurse has received the change-of-shift report on the clients. Who should the nurse assess first?
a client newly admitted after the implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due
Which client should the nurse assess first?
a client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain
When palpating the bladder of an adult client, a nurse would identify which finding as normal?
a nonpalpable bladder
Which finding will the nurse assess in a client diagnosed with peritonitis?
abdominal wall rigidity
The nurse is conducting a health history of a child. The parent states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which condition?
allergies
A client who fell through ice and was submerged for longer than 1 minute is admitted to the emergency department with hypothermia and near-drowning. At which point will the nurse best be able to determine the client's prognosis?
as soon as the client is warmed
A client reports abdominal pain. Which action allows the nurse to investigate this complaint?
assessing the painful area last
A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?
broth, gelatin cubes, and tea
A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate?
coughing when drinking liquids
An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult?
decreased healing
When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include
delayed gastric emptying.
A nurse is caring for a client with lower extremity peripheral vascular disease. Which pulse will be the priority assessment for this client?
dorsalis pedis
A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used.
inspection auscultation percussion palpation
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect
left calf circumference 1" (2.5 cm) larger than the right.
A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?
orthostatic blood pressure changes
The nurse is caring for a client who reports right lower quadrant pain. Which assessment is most important for this client?
palpation
A nurse is caring for a client during barbiturate therapy. The client receiving this drug should be evaluated for which condition?
physical dependence
After a local factory explodes, a nurse begins to triage the victims. Victim 1 is initially unconscious and not breathing. After the victim's airway is opened, the victim resumes spontaneous respirations at a rate of 18 and has a capillary refill time of less than 2 seconds, but remains unconscious. What color tag should the nurse use for this victim?
red
Which finding in a client who recently underwent a total hip replacement would require a nurse to take immediate action?
red painful area on the calf of the affected leg
When percussing a client's chest, what should the nurse expect to hear?
resonance
A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:
respiratory acidosis.
When examining a client who has abdominal pain, a nurse should assess
the symptomatic quadrant last.
Which sign is an early indication that a client has developed hypocalcemia?
tingling in the fingers
Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?
urine output of 90 mL over the past 6 hours
A nurse prepares to auscultate a client's carotid arteries for bruits. For this procedure, the nurse should
use the bell of the stethoscope.
A nurse correctly identifies which items as belonging to the dorsal cavity?
vertebral canal
A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?
"At first, the stoma may bleed slightly when touched."
A nurse is teaching a client about the importance of increasing fluids when experiencing the early stages of dehydration. Which statement by the client would express understanding?
"I should drink more water when feeling thirsty or becoming irritable."
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse?
"Tell me what you are feeling."
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
"What does the pain feel like?"
When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.
-allergies to any medications -allergies to items other than medications, such as foods and animals -reaction to the allergen -severity of the allergy
Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?
There is no bleeding at the aspiration site.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess?
changes from the normally expected findings
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
every 15 minutes
The nurse is assessing the progression of jaundice in a neonate who requires phototherapy. Place the assessment areas in the expected order. All options must be used.
face chest abdomen extremities
Which observation by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding?
formula in the client's mouth during the feeding, and increased cough
A client has just been transferred to the postanesthesia recovery room following a laparotomy. The nurse has completed assessing vital signs. What other important initial assessments would the nurse make?
level of consciousness, pain level, and wound dressing
A client tells a nurse that about a rash on the back and right flank. The nurse observes elevated, round, blister-like lesions filled with clear fluid. When documenting the findings, what medical term would the nurse use to describe these lesions?
vesicles
A client asks the nurse why a prostate-specific antigen (PSA) level is determined before a digital rectal examination. What should the nurse tell the client?
"A prostate examination can possibly increase the PSA."
The nurse is conducting an admission interview with a client and is assessing for risk factors related to the client's safety. The nurse should include which targeted assessment(s)? Select all that apply.
-suicide or self-harm ideation -recent use of substances of abuse -allergic reactions or adverse drug reactions
The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?
28 breaths/min and audible
The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN?
Administering a client's tube feeding
A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
Assess the vital signs and oxygen saturation levels.
The nurse is caring for a client who has become unresponsive. The blood pressure is 80/40 mm Hg, and oxygen saturation (SpO2) is 90% on a 50% partial rebreather mask. What should the nurse do next?
Call the rapid response team.
The surgical floor receives a client from the postanesthesia care unit. Ten minutes ago, the final assessment in the postanesthesia care unit indicated that the client had a patent airway and stable vital signs. The client's pain level was 2. What should the nurse do next?
Check the dressing for signs of bleeding.
The nurse assists a parent in performing daily peritoneal dialysis and catheter exit site care for the first time for a child with chronic renal failure. Which information would be an important step to emphasize to the parent?
Examine the site for signs of infection while cleaning the area.
The nurse is caring for a client with peripheral vascular disease (PVD). Which action would the nurse do to ensure an accurate assessment?
Keep the client warm.
A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?
signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes
The nurse is caring for a client with a head injury. Which client goal is most appropriate for the acute phase of a neurological injury?
The client's vital signs will stabilize, returning to normal range.
The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do?
Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.
Which client should the nurse assess first?
a client being treated for chronic stable angina who reports a recent increase in chest pain frequency
After administering prescribed medications to clients, which client requires immediate intervention?
a client taking digoxin who has a morning potassium level of 3.0 mEq/L
A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?
obtaining a rubella titer on a woman who is planning to start a family
A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?
pulse deficit
The nurse is assessing a client's activity tolerance. Which report from a treadmill test indicates an abnormal response?
respiratory rate decreased by 5 breaths/minute
A nurse reviews the arterial blood gas (ABG) values of a client who reports difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases?
tachypnea
The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli?
tactile
A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain?
temporal
The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.
-Hello. My name is Nurse Jones from Unit D. -I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. -Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. -Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. -I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment.
A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?
Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.
The nurse is caring for a client who has just had an upper gastrointestinal (GI) endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8°F (38.8°C). What should the nurse do next?
Promptly assess the client for potential perforation.
A nurse cares for clients on a medical surgical unit and has been assigned to care for the following clients. When the nurse is creating their plans of care, which client(s) would the nurse identify intake and output (I&O) monitoring as a care intervention? Select all that apply.
-an 80-year-old postsurgical client experiencing dysphagia -a 60-year-old client with a nasogastric (NG) tube attached to drainage -a 25-year-old client diagnosed with Crohn disease who is receiving parenteral feedings -a 30-year-old client admitted a diagnosis of congestive heart failure
A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are
progressively deeper breaths followed by shallower breaths with apneic periods.
A nurse assesses the client's pulse as weak and thready in both lower extremities. How would the nurse best document this finding?
pulse amplitude +1 bilateral lower extremities
The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply.
-vital signs -skin color -urine output -peripheral pulses
A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?
The client's pulse and respiratory rates increased moderately during ambulation.
What are important nursing responsibilities when a referral to other health team members has been made for a client?
sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living
The nurse is caring for an infant who is retaining fluid. How will the nurse assess for urine output?
weighing the diaper before and after micturition
A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?
ineffective breathing pattern
An older adult who was admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the lab results (see chart). Which abnormal lab value is consistent with the client's symptoms?
serum sodium
A public health nurse is teaching a community seniors group about the risk of falls. Which aging characteristic increases the risk of falls in elderly individuals?
forward-flexed posture
When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?
vesicle
The client has heart failure and is taking a diuretic to promote fluid loss. Which is the most accurate method of determining the extent of a client's fluid loss?
weighing the client
A client with a spinal cord injury says they are having difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury?
fever and change in urine clarity
An adult male client has been unable to void for the past 12 hours. What is the best method for the nurse to use when assessing for bladder distention in a male client?
Palpate for a rounded swelling above the pubis.
The nurse is monitoring a very drowsy client in the immediate postprocedure phase of moderate sedation. The client will open the eyes to repeated verbal stimulation but does not respond verbally. The nurse has an order to give an antiemetic that is known to cause sedation. What assessment tool should the nurse utilize for this client?
Richmond Agitation-Sedation Scale (RASS)
The nurse is assessing an older adult's ability to perform activities of daily living. Which approach will be most effective?
Observe the client performing varied activities of daily living.
A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?
Obtain vital signs.
