EAQ Health Assessment Exam 2

Which assessment would be the highest priority for the nurse to perform on a client who has received sedative and opioid medications postoperatively?

Respiratory assessment - most important assessment, sedative and opioid medications have known side effects of respiratory depression.

The nurse performs a respiratory assessment and auscultates high-pitched, creaking, and accentuated breath sounds on expiration. Which term describes the findings?

Wheezes - asthma and COPD produces as air flow through narrowed passageways high pitched

While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system is affected?

abnormal eye movement is seen in nystagmus. Dizziness when standing or walking may indicate vertigo in the client. These both manifest problems with balance, which is maintained by the vestibular system

which nursing assessment supports a diagnosis of atelectasis in a postoperative client

diminished breath sounds - atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation of infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Rhonci are most commonly heard in clients with infectious of inflammatory diagnoses such as pneumonia or chronic bronchitis.

The nurse is caring for a client with emphysema. During assessment, the nurse would expect to auscultate which type of breath sounds?

diminished breath sounds - breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection. Pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Rhonci signify airway obstruction expiratory wheezing and coughing are associated with asthma or bronchitis.

The nurse reviews the medical record of a client with ascites. Which client condition is a contributing factor to the development of ascites?

diminished plasma protein level - the liver manufactures albumin, the major plasma protein. A deficiency of this protein lowers the osmotic pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased pressure

A client with jaundice associated with hepatitis expresses concern over the change in skin color. Which does the nurse explain is the cause of this color change?

inability of the liver to remove normal amounts of bilirubin from the blood - damage to liver cells affects the ability to facilitate removal of bilirubin from the blood, resulting in deposition in the skin and sclera.

Which combination of client responses would the nurse determine represents the highest risk for the development of pressure injuries

incontinence, inability to move independently - constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure injuries. Although periodic exposure to moisture and occasional friction are risk factors, they do not place the client at highest risk.

When preparing to assess the four abdominal quadrants of a client who reports stomach pain, when would the nurse assess the symptomatic quadrant ?

last - the nurse would systematically assess the abdomen concluding with the symptomatic area which is the area in which the client reports pain. Pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in the other abdominal areas to tighten.

a client suffers from hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is the best site to assess this condition.

lips mouth nail beds prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, and nail beds

Which diagnosis would cause the nurse to assess for signs and symptoms of hypoglycemia

liver failure - the client with liver disease is at risk for hypoglycemia limited in mobilizing carbohydrates because of a decreased ability to form glycogen and to form glucose from glycogen

which finding in a client with asthma exacerbation requires the most rapid action by the nurse

markedly decreased breath sounds - markedly decreased breath sounds may indicate very limited airflow and life threatening asthma exacerbation. the nurse would immediately check oxygen saturation and anticipate possible need for mechanical ventilation

Which assessment would be the most accurate method of monitoring the hydration status of a 2 month old infant with diarrhea and dehydration

obtaining daily weights - daily weighing provides an objective measurement, because a weight loss indicates a loss of fluid.

Which body system would the nurse assess in a client with HIV when inquiring about papilledema and the presence of exudates

ocular - exudates and papilledema are conditions that involve the eyes.

The nurse is assessing female clients and identifies that which client has the greatest risk of developing gallbladder disease

older than 40 and obese - female, fat, forty, fertile

when a client is admitted with dehydration, which clinical manifestation would the nurse expect to find:

oliguria hypotension tenting skin turgor - the body tries to conserve fluid, resulting in lowered urinary output - dehydration leads to hypovolemia and less circulatory volume, decreasing BP - dyspnea is a result of pulmonary congestion, which is associated with hypervolemia.

the nurse is caring for a client with suspected appendicitis. Which assessment finding would the nurse determine would further support the diagnosis

pain in the Right Lower Quadrant - pain shifting to the RLQ between the anterior iliac crest and the umbilicus is McBurney point and is indicative of appendicitis

The nurse is caring for a client with a history of alcoholism and cirrhosis who is hospitalized with severe dyspnea as a result of ascites. an increase in which process most likely caused the ascites

pressure in the portal vein - the enlarged cirrhotic liver impinges on the portal system , causing increased hydrostatic pressure from increased pressure in the portal vein, resulting in ascites

Which finding in the client's health history will alert the nurse to the most likely cause of sensorineural hearing loss? prolonged exposure to noise buildup of cerumen in the ear blockage of the ear from a foreign body perforation of the tympanic membrane

prolonged exposure to noise. sensorineural hearing loss occurs as a result of damage to the auditory nerve in the inner ear. prolonged exposure to noise can cause damage to the cochlea.

Which term would the nurse use to document a client with drooping of the eyelid over the pupil

ptosis - drooping of the eyelids over the pupil is called ptosis, which is how the nurse would document the finding. Ectropion when the eyelid margin turns out Entropion when the eyelid margin turns in Nystagmus involuntary oscillation of the eyes, usually occurs after eye injury

Which action would the nurse take to obtain subjective data about a client's respiratory status

question the client about shortness of breath ask the client about color and quantity of sputum

A client is admitted with an acute onset of right lower quadrant pain at McBurneys point, and appendicitis is suspected. For which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis

rebound tenderness - rebound tenderness is a classic subjective sign of appendicitis.

The nurse is caring for a 9 year old child in the post anesthesia care unit after craniotomy for the removal of an astrocytoma. Which intervention would the nurse perform when the child's right pupil suddenly dilates?

Notify the health care provider - sudden dilation of one pupil denotes an emergency. pressure is suddenly being exerted on the third cranial nerve on the affected side as a result of displacement of the tentorium or uncus. The healthcare provider should be notified immediately. - increased intracranial pressure

Which findings would the nurse expect when assessing an older adult with hearing loss secondary to aging

- dry cerumen - difficulty hearing high pitched voices cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices, older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds

a client is hospitalized with pressure injuries. which tasks could be delegated to an unlicensed assistive personnel

- empty wound drainage containers - report changes in wound appearance

Which intervention would the nurse use first for a client with the diagnosis of Guillain Barre syndrome who is having difficulty expectorating respiratory secretions

- suction the client's oropharynx a patient airway is the priority. The client does not have the ability to deep breathe and cough, so oropharyngeal suctioning can provide immediate relief from the secretions obstructing the airway. oxygen administration will be useless if the airway is not patent.

which blood glucose levels would the nurse identify as hypoglycemia?

68 mg/dL Normal blood glucose levels for an adult is 72 to 108 mg/dL. clients who have a blood glucose levels less than 72 mg/dL may experience hypoglycemia.

Which action will the nurse take after stopping the antibiotic infusion of a client who becomes restless and flushed, and begins to wheeze during the administration of an antibiotic

Assess the client's respiratory status - the client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client airway is the priority.

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would support a diagnosis of glaucoma?

elevated intraocular pressure - in glaucoma there is an obstruction of aqueous humor due to intraocular structural damage which may result from elevated intraocular pressure.

Which cranial nerve would the nurse suspect is affected when a client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds while receiving long term aminoglycoside therapy

CN VIII is the vestibulocochlear nerve, a part of central auditory system. Medications such as aminoglycosides are ototoxic and can damage CN VIII and cause hearing loss, tinnitus, and vertigo.

Which condition would the nurse suspect in a 6 year old child who was admitted with abdominal pain, guarding, nausea, anorexia, and pain with palpation of the right lower quadrant?

Inflamed appendix - child has classic signs and symptoms of appendicitis. The symptoms are caused by inflammation and altered gastrointestinal function. The general symptoms may be seen in children with viral infections, irritable bowel, and parasitic infections. However, abdominal guarding and pain in the right lower quadrant indicates a more specific condition, appendicitis

the nurse pulls up on the client's skin and releases it to determine whether the skin immediately returns to its original position

skin turgor

Which condition would the nurse suspect when a client's respiratory rate increases and the respirations are abnormally deep and regular?

Kussumal's respirations alteration in the breathing process characterized by an increased and abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have an abnormally low respiratory rate and the depth of ventilation is depressed. In Biot respiration, respirations are abnormally shallow for two to three breaths, followed by irregular periods of apnea. An irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyne-Stokes respirations.

A client reports nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating ground beef, sausage, or hot dogs. What diet would the nurse instruct the client to follow

Low fat: The presence of fat in duodenum stimulates painful contractions of the gallbladder to release bile, causing right upper quadrant pain; fat intake should be restricted. Foods that trigger gallbladder attacks include products rich in saturated fat and cholesterol, such as ground beef. processed foods such as sausage and hot dogs can aggravate gallbladder pain.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?

Vesicular breath sounds - normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli.

Which finding would the nurse expect when assessing a client with left sided pleural effusion

Reduced or absent breath sounds at the left base of the lung - compression of the lung by fluid that accumulates at its base reduces expansion and air movement, causing reduced or absent breath sounds at the left base of the lung

A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately?

Suction the tracheostomy Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed.

Which term would the nurse use to describe a noticeable difference in the pupil sizes

anisocoria - normal diameter of pupil is 3 and 5 mm.

Which action would the nurse take to evaluate whether interventions have been effective in treating a client's exertional dyspnea?

ask a client about shortness of breath with various activities - because dyspnea is subjective, the nurse will need to ask the client about whether dyspnea has improved. Auscultation of breath sounds provides objective evidence of whether problems like pneumonia or asthma have improved, but does not evaluate for subjective improvement. Oxygen saturation provides clear objective data about oxygen level, but it is not the best indicator for improvement in dyspnea on exertion.

which priority action would the nurse perform when caring for a client with suspected anaphylaxis

assess airway and oxygenation

When performing a focused respiratory assessment, which action would the nurse take first?

check for any evidence of respiratory distress - initial action in respiratory assessment is to observe for any signs of respiratory distress.

A client reports right ear hearing loss. When performing a weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

conductive hearing loss - during a weber test, conduction hearing loss often causes the tuning fork to be heard better and more clearly in the impaired ear. people with sensorineural hearing loss will hear the sound better in the normal ear - mixed hearing loss is a combination of both conduction and sensorineural hearing loss

The nurse assess the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?

crackles - produced by air moving across fluid in the alveoli

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

decreased sounds - collapsed lung no air movement

Which factor in a client's health history increases the risk of hearing loss

diabetes noisy environment ear infections loud music diabetes may decrease the blood supply to the ears and thereby decreasing hearing acuity. Exposure to loud noise causes hearing loss. Past ear infections may lead to a decrease in hearing acuity. Exposure to loud music often may cause loss of hearing acuity. deficiency of vitamin B12 and folic acid may cause hearing loss

which action will the nurse take after noticing bibasilar crackles in a client who had an open cholecystectomy on the previous day?

encouraging turning, coughing, and deep breathing exercises perform frequent breath sounds assessment this client likely has postoperative atelectasis and requires frequent breath sounds assessments because of the presence of adventitious breath sounds. The client should turn cough and deep breathe to improve ventilation and resolve atelectasis. The client may be encouraged to increase intake to thin any secretions

peritonitis develops in a client who had surgery for a ruptured appendix. which clinical findings should the nurse expect the client to exhibit?

fever abdominal muscle rigidity - a moderate fever is associated with inflammation of the peritoneal membrane. Muscular rigidity over the affected area is a classic sign of peritonitis. Malaise, rather than hyperactivity is often associated with peritonitis. Nausea, not hunger. Even though kidneys are making the urine, the bladder often retains the urine after surgery complication.

the nurse is preforming an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are consistent with which condition?

hyperthyroidism - visual changes such as blurring or double vision and tiring of the eyes, may be among the earliest problems for a client with hyperthyroidism exophthalmos or protruding eyes is seen in hyperthyroidism

a client appears anxious, 40 shallow breaths per minute. The client reports dizziness, lightheadedness and tingling sensations of the fingertips and around the lips

hyperventilation - client is blowing off excessive carbon dioxide which can lead to respiratory alkalosis

which assessment finding would the nurse document in the client's health record as a positive Romberg test?

inability to stand with feet together when eyes are closed

After performing an optical assessment on a client, a primary health care provider notices impaired near vision, which other finding would confirm the client's diagnosis as presbyopia?

loss of elasticity of the lens - presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle aged and older adults. increased opacity of the lens is seen in cataracts. elevated intraocular pressure is associated with glaucoma. retinopathy causes noninflammatory eye changes.

The nurse is providing care to a client with ascites secondary to liver failure. Which intervention is appropriate to include in the client's care?

low sodium diet (sodium retains fluid) daily abdominal girth measurement daily weights - the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluid leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. Low sodium, low protein diet is recommended. A high protein diet will worsen the symptoms and often these clients are on a fluid restriction. taking daily abdominal girth measurements and daily weights is the most reliable indicator of fluid retention

which structure is a component of the auditory ossicles

malleus - the malleus along with the incus and stapes constitutes the auditory ossicles.

Which is the correct technique when using an otoscope to examine the ears of an infant

pull pinna down and back

An auditory screening reveals that a child has mild hearing loss. Which statement would the nurse use to explain this degree of hearing loss?

speech therapy and hearing aids may be required - a mild degree of hearing loss causes the child to miss 25% to 40% of conversation. it may result in speech deficits and interfere with the child's educational progress. Hearing aids usually help to improve function.

which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons

stage IV - stage IV involves full-thickness tissue loss and the tendons, bones, muscles are exposed

which rationale supports the nursing intervention to turn the client with paraplegia every 1 to 2 hours

to prevent development of pressure injuries

when providing care for several clients on a medical surgical unit which task would the nurse appropriately delegate to the unlicensed assistive personnel

turn a bed bound client to prevent pressure injuries

Which vitamin would the nurse anticipate may be needed when a client with liver damage reports bleeding gums and the nurse observes small facial hemorrhagic lesions

vitamin k - petechiae represent evidence of capillary bleeding, the diseased liver is no longer able to metabolize vitamin k, a process that is necessary to activate blood-clotting factors.

Which test helps a primary health care provider distinguish between conductive and sensorineural hearing loss

weber test - tuning fork tests help in differentiating conductive and sensorineural hearing loss. The weber test and Rinne test are two of the most common tuning fork tests performed to make this distinction. the whisper test provides general information about the client's hearing ability.

The nurse is caring for a client with cholelithiasis. which clinical manifestation would the nurse expect if the client develops obstructive jaundice ?

yellow sclera - yellow sclera results from failure of bile to enter the intestines, with subsequent backup into the biliary system and diffusion into blood. Bilirubin is carried to all body regions, including skin and mucous membranes.