Fundamentals of Nursing Chapter 25 PrepU

A nurse caring for patients in a long-term care facility is performing a functional assessment of a new patient. Which questions would the nurse ask? Select all that apply.

a, d, e. A functional health assessment focuses on the effects of health or illness on a patient's quality of life, including the strengths of the patient and areas that need to improve. The nurse would assess the patient's ability to perform ADLs and IADLs such as dressing, grooming, preparing meals, and managing finances. A history of smoking is a lifestyle factor and the chief complaint is the reason for seeking health care, both assessed during the health history. Social networks and support persons are assessed as psychosocial factors related to the health history

A nurse auscultates the thorax and lungs and hears coarse, low-pitched, continuous sounds on expiration. When the patient coughs, the sounds clear up somewhat. The nurse would document these sounds as:

a. Adventitious breath sounds are sounds not normally heard in the lungs. Bronchovesicular breath sounds are normal sounds heard on inspiration and expiration. Vesicular breath sounds are soft, low-pitched, whispering sounds; heard over most of the lung fields. Bronchial sounds are blowing, hollow sounds, auscultated over the larynx and trachea.

When inspecting the skin of a patient who has cirrhosis (chronic liver damage) of the liver, the nurse notes that the skin has a yellow tint. What would the nurse document related to this finding?

a. Jaundice is a yellowish skin color caused by liver disease. Cyanosis is a bluish skin color caused by a cold environment or decreased oxygenation. Erythema is a reddish color caused by blushing, alcohol intake, fever, injury trauma, or infection. Pallor is a paleness caused by anemia or shock.

A nurse is palpating the breast of a woman during an assessment. Which technique is performed correctly?

a. When palpating the breast, the nurse would palpate each quadrant of each breast in a systematic method using either the circular, wedge, or vertical strip technique and then use the pads of the first three fingers to gently compress the breast tissue against the chest wall. In the circular method, the nurse would start at the tail of Spence and move in increasing smaller circles. In the wedge method, the nurse would work in a clockwise direction and palpate from the periphery toward the areola. In the vertical strip method, the nurse would start at the outer edge of the breast and palpate up and down the breast.

Which actions would the nurse perform when using the technique of palpation during the physical assessment of a patient? Select all that apply.

b, c, d. During palpation, the nurse uses the sense of touch to take a pulse, test for skin turgor, and check lymph nodes. With inspection, a comparison of bilateral body parts is necessary for recognizing abnormal findings. During percussion, the fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The characteristics of the sounds produced are used to assess the location, shape, size, and density of tissues. Auscultation is the act of listening with a stethoscope to sounds produced within the body.

A nurse is assessing a patient's eyes for accommodation. What actions would the nurse perform during this test? Select all that apply.

b, f. To test accommodation the nurse would hold the forefinger, a pencil, or other straight object about 10 to 15 cm (4″ to 6″) from the bridge of the patient's nose. Then the nurse would ask the patient to first look at the object, then at a distant object, then back to the object being held. The pupil normally constricts when looking at a near object and dilates when looking at a distant object. To test for convergence, the nurse would darken the room and ask the patient to look straight ahead. The nurse would then bring the penlight from the side of the patient's face and briefly shine the light on the pupil, observing the reaction. When testing convergence the nurse would hold a finger about 6″ to 8″ from the bridge of the patient's nose and move it toward the patient's nose.

A home health care nurse takes the vital signs of a patient who is receiving supplemental oxygen at home for chronic obstructive pulmonary disease (COPD). This is the nurse's fourth visit to the patient's home. The nurse records the data collected on the patient's chart. What type of assessment has this nurse performed?

b. An ongoing partial assessment, or follow-up assessment, is conducted at regular intervals (e.g., at the beginning of each home health visit or each hospital shift) during care of the patient. This type of assessment concentrates on identified health problems to monitor positive or negative changes and evaluate the effectiveness of interventions. A comprehensive assessment with a health history and complete physical examination is usually conducted when a patient first enters a health care setting, with information providing a baseline for comparing later assessments. A focused assessment is conducted to assess a specific problem. An emergency assessment is a type of rapid focused assessment conducted when addressing a life-threatening or unstable situation.

A nurse is assessing the level of consciousness of a patient who sustained a head injury in a motor vehicle accident. The nurse notes that the patient appears drowsy most of the time but makes spontaneous movements. The nurse is able to wake the patient by gently shaking him and calling his name. What level of consciousness would the nurse document?

b. The stages of consciousness are: Awake and alert: fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands. Lethargic: appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient's name. Stuporous: unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements. Comatose: cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma

A nurse is assessing a patient's eyes for extraocular movements. Which action correctly describes a step the nurse would take when performing this test?

b. The steps in testing for extraocular movement are: (1) Ask the patient to sit or stand about 2 feet away, facing the nurse, who is sitting or standing at eye level with the patient; (2) ask the patient to hold the head still and follow the movement of a forefinger or a penlight with the eyes; (3) keeping the finger or light about 1 foot from the patient's face, move it slowly through the cardinal position—up and down, left and right, diagonally up and down to the left, diagonally up and down to the right.

A nurse is using the FOUR Coma Scale to assess the neurologic status of a patient following surgery to remove a brain tumor. The nurse rates the patient as M2 for motor response. What condition does this number represent?

b. To assess motor response, patients are asked to make a peace sign, a fist, and show thumbs up. Patients are scored as follows: M4 Thumbs-up, fist, or peace sign M3 Localizing to pain M2 Flexion response to pain M1 Extension response to pain M0 No response to pain

After inspecting the skin of a patient, the nurse documents the presence of a skin lesion as a palpable solid mass measured at 1 cm. What types of skin lesions might this describe? Select all that apply.

c, d. Plaque and nodules are palpable, elevated, solid masses that may measure 1 cm. Macules and patches are circumscribed, flat, nonpalpable changes in skin color. Macules are less than or equal to 1 cm and patches are greater than 1 cm. Bulla and pustules are circumscribed, superficial skin elevations formed by free fluids in a cavity with skin layers. Bulla are greater than 0.5 cm and pustules are filled with pus.

A nurse is conducting an assessment of a patient's cranial nerves. The nurse asks the patient to raise the eyebrows, smile, and show the teeth to assess which cranial nerve?

c. Motor function of the facial nerve (cranial nerve VII) is assessed by asking the patient to raise the eyebrow, smile, and show the teeth. The olfactory nerve (cranial nerve I) is tested by testing smell reception with various agents. The nurse tests the optic nerve (cranial nerve II) for acuity and visual fields and the vagus nerve (cranial nerve X) by asking the patient to swallow and speak, noting hoarseness.

A patient's visual acuity is assessed as 20/40 in both eyes using the Snellen chart. The nurse interprets this finding as:

c. Normal vision is 20/20. A finding of 20/40 would mean that a patient has less than normal vision.

During a physical assessment, a nurse inspects a patient's abdomen. What assessment technique would the nurse perform next?

c. When assessing the abdomen, the sequence is inspection, auscultation, percussion, and palpation. Auscultation follows inspection because percussion and palpation stimulate bowel sounds.

When assessing a patient's breath sounds, the nurse hears a high-pitched continuous sound. What type of breath sound would the nurse document?

d. Wheezes are musical or squeaking high-pitched, continuous sounds heard as air passes through narrowed airways. Rhonchi are low-pitched, continuous sounds with a snoring quality that occur when air passes through secretions. Crackles are bubbling, cracking or popping, low- to high-pitched, discontinuous sounds that occur when air passes through fluid in the airways. Stridor is a harsh, loud, high-pitched sound due to narrowing of the upper airway.