Health and Physical Assessment AQ

Which questions would the nurse ask the client when obtaining the health history? Select all that apply. One, some, or all responses may be correct.

The health history of a client includes the client's food habits so that the nurse can obtain an assessment of the client's nutrition status. The nurse also assesses the client's habits and lifestyle patterns. Asking about the use of alcohol and tobacco helps determine the client's risk for diseases involving the liver or lungs. The health history includes descriptions of allergies and reactions to food, latex, drugs, or contact agents such as soap.

A client presents to the health care facility with abdominal pain. Which question would the nurse ask the client to obtain information about concomitant symptoms?

"What other discomfort do you experience?" Symptoms that accompany the primary symptom of the illness and worsen the health condition are called concomitant symptoms. An example is nausea that may accompany the primary symptom of pain.

Which action by the client indicates the need for further instruction on insulin administration? Select all that apply. One, some, or all responses may be correct.

Aspiration is not performed for insulin administration. The client would use a 27-gauge needle to administer the dose of insulin. The abdomen is the appropriate location for administering rapid-acting insulins. The client would hold the needle in place for several seconds after administering the insulin. Appropriate locations to administer insulin are those where 2.5 cm (1 inch) of subcutaneous fat can be pinched.

The nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. Which physical principle causes the sterile field to become contaminated?

Capillarity When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads.

A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition would the nurse expect?

Kussmaul's respiration is an alteration in the breathing process characterized by an increased and abnormal deep and regular rate of respiration.

After assessment, the nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. Which would be the cause of these sounds?

Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways.

While performing a physical assessment of a client, the nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. Which is the probable cause for this condition?

Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease.

In which situation would the nurse consider family members as the primary source of information? Select all that apply. One, some, or all responses may be correct.

The client is an infant or child. The client is brought in as an emergency. The client is critically ill and disoriented. The nurse interviews the parents who care for the infant or child. Thus the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions.

Arrange the sequence of steps in which the assessment of a lesion would be performed.

The first step in assessing the lesion is to collect standard information about the lesion. This information includes the color, location, texture, size, shape, type, grouping (clustered or linear), and distribution (localized or generalized). The next step is to observe for any exudate, odor, amount, and consistency. After this step, the size of the lesion is measured in centimeters by using a small, clear, flexible ruler. Finally, each lesion is measured for height, width, and depth.

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

The liver manufactures albumin, the major plasma protein. A deficiency of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure.

Which are levels of critical thinking in nursing? Select all that apply. One, some, or all responses may be correct.

The three levels of critical thinking in nursing are basic, complex, and commitment. Analyzing and evaluating are skills associated with critical thinking, not levels

In which position would the nurse place a client recovering from general anesthesia?

Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state.