Health Assessment Ch. 22

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork?

The nurse should place the stem of the vibrating tuning fork on the mastoid area behind the ear to test for bone conduction of sound waves in the tested ear.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

To check the skin temperature and moisture.

The nurse would auscultate for voice sounds during which part of the comprehensive examination? A) Posterior chest B) Abdomen C) Head and face D) Neck

a

When observing a client's behavior, which of the following would be most important for the nurse to compare the observations with? A) Developmental stage B) Stated age C) Overall physical development D) Vital signs

a

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? A) The client has the right to refuse. B) Permission maintains the client's confidentiality. C) It ensures that the client will answer personal questions. D) The client's level of comfort will be increased

a

Which of the following would be an example of information obtained during the health history about a review of the client's body systems? A) Wears dentures; denies problems with eating, chewing, and swallowing. B) States her father died of a heart attack at age 60 C) Uses over-the-counter antacid for occasional heartburn D) Vaginal delivery of two children without complications

a

uring which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

Ausculation of a patient's heart murmur.

The nurse is preparing to examine a patient's posterior thorax. What will be included in this examination?

Auscultation of lung sounds

How will the nurse, who is conducting the physical assessment, encourage the client to be honest and open in identifying the health problem?

By explaining that all information will be kept confidential.

A nurse would expect to assess the epitrochlear lymph nodes when assessing which of the following? A) Neck B) Arms C) Posterior chest D) Sinuses

b

An adult client states she has been drinking a very large amount of water since she has begun walking everyday. She has been transported to the emergency room due to acute confusion. Which electrolyte imbalance is most likely the cause of this client's symptoms?

Hyponatremia

tricuspid area

5th left ICS close to the sternum

Mitral (Apical) area

5th left ICS medial to the MCL

crepitus

A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.

When assessing the abdomen, which assessment technique is used last?

Palpation

Testing CN I

Present odors, test nostrils seperately

pulmonic area

2nd left ICS close to the sternum

aortic area

2nd right ICS close to the sternum

he nurse is assessing cranial nerves and should look for which sign of cranial nerve VII damage?

Asymmetrical smile. Facial asymmetry may indicate damage to facial nerve (cranial nerve [CN] VII) or a serious condition such as a stroke.

CN VI

Abducens nerve- lateral movement of eyeballs

When you enter the room of a hospitalized patient, the intravenous pump is alarming. The patient is restless, moaning, crying, and exhibiting guarding behavior. An uneaten meal is sitting on the over-bed table; several family members are arguing loudly. What would be your priority?

Assessing for pain

To properly evaluate the jugular venous pressure in a client, the nurse should perform which intervention?

Assist client to supine position with head elevated

Testing CN III, IV, VI

Pupillary reaction, extraocular movements

The nurse is assessing the upper extremities of the client. What pulses should be assessed? Select all that apply.

Brachial and radial

During the eye assessment, a nurse performs part of the neurological examination for which cranial nerve?

The nurse checks the function of cranial nerve VII when assessing the corneal reflexes during an eye assessment.

The nurse is to perform an assessment on a newly admitted client. Which assessment would be most appropriate?

Comprehensive. A comprehensive assessment of a newly admitted client. This assessment is more detailed and complete than shift and focused assessments, which evaluate progress toward a goal later in the stay

What type of assessment would a nurse perform on a patient being admitted to the hospital?

Comprehensive. The nurse in the hospital performs a comprehensive assessment of the client on admission. This assessment is more detailed and complete than screening and focused assessments that evaluate progress toward a goal later in the stay.

The nurse should recognize that which acute change in heart rate requires urgent attention and intervention in an adult hospitalized client?

Decrease to 44 beats/minute. Acute and urgent situations such as the following warrant immediate attention and interventions: Acute change in heart rate to fewer than 50 or greater than 120 beats per minute.

The nurse has entered a client's room to begin a head-to-toe assessment. The client appears anxious, is pale, and is struggling to breathe. What is the nurse's priority action?

Ensure patient airway

A nurse is conducting the general survey at the beginning of the head-to-toe assessment. Which of the following does the nurse need to address as part of the general survey?

Evaluate personal hygiene

A new nurse is learning how to perform a head-to-toe assessment. Her preceptor correctly tells the new nurse that it's best to do the musculoskeletal examination with range of motion before assessing the cardiac and respiratory status

False

To properly evaluate a male client's genitalia, the nurse should have the client do which of the following?

Have the client stand and face the nurse with gown raised

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?

Inspection. The nurse should use the technique of inspection for assessment of the vagina. The nurse should insert the speculum and inspect the vagina for color, consistency, and discharge

LOC

Level of Conciousness- Oriented to time, place, and person

A nurse has introduced herself to a new client and asked the client to accompany her to an appropriate location for assessment. During this initial interaction with the client, the nurse is able to ascertain the client's:

Level of consciousness. The client's response to the nurse's introduction and direction gives useful information about his or her level of consciousness.

After examining a patient's nose and sinuses, the nurse should examine which structure?

Mouth and pharynx

CN III

Oculomotor nerve- pupillary constriction lid elevation

CN I

Olfactory nerve- sense of smell

It is important to apprise the patient of what you are doing and what you find as it does what?

Opens up teaching/learning moments

CN II

Optic nerve- vision

A nurse has been ordered to include an ear assessment as part of a head-to-toe examination of a client. Which of the following pieces of equipment will the nurse need for this assessment?

Otoscope

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed. PERRLA stands for pupils equal, round, reactive to light, and accomodate. L 6-4, R 6-4 indicates the pupil sizes of both eyes changed from 6 mm to 4 mm when testing pupil reaction. These results are normal for an adult. There is no indication or need for an opthamologist consult, Weber test (hearing), or Romberg test (balance) based on these results

At the beginning of the exam you would perform a general survey. What would you assess at this time?

Safety

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed?

Sanguineous

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin. Sequential compression devices are placed on extremities. It is important that skin under these devices be at least every shift

A nurse should perform an ongoing assessment of which system throughout the entire examination?

Skin. The nurse should assess the skin with each part of the head-to-toe assessment looking for color changes or any suspicious lesion

Which equipment will the nurse gather to conduct a physical examination of a patient's eyes? (Select all that apply.)

Snellen chart, Rosenbaum card, Ophthalmoscope

During the admission assessment of a new patient, the nurse is now preparing to assess the patient's thyroid gland. How should the nurse perform this assessment?

Stand behind the patient and palpate the sides of the trachea

A nurse is preparing to perform the nurse's first complete assessment of a client at a hospital. Which of the following should the nurse consult to find out what can legally be assessed and diagnosed?

State's nurse practice act

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

CN V

Trigeminal nerve- innervates at the temporal and masseter muscles

CN IV

Trochlear nerve- downward/inward movement of eyeballs

Testing CN II

Visual activity, Snellen chart, determine visual fields

How should a nurse assess graphesthesia as a part of the physical assessment of arms, hands, and fingers?

Write a number in the palm of the client's hand

At which time would a nurse observe and evaluate jugular venous pressure? A) After examining the breasts B) When moving from the posterior to the anterior chest C) After assessing the heart D) Before examining the abdomen

a

Before performing a complete assessment, which of the following would be most important for the nurse to do? A) Check the state's Nurse Practice Act. B) Review the client chart. C) Gather personal protective equipment. D) Get necessary supplies ready.

a

During which part of the comprehensive assessment would the nurse auscultate after inspecting but before percussing? A) Abdomen B) Anterior chest C) Neck D) Heart

a

A nursing instructor is describing the use of a head-to-toe approach for a comprehensive health assessment and how body systems may be combined, using the legs as an example. Which of the following would the instructor describe as being included in this assessment? Select all that apply. A) Skin color and condition B) Cardiovascular system C) Peripheral vascular system D) Neurologic system E) Musculoskeletal system

a c d e

When assessing a client's cognitive capabilities, which of the following would the nurse assess? Select all that apply. A) Remote memory B) Posture C) Speech D) Abstract reasoning E) Judgment F) Perceptions

a d e

When assessing the legs, feet, and toes, which pulses would the nurse expect to palpate? Select all that apply. A) Femoral B) Brachial C) Temporal D) Dorsalis pedís E) Popliteal F) Posterior tibial

a d e f

Before beginning a physical assessment it is important for the nurse to

acquire your client's verbal permission to perform the physical examination

When integrating the total physical examination the nurse should

assess peripheral vascular status when examining the lower extremities. When you assess the legs you will be assessing the parts of the skin (color and condition of skin on legs), peripheral vascular system (pulses, color, edema, lesions of legs), musculoskeletal system (movement, strength, and tone of legs), and neurologic system (ankle and patellar reflexes, clonus)

A nurse has completed examining a client's nose and sinuses and is about to examine the client's mouth and throat. Which of the following would be most important for the nurse to do? A) Warm the hands B) Put on gloves C) Obtain a tuning fork D) Collect a saliva specimen

b

A nurse is performing a head-to-toe assessment and is preparing to examine the client's ears. Which equipment would the nurse need to have readily available? A) Ophthalmoscope B) Tuning fork C) Tongue depressor D) Stethoscope

b

After teaching a group of students about areas to include when examining a client's mental status, the instructor determines that the teaching was successful when the students identify which of the following as important? A) Ability to concentrate B) Thought processes C) Level of orientation D) Recall ability

b

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? A) "I try not to let the pain affect my life." B) "I haven't had a checkup in over 5 years." C) "I had my appendix removed when I was 14 years old" D) "I have an aunt who had breast cancer."

b

When performing a head-to-toe assessment, during which part would the nurse assess the motor function of cranial nerve VII? A) Mental status examination B) Head and face C) Ears D) Mouth and throat

b

Flexion

bending at the joint

apical impulse (PMI-Point of Maximal Impulse)

brief systolic beat usually found in the 5th left ICS, 7-9 cm from the midsternal line

A novice nurse is practicing how to complete a comprehensive assessment to gain confidence and skill. Which of the following would be most important for the nurse to remember? A) Gather health history information first. B) Intersperse the physical exam with the history. C) Establish a routine for the assessment. D) Allow the client a break between the two parts of the history/exam.

c

A nurse is preparing to complete a comprehensive health assessment on a female client. Prior to beginning the assessment, a client states, "I'm really having a good deal of pain in my hip now." Which of the following would be most appropriate for the nurse to do? A) Begin the comprehensive assessment. B) Explain the reason for the assessment. C) Delay the full exam until the client is more comfortable. D) Encourage the client to talk about how she is feeling. .

c

A nurse who is skilled in assessment is to obtain a comprehensive health assessment. The nurse would most likely be able to complete this assessment within which time frame? A) 2 hours B) 1 hour C) ½ hour D) ¼ hour

c

The nurse is completing the general survey. In addition to observing the client's appearance, the nurse would assess which of the following? A) Mental status B) Cognitive abilities C) Vital signs D) Thought processes

c

The nurse is palpating the tonsillar, submandibular, and submental lymph nodes. The nurse is most likely examining which area during a comprehensive assessment? A) Nose and sinuses B) Abdomen C) Neck D) Face

c

The nurse would test for stereognosis during which part of the comprehensive exam? A) Posterior and lateral chest B) Nose and sinuses C) Arms, hands and fingers D) Legs, feet, and toes

c

Which statement about assessment findings obtained from a comprehensive assessment would be identified as part of the general survey? A) Hair neat clean with white and gray streaks; no scalp lesions noted B) Sclera white; conjunctiva slightly reddened without lesions C) Client alert and cooperative; sitting comfortably on chair with hands in lap D) Head symmetrically round; neck nontender with full range of motion

c

circumduction

circular motion

A client is admitted to the health care facility for the onset of a stroke. To test the function of cranial nerve I, the nurse should ask the client to:

close eyes and assess for smell.

dub

closing of aortic and pulmonic valves

lub

closing of mitral and tricuspid valve

A nurse is going to complete a comprehensive assessment on a client. When collecting objective data, which of the following would the nurse do first? A) Assess the client's vital signs B) Take body measurements C) Assess mental status D) Observe the overall appearance

d

The nurse would palpate the axillae during examination of which area? A) Neck B) Anterior chest C) Heart D) Breasts

d

atrophy

decrease in muscle size; wasting away

Two body systems that may be logically integrated and assessed at the same time are the

eye exam and cranial nerves II, III, IV, and VI.

The nurse is preparing to conduct a physical examination of an adolescent patient for a school physical. Which examination approach would be the most appropriate for this patient?

head-to-toe assessment

When listening to heart sounds, the nurse notes a swishing sound. The nurse recognizes that this as what?

heart murmur

hypertrophy

increase in muscle size

Abduction

moving away from midline

Adduction

moving toward midline

sinoatrial node (SA)

pacemaker of the heart; electrical impulses are generated here

pitting edema

sign of fluid retention; Press the edematous area with the tips of your fingers, hold for a few seconds, then release. If the depression does not rapidly refill and the skin remains indented on release, pitting edema is present.

Extension

straightening at the joint

external rotation

turning away from center

internal rotation

turning toward the center

McBurney's test

used to evaluate for appendicitis

McMurray's test

used to evaluate for tears in the meniscus of the knee

The nurse should include which important safety checks before leaving a hospitalized client's room? (Select all that apply.)

• Call bell within reach • Wearing client identification bracelet • Correct intravenous lines and fluids • Correct tubes and drains intact

The client has a Foley catheter. What should be assessed related to catheter that may alert the nurse to an infection? Select all that apply.

• Color • Odor • Pain • Temperature

The nurse is conducting a head-to-toe assessment on a client. The nurse would be concerned if the following characteristics were noted? (Select all that apply.)

• Lesions • Rashes • pressure ulcers

What symptom found during assessment would cause the nurse to suspect the client may be experiencing sepsis?

• Temperature greater than 102 F (38.9 C) • Respiratory rate 36