Health Assessment Exam 2-The Point

A nurse in the operating room has a client who just underwent gastric bypass surgery and weighs 243 kg (534.6 lbs). Upon extubating, the client's oxygen saturation drops to 84% and the client has difficulty catching her breath. What could be causing these problems?

Obesity, which can limit chest wall expansion and compromise breathing

The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond?

"It is important to perform self breast exams as there could be changes or additional lumps in your breasts that would need further examination"

What are the openings to the middle ear? Select all that apply.

-the tympanic membrane -the round window -the oval window -the eustachian tube

The nursing instructor discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply.

-patency of the sinus ostia -normal cilia function -normal quality and quantity of the mucus

Equipment used for objective data collection involving the eyes includes which of the following? Select all that apply.

-penlight -opthalmoscope -Snellen chart -occlusive covers

During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply.

-pneumonia -atelectasis -trauma -pneumothorax

What are the signs of hypoxia? Select all that apply.

-respiratory rate > 30 -cyanosis -retractions -use of accessory muscles to breathe

Hypothyroidism in the older adult can be difficult to diagnose. What are some of the reasons it is difficult to diagnose? Select all that apply.

-subtle onset -symptoms attributed to the aging process -Chronic diseases

When examining the male breast, for what does the nurse inspect? Select all that apply.

-swelling of the nipple -ulceration of the areola -nipple drainage

A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply.

-tachycardia -diarrhea -anxiety

The client is having a thyroid crisis. What symptoms would the nurse assess for? Select all that apply.

-tachypnea -nausea -anxiety

When writing a care plan for a client with mouth and nose problems, what outcomes might the nurse identify? Select all that apply.

-the client states that breathing is more comfortable and less congested -the client's oral mucous membranes are pink and intact -the client swallows with evidence of aspiration

What interventions might the staff educator at a long-term care facility suggest to improve the status of clients with hearing loss? Select all that apply.

-turn off the television and radio when communicating -close the door if the hallway noise is loud -provide visual aids for detailed discussion

A comprehensive physical examination of the eye includes tests for which of the following? Select all that apply.

-visual acuity -eye muscle function -internal ocular structures -the external eye

A respiratory pattern that gradually becomes faster and deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?

Cheyne-Stokes

During a breast assessment the nurse finds scaly lesions at the nipple with a lump behind the nipple. The nurse suspects what?

Paget disease

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?

Kisselbach plexus

What is the most important focus area for the integumentary system?

UV radiation exposure

Upon assessing the skin, the nurse finds pustular lesions on the face. The nurse identifies that these could be what?

Acne

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular

The client is complaining of breast pain and the nurse finds a lump upon further assessment. The nurse suspects this could be what?

Mammary duct ectasia

A client has a 7-mm lesion with irregular borders and color variation that has grown over the last several weeks. The nurse knows that this lesion could possibly be what type of cancer?

Melanoma

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?

Migraine

The nurse observes a young client holding a newspaper up close to read. Which condition does the nurse suspect the client suffers from?

Myopia

When teaching a class of school-age children about hygiene, the nurse should include which information about the ears?

Never put anything smaller than your elbow in your ears

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation

An adult farm worker presents at the ED after falling out of a hay loft. The client states falling approximately 4 hours ago and did not lose consciousness. The client is experiencing only a mild headache. When asked why the client came to the ED, the patient states that he had a clear discharge from the right ear ever since the accident. What should this finding indicate to the nurse?

Possible basilar skull fracture

The nurse observes a white patchy area in the pharyngeal fossa of a client. What is the nurse's best action?

prepare client for a biopsy of the lesion

What part of the eye receives and transmits visual stimuli to the brain for processing?

retina

A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?

rinse mouth with antifungal medication as prescribed

The nurse practioner in an oncology clinic is examining a client who had a mastectomy 5 weeks ago. What is one area of the breast that the nurse would be especially careful to examine because it is known for recurrent malignancies?

scar site

When assessing the tympanic membrane, a variation of normal is tympanic membrane with what?

sclerosis

The clinic nurse is assessing an older adult client who fell. The nurse asks if the client ever feels dizzy or has problems with balance. For what is the nurse assessing?

vertigo

A client has been found to have a breast lump and an ultrasound has been ordered. The client voices concerns to the nurse she is afraid of the painful testing she is going to endure. How should the nurse best respond?

"this noninvasive test uses high frequency waves to determine if the mass is solid or cystic"

A client recently diagnosed with Grave's disease exhibits protruded eyeballs. Which eye care instruction should the nurse discuss with this client?

"wear an eyepatch and use moisturizing eye drops"

The results of the client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?

"you have a conductive hearing loss"

The nurse is teaching about the importance of regular eye examinations and should include information about which conditions that place clients at highest risk for blindness? Select all that apply.

-Diabetes -Hypertension

A nurse notices that a client's nails on the right hand have separated from the nail bed and appear yellow. What could be a cause of this condition? Select all that apply.

-Fungal infections -Trauma -Warts

A nurse has been asked to give an educational presentation for low-income mothers at the local community health care office. The community is culturally diverse. When talking about otitis media, the nurse would be sure to emphasize that incidence of otitis media is higher in which pediatric populations? Select all that apply.

-Native American -Alaskan Eskimo -Indigenous Australian

The nurse is performing teaching on breast health at a community center. The nurse would identify what risk factors related to breast cancer? Select all that aply.

-Obesity -Physical activity

A client has a nursing diagnosis of impaired gas exchange related to alveolar-capillary membrane changes. What interventions are appropriate in this situation? Select all that apply.

-administer oxygen -facilitate deep breathing -use an incentive spirometer

Gynecomastia is a normal occurrence in adolescent males. What are abnormal causes of gynecomastia? Select all that apply.

-anabolic steroids -side effect of some medications -diseases

When collecting a client's medical history, the nurse should ask if the client is taking which medications that most likely contribute to complaints of recurrent epistaxis? Select all that apply.

-anticoagulants -herbal supplements -antihistamines

A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client experienced head trauma in the accident. What laboratory studies might the nurse practitioner order for this client? Select all that apply.

-basic blood panel -beta-2-transferrin

What are the causes of lymphadenopathy? Select all that apply.

-blocked nodes postmastectomy -infection -malignancy

The nurse is examining the breast of a clinic client and palpates a lump. What would the nurse be sure to document about this lump? Select all that apply.

-consistency -distinctness -mobility

An adult client comes to the clinic. The client is pale and diaphoretic, the respiratory rate is 30 breaths/minute. Coarse crackles are noted in all lung fields. The client has smoked for 40 years. Why is this client at increased risk for pneumonia? Select all that apply.

-decreased ability to cough up secretions because of weakened chest muscles -pooling of secretions because of decreased function of the cilia -increased risk for COPD because of years of smoking -at great risk for "stiff lungs", which are harder to ventilate, because of his age

The nurse is caring for an adult client admitted to the unit 10 days ago with pneumonia. When making shift assessment, the nurse notes white patchy lesions in the client's mouth. The nurse suspects candidiasis and updates the care plan to include the findings. One outcome written for this client is "oral mucous membranes pink, moist, and without coating, lesions, or masses." What interventions might the nurse use to achieve this outcome? Select all that apply.

-encourage fluids -provide oral care every shift

What assessment findings would be expected for a woman that is 3 months pregnant? Select all that apply.

-enlarged breast -darkened nipples -nodular feeling breasts

A nurse takes a phone call from the mother of a 4-day-old infant. The woman says that she is breast-feeding and that her milk production has started but that she is having a problem with her breasts. What could the nurse tell the woman are normal breast findings at this point in time? Select all that apply.

-erythema -engorgement -increased size

An elderly bedridden client has a pressure ulcer that is not healing on the coccyx. What must the nurse do to improve this client's outcome? Select all that apply.

-evaluate the client's outcomes, -modify nursing interventions

A nursing student in the otolaryngology clinic is asked by the instructor about what findings during a sinus examination suggest infection. Which of the following would the student include in her response? Select all that apply.

-fullness -tenderness

The thoracic cavity contains which of the following organs? Select all that apply.

-heart -lungs -most of the esophagus

A nurse practitioner is assessing a client in the ED following a motor vehicle accident. The client complains of ear pain. The nurse practitioner is performing an otoscopic examination. What would demonstrate the correct technique for using the otoscope? Select all that apply.

-holding the otoscope so that the thumb is by the window -holding the client's ear at the helix -rotating the otoscope slightly

What does examination of the skin involve? Select all that apply.

-inspection -Palpation

Which of the following eye abnormalities would the nurse observe for during assessment of the external eyes? Select all that apply.

-iris nevus -exophthalmos -osteogenesis imperfecta

A woman who has had a mastectomy is undergoing radiation and chemotherapy. The nurse suggests that the client and family make arrangements for assistance from a homemaker or "chore worker." What services could this homemaker or "chore worker" provide?

-laundry, meal preparation, shopping

When performing a breast assessment, the nurse finds a lump. Further assessment should include what? Select all that apply.

-location -distinctness -shape -mobility

Risk factors for cancers of the neck include which of the following? Select all that apply.

-male gender -alcohol-consumption -tobacco use

A RN is working with a nurse practitioner at a local walk-in clinic. The nurse practitioner needs to perform an objective assessment of a client's left ear. What equipment would the RN make sure is in the room? Select all that apply.

-otoscope -high-pitched tuning fork

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

This could be a sign of dehydration

A nurse is going to inspect and palpate a client's head and neck. After asking the client to remove the wig, what should the nurse do next?

Wash hands

The three salivary glands also contain drainage ducts. Which drainage ducts are associated with the submandibular gland?

Wharton's ducts

A 2-month-old infant is being examined at the pediatrician's office. The mother said she noticed the baby was not making tears in the left eye. What does this finding suggest?

a blocked lacrimal apparatus

When caring for a client with chronic shortness of breath, fatigue is an issue. How might the nurse limit fatigue and still gather assessment information needed for daily care?

cluster care during times when the client is more rested

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

conjunctiva

A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition?

corrective lenses

The nurse is assessing a client's visual acuity and visual fields. The nurse evaluates that the assessment results are within expected parameters. How should the nurse document this assessment finding?

cranial nerve II intact

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis

Why is it important to ask the client regarding discharge or drainage from the eyes?

discharge is associated with inflammation or infection

A woman brings her 1-month-old infant to the ED. The mother states the baby's head bulges when the baby cries. The nurse assesses the baby and notices both fontanels appear normal and the baby seems perfectly healthy. What should the nurse do next?

document a normal finding

A client in the ED tells the nurse that she is having difficulty breathing at rest. What term would the nurse use in documenting this finding?

dyspnea

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

encourage the use of safety equipment

A client diagnosed with peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?

ensure a patient airway

A client has a 0.75-inch lump in the right upper outer quadrant of the left breast. What is the standard procedure for removing this suspicious lump?

excisional biopsy

What muscles control the eye movement and hold the eye in place in the socket?

extraocular

A client diagnosed with Sjogren syndrome should be given which instructions?

eye drops and sucking on hard candy may be used to relieve dryness

A client exhibits purulent drainage in the right external ear canal. The client complains of pain that increases when the ear is touched. Which client teaching instructions should the nurse provide?

finish the entire course of antibiotic therapy

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

fluid in the alveoli

The nurse is assessing a 5-month-old Asian American infant whose mother has brought him to the clinic with reports that the baby is pulling at the ear and is sleepless and crying at night. When assessing the infant's ear's, what color cerumen would the nurse expect to find?

grey

The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation?

hearing intact bilaterally on whisper test

A nurse is admitting an elderly client for surgery the following morning. The nurse notices that the client has excessively dry skin. The client says showering every day, sometimes twice, but has trouble keeping skin moist. What client education is appropriate?

the elderly should bathe or shower only every 2 to 3 days

The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?

this client could be experiencing a stroke

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

this could be a sign of cancer

When assessing the ears of older adults, it is necessary to remember that physiologic changes take place as people age. What is a physiologic change that takes place in the ear of an older adult?

tympanic membrane is more opaque

What is an appropriate outcome for a client who has had a mastectomy?

the client returns to previous social involvement

An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response?

" you can wrestle after the lesions stop weeping and have crusted over"

The client reports to the nurse that she is concerned she has cancer as she has been experiencing clear discharge from her breasts. What is the best response of the nurse?

"Do you take any medications"

The nurse is assessing cranial nerves III, IV, and VI. Which instructions should the nurse provide to the client in order to perform this assessment?

"Follow my finger with only your eyes."

The client tells the nurse "I am so glad I had a mastectomy and I will never have breast cancer again." How should the nurse best respond?

"We need to continue to perform examinations. Breast cancer can reoccur"

The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane, What is the nurse's best response?

"it's safe to fly because the tubes will equalize pressure"

A nurse is receiving a report from the night shift about four clients. Which client would the nurse see first?

A 64-year-old man with COPD who is short of breath and has a respiratory rate of 32 breaths/min

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?

Angular chelities

A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action?

Ask the mother how long the tubes have been in place

A client is being assessed following a motor vehicle accident. The client's right eye is swollen shut and very painful. Why does this require further assessment?

Blunt-force trauma often results in fracture of the orbit

A woman who is 5 months pregnant is being assessed at a routine visit. She has increased pigmentation around the eyes. This is known as what?

Chloasma

An Asian American primipara asks to speak with the nurse about a concern she has over potential genetic defects in her fetus. What congenital problem would the nurse expect questions about based on the patient's ethnicity?

Cleft lip and palate

An elderly Vietnamese client is having his skin assessed. The nurse notes multiple bruises and abrasions on his legs. What practice by Southeast Asian people could this be the result of?

Coining--patients rub a coin or other specific objects across the skin in a particular manner to treat bruising and abrasions

A nurse practitioner in the urgent care center is assessing a child who was involved in a skateboarding accident. Which of the following findings is indicative of nasal fracture?

Crepitus

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest

What is the most common type of hyperthyroidism?

Graves' disease

The nurse is assessing a 15 year old male and finds soft, fatty enlargement of breast tissue. The nurse would document his as what?

Gynecomastia

A client presents to the emergency department after being hit in the head with a baseball bat during a game. The nurse should assess for which condition?

Hyphema

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax

A client presents with possible lice infestation of the scalp. The nurse observes nits very close to the scalp. What does this finding tell the nurse?

The client had a recent infestation

An adult client is having his skin assessed. The client tells the nurse he has been a heavy smoker for the last 40 years. The client has clubbing of the fingernails. What does this finding tell the nurse?

The client has chronic hypoxia

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

An elderly client comes to the clinic for evaluation. During the skin assessment, the nurse notes considerable skin tenting. Why does this finding require further assessment?

tenting indicates dehydration

The nurse is assessing a school aged child for allergies. What might the nurse expect to find as an indication of allergies in this client?

a transverse ridge

Where is the temporal artery palpated?

above the cheek bone near the scalp line

An adult client is brought to the ED by her daughter. The client is cyanotic; her pulse is 117 beats/min, respirations 36 breaths/min, blood pressure 110/64, and oxygen saturation 82%. What is the first nursing action?

administer oxygen

What do retinal abnormalities include?

age-related macular degeneration

The nursing instructor teaches students the most accurate location to auscultate the right middle lobe of the lung where?

anterior

When assessing the tympanic membrane, where would the nurse expect to see a cone of light?

anterior quadrant

When assessing a client's lips, which of the following is an indication of a viral infection?

aphthous ulcer

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

arthritic changes of the cervical spine

A client has a nursing diagnosis of ineffective airway clearance related to fatigue and inability to cough effectively as evidenced by respiratory rate and dyspnea. What outcome would be appropriate for this client?

breath sounds return to baseline within 1 week

A client tells the nurse about a raised lesion on the client's leg. What is the nurse's first nursing action?

inspect the area

The nurse auscultates the base of the lungs to assess for what reason?

it is where fluid occurs with pulmonary edema

Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?

lymphatic

When using hand gel to clean the hands, what must the nurse do before touching a client's eyes?

make sure the hands are completely dry

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

melasma generally resolves postpartum

During adolescence, what vision change is common?

nearsightedness

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?

notify the health care provider

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

notify the healthcare provider about the finding

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

pleurisy

What would the nurse identify as a priority educational need for clients with chronic back problems.

proper posture, bending, and lifting techniques

The client tells the nurse that he has been coughing up pink, frothy sputum. The nurse notifies the health care provider because the client may have what condition?

pulmonary edema

Which instructions should the nurse provide to the client taking a sublingual medication?

put the medication underneath your tongue

A young adult client has just had x-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next?

range of motion of the neck

A client comes to the clinic with reports of a reddened, tender lump on the left breast. What would the nurse document about this lump?

size

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?

skin cancer prevention

A client presents to the clinic and reports numerous skin tags in the left axillary area. The client is worried about skin cancer. What can the nurse tell the client about skin tags to alleviate fear of cancer?

skin tags are common benign skin lesions

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

stridor