Health Assessment- PrepU Chapter 8

When can the general inspection be started?

As soon as the examiner first sees the client The first moments of interaction between client and examiner should constitute the beginning of the general inspection. This should not wait until after height and weight have been measured or until the client is completely exposed. It is not possible to begin a general inspection prior to seeing (or smelling or hearing) the client.

Which abnormal skin color should a nurse anticipate assessing on a dark-skinned client?

Ashen gray The skin of a dark-skinned client with cyanosis would be ashen gray. The skin tone would appear yellowish in a light-skinned client if the client had jaundice. A beige-pink skin tone would be a normal finding for the light-skinned client. A reddish skin tone could be related to fever, sunburn, or infection.

An 86-year-old male client with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. As well, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with assessment?

Assess the client's temperature by axilla The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.

As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

The blood pressure increases The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system that is reflected in an increased blood pressure.

Which of the following would the nurse need to keep in mind when assessing the blood pressure of a client who is receiving anticoagulant therapy?

The blood viscosity would be thinner, causing the blood pressure to decrease. Blood viscosity is thinned with anticoagulant therapy. Therefore the blood pressure would most likely decrease. Anticoagulant therapy does not affect cardiac output or arterial resistance.

The nurse assesses the amplitude of the client's radial pulse and finds it to be weak and diminished. Which of the following scores should the nurse record?

1+ Pulse amplitude of 0 means that it is absent, 1+ that it is weak and diminished (easy to obliterate), 2+ that it is normal (can be obliterated with moderate pressure), and 3+ that it is bounding (unable to obliterate or requires firm pressure).

The nurse is caring for a client who is having nothing by mouth (NPO) on the first postoperative day. The client's blood pressure was 120/80 mm Hg approximately 4 hours ago, but it is now 140/88 mm Hg. The nurse should ask the client which of the following questions?

"Are you having pain from your surgery?" A client's blood pressure will normally vary throughout the day due to external influences. This includes pain.

A nurse notes that the pulse rate of a client is less than 60 beats per minute. Which question is appropriate for the nurse to ask the client in regards to this finding?

"Have you been sitting for a long time?" Sitting or standing for too long may cause the blood to pool and decrease the pulse rate. Fever and stress cause the pulse rate to increase, not decrease. Vitamin supplements do not affect the pulse rate.

A nurse has an order to obtain orthostatic blood pressure readings on a client admitted with dehydration. The sitting blood pressure is 140/75 mm Hg. Which blood pressure reading with the client standing should the nurse recognize as orthostatic hypotension?

120/55 mm Hg A drop in both the systolic and diastolic readings of 20 mm Hg or more from the sitting position to the standing position indicates orthostatic hypotension. A drop of less than 20 mm Hg from the sitting position is considered normal. An elevation is not called hypotension but hypertension.

A nurse is assessing the pulse rate of an athletic client during a routine checkup. The nurse should anticipate the pulse rate to be in what range of beats per minute?

45 to 60 The normal pulse rate of a well-conditioned athletic client is often less than 60 beats per minute because of the conditioning of the cardiovascular system. A pulse rate ranging between 60 and 100 beats/min is normal for adults. A pulse rate of more than 100 beats/min would indicate tachycardia.

A nurse has assessed the blood pressure of a recently admitted client and obtained a reading of 128/78 mm Hg. What is this client's pulse pressure?

50 mm Hg The pulse pressure is the difference between the SBP and the DBP and reflects the stroke volume. Normal pulse pressure is approximately 40 mm Hg. The mean arterial pressure is calculated by adding one third of the SBP and two thirds of the DBP. A mean pressure of 60 mm Hg is needed to perfuse the vital organs.

A nurse is taking a rectal temperature on an unconscious client. What reading would reflect temperature within the normal range?

99°F The normal rectal temperature range is around 37°C (99°F). A rectal temperature above 100°F or at 97°F is outside the normal range. Rectal temperatures are about 0.5°C (0.8°F) higher than oral temperatures.

A nurse is assessing the general status and vital signs of a client. Which of the following are subjective findings, which the nurse obtained from the client? Select all that apply A. Date and location of the clients last blood pressure check B. Respiratory rate C. Core body temperature D. Onset and character of the clients chest pain E. Blood pressure F. A list of all of the client's current medications

A. Date and location of the clients last blood pressure check D. Onset and character of the clients chest pain F. A list of all of the client's current medications Subjective findings, which are those the client must report to the nurse, include date and location of the clients last blood pressure check, the onset and character of the clients chest pain, and a list of all of the clients current medications. Objective findings, which are obtained by the nurses direct observation or assessment, include respiratory rate, core body temperature, and blood pressure.

A female client is admitted to the health care facility due to reports of decreased appetite, loss of sleep, feelings of being unsafe in her own home, and inability to concentrate. She appears pale; her hair is disheveled, she is not wearing makeup, and she will not make eye contact. Based on this data, which nursing diagnosis can the nurse confirm?

Anxiety The major defining characteristics of anxiety are present: loss of sleep, feeling unsafe, inability to concentrate, and poor eye contact. There are no major characteristics for the nursing diagnosis of imbalanced nutrition: less than body requirements, risk for self-directed violence, or impaired verbal communication.

Before assessing vital signs, the nurse knows that it is important to assess what?

Any medications the client is currently taking Prior to assessing vital signs, it is important to assess any medications the client is currently taking because medications can affect a client's vital signs. It is not necessary to know the client's height and weight, mental status, or a complete family history before assessing vital signs because these things do not affect a client's vital signs.

A 55-year-old bookkeeper comes to the office for a routine visit. The nurse notes that on a previous visit for treatment of contact dermatitis, the client's blood pressure was elevated. She does not have prior elevated readings, and her family history is negative for hypertension. The nurse measures her blood pressure in the office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted. A blood pressure cuff that is too tightly fitted can result in a false high reading. Resting prior to assessment, measuring on a bare arm, and supporting the client's arm at mid-chest level all foster accurate BP measurement.

A nurse observes the posture of a male client and finds him leaning forward and bracing himself while sitting on the exam table. Which of the following would the nurse most likely suspect?

Chronic obstructive pulmonary disease Leaning forward and bracing assists with greater lung expansion and easier breathing in clients with chronic obstructive pulmonary disease. Other deficits or disorders would present with other types of positioning.

On which health problem should the nurse focus when assessing this client?

Cushing's syndrome Central body weight gain with excessive cervical obesity (Buffalo's hump), also referred to as endogenous obesity, is seen in Cushing's syndrome. Excessive body fat that is evenly distributed is referred to as exogenous obesity. Overgrowth of bones in the face, head, hands, and feet with normal height is seen in acromegaly. Arm span that is greater than height, and pubis to sole measurement exceeds pubis to crown measurement is seen in Marfan syndrome.

Body temperature is not impacted by which of the following factors?

Diet Body temperature varies with diurnal cycle, physical activity, age, gender, and state of health. It also normally fluctuates with activity and time of day. Diet does not affect a client's body temperature, though if a client has consumed hot or cold food or beverages before having an oral temperature taken, the reading may be impacted. To ensure accuracy, the nurse should wait 15-30 minutes to take temperature after the client has had anything hot or cold to eat or drink, has smoked, or has chewed gum.

A nurse obtains a blood pressure on an elderly client of 160/70 mm Hg. The nurse knows that the term for this condition is what?

Isolated systolic hypertension The elderly are prone to isolated systolic hypertension (systolic greater than 140 but diastolic under 90) due to arteriosclerosis that makes blood vessels stiff and less compliant. Orthostatic hypotension is a blood pressure that drops when a client changes positions. Stage 1 hypertension is a blood pressure reading of 140 to 159/90 to 99 mm Hg. Hypertension is not normal for any client.

A nurse observes that a young man's arm span appears to be greater than his height. Which condition should the nurse suspect in this client?

Marfan syndrome Arm span is greater than height and pubis to sole measurement exceeds pubis to crown measurement in Marfan syndrome. In gigantism, there is increased height and weight with delayed sexual development. Extreme weight loss is seen in anorexia nervosa. Central body weight gain with excessive cervical obesity (Buffalos hump), also referred to as endogenous obesity, is seen in Cushing syndrome.

When assessing a client's respirations, what is most important to include in the documentation?

Presence of dyspnea. The presence of dyspnea is the most important of the choices listed to include in the documentation. Dyspnea can be an indicator of potential respiratory distress. The presence of pain and position of the client can impact the client's respiratory status, but are not the primary piece of information to include in the documentation. Assessment of pedal pulses is a component of a circulatory assessment.

The nurse is providing care for an 83-year-old woman with a history of hypotension who has been admitted to hospital following a fall. The nurse recognizes the need to assess for orthostatic hypotension. How should the nurse perform this assessment?

Measure the client's heart rate and blood pressure while supine then within 3 minutes of Orthostatic blood pressure is measured by recording blood pressure and heart rate with the client in two positions supine after the client is resting up to 10 minutes, then within 3 minutes after the client stands up. Usually, as the client rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, while diastolic pressure rises slightly.

A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the least appropriate method for the nurse to use to obtain an accurate temperature reading?

Oral Temperature The oral temperature would give a falsely elevated reading because the client is sipping hot tea. The axillary temperature will take the longest to register, but would not be affected by the client's tea consumption. Both the tympanic and temporal artery methods are considered safe, reliable, and noninvasive and either would be most appropriate to use.

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur?

Orthostatic hypotension Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness.

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.

In interviewing a client about his heart rate, the nurse asks whether he has noticed any alteration to his heartbeat. The client responds that he sometimes feels his heart race even when he has not been exerting himself physically. This alteration is known as which of the following?

Palpitation An alteration in heartbeat felt by a client is called a palpitation and can be caused by various circumstances including thyroid dysfunction, medication reaction, or alteration in fluid volume. Dyspnea is difficulty breathing. Pulse pressure is the difference between systolic and diastolic blood pressures. Apical beats are simply the beats of the heart palpated directly over the apex of the heart, on the chest.

A client rates the current pain level as being a 5 on the Numeric Rating Scale. How should the nurse document this pain assessment?

Patient rated pain level as being a 5 using the rating scale. The nurse should document the exact pain assessment finding which would be "client rated pain level as being a 5 using the rating scale." The statement "client experiencing a moderate amount of pain" is a subjective statement made by the nurse and is inaccurate. The statement "client experiencing mild pain" is a subjective statement made by the nurse and is inaccurate. The statement "client stated pain level not that bad" is a subjective statement made by the client however does not identify that the client rated the pain level as being a 5 on the Numeric Rating Scale.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

Pulse is felt with difficulty and disappears with slight pressure. Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.

A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

Reading is erroneously high. The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

The nurse is taking routine vital signs toward the end of shift. A client's BP reads 204/148. The client's baseline BP has been in the 130's systolic. What should the nurse do first?

Retake the blood pressure When encountering an abnormal value, obtain the vital sign(s) again to assess accuracy. It would be inappropriate to notify the physician immediately, give PRN blood pressure medications, or document the findings before rechecking the reading.

The nurse is assessing an elderly client's blood pressure and finds it to be high. Which of the following characteristics should the nurse suspect to find in respect to this client's arteries?

Rigid The older clients artery may feel more rigid, hard, and bent. More rigid, arteriosclerotic arteries account for higher systolic blood pressure in older adults. Normal arteries should feel resilient, straight, and springy.

A nurse measures a client's blood pressure at 174/102 mm Hg. The nurse recognizes this as what classification of blood pressure measurement?

Stage 2 hypertension The latest guidelines (November 2017) released by the American College of Cardiology and the American Heart Association are: Normal blood pressure: Systolic less than 120 mm Hg and diastolic less than 80 mm Hg. Elevated blood pressure: Systolic between 120 and 129 mm Hg and diastolic less than 80 mm Hg. Stage 1 hypertension: Systolic between 130 and 139 mm Hg or diastolic between 80 and 89 mm Hg. Stage 2 hypertension: Systolic of 140 or greater mm Hg or diastolic of 90 or greater mm Hg.

Upon entering an adult client's room to begin a shift assessment, the nurse should call the rapid response team based on which assessment finding?

Systolic pressure 180 mm Hg. The nurse may call a rapid response team if the client displays the following: respirations less than 10 breaths/min; oxygen saturation less than 92%; pulse less than 55 beats/min or greater than 120 beats/min; systolic blood pressure less than 100 or greater than 170 mm Hg.

When measuring a client's pulse rate, the nurse records 125 bpm. How will the nurse document the information in the medical records?

Tachycardia Tachycardia (100 to 150 bpm) is a fast heart rate. In tachycardia, the heart and pulse rates can exceed 150 bpm as well. Bradycardia, or a slow pulse rate, occurs in adults if the heart rate falls below 60 bpm. Heart palpitations represent the physical sensation of irregularities in the beating of the heart.

Before calling a client back to an examination room, the nurse quickly observes the client in the waiting room from head to toe. Which of the following is the best rationale for this action?

To see the client before the client assumes a social face or behavior If possible, try to observe the client and environment quickly before interacting with the client. This gives you the opportunity to see the client before the client assumes a social face or behavior and allows you to glimpse any distress, sadness, or pain before the client, knowingly or unknowingly, may mask it. An initial observation of the client from a distance would not be effective for assessing for skin lesions. Trying to overhear the client conversation with a family member would be inappropriate. You may determine whether you recognize the client from a previous visit by a quick observation, but this is not the primary rationale for this action.

Students are touring the hospital before starting their clinical rotations. The instructor points out that the type of thermometer used in this facility is noninvasive, safe, efficient, and quick. What type of thermometer is theinstructor describing?

Tympanic Tympanic thermometers use infrared sensors to detect the heat that the tympanic membrane produces. The tympanic membrane thermometer is noninvasive, safe, efficient, and quick. Because the reading is so quick (2 to 3 seconds), it is commonly used in emergency departments and hospitals.

The nurse is assessing a client's respiratory rate. Which of the following should the nurse do to ensure accuracy of this assessment?

Watch chest movement before removing the stethoscope after counting the apical beat

A client's radial artery pulse rate is 42 beats in 30 seconds with occasional pauses. What action should the nurse take?

auscultate the heart rate for a full minute If the radial pulse is irregular, the apical heart rate should be auscultated for a full minute. There is no need to palpate the carotid artery. Documenting that the pulse is 84 and irregular cannot be validated unless the heart rate is auscultated for a full minute. Palpating the radial pulse for a full minute will not necessarily provide the client's correct pulse rate since pauses are occurring.

The nurse assesses the client's vital signs as follows: respirations 20 breaths/minute, tympanic temperature 100.9°F, pulse 88 beats/minute, and blood pressure 104/64 mm Hg. The nurse should

record the vital signs. Validate the assessment data you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

An elderly client is seen by the nurse in the neighborhood clinic. The nurse observes that the client is dressed in several layers of clothing, although the temperature is warm outside. The nurse suspects that the client's cold intolerance is a result of

decreased body metabolism. Research has shown that for older adults, normal body temperature values for all routes are consistently lower than values reported in younger populations.

A client is wearing a hospital gown and sitting on the examination table. What area should the nurse include when completing the general survey?

facial expression The general survey provides an overall impression of the client and includes facial expression. Pulse rate is palpated and would occur later in the examination. Breath sounds are auscultated and would occur later in the examination. Skin temperature is palpated and would occur later in the examination.

While caring for an 80-year-old client in his home, the nurse determines that the client's oral temperature is 35.8 °C (96.5 °F). The nurse determines that the client is most likely exhibiting

normal changes that occur with the aging process. In the older adult, temperature may range from 95.0°F to 97.5°F. Therefore, the older client may not have an obviously elevated temperature with an infection or be considered hypothermic below 96°F.

Which of the following is a normal temperature in centigrade for a healthy adult?

oral: 36.8°C Normal values for temperature fall within a range. Normal values for an oral temperature are around 36.8°C, a rectal temperature around 37.1°C, an axillary temperature around 36.0°C, and a tympanic temperature around 37.0°C.

The current blood pressure measurement on a 24-hour uncomplicated postoperative client while standing at the bedside is 105/65. The last two readings were 130/75 and 125/70 while resting in bed. The nurse should be alert for signs of:

orthostatic hypotension.

The nurse is assessing an elderly postsurgical client in the home. To begin the physical examination, the nurse should first assess the client's

vital signs It is a good idea to begin the "hands-on" physical examination by taking vital signs. This is a common, noninvasive physical assessment procedure that most clients are accustomed to.