Module 3: Assessment

The nurse is performing a focused assessment of the skin, hair, and nails. Which assessment findings would require immediate intervention? Select all that apply.

Tenderness and edema to the left calf Blue tinge to all of the nail beds

The nurse is conducting a focused musculoskeletal and peripheral vascular assessment on a client. What should the nurse do first?

Examine range of motion

The nurse working on the rehabilitation unit is examining the shoulder of a client during a detailed muscloskeletal assessment. Which four motions should be included during this examination?

Forward flexion, internal rotation, abduction, and external rotation

The nurse is about to begin a focused abdominal assessment on a client that is scheduled for surgery tomorrow. What primary nursing action should be done prior to the physical assessment?

Request that the client try to empty the bladder.

When performing a general survey assessment, how would the nurse assess the client's orientation? Select all that apply.

Request the client states his or her name. Query about today's date and season. Question where the client is now.

The nurse is conducting an initial cranial nerve assessment of a client with meningioma of the sphenoid ridge. Which actions should the nurse perform to assess cranial nerve I? Select all that apply.

Test each nostril independently. Examine the client's ability to smell.

The nurse is caring for a client who is reporting throat pain, fever, and difficulty swallowing. Which technique should the nurse use to palpate the client's lymph nodes for enlargement or tenderness?

Use gentle pressure, a circular manner, and palpate with bilateral finger pads to compare both sides.

The nurse is to assess the cranial nerves of a client admitted with a suspected tumor of the sternocleidomastoid muscle. When assessing the motor function of the spinal accessory nerve, what is the nurse evaluating?

Ability to rotate the head

A client with a history of congestive heart failure comes to the cardiac wellness clinic reporting "frequent awakening from sleep due to shortness of breath." Which action by the nurse is most appropriate?

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.

The emergency room nurse is caring for a client reporting severe right lower quadrant pain that had started as milder pain near the umbilicus. Vital signs include a fever of 38.6°C (101.5°F), pulse 92 bpm, respirations 24 breath/min, and blood pressure 136/80 mm Hg. What should the nurse do next? Select all that apply.

Begin an OR checklist Keep the client NPO Cleanse the abdomen with chlorhexidine

The nurse is conducting an initial assessment of the abdomen. When checking for vascular sounds in the abdomen, what should the nurse do? Select all that apply.

Evaluate the aortic region of the abdomen first. Expose only the region of the client being assessed. Assess the lower region of the abdomen last.

A nurse is conducting a peripheral vascular assessment on a client admitted with congestive heart failure. The nurse notes an 8-mm deep depression in the skin after pressing that remains for a prolonged period on both legs. How should the nurse document this finding?

4+ pitting edema

The nurse is preparing to conduct a 10-minute head-to-toe assessment on a client admitted with pneumonia. What should the nurse do first?

Complete a general inspection.

The nurse is caring for a client who is being admitted to the intensive care unit with bilateral pulmonary emboli. The client is reporting anxiety and apprehension. What would the nurse do? Select all that apply.

Encourage client to express and acknowledge feelings. Modify procedures as much as possible to limit stress. Note cultural influences that may influence individual response.

The telemetry nurse is conducting an initial cardiac assessment on a client admitted with chest pain and coronary artery disease (CAD). What should the nurse do first?

Examine the client's chest for any visible pulsations.

The nurse is completing a quick head-to-toe assessment on a client admitted with right-sided heart failure. Which body parts should be examined for peripheral edema? Select all that apply.

Hands, Sacrum, Feet

The nurse is admitting a client with diabetes and a stage II wound to the right heel. When assessing the client's skin, what would the nurse do first?

Inspect overall skin color.

The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first?

Inspect the skin, bones, and muscles of the entire posterior thorax.

The nurse is reviewing the lab work of a client who has a serum bilirubin level of 0.3 mg/dL (5.13 μmol/L). What assessment findings would the nurse expect when conducting a focused skin assessment of this client? Select all that apply.

Jaundice of the sclera Generalized pruritus

The nurse is planning to assess an older adult client admitted with abdominal pain. Which special considerations are important to contemplate when assessing the older adult client? Select all that apply.

Short term memory may diminish with age; Presence of heart sound S4 is considered normal; Older adults take longer to perform certain actions

A nurse is preparing to perform a general survey of a client. What equipment would the nurse require to perform this assessment? Select all that apply.

Sphygmomanometer Stethoscope Tape measure Standing scale

The nurse is performing a cranial nerve assessment on a client admitted with head trauma who is alert and oriented. Which actions should the nurse perform to assess cranial nerve V? Select all that apply.

Touch a cotton ball to the client's forehead, cheek, and jaw bilaterally. Palpate the masseter and temporal muscles with the client's teeth clenched.

The nurse is performing a quick assessment at the beginning of the shift. During auscultation of the client's lungs, decreased breath sounds, prolonged expiration, and expiratory wheezes bilaterally are auscultated. What would the nurse suspect?

An acute asthmatic exacerbation is occurring

The nurse is assessing the client's hair, skin, and nails during the health assessment. The nurse uses which action to assess capillary refill?

Applies pressure to the nail beds.

The nurse is performing a general survey on a client who is being admitted to the medical unit with abdominal pain. Which components would the nurse assess during the general survey? Select all that apply.

Ask client for today's date and time Observe the client's gait Assess the client's vital signs

An intensive care nurse is caring for a client who sustained a head injury from a motor vehicle accident. During the morning assessment, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 3 mm and reacts to light. What is the nurse's priority action?

Notify the health care provider immediately

A nurse is preparing to perform a focused hair and scalp assessment on an 8‑year‑old client who reports, "my head has been itchy for the past couple days." What should the nurse do first?

Put on a pair of gloves.

An emergency room nurse is conducting a quick head-to-toe assessment of a client reporting flu-like symptoms. What pulse grade would the nurse document if the client's radial pulses were "full, easy to palpate, and cannot be obliterated"?

+2 pulse

The nurse is to assess the cranial nerves of a client admitted with a recent cerebral vascular accident. What is the nurse evaluating when assessing the motor function of the glossopharyngeal nerve?

Capability to swallow.

The gerontologic nurse is assessing the muscles of an older adult client. Which muscle components are the most important for the nurse to assess with this client? Select all that apply.

Contour, pain, range of motion, and symmetry; tone strength, size, and tenderness

The emergency room nurse is caring for a client reporting dizziness and headache with identified nystagmus. Which cranial nerves would the nurse plan to assess? Select all that apply.

Cranial nerve III, Cranial nerve IV, Cranial nerve VI

The nurse is beginning a general survey on a client who is being admitted to the hospital for abdominal pain. After identifying the client, which components would the nurse include in the general survey? Select all that apply.

Does the person's body structure match the stated age? Are there any tubes, lines, or drains? Does the client appear to be alert? Is the client's color appropriate for ethnicity?

A 40‑year‑old female client reports dull pain in the left breast. Before examining the client's breasts, using the wedge method, the nurse places the client in which position?

Dorsal recumbent with the arm of the side being examined above the head

The nurse is caring for a client who was recently admitted to the cardiac care unit after open‑heart surgery. The current assessment by the nurse reveals +0 pedal pulse on the left foot and +2 pedal pulse on the right foot. What should the nurse do first?

Notify the health care provider of this abnormal finding.

A nurse is caring for a client who has a right femur fracture that is currently in traction. The client has a prescription for hourly circulatory assessment. Which nursing assessment findings should be reported to the health care provider? Select all that apply.

Numbness and tingling to the right leg Edema and coolness to the right calf Right capillary refill of 4 seconds

The emergency room nurse is conducting a focused thorax and lung assessment on a client reporting chest pain, cough, and dyspnea. Which assessment findings indicate the need for further assessment? Select all that apply.

Observed the client have a moist cough with production of yellow sputum Auscultated low pitched, bubbling sounds during inspiration in right upper lobe

The nurse is completing head and neck assessments on four different older adult clients in a long‑term care facility. Which findings would the nurse promptly report to the health care provider for further testing? Select all that apply.

Obvious turbulence upon auscultation of the bilateral carotid arteries New, mild, left sided facial droop upon inspection of the client's face Right pupil that is slightly misshapen and is not constricting with light

The nurse on a telemetry unit is performing morning assessments on the clients. Upon auscultation of an adult client's heart sounds, the nurse notes a scratchy, high‑pitched sandpaper sound. How should the nurse document this sound?

Pericardial friction rub

The medical‑surgical nurse is caring for a client admitted with gastroenteritis. Which assessment finding would indicate that the nurse should contact the health care provider?

Whooshing sound at the top of the abdomen near the aorta

The nurse is performing morning assessments on the medical‑surgical unit. Which clients are most likely to have palpable lymph nodes in the neck? Select all that apply.

Woman, 62, with chronic bronchitis Man, 67, with aspiration pneumonia