(N125) Ch 8 & 9

A nurse is meeting with the parents of a 10-year-old child who was recently diagnosed with cerebral palsy. What suggestion does the nurse give to the child's parents to help the child dress more easily?

"Select clothes with Velcro fasteners for the child."

Which sounds would the nurse be able to hear with the diaphragm of a stethoscope?

*Bowel sounds *Breath sounds *Normal heart sounds

Which senses does the nurse use while inspecting a patient during a routine physical examination?

Sight Smell

The nurse places the patient's arm at the level of the heart when measuring the blood pressure. What is the reason for this nursing intervention?

To eliminate the effect of hydrostatic pressure

The nurse gives the stethoscope to a toddler to play with for awhile before auscultating. What is the reason behind this intervention?

To reduce the child's fear

While assessing a patient's blood pressure by using a Doppler technique, the nurse concludes that the patient has stage 2 hypertension. Which blood pressure finding enabled the nurse to make such a conclusion?

170/110 mm Hg The normal range of stage 2 hypertension is systolic pressure of 160 or greater and diastolic pressure of 100 or greater.

When the nurse is assessing a 9-year-old patient, what respiratory rate would be considered normal?

22 breaths per minute

While performing a physical examination, the nurse suspects the patient has Cushing syndrome. Which findings in the patient would confirm this condition?

*Buffalo hump *Moonlike face *Purple abdominal striae Rationale: The patient with Cushing syndrome may have a buffalo hump due to the deposition of fat in the trunk and cervical region of the spinal cord. The patient has a moonlike face due to cervical obesity. The skin becomes fragile, which leads to the formation of purple striae on the abdomen.

Which assessment findings would the nurse obtain by using the sense of touch during the physical examination of a patient?

*Enlarged organ *Normal arterial pulsations *Presence of muscle spasticity

The nurse is caring for a patient with an acute myocardial infarction. What does the nurse expect to find in the patient?

*Hypotension *Cool, clammy skin *Shoulder and jaw pain Rationale: In patients with acute myocardial infarction, the superficial blood vessels constrict to shunt blood to the vital organs; therefore, the patient has cool and clammy skin. The patient with acute myocardial infarction may develop shoulder and jaw pain because the afferent sympathetic fibers enter the spinal cord from levels C3 to T4, accounting for a variety of locations and radiation patterns of chest pain; discomfort may radiate to the neck, lower jaw, left arm, and left shoulder, or occasionally to the back or down the right arm.

While assessing an elderly female patient, the nurse records the patient's waist circumference at 39 inches and ascertains her body mass index (BMI) as 34. Which other findings does the nurse expect to see in the patient's laboratory reports?

*Increased blood pressure *Increased blood sugar levels *Increased blood cholesterol levels

The nurse is caring for a patient who has acromegaly. Which findings does the nurse expect to find in the patient's laboratory reports?

*Increased blood sugar levels in the patient *Increased growth hormone levels Rationale: Excessive secretion of growth hormone from the pituitary gland during adulthood results in acromegaly. It is manifested by the overgrowth of bone in the face, head, hands, and feet of the patient. Acromegaly is also associated with metabolic disorders such as diabetes mellitus. Therefore, the nurse can expect an increase in blood sugar levels in the patient's laboratory reports.

A patient has increased blood pressure. Which factors could be responsible for this finding in the patient?

*Increased blood volume *Increased vasoconstriction

Which nursing interventions assist the nurse in obtaining an accurate oral temperature using a glass thermometer in a febrile patient?

*Measure the temperature when the patient's lips are closed. *Measure the temperature underneath the tongue at the base. *Measure the temperature at the posterior sublingual pocket.

While assessing a patient with Marfan syndrome, the nurse finds hyperextensible joints and long, thin fingers. Which other findings does the nurse expect to observe in this patient?

*Pectus excavatum (or sternal deformity) *High-arched narrow palate

After performing physical exams on a group of elderly patients at a community center, the nurse finds that several of the patients are shorter than they were 10 years ago. What are possible explanations for this finding?

*Postural changes of kyphosis *Slight flexion in the in knees and hips *Shortening of the individual vertebrae

What are the different criteria that the nurse should observe while doing a body structure assessment of a patient during a general survey?

*Stature (or height) *Symmetry *Contour (or body build)

Which equipment does the nurse use to assess a patient's blood pressure?

*Stethoscope *Sphygmomanometer The stethoscope is used for identifying the Korotkoff's sounds, and the sphygmomanometer indicates the blood pressure.

The nurse finds that the pulse rate of a healthy individual is 60 beats/minute during the assessment. What respiratory rate does the nurse expect in the individual?

15 Rationale: In general, the pulse rate and respiratory rate exist in a constant ratio of 4:1. Therefore, the pulse rate can give information regarding the respiratory rate. Here, the person with a pulse rate of 60 beats/minute might have the respiratory rate of15 breaths/minute.

While measuring the head of an average, healthy 5-month-old infant, the nurse measures the head circumference at 34 cm and reports it to be normal. What does the nurse expect the infant's chest circumference to be?

32 Rationale: In infants younger than 6 months, the head circumference is expected to be 2 cm greater than the chest circumference.

While assessing the blood pressure of a 6-month-old infant, the nurse finds the systolic blood pressure to be 100 mm Hg and the diastolic blood pressure to be 65 mm Hg. What is the pulse pressure of this infant?

35 subtract the diastolic blood pressure from systolic blood pressure.

The nurse is caring for a geriatric patient who has a fever. The nurse records the patient's oral temperature at 37.5° C. What will this patient's rectal temperature be?

38*C

While assessing a patient with an acute myocardial infarction, the nurse finds that the patient has hypotension. What is the most likely reason for this finding in the patient?

A decrease in cardiac output in the patient Rationale: The patient with acute myocardial infarction may have arrhythmias such as ventricular tachycardia. These may cause ineffective pumping of the blood from the heart throughout the body and, therefore, decrease cardiac output in the patient. This decreased cardiac output causes hypotension.

What is orthostatic hypotension?

A drop in systolic pressure of more than 20 mm Hg OR more that occurs with a quick change to a standing position

The nurse is caring for a patient who has a big head with a receding hairline. On further assessment, the nurse finds that the patient has an increased curvature of the thoracic spine and an inward curvature of the lumbar spine. Which medical condition do these findings suggest?

Achondroplastic Rationale: Achondroplastic dwarfism is a disorder in which the patient's body system is unable to convert cartilage into bone. The patient with this abnormality has a normal trunk size, short arms and legs, and a short stature. The patient with this disorder has a relatively large head with frontal bossing, thoracic kyphosis, and prominent lumbar lordosis.

The nurse is treating a patient who is curling over in the fetal position while sitting on the exam chair. What is the first thing the nurse should assess for in this patient?

Acute abdominal pain

While performing chest percussion on a patient, the nurse obtains a loud sound. Under which percussion note characteristic does the nurse document this finding?

Amplitude

Why is a patient's weight considered a vital sign during a survey?

An unexplained loss of weight may be an early sign of illness

The nurse suspects that a patient has emphysema. Which method would the nurse prefer to confirm emphysema?

By percussing the lung borders

The nurse is leading a parent education session on general health checks. One parent asks about the correct age to start routine blood pressure (BP) measurement in children. Which answer by the nurse is most appropriate?

Can start at 3 years old

The patient with _________ gains weight due to edema and fat deposition.

Cushing syndrome

The health care provider asks the nurse to purposefully induce hypothermia in a patient who is in the post-cardiac arrest period. What is the reason for this intervention?

Decrease in the oxygen requirement of the body

Which is the major task of infancy according to Erikson's stages of psychosocial development?

Developing a sense of trust

Which equipment would the nurse use to augment pulse or blood pressure sounds during cardiovascular assessment

Doppler sonometer

Which thermometer can measure the oral temperature of a child within 25 seconds?

Electronic thermometer with blue-tipped probe

What measures should the nurse take while assessing a 3-month-old infant in a clinical setting?

Examine the Moro reflex at the end of the assessment. Maintain eye contact with the infant throughout the assessment. Ask the parent to remove the outer clothing of the infant.

Which nursing intervention will help the nurse most accurately measure respiratory rate in an obese patient?

Feel the breaths by placing a hand on the patient's abdomen

The nurse is performing a physical assessment of a patient who is having an anxiety attack. What type of pulse should the nurse expect to find in the patient?

Full and bounding

While assessing mobility in a patient, the nurse asks the patient to walk across the room. What is the nurse observing in the patient?

Gait

What specific measure should the nurse take while percussing the lungs of an obese patient?

Give a strong percussion stroke with the middle finger of the striking hand.

Which equipment would the nurse use to measure the range of motion of a shoulder joint?

Goniometer

Which organ is considered the thermostat of the human body?

HYPOTHALAMUS

Which sounds would best be heard using the bell endpiece of the stethoscope?

Heart murmurs Extra heart sounds

While assessing the body structure of a patient, the nurse suspects that the patient has arthritis. Which finding would support this?

Rigid spine and neck

The nurse has come to the patient's room to perform the physical assessment of a 4-month-old infant. The nurse finds that the child is sleeping. What would the nurse do in this situation?

Heart, lung, and bowel sounds can be clearly heard when the child is sleeping. Therefore, the nurse should seize this opportunity and auscultate the lung, heart, and bowel sounds of the child.

Which infections can be prevented if the nurse uses alcohol-based hand rubs frequently?

Hepatitis B virus Mycobacterium tuberculosis Human immunodeficiency virus

Which type of sounds does the nurse expect to hear while percussing the right upper quadrant of the abdomen?

High-pitched, soft sounds occurring for a short time (the liver is present)

While assessing an adolescent, the nurse registers high blood pressure in the right arm. The nurse suspects coarctation of the aorta in the patient. Which finding in the patient supports the nurse's conclusion?

Higher systolic blood pressure in the thigh than in the arm Rationale: Coarctation of the aorta is a condition characterized by the narrowing of the blood vessel walls. Blood flow to the lower half of the body is affected. Therefore, the patient with coarctation of the aorta has higher systolic pressure in the thigh than in the arm. Generally, the diastolic blood pressure remains the same in both upper and lower extremities; therefore, the patient may not a have higher diastolic pressure in the thigh than in the arms.

The nurse is reviewing the laboratory reports of a patient with Cushing syndrome. What finding does the nurse observe in this patient's reports?

Hypercortisolism

Which percussion note heard over the lung is considered normal in children but abnormal in adults?

Hyperresonant (Percussion notes with loud amplitude, low pitch, and a booming quality that last for a long duration)

During a home visit, the nurse observes that a 10-year-old child has infantile facial features and chubbiness. The nurse finds that hypothyroidism is indicated in the patient's lab reports. Which condition is indicated by these findings?

Hypopituitary dwarfism

The nurse is using the palpation technique during the physical examination of a patient. Which interventions are appropriate for this technique?

Identifying the tender areas first and palpating them at the end Starting the assessment with light palpation followed by deep palpation Suggesting the patient use relaxation techniques during deep palpation

While assessing an older adult patient in a supine position, the nurse measures the blood pressure of the patient at 110/70 mm Hg. When the patient stands, the nurse immediately finds the blood pressure of the patient to be 90/70 mm Hg. What is the reason for the drop in blood pressure?

Increased peripheral vasodilation

The nurse is measuring a patient's thigh blood pressure (BP). What is the most important point that the nurse should remember about thigh pressure?

It is higher than in the arm. If thigh pressure is lower than the arm pressure, it indicates coarctation of the aorta.

The nurse is assessing an infant. What steps should the nurse follow?

Listen to the heart and lung sounds when the baby is asleep. Perform the least distressing steps first. Elicit the startle reflex at the end.

During a public health fair, the nurse measures the oral temperature of a patient and then learns the patient just drank a cup of iced coffee. Which action by the nurse is most appropriate?

Measure the patient's temperature 15 minutes after drinking the cold liquid.

The nurse is caring for a patient with Marfan syndrome. Which finding in the patient would indicate the patient is in the final stages of the disease?

Mitral regurgitation (improper closure of the mitral valve) Marfan syndrome involves the degeneration of the mitral valve, resulting in mitral regurgitation.

Which equipment is used to test loss of protective sensation (LOPS) in a patient's foot?

Monofilament

An experienced nurse is observing a new nurse during an assessment of a 2-year-old child. Why does the new nurse need correction when asking, "Will you please take a deep breath?"

Most 2-year-olds prefer making choices by themselves, and at this age children like to say no. Therefore, during assessment, the nurse should not ask the child any questions to which he or she does not have a choice in the decision. If the nurse asks "Will you please take a deep breath?" the child may say "no." If the nurse proceeds even after the denial, the child may neither trust the nurse nor cooperate during the assessment. Giving limited choices may be beneficial and enhance the autonomy of the child.

Which instrument is used to examine both the ear and the nose?

Otoscope

While performing a physical examination, the nurse taps the patient's skin with short, sharp strokes. What is the reason for this nursing assessment?

Percussion

While measuring a patient's blood pressure, which set of Korotkoff sounds should be recorded as systolic and diastolic pressure?

Phase I/phase V

While measuring a patient's blood pressure, the nurse hears crisp and high pitched sounds. The nurse recognizes these sounds as the blood flowing through the arteries for an abnormally longer duration. Which phase of Korotkoff sounds is the nurse listening to?

Phase III

While caring for a child with an infection, the nurse uses an electronic thermometer with a red-tipped probe to measure the body temperature. After assessment, the nurse documents the temperature reading as 37.7° C. Which route does the nurse select for assessment?

Rectal

Which equipment does the nurse use to obtain the vital signs of a patient in a home care setting?

Stethoscope Sphygmomanometer Thermometer

Which position does the nurse instruct a frail elderly patient to assume for the examination process?

Supine

The nurse is assessing a patient's blood pressure. Which type of Korotkoff sound does the nurse correlate with the systolic blood pressure?

Tapping sounds

The nurse is caring for a child with brain trauma. Which is the best thermometer to measure the temperature within 6 seconds?

Temporal artery thermometer Rationale: The child with brain trauma may have hyperthermia due to direct damage to the hypothalamus. The nurse swipes the temporal artery thermometer on the forehead of the child and releases the button. This measures the temperature of the temporal artery in the forehead. It works by taking multiple readings within 6 seconds and provides an average reading. Therefore, the nurse selects the temporal artery thermometer for quick and efficient readings.

What are the different factors that can be assessed by means of palpation?

Texture Organ location Organ size Presence of a lump

The nurse is assessing a pregnant woman's blood pressure. After assessment, the nurse documents the blood pressure as 140/96/80. What does this reading indicate?

The diastolic pressure difference is 10 mm Hg between phases IV and V. Rationale: the nurse documents the reading as 140/96/80, which indicates 140 mm Hg is the systolic pressure and 96/80 mm Hg indicate the phase IV and phase V diastolic pressures. The nurse should document the phase IV diastolic reading only if the pressure difference between phases IV and V is greater than 10 mm Hg

The nurse is assessing the respiratory rate of a neonate every minute for the past 20 minutes and finds that, on average, the neonate breathes 24 times a minute. What does the nurse conclude from the findings?

The neonate has dyspnea. Rationale: The normal respiratory rate in the neonate is in the range of 30 to 40 breaths per minute. Therefore, the respiratory rate of 24 breaths per minute indicates dyspnea in the neonate.

The patient enters the examination room for a physical assessment. The nurse switches on all the lights and stares at the patient for a few minutes before starting any procedure. What is the reason for this behavior by the nurse?

The nurse is doing inspection

At a community health fair, the nurse prepares to assess the blood pressure of a patient who is sitting in a chair by using the patient's bare right arm supported at heart level. What is the priority nursing intervention before beginning the blood pressure assessment?

The nurse should check the position of the patient's lower extremities in order to have accurate readings.

The nurse is caring for a patient with a respiratory infection. What intervention should the nurse perform to prevent the spread of infections?

The nurse should educate the staff, the patient, and visitors, because they act as the vectors of spreading and transmitting the contagious microorganisms.

The nurse wants to auscultate the lungs of a patient. What should the nurse do if the patient has excessive chest hair?

The nurse should wet the patient's chest hair before auscultating the lungs to prevent crackling sounds produced by friction between the stethoscope endpiece and the chest hair.

The nurse is conducting a physical examination of a patient who is tall with a narrow face and flat feet. The nurse finds that the arm span of the patient is greater than the height. What does the nurse infer from these findings?

The patient has Marfan syndrome.

The nurse obtains a dull percussion note while percussing the left lung and a resonant percussion note while percussing the right lung. What does the nurse interpret from this finding?

The patient may have fibrosis of the left lung. A fibrosed lung tissue would be denser than normal lung tissue. A dull percussion note is obtained when the organ being percussed is dense.

During the health screening of a toddler, the nurse suspects that the toddler has been abused. Which findings support the nurse's conclusion?

The toddler shows no sign of separation anxiety.

While assessing a patient, the nurse cleans the stethoscope endpiece with an alcohol wipe and warms it by rubbing it in the palm. What is the reason for warming the stethoscope?

To avoid chandelier sign during the assessment

What are the uses of performing percussion during the physical assessment of a patient?

To elicit a deep tendon reflex To detect an abnormal mass To map the location and size of an organ To identify the density of an internal structure

The nurse is assisting the health care provider during the assessment of a patient. The health care provider instructs the nurse to attach a short broad speculum to the head of an otoscope. What is the reason for giving this instruction to the nurse?

To view the nares clearly

Which equipment is used to test the hearing capacity of a patient?

Tuning fork

Which sound does the nurse expect to obtain while percussing over the stomach?

Tympany (A musical or drum-like sound is heard on percussing air-filled organs)

Which part of the hand is best suited for palpating vibrations produced during percussion?

Ulnar surface

What measures should the nurse take while assessing an adolescent?

Use the head-to-toe approach during the assessment. Give constant feedback while assessing the adolescent's body. Ensure that the parents are not present in the examination room.

The nurse is assessing a patient in hemorrhagic shock. Which findings would the nurse expect to observe in the patient?

Weak, thready pulse Decreased blood volume Decreased stroke volume

What measures should the nurse take while caring for a patient with an infection caused by Clostridium difficile?

Wear gloves and a gown Use soap and water for hand washing

Excessive secretion of _______ in the patient causes Cushing syndrome

adrenocorticotropin (ACTH)

Which patient would the nurse assess using the head-to-toe approach?

an adolescent, an aging adult, and a school-age child

What part of the hands are best for assessing vibration?

base of the fingers or ulnar surface of the hand

What part of the hands are best for assessing temperature?

dorsal side of the hands and fingers

What part of the hands are best for assessing texture, swelling, pulsation, and determining the presence of lumps?

fingertips

Which type of percussion note will the nurse hear while percussing over the scapula?

flat

What part of the hands are best for assessing the position, shape, and consistency of an organ or mass?

grasping action of the fingers and thumb

Which equipment would the nurse use to test sensations in the foot during a neurologic examination

monofilament

Which equipment would the nurse use to examine the internal structures of the eye

ophthalmoscope

While assessing the lungs and heart, _______ is performed before _________. However during abdominal examination, _______ the abdomen first may interfere with bowel sounds.

palpation auscultation palpating

Which assessment skill does the nurse use to determine organ density during the physical examination of a patient?

percussion

Which position does the nurse instruct the patient with overwhelming fatigue to assume during assessment?

supine position

Before auscultating the lungs of a child, the nurse asks the parent to remove the child's gown. What could be the reason for such an intervention?

to avoid sound artifacts