PrepU: Health Assessment

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? A. "What brings you here today?" B. "Are you having any pain?" C. "What medications do you normally use?" D. "Do you have any allergies?"

Answer: A - "What brings you here today?" Rationale: The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? A. Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." B. Client describes shortness of breath and increased sputum production. C. Client reports breathlessness and productive cough. D. Client reports respiratory distress and frequent spitting.

Answer: A - Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Rationale: The client's reason for seeking care should always be stated in the client's own words.

A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding? A. Erythema B. Pallor C. Flushed D. Ecchymosis

Answer: A - Erythema Rationale: The nurse should document this finding as erythema. If the skin appears pale, it is documented as pallor. The skin of a client with fever and hypertension appears pink and is documented as flushed. The presence of purple patches on the skin, due to trauma to soft tissue, is documented as ecchymosis.

A nurse is teaching a client about testicular self-examination. What should be included in the teaching? A. Examine testicles for lumps monthly while showering. B. Visualize the testes in the mirror looking for lumps monthly. C. Check the testes weekly for lumps while laying down in bed. D. Squeeze each testicle gently feeling for lumps twice a month.

Answer: A - Examine testicles for lumps monthly while showering Rationale: Male patients should examine the testes monthly at a time when the testicles are warm and positioned loosely within the scrotum, such as during bathing or showering. There is no need to visualize the testes in a mirror. Once a week is too frequent of a time frame, and squeezing will not help identify lumps.

The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? A. Palpation B. Inspection C. Percussion D. Auscultation

Answer: A - Palpation Rationale: The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.

A nurse is beginning a physical exam on a child who is admitted to the pediatric unit with suspected meningococcal meningitis. What is the nurse's priority action? A. Perform hand hygiene and apply personal protective equipment. B. Allow the child to examine the instruments. C. Gather and sterilize equipment. D. Begin with assessment of vital signs.

Answer: A - Perform hand hygiene and apply personal protective equipment Rationale: Regardless of the assessment location, the area should have facilities for hand hygiene. The nurse should wash hands before and after every physical patient encounter; after contact with blood, body fluids, secretions, and excretions; after contact with any equipment contaminated with body fluids; and after removing gloves. Initial therapeutic management of acute bacterial meningitis includes isolation precautions including gloves and mask. Equipment used for a physical exam does not need to be sterilized. Touching the child should not occur until hand washing and application of PPE is completed.

A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision? A. Snellen chart B. Stethoscope C. Ophthalmoscope D. Otoscope

Answer: A - Snellen chart Rationale: A Snellen chart is used as a screening test for distant vision. It consists of characters in 11 lines of different-sized type, with the largest characters at the top of the chart and the smallest characters at the bottom. Vision is recorded as a score; for example, 20/20 is normal vision. A stethoscope is used to auscultate body sounds. An ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted? A. The client's weak pulses may be indicative of cardiovascular disease B. The client has normal peripheral pulses. C. The client has increased radial pulses that may result from hypertension. D. The client shows no signs of a circulatory health problem.

Answer: A - The client's weak pulses may be indicative of cardiovascular disease Rationale: A peripheral pulse that is documented as 1+ is considered weak, a finding that may be indicative of decreased cardiac output.

A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture? A. The shoulder and upper back curves forward. B. The lumbar region tends to curve inward. C. The sacral region tends to turn outward. D. A portion of the spine is curved to the side laterally.

Answer: A - The shoulder and upper back curves forward Rationale: In kyphosis, the shoulder and upper back tend to curve forward. In lordosis, the lumbar region curves inward and the sacral region curves outward. Scoliosis is a curvature of a portion of the spine to the side, laterally.

A nurse has explained her intention to conduct a Weber test and Rinne test. Which pieces of equipment will the nurse require? A. Tuning fork B. Snellen chart C. Otoscope D. Ophthalmoscope

Answer: A - Tuning Fork Rationale: Weber test and Rinne test are performed in order to assess sound conduction; both require a tuning fork.

The Glasgow Coma Scale is a standardized assessment tool for a person's level of consciousness. Which client would this scale not be appropriate for? A. a client in the Intensive Care Unit for acute pancreatitis asking for pain medications B. a client in the Intensive Care Unit after having a stroke yesterday C. a client recovering from brain surgery for repair of an aneurysm D. a client with a brain tumor who is in the hospital because of respiratory depression

Answer: A - a client in the ICU for acute pancreatitis asking for pain medications Rationale: Although acute pancreatitis can be fatal if the client is asking for pain medications, she is at the very least alert. Clients who are being treated for a stroke, brain tumor, or who are recovering from brain surgery need to be monitored closely for level of consciousness.

The nurse should use the bell of the stethoscope during auscultation of: A. a client's heart murmur. B. a client's apical heart rate. C. a client's breath sounds. D. a client's bowel sounds.

Answer: A - a client's heart murmur Rationale: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the primary care provider? A. Auscultation of a bruit B. Percussion of tympanic sounds over the intestines C. Auscultation of peristalsis sounds D. Percussion of dull sounds over the right upper quadrant

Answer: A - auscultation of bruit Rationale: A bruit on auscultation suggests an aneurysm or arterial stenosis.

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings? A. Crackles are audible in the posterior bases bilaterally and they are abnormal. B. Bronchovesicular breath sounds are audible in the posterior lobes. C. Pleural friction rub is occurring in the posterior middle lower lobes. D. Gurgling is occurring in the lower posterior lobes indicating the client needs to cough.

Answer: A - crackles are audible in the posterior bases bilaterally and they are abnormal Rationale: Crackles, also called rales, are intermittent, high-pitched, popping sounds heard in distant areas of the lungs, primarily during inspiration. They are attributed to the opening of partially collapsed alveoli (terminal air sacs) or the movement of air over minute amounts of fluid in the periphery of the lungs during deep inspiration. The other options are not the correct interpretations.

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician? A. decreased heart rate B. visible pulsation through a thin chest wall C. sinus dysrhythmia that increases with inspiration and decreases with expiration D. presence of an S heart sound

Answer: A - decreased heart rate Rationale: Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound.

The nurse includes a percussion hammer in the assembled equipment to be used during a client's physical examination. The percussion hammer will be used to assess which of the following? A. Deep tendon reflexes B. Auditory function C. Vibratory perception D. Tympanic membrane function

Answer: A - deep tendon reflexes Rationale: The percussion hammer is an instrument with a rubber head used to test deep tendon reflexes. A tuning fork is a two-pronged instrument used to test auditory function and vibratory perception. An otoscope is used to examine the external ear canal and tympanic membrane.

The nurse is assessing a child brought to the clinic with severe itching of the scalp and white patches on the hair follicles. What would the nurse look for when beginning the examination? A. nits from a lice infestation B. tinea capitis C. alopecia D. seborrheic dermatitis

Answer: A - nits from a lice infestation Rationale: Based on the symptoms, the nurse should inspect the hair for debris such as nits (eggs from a lice infestation, i.e., pediculosis). Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin caused by a fungal infection. Alopecia is baldness and seborrheic dermatitis causes scaly, greasy patches to form on the head.

Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation? A. Palpate the pulse for 1 minute. B. Palpate the pulse for 15 seconds and multiply by 4. C. Palpate the pulse for 2 minutes. D. Palpate the pulse for 10 seconds and multiple by 6.

Answer: A - palpate pulse for 1 minute Rationale: If the pulse is irregular, such as in a client with atrial fibrillation, the nurse should palpate local peripheral pulses for 1 full minute, noting both rate and rhythm. The other choices are incorrect techniques.

A nurse is preparing to assess the integumentary system for texture, temperature, moisture, and edema. Which assessment technique will the nurse use? A. palpation B. inspection C. percussion D. auscultation

Answer: A - palpation Rationale: Palpation uses the sense of touch to assess the patient for texture, temperature, moisture, and edema. Therefore, the nurse will use palpation. Inspection involves vision; percussion assesses through the use of palpable vibrations and audible sounds; and auscultation uses the sense of hearing.

A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's: A. peripheral pulses B. liver C. lymph nodes D. thyroid gland

Answer: A - peripheral pulses Rationale: Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? A. The dorsum B. The palm C. The fingertips D. The knuckles

Answer: A - the dorsum Rationale: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal? A. The tympanic membrane is translucent, shiny, and gray. B. The ear canal is rough and pinkish. C. The tympanic membrane is reddish. D. The ear canal is smooth and white.

Answer: A - the tympanic membrane is translucent, shiny, and gray Rationale: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

An elderly man is brought to the emergency department with extreme dehydration. What would the nurse expect to see during the physical exam? (Select all that apply.) A. smooth mucous membranes B. dry cracked lips C. non-elastic turgor with prolonged tenting D. white patches on the mucous membranes E. capillary refill of 2 seconds

Answer: B & C - Dry cracked lips & non-elastic turgor w/ prolonged tenting Rationale: With dehydration, mucous membranes look dry and lips look parched and cracked. When the nurse checks for skin turgor, the tissue should return quickly to its original position. When documenting skin turgor, it could be described as non-elastic if the fold of skin remains longer than 3 seconds. Prolonged "tenting" indicates dehydration. The other responses are not found in dehydration.

A nurse is teaching a young female client about breast cancer prevention. The client asks at what age does she need to begin having mammograms. What is the nurse's best response? A. "Your physician will decide when it is best for you to begin having mammograms based on your family history." B. "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." C. "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." D. "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?"

Answer: B - "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." Rationale: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? A. "This is nothing to worry about. I won't hurt you." B. "Some of the examination may be painful, but I will be gentle." C. "Let me tell you what I will be doing. It should not be painful." D. "I have to do this, so just relax and it won't last long."

Answer: B - "Let me tell you what I will be doing. It should not be painful." Rationale: The client may be anxious for many reasons. Tell the client that the assessments should not be painful. Explaining the assessment in general terms can help decrease the client's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test.

When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition would the nurse document? A. Jaundice B. Cyanosis C. Erythema D. Pallor

Answer: B - Cyanosis Rationale: Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Jaundice is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis. Erythema is redness of the skin associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is paleness of the skin, which often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.

A nurse is assessing the pulses of a client's lower extremities and finds that the client's popliteal pulses are 1+. The nurse interprets this finding as: A. absent B. diminished, thready C. normal D. increased, full volume

Answer: B - Diminished, thready Rationale: Pulses that are diminished, thready, and easily obliterated are graded as 1+. Absent pulses are graded as 0. Pulses that are normal and not easily obliterated are graded as 2+. Pulses that are increased and full volume are graded as 3+.

A nurse uses percussion to assess a client's liver. What is the normal tone that should be heard in this situation? A. Flat B. Dull C. Resonance D. Tympany

Answer: B - Dull Rationale: A medium dull sound is heard over the liver; a flat sound is heard over bone or muscle. Resonance is a loud, hollow, low-pitched sound heard over a normal lung, and tympany is a high-pitched, loud, drumlike sound produced over the stomach.

A nurse is assessing a client and observes jaundice on the skin and hard palate on the sclera bilaterally. What is the appropriate action of the nurse? A. Percuss the spleen for tenderness. B. Palpate the liver for enlargement. C. Assess the client's temperature. D. Auscultate the lungs for crackles.

Answer: B - Palpate the liver for enlargement Rationale: Jaundice is exhibited by a yellow color, which indicates rising amounts of bilirubin in the blood due to liver disease, kidney disease, or destruction of red blood cells. Palpation of the liver will provide information on possible liver disease. Percussing the spleen, assessing temperature, and auscultating the lungs will not provide information on the cause of the jaundice.

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment? A. ability to identify sharp and dull touch B. ability to identify fine touch C. ability to differentiate temperature change D. ability to sense vibrations

Answer: B - ability to identify fine touch Rationale: Stroking the client's skin with a cotton ball at various places on both sides of the body helps to determine the client's ability to identify fine touch. The nurse uses both the pointed and curved ends of a safety pin to determine if the client can discriminate between sharp and dull touch. The nurse touches the client with warm and cold containers to assess the client's ability to identify differences in temperature. The client's ability to sense vibrations is determined by striking a tuning fork and placing the stem on bony areas, such as the wrist or along the shin.

A nurse is performing the diagnostic positions test to observe extraocular movements on a client during a routine eye exam. Which of the findings would the nurse expect to observe? A. convergence of the eyes B. coordinated movement of both eyes C. nystagmus in all positions D. constriction of both pupils

Answer: B - coordinated movement of both eyes Rationale: A normal response for the diagnostic positions test is parallel tracking or coordinated movement of both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it, and may suggest other neurological pathology. During the diagnostics positions test they eyes should not converge, there should be no nystagmus in any position and the pupils should remain round and equal in size.

A nurse is assessing the lungs of a client and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action? A. Suspect an inflamed pleura rubbing against the chest wall. B. Document normal breath sounds. C. Recommend testing for pneumonia. D. Assess for asthma.

Answer: B - document normal breath sounds Rationale: Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse's scope of practice. Asthma usually results in wheezing.

During assessment, the nurse observes that the client has a yellow discoloration on the skin. What is the nurse's appropriate action? A. Auscultate the lungs and abdomen. B. Inspect the sclera and mucous membranes. C. Observe for cyanosis or eccymosis. D. Assess oxygen saturation level.

Answer: B - inspect the sclera and mucous membranes Rationale: Jaundice is exhibited by a yellow color on the skin, sclera, and mucous membranes by bilirubin. Auscultation of the lungs and abdomen will not provide information about jaundice. Cyanosis is a bluish coloring of the skin, often related to poor circulation or oxygenation. Ecchymosis is a type of skin discoloration that results from blood underneath the skin's surface, such as in the case of a bruise.

The nurse is preparing to perform a head-to-toe physical assessment. What approach will the nurse use? A. Perform the examination from the left side of the bed. B. Organize the assessment so the client does not change positions too often. C. Begin by examining the thorax and abdomen. D. Examine the structures in each system separately.

Answer: B - organize the assessment so the client does not change positions too often Rationale: Using a head-to-toe approach reduces the number of position changes required of the client. The nurse can still move around the client, but typically has to move less. The examination begins at the head and groups structures together for easy examination.

A nurse practitioner is preparing to examine a child with a suspected otitis media. Which instrument will be required? A. pen light B. otoscope C. pphthalmoscope D. sphygmomanometer

Answer: B - otoscope Rationale: The otoscope directs light into the ear canal and onto the tympanic membrane that divides the external and middle ear. The pen light will not allow the visualization of tympanic membrane. The ophthalmoscope is used to visualize the internal structures of the eye and the sphygmomanometer is used to assess blood pressure.

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these? A. Crackles B. Rubs C. Wheezes D. Gurgles

Answer: B - rubs Rationale: Rubs are grating or leathery sounds caused by two dry, pleural surfaces moving over each other. Crackles are intermittent, high-pitched, popping sounds, which are heard in distant areas of the lungs during inspiration. Wheezes are whistling or squeaking sounds caused by air moving through a narrow passage, which can be heard throughout the chest during expiration or inspiration. Gurgles are low-pitched, continuous, bubbling adventitious sounds, which are prominent during expiration, and are heard in larger airways.

A nurse is performing a whisper test on an elderly client. How should the nurse complete this assessment? A. Stand in front of the client and have them close their eyes. B. Stand 2 feet behind and to the side of the client. C. Place a vibrating tuning fork on top of the client's head. D. Place headphones on the client to listen for recorded sounds.

Answer: B - stand 2 feet behind and to the side of the client Rationale: To performing a Voice/Whisper Test for Hearing Acuity, the nurse should stand approximately 2 feet behind and to the side of the client. This placement simulates the distance between most people during social interaction and prevents the client from observing visual cues. A tuning fork is used for the Rhine and Weber test. Head phones are used for audiometry testing.

The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation? A. Reassure the client that the procedure will only take a few minutes. B. Stop lifting the client and reassess him. C. Administer a sedative to the client and try again when the sedative takes effect. D. Enlist the help of another nurse to hold the client steady during the procedure.

Answer: B - stop lifting the client and reassess him Rationale: The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client's weight at this time. Another nurse holding the client steady does not address the client's agitation.

A nurse conducting physical assessment for a client is using the percussion technique. What is the purpose of using this technique? A. to check the skin temperature and moisture B. to determine the location, size, and density of underlying structures C. to assess the sounds from the heart, lungs, and abdomen D. to assess the mobility of normal tissues and unusual masses

Answer: B - to determine the location, size, and density of underlying structures Rationale: The nurse uses the percussion technique to determine the location, size, and density of the underlying structure, as per the quality of sound produced by the tapping. The nurse uses palpation to obtain information regarding the client's skin temperature and moisture, and the mobility of normal tissues and unusual masses. The nurse uses the auscultation technique to listen to the sound of the heart, lungs, and abdomen.

What is one purpose of documentation of the health assessment? A. to identify the nurse's role in health care B. to identify actual and potential health problems C. to expand nursing knowledge and skills D. to provide a basis for evidence-based nursing

Answer: B - to identify actual and potential health problems Rationale: The nurse organizes and documents assessment data to identify actual and potential health problems, to make nursing diagnoses, to plan appropriate care, and to evaluate the client's response to treatment. Evidence-based nursing is premised on research findings, not nursing documentation.

A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client? A. whether they have anemia B. whether they have a program of regular physical activity C. whether they have proper dietary habits D. whether they have home maintenance skills

Answer: B - whether they have a program of regular physical activity Rationale: Regular physical activity contributes to a person's physical and psychological well-being.

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is being tested by this action? A. Cranial nerve I B. Cranial nerves II and III C. Cranial nerve VII D. Cranial nerve VIII

Answer: C - Cranial nerve VII Rationale: Cranial nerve VII is the facial nerve tested by smiling, frowning, wrinkling the forehead, and puffing out the cheeks. Cranial nerve I is the olfactory nerve, cranial nerves II and III are the optic and oculomotor nerves, and cranial nerve VIII is the acoustic nerve.

A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? A. Comprehensive B. Ongoing partial C. Focused D. Emergency

Answer: C - Focused Rationale: A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the client about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment. Ongoing partial assessments are conducted at regular intervals, and emergency assessments are carried out in emergency situations (such as prior to CPR).

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization? A. There is no need to move the pinna. B. Gently pull the pinna up and back. C. Gently pull the pinna down and back. D. Pull the pinna parallel to the side of the head.

Answer: C - Gently pull the pinna down and back Rationale: To achieve better visualization of the ear canals and tympanic membranes of a child younger than 3 years of age, straighten the ear canal by gently pulling the pinna down and back. The ear canal of the adult is straightened by pulling the pinna up and back.

A client has been reporting persistent headaches. Which is an example of subjective data? A. Temperature is 104.1°F (40.05°C) B. The client appears lethargic. C. Pain is 4 out of 10 on a pain scale. D. The client is alert and oriented to person, place, and time.

Answer: C - Pain is 4 out of 10 on a pain scale Rationale: Communicating the client's pain level is only something the client can state and validate. Subjective data are those symptoms, feelings, perception, preferences, values, and information that only the client can describe. The rest of the options can be directly observed or measured and are known as objective data.

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening? A. calorie count B. vital signs C. height and weight D. abdominal girth

Answer: C - height and weight Rationale: The nurse documents the client's weight and height because these measurements provide more reliable data than a subjective assessment of body size, asking the client to provide the information, or measuring abdominal girth.

A nurse is assessing the bowel sounds of a client with abdominal pain. The nurse would describe the client's bowel sounds as hypoactive: A. if sounds occur 30 to 34 times a minute. B. if sounds occur frequently. C. if sounds occur after a long interval. D. if no sound is heard for 3 to 5 minutes.

Answer: C - if sounds occur after a long interval Rationale: Bowel sounds can be described as hypoactive if sounds occur after a long interval. Bowel sounds can be described as normal if they occur 5 to 34 times within a minute, hyperactive if they occur frequently, and absent if no sound is heard for 3 to 5 minutes.

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? A. oriented person, situation, and time B. oriented to hospital, person, and date C. oriented to person, place, and time D. oriented to person, place, and situation

Answer: C - oriented to person, place, and time Rationale: Oriented × 3 indicates that the client is oriented to person (one's own name, the names of significant others, or knowing the nurse), place (location, city, or state), and time (time of day, day of week, or date).

A nurse is planning to obtain a weight on an obese client who has a history of falls. What is the best way to obtain the client's weight? A. Assist the client to stand on a scale at the bedside. B. Delegate this task to the assistive personal. C. Use an electronic bed scale. D. Transfer the client to a chair scale.

Answer: C - use an electronic bed scale Rationale: Nurses use an electronic bed or chair scale to weigh medically unstable clients, clients who are extremely obese, and clients who cannot stand. Assisting the client to stand at the bedside, transfer to a chair or delegating this task to assistive personal places this client at risk of falls.

A nurse is assessing the thorax and lungs of clients visiting a physician's office. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply. A. softer auscultated breath sounds found in newborns and children B. children under 10 having a slower respiratory rate than an adult C. newborns and children using abdominal muscles during respirations D. older adults having an increased anterior-posterior (AP) chest diameter E. older adults having an increase in the dorsal spinal curve (kyphosis) F. older adults having increased thoracic expansion

Answer: C, D, & E - Newborns and children using abdominal muscles during respirations, older adults having an increased anterior-posterior (AP) chest diameter, older adults having an increase in the dorsal spinal curve (kyphosis) Rationale: Newborns and children use abdominal muscles to breath as opposed to adults, who use the thoracic muscles. Increased anteroposterior diameter of the chest is seen in older adults. Kyphosis is seen in older adults. Newborns and children have louder breath sounds and a higher respiratory rate than adults. Older adults have decreased thoracic expansion.

A group of nursing students is reviewing information about the various frameworks for health assessment. The group demonstrates understanding of the information when it identifies which area as reflecting the functional health pattern framework? Select all that apply. A. Respiratory system B. Eyes C. Elimination D. Values and beliefs E. Abdomen F. Activity

Answer: C, D, & F - Elimination, Values and beliefs, Activity Rationale: The functional health framework includes areas such as elimination, activity, and values and beliefs. The body systems framework focuses on specific body systems. The head-to-toe framework focuses on areas starting from the head and working systematically downward to the toes.

A nurse assesses a client for blood pressure. Which technique would be used for this assessment? A. Inspection B. Palpation C. Percussion D. Auscultation

Answer: D - Auscultation Rationale: Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? A. Air in the lungs B. A narrowing of the upper airway C. Narrowed small air passages D. Moisture in air passages

Answer: D - Moisture in air passages Rationale: Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in small air passages, and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs normally contain air.

The nurse is assessing a client's hearing acuity. During the voice test, the nurse stands approximately 2 feet behind and to the side of the client. Why should the nurse take this position during the voice test? A. to deliver a high-pitched sound toward the tested ear B. to facilitate sound conduction to the tested ear only C. To assess the client's ability to discriminate sound D. To simulate the distance between people during social interaction

Answer: D - To simulate the distance between people during social interaction Rationale: The nurse stands 2 feet behind and to the side of the client while performing a voice test for hearing acuity to simulate the distance between people during a social interaction; this will prevent the client from observing visual cues. Instructing the client to cover the ear on the opposite side allows assessment of sound conduction to the tested ear only. Whispering numbers, colors, or names toward the uncovered ear delivers a high-pitched sound, the most common type of hearing loss, toward the tested ear. Asking the client to repeat the whispered word allows the nurse to assess the client's ability to discriminate sound.

The client, Mrs. Rodrigquez, has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator? A. Talking directly to the translator facilitates the transfer of information. B. Talking loudly helps the translator and the client understand the information better. C. It is always okay to not use a translator if a family member can do it. D. Translators may need additional explanations of medical terms.

Answer: D - Translators may need additional explanations of medical terms Rationale: When using a translator it is important to remember that the client still comes first. This means that all information is directed at them and not the translator. Also, there are certain circumstances where it is not appropriate to use a family member, such as when an emotional topic is being discussed. Talking loudly not only inhibits better understanding, but it can also come across as hostile and rude. It is true that even professional translators don't understand all medical terms and may need some clarification at times.

The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis? A. a gentle concave and convex curve of the spine B. an exaggerated lumbar curve of the spine C. an increased curve in the thoracic area D. a pronounced lateral curvature of the spine

Answer: D - a pronounced lateral curvature of the spine Rationale: Scoliosis is a pronounced lateral curvature of the spine. The normal spine appears in midline with gentle concave and convex curves when viewed from the side. Lordosis is a condition in which the natural lumbar curve of the spine is exaggerated. Kyphosis causes an increased curve in the thoracic area.

The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands. True False

Answer: True