Skills Question (Health Assessment)

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 explains to another nurse the meaning of situational awareness. Which client exemplar does the nurse use to illustrate situational awareness?

"If the call bell has been out of the client's reach, I ask if the client needs to void or defecate."

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.

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 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

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 preparing to obtain biographical data from a client before initiating a health assessment. Which biographical data should the nurse plan to collect? Select all that apply.

Gender, Occupation, Date of birth, Name

The nurse is completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

The IV is not infusing at the correct rate., There is spilled water on the floor., The client is wearing the oxygen around the neck., The skin is a bluish-color.

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 assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Ask the client about any usual genital observations.

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 nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

Assess the client's ability to stand or sit.

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.

Assess the client's vital signs

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.

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

A nurse must assess the bowel sounds of a client who is having abdominal pain. Which type of assessment should the nurse perform?

Auscultation

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, Cleanse the abdomen with chlorhexidine, Keep the client NPO

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 nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?

Circumoral cyanosis when the client is at rest

The nurse is asking admission interview questions, and the client has explained the reason for seeking care. Which is the most appropriate way to document the response?

Client states, "I feel winded all of the time, and yesterday I started spitting up a lot of phlegm."

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 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 assesses a female client's genitalia and notes the vulva appears darker than the surrounding area and a clear discharge is present. What action does the nurse take?

Document the physical findings in the medical record.

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?, Is the client's color appropriate for ethnicity?, Are there any tubes, lines, or drains?, Does the client appear to be alert?

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 shoulders of a client during a detailed musculoskeletal assessment. Which four motions should be included during this examination?

Forward flexion, internal rotation, abduction, and external rotation.

Which are included in the integumentary system? Select all that apply.

Hair, Nails, Sweat glands, Skin

The nurse is about to conduct a general survey on a client being admitted to the medical-surgical unit. What should the nurse do first?

Identify the client by two methods.

The nurse is going to conduct an assessment of a female client's genitalia. Which order is most appropriate for conducting a genitalia assessment?

Inspect and then palpate

The nurse is going to perform an assessment of a male client's genitalia. Which order is most appropriate for conducting a male genitalia assessment?

Inspect external genitalia, palpate scrotum, and inspect inguinal area.

The nurse is reviewing the lab work of a client who has a serum bilirubin level of 0.5 mg/dL (8.55 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

A nurse working in an outpatient clinic is inspecting the external genitalia of an adult male client. Which assessment finding is of the most concern?

Lump in the scrotum

The nurse is palpating a client's precordium. Which is an expected clinical finding?

Palpable pulsation over the mitral area

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.

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

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?

Pink labia lesions

The nurse is preparing to palpate a client's peripheral pulses. The nurse should plan to assess which pulses? Select all that apply.

Popliteal, Posterior tibial, Radial, Brachial, Dorsalis pedis

A nurse is caring for a client with a recent traumatic brain injury. The client is comatose at present. What type of scale would be appropriate to use to weigh this client?

Portable bed scale

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.

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.

Sacrum, Feet, Hands

Which senses are used when the nurse performs the inspection phase of assessment? Select all that apply.

Smell, Hearing, Sight

The nurse is performing a quick head-to-toe assessment on a client admitted with an infected left heel wound. When auscultating the lower lobes of the client's lungs, what might the nurse expect to find?

Soft, low pitched sounds bilaterally

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.

Standing scale, Tape measure, Sphygmomanometer, Stethoscope

The nurse performs a situational assessment for a client with a high risk of injury. Which findings during this assessment require the nurse to act? Select all that apply.

The client is confused as to why the call bell won't call home., The client needs the assistance of two staff when getting out of bed., The client's adult child places shoes and a cane next to the raised bed rail.

During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique?

To assess capillary refill and oxygenation

The nurse is completing the abdominal portion of an admission assessment for a client admitted with asthmatic bronchitis who is otherwise healthy. What would the nurse expect to document? Select all that apply.

bowel sounds occurred every 5 to 34 seconds, soft, tinkling sounds in the right lower quadrant"

When performing a situational assessment, which assessment would the nurse complete as the last step?

safety survey

The nurse is completing a focused head and neck assessment of a client admitted with tension headache. What questions would the nurse ask the client? Select all that apply.

"Could you describe the pain you are feeling to me?", "Have you had any recent job changes or anxiety?"

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 completing a situational assessment. Which findings would cause the nurse concern? Select all that apply.

-There is spilled water on the floor. -The client is wearing the oxygen around the neck. -The IV is not infusing at the correct rate. -The skin is a bluish-color.

The nurse is preparing to assess a client's abdomen. Place the following steps of the assessment in the correct order. Use all options.

1)Inspection 2)Auscultation 3)Percussion 4)Palpation

The nurse must weigh a client using a bed scale. Place the following steps in the correct order. Use all options.

1)Place a cover over the sling of the bed scale. 2)Attach the sling to the bed scale. 3)Balance the scale so that weight reads 0.0. 4)Roll client back over the sling and onto other side. 5)Gradually elevate the sling so that the client is lifted up off of the bed. 6)Note weight reading on the scale.

A nurse is caring for a client requiring daily weights. What nursing actions are indicated when obtaining a weight using a portable bed scale? Select all that apply.

Attach the sling to the bed scale and cover with a bath blanket., Perform hand hygiene and put on personal protective equipment, if indicated., Close the curtains around the bed and close the door.

The surgical nurse is caring for four clients. Which tasks can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Attaining an admission weight for a client using a portable bed scale., Documenting the urinary output of the client with a Foley catheter., Ambulating the client who is third day postoperative from right knee surgery.

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.

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

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Auscultation of a bruit

The nurse is assessing a client's thorax and lungs. Which finding would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

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

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.

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

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., Note cultural influences that may influence individual response., Modify procedures as much as possible to limit stress.

The nurse weighs the client using a portable bed scale. The obtained weight is 10 lb (4.5 kg) more than the nurse expected. What action does the nurse take next?

Ensure equipment is not hanging into the sling.

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.

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

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.

A wellness clinic nurse is about to perform an assessment of a male client's genitalia. What should the nurse do first?

Explain the purpose of exam.

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.

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, Obvious turbulence upon auscultation of the bilateral carotid arteries

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

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.

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene?

Palpation of both carotid arteries at the same time

A nurse needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment?

Penlight

A nurse prepares to assess a female client's genitalia. What should the nurse do first?

Perform hand hygiene.

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

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

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

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.

The gerontologic nurse is inspecting the genitalia of an older adult female client. Which assessment findings are of the most concern? Select all that apply.

Scant red vaginal discharge, Increased size of the labia unilaterally

A gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply.

Scant yellow discharge, Bulge to the left inguinal area

The nurse is preparing to assess a client's cranial nerves. Which technique should the nurse use to assess cranial nerve III?

Shine a bright light in the client's eyes and observe for bilateral pupillary response.

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., Older adults take longer to perform certain actions., Presence of heart sound S4 is considered normal.

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 typically delegates a situational assessment to the unlicensed assistive personnel (UAP) for the home care client with heart failure. Which finding causes the nurse to perform this assessment rather than delegate it?

The client went to the emergency department to be evaluated after a fall.

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.

Tone, strength, size, and tenderness, Contour, pain, range of motion, and symmetry

The nurse is caring for a client admitted with degenerative disease of the cervical spine. The client reports moderate pain. During the inspection phase of the musculoskeletal assessment, what should the nurse expect to find?

Torticollis

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 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