Chapter 22 - Health Assessment

10.You are preparing to conduct a comprehensive physical examination on a client. In which position should you place the client to start? 1) Seated 2) Standing 3) Prone 4) Supine

1

The left pupil of a patient fails to accommodate. This finding may reflect an abnormality in which cranial nerve? 1)CN III - Occulomotor 2)CN V - Trigeminal 3)CN VIII - Vestibulococchlear 4)CN X - Vagus

1

The nurse should assess skin temperature by using the: 1)Dorsum of the hand. 2)Pad of the fingertip. 3)Palm of the hand. 4)Dorsum of the wrist.

1

As you examine a client's eyes, you note that one eyelid is drooping. This condition, known as ptosis, is most likely caused by which of the following? 1) Anticholinergic drugs 2) Hyperthyroidism 3) Bell's palsy 4) Glaucoma

3

Which skin assessment finding would cause the nurse to suspect dehydration in a middle-aged patient admitted to the hospital with traveler's diarrhea? 1)Edema 2)Hyperhidrosis 3)Pallor 4)Tenting

4 The skin takes several seconds to return to normal

What is Fowlers position?

60 degrees

Which type of assessment is best suited for use in an emergency or urgent patient situation? A. Ongoing B. Focused C. Psychosocial D. Comprehensive

B

Which of the following data would you likely obtain during a general survey of the client during the physical examination? Select all that apply. A. Bowel sounds present × 4 quadrants B. Blood pressure 130/70 mm Hg C. Speech appropriate to developmental stage D. Gait steady

B,C,D

In completing a nursing assessment of the skin, the nurse knows to instruct the client to seek medical attention for which of the following? A. Acne on the face and neck B. Crusts that have formed over pustules C. Striae found on a female patient's abdomen D. A mole that has become asymmetrical

D

What is Lithotomy?

Dorsal recumbent with stirrups: female pelvic exam

In determining the location, size, and density of the liver, the nurse uses the assessment skills of auscultation. True False

False

What are the 5 skills used in order (not abdominal)

Inspect, Palpate, Percussion, Auscultation, Olfaction

What is Sim's

Lateral recumbent with flexion of hip: rectal area

What is lateral recumbent?

Lying on side, straight legs: cardiovascular

What is Prone position?

Lying on stomach?

What is Knee-Chest?

Similar to doggy position: visualization of rectal area

What is dorsal recumbent?

Supine with knees flexed. Good for abdominal assessment

If a 3-year-old child becomes fearful and cries during a physical assessment, it would be helpful to continue the assessment while the child sits in the lap of a parent. True False

True

A mother brings her 6-month-old infant to the clinic for a well-baby checkup. How should the nurse proceed when weighing the patient? 1)Have the mother remain outside the room. 2)Ask the mother to remove the infant's clothing and diaper. 3)Weigh the infant with the diaper only. 4)Place the infant supine on the scale with his knees extended.

2

Abdominal palpation should be avoided in a child who has which disorder? 1)Appendicitis 2)Wilms' tumor 3)Crohn's disease 4)Small bowel obstruction

2

Based on developmental stage, how should the nurse modify the comprehensive physical examination of an older adult? 1)Work rapidly to finish as quickly as possible. 2)Sequence the exam to limit position changes. 3)Demonstrate equipment before using it. 4)Omit portions of the exam that may be tiring.

2

For all body systems except the abdomen, what is the preferred order for the nurse to perform the following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion 1) D, B, A, C 2) C, A, D, B 3) B, C, D, A 4) A, B, C, D

2

How should the nurse modify an examination for a 7-year-old child? 1) Ask the parents to leave the room before the examination. 2) Demonstrate equipment before using it. 3) Allow the child to help with the examination. 4) Perform invasive procedures (e.g., otoscopic) last.

2

The nurse is performing an otoscopic examination on an adult patient. She has the patient tilt his head to the side not being examined and looks into the ear canal to make sure a foreign body is not present. Which step should she perform next? 1)Straighten the ear canal by pulling the helix up and back. 2)Insert the speculum into the ear canal slowly. 3)Test the mobility of the tympanic membrane. 4)Straighten the ear canal by pulling the helix down and back.

1

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip replacement 2 weeks ago. Which position should the nurse avoid when examining this patient's rectal area? 1) Sims' 2) Supine 3) Dorsal recumbent 4) Semi-Fowler's

1

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no contraindications, how should the nurse position the patient for this portion of the admission assessment? 1) Sitting upright 2) Lying flat on the back with knees flexed 3) Lying flat on the back with arms and legs fully extended 4) Side-lying with the knees flexed

1

A client arrives at your clinic with complaints of abdominal distress. Which of the following types of physical assessment would be most appropriate to perform in this case? 1) Comprehensive 2) Focused 3) System-specific 4) Ongoing

2

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds. Which type of assessment is the nurse performing? 1) Ongoing assessment 2) Comprehensive physical assessment 3) Focused physical assessment 4) Psychosocial assessment

3

The nurse should use the diaphragm of the stethoscope to auscultate which of the following? 1) Heart murmurs 2) Jugular venous hums 3) Bowel sounds 4) Carotid bruits

3 The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart, lungs, and abdomen.

What is semi-fowlers position?

30-45 degrees

A patient's ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as: 1)Trace edema. 2)+1 edema. 3)+2 edema. 4)+3 edema.

4 To assess edema, the nurse presses firmly with her fingertip for 5 seconds over a bony area. Trace appears as a minimal depression; +1 appears as a 2-mm depression with a rapid return of skin to position; +2 reveals a 4-mm depression, which disappears in 10 to 15 seconds; +3 displays a 6-mm depression that lasts 1 to 2 minutes, and +4 demonstrates an 8-mm depression that persists for 2 to 3 minutes. The area is grossly edematous.

The nurse obtains vital signs for a 56-year-old patient who underwent surgery yesterday. Which finding(s) require(s) further assessment? Select all that apply. 1)Blood pressure 110/64 mm Hg 2)Pulse rate 118 beats/minute 3)Respiratory rate 35 breaths/minute 4)Oral temperature 98.6°F (37°C)

2,3

Which of the following are the purposes of a physical examination? SELECT ALL THAT APPLY. 1) To learn about the client's family history 2) To obtain baseline data 3) To administer prescribed medications 4) To identify nursing diagnoses 5) To monitor the status of a previously identified problem 6) To screen for health problems

2,4,5,6

1.You are preparing to examine a toddler. Which of the following actions should you take to adapt the assessment to the unique needs of this stage of development? 1) Pretend to take the blood pressure of the child's stuffed animal first to relieve anxiety. 2) Ask the child what her favorite subject in school is. 3) Ask the child whether she would like to have her mother take her temperature or to have you take it. 4) Screen the child for depression.

3

A father brings his 18-month-old child to the pediatrician's office for a well-baby checkup. The father tells the nurse that he is concerned because his child's legs are bowed. Which response by the nurse is appropriate? 1)"Your child will most likely require physical therapy." 2)"You should consider having your child seen by an orthopedic surgeon." 3)"This is a normal finding in children for 1 year after they begin walking." 4)"Your child is walking fine, so you don't need to worry

3

Bronchovesicular breath sounds are best heard over which area? 1)Midline over the trachea just below the larynx 2)Fourth intercostal space, in the midclavicular line 3)First and second intercostal spaces next to the sternum 4)At the base of the lungs near the diaphragm

3

Where should the nurse assess skin color changes in the dark-skinned patient? 1)Nailbeds 2)Any exposed area 3)Oral mucosa 4)Palms of the hands

3

The nurse assesses a 4-year-old child's vision as 20/40. This finding is considered: 1)Myopia. 2)Hyperopia. 3)Normal. 4)Presbyopia.

3 Children typically do not have 20/20 vision until the ages of 6 or 7 years. A finding of 20/60 in a 4-year-old child is considered normal. Myopia is diminished distant vision, which is associated with Snellen chart reading of 20/100. Hyperopia is diminished near vision and is represented by a large fraction, such as 20/15; when found in people over age 45 it is known as presbyopia.

A 48-year-old patient comes to the physician's office complaining of diminished near vision, which the nurse confirms with testing. She should document this finding as: 1)Myopia. 2)Diplopia. 3)Presbyopia. 4)Mydriasis.

3 Diminished near vision in a patient over age 40 or so years is known as presbyopia. Diminished distant vision is known as myopia. Double vision is known as diplopia. Mydriasis or enlarged pupils may be seen with glaucoma.

A female patient has excessive facial hair. The nurse should document this finding as: 1)Alopecia. 2)Albinism. 3)Hirsutism. 4)Lanugo.

3 Hair loss should be documented as alopecia. Albinism is a condition caused by lack of pigment in which the patient has white hair and very pale skin. Lanugo is the fine, downy growth of hair that covers the body of a newborn.

A patient's jugular venous pressure measures 5 cm. This finding indicates: 1)A normal finding. 2)Hypovolemia. 3)Heart failure. 4)Dehydration.

3 Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure.

An older adult comes to the clinic complaining of pain in the left foot. While assessing the patient, the nurse notes smooth, shiny skin that contains no hair on the client's lower legs. Which condition does this finding suggest? 1)Venous insufficiency 2)Hyperthyroidism 3)Arterial insufficiency 4)Dehydration

3 Venous insufficiency leads to thick rough skin Hyperthyroidism leads to warm skin Decreased turgor would be dehydration

The nurse notes a small pulsation at the fifth intercostal space midclavicular line. This should be documented as a: 1)Thrill. 2)Murmur. 3)Normal finding. 4)Heave.

3 A small pulsation at the fifth intercostal space midclavicular line is known as the point of maximal impulse (PMI) and is considered a normal finding. A thrill is a vibration or pulsation palpated in any area except the PMI. A murmur occurs when structural defects in the heart's chambers or valves cause turbulent blood flow. A heave, which is a visible palpation, is associated with an enlarged ventricle.

13.You are preparing to examine an adolescent. Which of the following actions should you take to adapt the assessment to the unique needs of this stage of development? 1) Assess the client's ability to perform activities of daily living. 2) Observe the client's energy level .3) Assess the client's support system. 4) Screen the client for depression.

4

High-pitched breath sounds produced by airway narrowing are known as: 1)Rales. 2)Crackles. 3)Rhonchi. 4)Wheezing.

4

Assessing a client's nails and hair is often not a critical assessment. But these items are important to include in a complete physical exam for which of the following reason(s)? Select all that apply. A. Abnormal assessment findings may indicate a self-care deficit. B. Changes in the distribution of hair and/or color of nailbeds may indicate the presence of a more serious disease. C. Alterations in assessment findings related to hair and nails may represent underlying malnutrition. D. The presence of a callus formation around the nail may indicate a malignancy.

A,B,C

While examining a client's oral cavity, you observe that the tongue has a black, hairy appearance. Which of the following is likely the cause of this finding? 1) Dehydration 2) Fungal infection 3) Allergy 4) Iron deficiency

2

Which statement best describes the procedure used to assess capillary refill? 1)Briefly press the tip of the nail with firm, steady pressure, then release and observe for changes in color. 2)Press firmly with your fingertip for 5 seconds over a bony area, release pressure, and observe the skin for the reaction. 3)Tap on the skin with short strokes from your fingers. 4)Lift a fold of skin, and allow it to return to its normal position.

1

While examining the skin of a newborn, you notice small, irregular pink-red areas around the face and nape of the neck. Which of the following are these marks? 1) Mongolian spots 2) Capillary hemangiomas 3) Café-au-lait spots 4) Striae

2

You are preparing to conduct a general survey of your client. Which of the following should you evaluate in this part of the assessment? SELECT ALL THAT APPLY. 1) Appearance and behavior 2) Body type and posture 3) Pupils 4) Speech 5) Vital signs 6) Hearing

1,2,4,5

The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests: 1)Heart failure. 2)Coronary artery disease. 3)Hypertension. 4)Pulmonic stenosis.

1 A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.

A 6-week-old infant is brought to the pediatrician's office for a well-baby checkup. The nurse notes a flattening of the skull. Flattening of the skull in the infant might suggest: 1)The baby has been lying in the same position for several hours a day. 2)A disorder associated with excessive growth hormone. 3)An accumulation of excessive cerebrospinal fluid. 4)Temporomandibular joint syndrome.

1 Abnormal flattening of the skull in infants may result from placing the baby in the same position for several hours every day. A large head in an adolescent or adult may be associated with acromegaly, a disorder associated with excess growth hormone. In infants and children, a head that is growing disproportionately faster than the body may be a sign of hydrocephalus, which is fluid collection in the cavity within the brain. Irregular jaw movement and cracking of the jaw in adults may indicate temporomandibular joint (TMJ) syndrome.

You are preparing to test a client's hearing. Which of the following tests should you perform first? 1) Weber test 2) Rinne test 3) Romberg test 4) Ishihara test

1 If it is positive, use the Rinne test The Romberg tests for equilibrium

A patient is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Which finding might the nurse expect when assessing the patient's nails? 1)Soft, boggy nails 2)Brittle nails 3)Thickened nails 4)Thick nail with yellowing

1 Soft, boggy nails are seen with poor oxygenation. Brittle nails are seen with hypothyroidism, malnutrition, calcium, and iron deficiency. Thickened nails may result from poor circulation. A thick nail with yellowing is an indication of fungal infection known as onychomycosis.

____ 2. Which disorder(s) might limit a patient's visual field? Select all that apply. 1)Diabetes 2)Advanced glaucoma 3)Peripheral vascular disease 4)Cataracts

1,2,4

You are preparing to perform a physical examination on a client. Which of the following actions should you take to prepare the environment of the examination room? SELECT ALL THAT APPLY. 1) Drape the client for modesty and comfort. 2) Adjust the room temperature according to your preference. 3) Turn on the television to help distract the client 4) Dim the lights to help the client relax. 5) Gather needed equipment.6) Close the door to the client's room for privacy.

1,5,6

The nurse is caring for a patient who underwent abdominal surgery 24 hours ago and has a nasogastric tube to intermittent suction. How should the nurse proceed when performing an abdominal assessment on this patient? 1)Avoid palpating the patient's abdomen. 2)Turn off the suction before auscultating bowel sounds. 3)Listen for bowel sounds for 2 minutes in each quadrant. 4)Percuss the abdomen before auscultating bowel sounds.

2

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How should she position the patient to begin and perform most of the physical examination? 1) Dorsal recumbent 2) Semi-Fowler's 3) Lithotomy 4) Sims'

2

Which abnormal laboratory value is associated with icteric sclera? 1)Bleeding time 2)Bilirubin 3)Hemoglobin 4)Glucose

2

Which portion of the ear is responsible for maintaining equilibrium? 1)External ear 2)Inner ear 3)Middle ear 4)Ossicles

2

While the nurse assesses a newborn of African American descent, the mother points out a blue-black Mongolian spot on the newborn's back and asks, "What's that? Is something wrong with my baby?" Which response by the nurse is best? 1)"I'll ask the physician to look at the spot." 2)"Those spots are quite common and typically fade with time." 3)"You may want a plastic surgeon to look at that." 4)"That spot is benign so it's nothing you need to worry about."

2

You auscultate a client's abdomen for a full minute and hear only three very faint sounds. Which of the following conditions should you most suspect in this client? 1) Diarrhea 2) Bowel obstruction 3) Gastroenteritis 4) Normal

2

You need to assess a client's lungs for the presence of high-pitched sounds. Which of the following examination techniques should you use? 1) Percussion 2) Auscultation with the diaphragm of the stethoscope 3) Auscultation with the bell of the stethoscope 4) Direct auscultation

2

The nurse applies resistance to the top of the client's foot and asks him to pull his toes toward his knee. The nurse observes active motion against some, but not against full, resistance. How should the nurse document this finding? 1)5: Normal 2)4: Slight weakness 3)3: Weakness 4)2: Poor ROM

2 5 Active motion against full resistance Normal 4 Active motion against some resistance Slight weakness 3 Active motion against gravity Weakness 2 Passive ROM Poor ROM 1 Slight flicker of contraction Severe weakness 0 No muscular contraction Paralysis

An 85-year-old patient is brought to the emergency department with lethargy and hypotension. When the nurse assesses the patient's tongue, she notes that it appears dry and furry. This finding suggests: 1)Fungal infection. 2)Dehydration. 3)Allergy. 4)Iron deficiency.

2 A dry, furry tongue is associated with dehydration. A black, hairy tongue is characteristic of a fungal infection. Absence of papillae, reddened mucosa, and ulcerations may indicate allergy. Patients who have a deficiency of iron may have a smooth, red tongue.

The nurse asks the patient to spread his fingers and then bring them together again. Which of the following is the nurse testing when asking to bring his fingers together? 1)Abduction 2)Adduction 3)Flexion 4)Extension

2 Asking the patient to spread his fingers tests abduction; asking him to bring them together assesses adduction. Asking the patient to make a fist tests flexion, whereas asking him to extend the hand tests extension.

Which test should the patient undergo when the Weber test is positive? 1)Romberg test 2)Rinne test 3)Pure tone audiometry 4)Tympanometry

2 If the Weber test is positive, the patient should undergo the Rinne test to assess the type of hearing loss. The Romberg test is performed to test equilibrium. Pure tone audiometry uses a machine to hear sounds at different volumes while the patient wears a headset. Tympanometry assesses pressure in the ear; it does not assess hearing.

Which assessment should the nurse perform if she notes a palpable thyroid gland? 1)Illuminate the thyroid gland for the presence of fluid. 2)Auscultate the thyroid gland for bruits. 3)Percuss the thyroid gland for mass size. 4)Measure the thyroid gland to assess change.

2 Normally, the thyroid gland is smooth, firm, and nontender. It is often nonpalpable. If the thyroid gland is palpable, the nurse should auscultate it for bruits. It is not necessary to measure or illuminate the thyroid gland. The thyroid gland should not be percussed.

The nurse notes ptosis in a patient who just arrived in the emergency department. The nurse quickly triages the patient because she knows that this finding, along with other symptoms, might suggest: 1)Hyperthyroidism. 2)Stroke. 3)Glaucoma. 4)Macular degeneration.

2 Ptosis is dropping of the upper - eyelid

Which of the following is a correct developmental outcome for an infant? The infant's anterior fontanel (soft spot) typically fuses: 1)At about 8 weeks. 2)At about 14 months. 3)By 6 months of age. 4)Before 1 year of age.

2 The large soft spot on the top of the head, known as the anterior fontanel, typically fuses at about 12 to 18 months. The infant should be able to hold up his head by age 6 months. The posterior fontanel fuses at about 8 weeks of age.

Which assessment question helps assess immediate memory? 1)"How did you get to the hospital today?" 2)"Can you repeat the numbers 2, 7, 9 for me?" 3)"Do you recall the three items I mentioned earlier?" 4)"What was your birth date including the year?"

2 The nurse can assess immediate memory by asking the patient to repeat a series of three numbers and gradually increasing the length of the series until the patient cannot repeat the series correctly. The nurse can assess recent memory by asking the patient how he got to the hospital or by asking the patient to repeat three items that the nurse mentioned earlier in the examination. The nurse can assess remote memory by asking the patient his birth date or the date of a significant historical event.

Assuming that all are accurate, which documentation about a patient's level of consciousness is best? 1)Patient is lethargic and slept when undisturbed. 2)Patient responds to tactile stimulation; falls back to sleep immediately after tactile and verbal stimulation are stopped. 3)Patient slept throughout the day, missing his meals and bath. 4)Patient appears to be tired as he slept throughout the day except when bathed.

2 The option that includes the most detailed information provides the most accurate description of the patient's level of consciousness. The other documentation provides little information about the level of consciousness. From those descriptions, the patient might have a decreased level of consciousness or could simply be exhausted.

When testing near vision, the nurse should position printed text how many inches away from the patient? 1)20 2)18 3)16 4)14

4

While assessing an older adult patient, the nurse notes clubbing of the fingers. This finding is a sign of: 1)Fungal infection. 2)Poor circulation. 3)Iron deficiency. 4)Long-term hypoxia.

4 Clubbing (when the nail plate angle is 180° or more) is associated with long-term hypoxic states such as chronic lung disease. A thick nail with yellowing indicates a fungal infection. Spoon-shaped nails may result from iron-deficiency anemia. Brittle nails are commonly seen with malnutrition, hyperthyroidism, and malnutrition.

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the physician's office for a college physical. This patient is considered: 1) obese. 2) overweight. 3) average. 4) underweight.

4 For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.

An adult admitted to the hospital after a stroke does not respond to verbal stimuli. What should the nurse do next to try to provoke a response? 1)Apply pressure to the mandible at the jaw. 2)Rub the patient's sternum. 3)Squeeze the trapezius muscle. 4)Gently shake the patient's shoulder.

4 If the patient does not respond to verbal stimuli, the nurse should try tactile stimuli by gently shaking the patient's shoulder. If the patient does not respond to tactile stimuli, the nurse should try painful stimuli by squeezing the trapezius muscle, rubbing the sternum, applying pressure on the mandible at the angle of the jaw, or applying pressure over the moon of the nail. But do not start out with painful stimulation before you are sure the patient is not going to react to a less invasive approach.

Which of the following is an abnormal capillary refill finding that the nurse should report? 1)1 second 2)2 seconds 3)3 seconds 4)4 seconds

4 Normal capillary refill is less than 3 seconds; therefore, the nurse should report a capillary refill of 4 seconds.

The admission assessment form indicates that the patient has pedal pulses that are rated 1 in amplitude. This documentation indicates that the patient's pulses are: 1)Bounding. 2)Normal. 3)Full. 4)Diminished.

4 Pulses documented as 1 are diminished and barely palpable; 2 are normal; 3 are full and increased; and 4 are bounding.

Small hemorrhages are noted under the nailbed of a patient with a history of intravenous drug abuse. This finding is associated with: 1)Low albumin levels. 2)Zinc deficiency. 3)Renal disease. 4)Bacterial endocarditis.

4 Small hemorrhages under the nailbed, known as splinter hemorrhages, are associated with bacterial endocarditis, a complication of IV drug abuse. A distal band of reddish-pink covering 20% to 60% of the nail (half and half nails) is seen in patients with low albumin levels and renal disease. White spots may indicate zinc deficiency.

While palpating the anterior chest, the nurse notes crackling in the skin around the patient's chest tube insertion site. The nurse recognizes this finding is: 1)Tactile fremitus. 2)Egophony. 3)Bronchophony. 4)Crepitus.

4 The nurse should document this finding as crepitus, crackling skin caused by air leaking into the subcutaneous tissues. Tactile fremitus involves palpating for vibrations as the client says "99," which indicates the presence of fluid in the chest. Bronchophony is present if the words "1, 2, 3" are clearly heard over the lungs as the nurse listens while the patient says those words. Egophony is present if the sound heard is "ay" when the nurse listens over the lung fields as the patient says "eee."

Below are the heart sound landmarks you should use when auscultating the heart. Put them in the correct order. Pulmonic Tricuspid Aortic Mitral

Aortic Pulmnic Tricuspid Mitral