Chapter 26: Health assessment
A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. What statement by the nurse would be the most appropriate?
"Let me tell you what I will be doing. It should not be painful"
The nurse is assessing the skin of a veteran who has returned from deployment overseas. Which response by the nurse reflects the best strategy to gain cooperation of the client?
"May I look at your skin to determine if there are any issues?"
When taking the client's temperature, the student nurse will require further education when he states:
"the axillary route is the most accurate of all routes"
pallor
(n.) an extreme or unnatural paleness -decrease in hemoglobin which carries oxygen
How do you prepare the client for a physical assessment?
-consider the physiologic and psychological needs of the patient --mental health of the patients -explain the procedure to the patient -explain each procedure in detail as it is conducted -answer patient questions directly and honestly
What are some considerations when performing physical assessments?
-cultural considerations and sensitivity -patient preparation -environmental preparations
What are variations in older adults for the cardiovascular and peripheral vascular assessments?
-difficult to palpate apical pulse -difficult to palpate distal arteries -more prominent and tortuous blood vessels; varicosities common -increased systolic and diastolic blood pressure -widening pulse pressure -assessing the breasts axillae
What are some purposes of the Health Assessment?
-establishes the nurse-patient relationship -gather data about the patients' general health status -identify patient strengths -identify actual and potential health problems -establish a base for the nursing process
What should the size and shape of the head be in a physical assessment?
-in proportion to each other and symmetric -gently curved with prominences at frontal and parietal bones
What are the common variations in older adults for thorax and lung variations?
-increased anteroposterior chest diameter -increase in the dorsal spinal curve -decreased thoracic expansion -use of accessory muscles to exhale
What are variations in older adults for the musculoskeletal assessment?
-loss of muscle mass and strength -decreased ROM -kyphosis -decreased height -osteoarthritic changes in joints
The nurse is documenting morning care for a client with diabetes. Which documentation is the most appropriate for this client?
0800: consumed 80% of breakfast. Reports pain level of 3 on scale of 1-10.
How deep should the palpation be in a GI assessment?
1 centimeter
How do you perform a whisper test? (head and neck assessment)
1) Stand 1-2 feet behind client so they can not read your lips. 2) Instruct client to place one finger on tragus of left ear to obscure sound. 3) Whisper word with 2 distinct syllables towards client's right ear. 4) Ask client to repeat word back. 5) Repeat test for left ear. 6) Client should correctly repeat 2 syllable word.
What are the three normal breath sounds?
1. Bronchial 2. Bronchovesicular 3. Vesicular
What strength/ amplitude should the pulse be at?
2+
At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time should the nurse use?
2015
The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given?
2130
Where is the Pulmonic valve located?
2nd intercostal space, left sternal border
Aortic valve is where?
2nd intercostal space; right sternal border
How long should you listen to the abdomen for a bowel sound?
5 to 34 seconds
Where is the tricuspid valve located?
5th intercostal space and right midclavicular line
The mitral valve is located where?
5th intercostal space; left midclavicular line
The normal adult temperature obtained through the oral route ranges from:
97.6°F to 99.6°F (36.4°C to 37.6°C)
What is a bruit?
Abnormal blowing or swishing sound due to an abnormal narrowing of an artery.
What is the mnemonic used to remember valves of the heart that you assess?
All Patients Take Meds
As a component of a head-to-toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment?
Ask the client to follow her finger as she slowly moves it toward the client's nose.
crackles
Bubbling, crackling, popping -Low- to high-pitched, discontinuous sounds -Auscultated during inspiration and expiration -Opening of deflated small airways and alveoli; air passing through fluid in the airways
Turgor
Elasticity of the skin
What shape is done for EOM?
H
What are IADLs?
Instrumental Activities of Daily Living These are more sophisticated activities involving several steps and more advanced problem solving and decision making skills -housekeeping, meal prep, finances, and transportation
Why would you use the dorsal recumbent position?
It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses.
What is the sims position used to assess?
It is used to assess the rectum or vagina
Why should you not use the dorsal recumbent position in assessing the abdomen?
It should not be used for abdominal assessment because it causes contraction of the abdominal muscles.
A nurse is measuring the apical pulse of a client. Where should she place the diaphragm of the stethoscope in this assessment?
Over the space between the fifth and sixth ribs on the left midclavicular line
Which abbreviation is correct for use in documentation?
PO
A client has been reporting persistent headaches. Which is an example of subjective data?
Pain is 4 out of 10 on a pain scale
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 is preparing to conduct a basic physical assessment of a client who has just been admitted to the unit. What equipment will the nurse require in order to perform this assessment?
Penlight or flashlight
What is the sequence for a GI assessment?
RLQ>RUQ>LUQ>LLQ
friction rub
Rubbing or grating -Loudest over lower lateral anterior surface -Auscultated during inspiration and expiration -Inflamed pleura rubbing against chest wall
A client with dark skin color who has jaundice has been admitted to the health care facility. Which body area is the best place to assess jaundice?
Sclera
How do you assess visual acuity? (head and neck assessment)
Snellen chart
Rhonchi (sonorous wheeze)
Sonorous or coarse; snoring quality -Low-pitched, continuous sounds -Auscultated during inspiration and expiration -Coughing may clear the sound somewhat -Air passing through or around secretions
Which organization audits charts regularly?
The Joint Commission
As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?
The blood pressure increases
sims position
The patient lies on either side with the lower arm below the body and the upper arm flexed at the shoulder and elbow. -- -Both knees are flexed, with the upper leg more acutely flexed. -It is used to assess the rectum or vagina
dorsal recumbent
The patient lies on the back with legs separated, knees flexed, and soles of the feet on the bed. -It is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. - It should not be used for abdominal assessment because it causes contraction of the abdominal muscles.
A new graduate is working at a first job. Which statement is most important for the new nurse to follow?
Use abbreviations approved by the facility
A client who is an avid runner has been monitoring her pulse at home. Recently, her pulse has been below the normal range of 60 to 100 bpm for adults. Today her pulse is 58 bpm. The client asks the nurse at her annual screening if she should be concerned. What is the most appropriate response by the nurse?
Well-conditioned athletes can run lower pulse rates because of the greater efficiency and strength of the heart muscle from regular cardiovascular exercise
cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
The nurse should use the bell of the stethoscope during auscultation of:
a client's heart murmur
health history
a collection of subjective information form the patient
Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 bpm. The nurse notifies the health care provider because the client is exhibiting signs of:
a dysrhythmia
What is the ongoing partial health assessment?
a follow up assessment conducted at regular intervals; concentrates on identified health problems to monitor positive and negative changes
What does the physical assessment for musculoskeletal assessment provide?
about posture, gait, bone size, structure, joint ROM, and muscle strength
What are ADLs?
activities of daily living -eating, bathing, dressing, toileting
Why would you use the sitting position?
allows visualization of the upper body, facilitates full lung expansion, and used to assess vital signs and head, neck, anterior and posterior thorax, lungs, heart, breasts and upper extremities
S2 is due to which valves closing?
aortic and pulmonic
How do you assess a persons' reason for seeking health care?
ask open ended questions and let them describe in their own words why they are there NO PARAPHRASING OR INTERPRETING
To assess subjective data related to a client's elimination pattern, the nurse:
asks the client about changes in elimination patterns
To obtain subjective data about a newly admitted client's sleep pattern, the nurse:
asks the client what promotes sleep
What is auscultation used for?
assessing the four characteristics of sound
A nurse assesses a client for blood pressure. Which technique would be used for this assessment?
auscultation
What do you use to listen to a bruit or murmur?
bell of stethescope
What factors do you assess during a health history?
biographical data reason for seeking health care history of present illness past health history family history functional health psychological and lifestyle factors review of systems
What are the primary structures of the musculoskeletal system? (assessing musculoskeletal system)
bones, muscles, cartilage, ligaments, tendons, and joints
How would you assess the nares and turbinates?(head and neck assessment)
by tipping the patients head back slightly and shining a light into the nares
What should the uvula normally look like during a head and neck assessment?
centered and freely movable
What are some risks during the health history of an head and neck assessment?
changes in vision or hearing with aging -history of use of corrective lenses or hearing aids -history of allergies -history of disturbances in vision or hearing -history of chronic illnesses -exposure to harmful substances or loud noises -history of smoking -presence of tattoos or piercings -history or eye or ear infections -history of head trauma - oral and dental care practice
What characteristics do you look for in the genitourinary ?
color clarity odor
Which statement about client records and documentation is correct?
communication is the primary purpose of client records
What are types of health assessments?
comprehensive ongoing partial focused emergency objective
What is the focused health assessment?
conducted to assess a specific problem Ex: chest pain (focused cardiac assessment)
What does the physical examination provide during the head and neck assessment?
data about the shape and structures of cranial bones, function of special senses, nasal and oral structures, and any swelling or pain in lymph nodes
What are common variations in older adults during the gastrointestinal assessment?
decreased bowel sounds
When assessing a client's respiratory rate, the nurse should take which action?
do it immediately after the pulse assessment so the client is unaware of it
When do you not use the standing position?
do not use on patients who are weak, dizzy, or prone to fall
What do you do if you see abnormalities in the face of a head and neck assessment?
document location, amount, duration and timing
What are some abnormalities in the external eye structures? (head and neck assessment)
drooping of upper eyelids inward turning of lower lids and lashes outward turning of lower lids and lashes redness or drainage edema and pain
What are some abnormalities of the face in a head and neck assessment ?
edema involuntary facial movements
What are palpating for when assessing the lymph nodes? (head and neck assessment)
enlargement tenderness mobility
What should the eyes be normally?
equal black smooth
What should the nipples be normally in the breast and axillae assessment?
equal in size, round or oval, with smooth surface, everted
What is palpation?
examination of the body using touch
When assessing the nose, what are you examining?(head and neck assessment)
external nose, nares and turbinates
What does EOM stand for?
extraocular movements
What does the Glasgow Coma Scale measure?
eye opening, verbal response, motor response
Why would you use the supine position?
facilitates abdominal muscle relaxation and is used to assess vital signs and head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities and peripheral pulses
What do the front of the hand, finger pads, and fingers used to measure?
firmness contour shape tenderness consistency
What are some joint movements you should assess while in the musculoskeletal assessment?
flexion extension hyperextension adduction abduction supination pronation
What information do you accumulate in assessing the history of a present illness?
get all the symptoms -location, problem, duration, intensity, quality/ description, relieving/exacerbating factors, past occurrences, treatments, and how the problem has affected the patient
What do fingers and the back of the hands used to measure?
gross measurements of temperature
What are some areas you assess for the integument assessment?
hair scalp skin hairs
stridor
harsh, loud, high pitched -auscultated on inspiration -narrowing of upper airways (larynx or trachea); presence of foreign body in airway
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records
What do you assess in the cardiovascular and peripheral vascular systems?
heart and extremity pulses
What is the diaphragm used to listen to? and what sounds?
high pitched sounds to the lungs, hear, bowels
A client reports feeling "different" than earlier in the day. When would the nurse anticipate assessing the vital signs?
immediately
What are normal variations in older adults during a head and neck assessment?
impaired near vision decreased color and peripheral vision decreased adaptation to light and dark a white ring around cornea entropion hearing loss elongated ear lobes decreased neck ROM smaller, more easily palpated lymph glands
Where do you assess turgor?
in between the sternum and under the clavicle
bronchial sound
in larynx and trachea -high pitched, harsh, blowy
bronchovesicular
in mainstem sternum and bronchus -moderate blowing sounds and inspiration/expiration sounds equal
What are common variations in adults during the thorax and lung assessment?
increased anteroposterior chest diameter use of accessory muscles to exhale
What are common variations in the cardiovascular and peripheral vascular assessment in older adults?
increased blood pressure
A healthcare provider approaches the nurse caring for the client in room 25 states, "the client is a friend of mine. What treatment is being given?" Which response by the nurse is most appropriate?
inform the healthcare provider that client permission is needed to release any information
The nurse is calling a health care provider to give an update on a client's condition. The nurse receives a telephone order and when requests that the order to be read back to the provider for confirmation, the provider states, "I don't have time for this". What is the most appropriate action by the nurse?
inform the provider, to ensure safety for the client, it must be read back
What does the family history provide?
information about diseases and conditions
What is the objective health assessment?
information changing statuses on patient through head to toe /system sequence based on the type of assessment
How are self questionnaires used in hearing?(head and neck assessment)
initial screenings to identify the needs for an audiologic evaluation by a professional
What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?
inspection
What are the techniques that are used during a physical assessment?
inspection auscultation percussion palpation
What is the comprehensive health assessment?
it is broad conducted upon admission to a healthcare facility includes health history and physical assessments provides a baseline to compare to later
The nurse is performing a head and neck assessment for a client. When inspecting the face, the nurse notes that the skin, sclera, and mucous membranes appear yellowish. In the electronic medical record the nurse chooses which drop-down box selection to document this finding?
jaundice
What is the biggest barrier and increases patient safety?
language
Besides being an instrument of continuous client care, the client's health care record also serves as a(an):
legal document
What are somethings to test in the neurological assessment?
level of awareness PERRLA(C) EOM glasgow coma scale speech hearing balance and gait tactile sensation muscle strength
If you do not hear any bowel sounds, before putting absent bowel sounds, what should you do?
listen to each quadrant for 2 minutes
What is auscultation?
listening to the sounds produced by the body using a stethoscope
What is the bell used to hear?
low pitch sounds like murmurs and bruits
What position should a person who is getting a breast/axillae exam ?
lying or sitting -sitting : erect, arms at sides or raised overhead -supine: patients hand on the side being examined us placed under the head if possible
When palpating and assessing the trachea, what do you want to see? (head and neck assessment)
midline and symmetrical no lumps
S1 is due to which valves closing?
mitral and tricuspid
What is the nasal mucosa usually like?(head and neck assessment)
moist and darker red than oral mucosa
What are some structures to assess while in the musculoskeletal assessment?
muscle bone joint spinal curves
Wheeze (sibilant)
musical or squeaking -high-pitched, continuous sounds -auscultated during inspiration and expiration -occurs in narrowed air passages
what should you acquire from a persons medications?
name, purpose, dose, route, frequency for each medication
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing?
nutritional consult
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"?
oriented to place, person and time
A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?
orthostatic hypotension
What is in a general survey?
overall health of the patient signs of distress patient level of consciousness facial expressions and mood posture assistive equipment
What are you assessing when looking at the nose?(head and neck assessment)
patency by occluding one nostril at a time and asking the patient to inhale and exhale
How do you perform tactile sensation?
patient closes eyes then you randomly touch the patient with a sharp or soft object and ask them to explain how it felt and where it was done
Lithotomy
patient is in the dorsal recumbent position with the buttocks at the edge of the examining table and heels in stirrups -used to assess female genitalia and rectum
Knee chest
patient kneels with the body at a 90* angle to the hips, back straight, arms above the head -used to assess the anus and rectum
Supine position
patient lies flat on back with legs extended and knees slightly flexed -facilitates abdominal muscle relaxation and is used to assess vital signs and head, neck, anterior thorax, lungs, heart, breasts, abdomen, extremities and peripheral pulses
Prone
patient lies flat on the abdomen with head turned to one side -used to assess the hip joint and posterior thorax
sitting position
patient may sit in a chair, on the side of the head or examining table, or remain in bed with the head elevated -allows visualization of the upper body, facilitates full lung expansion, and used to assess vital signs and head, neck, anterior and posterior thorax, lungs, heart, breasts and upper extremities
What does the integument provide information on?
patient overall health -data about self care activities to maintain health, hygiene, and nutrition
Standing position
patient stand erect -do not use on patients who are weak, dizzy, or prone to fall -used to assess posture, balance, and gait
What is inspection?
performing deliberate, purposeful observations in a systematic manner begins with initial patient contact and continues
When looking through patient problems which one do you pick? If you rid or maintain problems, how does it affect patient outcomes?
pick the top priority problem it gives a positive patient outcome
What is the norm for the tongue and oral mucosa when assessing the head and neck?
pink moist free of swelling and lesions
When you assess the lips around the oral cavity, what are you looking for it to be normally?(head and neck assessment)
pink moist smooth
What should the gums look like normally? (head and neck assessment)
pink smooth
If someone is oriented x3 what are they oriented to?
place time person
Why would you use the standing position?
posture, balance, and gait assessment
Where do you assess capillary refill?
pressing nail beds
diaphoresis
profuse sweating
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?
pulse is felt with difficulty and disappears with slight pressure
What does PERRLA(C) stand for?
pupils are equal, round, and reactive to light and accommodation and convergence
What does ROM stand for?
range of motion
What is the emergency health assessment?
rapid focused assessment conducted to determine life threatening or unstable conditions
A nurse has an order to take the core temperature of a client. At which site would a core body temperature be measured?
rectal
erythema
redness of the skin due to capillary dilation
What are some examples of biographical data in a health history?
sex, age, birth date, marital status, race, ethnic origin, religious preference, primary health care provider, language
What do you assess with percussion?
shape location size density of tissues
What do you inspect in the GI area?
shape symmetry pulsations masses
What are some environmental preparations?
showing calmness to increase rapport warm, quiet, well lit room, have necessary equipment prior to entering, and privacy
What position should the patient be in when examining the nose?(head and neck assessment)
sitting and his or her head slightly tilted back if possible
What position should the patient be in when you assess their neck?
sitting and neck slightly hyperextended
What position should the patient be in when assessing the thorax and lungs?
sitting or supine position with head of the bed raised about 30 degrees
What position is the patient in for cardiovascular and peripheral vascular system assessment?
sitting or supine with head of bed raised about 30*
What do you examine when inspecting the breasts? (breast and axillae assessment)
size shape symmetry color texture skin lesions
What do you assess when inspecting?
size color shape position symmetry
What does assessing the head and neck include?
skull face eyes ears nose sinuses mouth pharynx trachea thyroid gland and lymph nodes
What are common variations in older adults during the neurological assessment ?
slower thought processes/verbal responses and conditions
What should the lymph nodes feel like? (head and neck assessment)
small mobile smooth nontender location size consistency
If someone still has their tonsils, what should they look like ? (head and neck assessment)
small pink symmetric
When assessing the external ear, what should the ears be?(head and neck assessment)
smooth symmetric and proportional to the head
vesicular
soft, low pitched, whispering sounds -most lung fields
What are normal findings in the gastrointestinal area?
soft, relaxed, free of tenderness
What positions should the patient assume while in a musculoskeletal assessment?
standing sitting supine
What are the positions used in a physical assessment?
standing sitting supine dorsal recumbent
The nurse preparing to perform an abdominal assessment on a client places the client in which position?
supine
What position should the patient be in for the Gastrointestinal assessment?
supine with head slightly elevated and arms at side; small pillows under the head and knees for comfort
What should the neck look like normally? (head and neck assessment)
symmetric smooth controlled ROM
When inspecting the thyroid gland, what are you looking for ? (head and neck assessment)
symmetry any visible masses
What do you inspect for in the face of a head and neck assessment?
symmetry color distribution of facial hair
when assessing the thorax, what should you see in the chest?
symmetry in structure and when it expands -warm, dry, without masses, tenderness, or vibrations
What is a health assessment?
systematic method of collecting and analyzing data -physical assessment and health history
Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?
systolic pressure
A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?
tachycardia
An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding?
tachycardia
What is percussion?
tapping the person's skin with short, sharp strokes to assess underlying structures
What is patient teaching?
teaching the patient through educating them on various aspects of their life
When palpating the skin, what do you look for?
temperature texture moisture turgor
What do you assess when palpating?
temperature turgor texture moisture vibrations shape
Clients demonstrating apnea have what?
temporary cessation of breathing
After the assessments what do you do ?
thank patient explain abnormal findings answer questions ensure you have met any other needs your patient may have ensure call bell is within reach notify health care provider of any abnormalities or concerns you have regarding the patient (SBAR) document assessment
When palpating sinuses, what are you looking for?(head and neck assessment)
that the patient feels pain from an infection or obstruction
Where is the precordium?
the area on the anterior chest overlying the heart and great vessels
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?
the client is dehydrated
A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?
the client's pupils are black, equal in size, and round and smooth
What does functional health focus on? What are some types?
the effects of health or illness on a patient's quality of life -ADL -IADLs
While assisting a client with a delivery, a nurse takes a photo of the newborn and posts it on a social media website. What action may occur related to this privacy violation?
the nurse could be fined or even go to jail for violating HIPAA
How do you assess ROM?
tilt head back, forward, side to side
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
What does past history give insight to?
to causing current symptoms and health maintenance screenings
Why would you breathe through the mouth?
to enhance the flow
Why would you perform a breast and axilla assessment?
to identify lumps and or enlargement or pain in axillary lymph nodes
Assessing the neck includes:
trachea lymph nodes thyroid gland
The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data?
urine output 100 ml
What would you use the lithotomy position to asses?
used to assess female genitalia and rectum
Why would you assess when the patient is in knee-chest?
used to assess the anus and rectum
What would you assess in the prone position?
used to assess the hip joint and posterior thorax
The nurse is preparing to assess the client's vital signs. The client just had morning coffee. What explanation and action does the nurse take in this situation?
wait 30 minutes, then assess the oral temperature because the client had a beverage
What are some adventitious sounds?
wheeze (sibilant) rhonchi (sonorous wheeze) crackles stridor friction rub
Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?
wheezes
What are some ways to test hearing?(head and neck assessment)
whisper test audiometer self report questionnaires
A 70-year-old client is taking his own pulse at home. He is following the instructions provided by the nurse. He counts his pulse 62 times in one minute. What should he do next?
write it down
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
