Chapter 26: Health Assessment

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding?

A reddish retina Explanation: Normal findings of the internal eye structures include a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins.

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?

Document normal breath sounds. Explanation: 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.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat. Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first?

Evaluate the blood pressure and pulse Explanation: In this acute-care emergency situation, the nurse should assess the pulse and blood pressure, since the client seems to be presenting with signs and symptoms of shock.

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?

In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard.

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. Explanation: The pupils should be black, equal in size, and round and smooth. When an object moves towards the client's nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The client's pupils should constrict when looking at a near object and dilate when looking at a distant object.

The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray. Explanation: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

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 Explanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure. The other findings are normal.

What percentage of weight change in 6 months is considered abnormal?

e: 10% Explanation: A 10% change in weight in 6 months is considered abnormal.

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:

fissure. Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.

A nurse is assessing a client's level of consciousness using the Glasgow Coma Scale. The assessment reveals that the client opens the eyes to pain, exhibits abnormal flexion posturing, and produces sounds that are not identifiable. Which score would the nurse assign the client?

6 Explanation: Based on the assessment findings, the client would receive a score of 2 for eyes opening to pain, a score of 3 for abnormal flexion posturing, and a score of 1 for incomprehensible sounds, for a total score of 6.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?

Ask the client to empty her bladder. Explanation: Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

Assess the client for dehydration. Explanation: Turgor is the fullness or elasticity of the skin. The client should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the client is dehydrated, the skin's elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease nor cystic fibrosis.

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 Explanation: A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

Warm the diaphragm of the stethoscope. Explanation: Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.

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 client in the Intensive Care Unit for acute pancreatitis asking for pain medications Explanation: 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 client's heart murmur. Explanation: 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.

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

tuning fork Explanation: Rinne and Weber tests are performed in order to assess sound conduction; both require a tuning fork. A Rinne test evaluates hearing loss by comparing air conduction to bone conduction. The nurse strikes a tuning fork and places it on the mastoid bone behind one ear. When the client can no longer hear the sound, they signal to the nurse. The nurse then moves the tuning fork to the ear canal. When the client can no longer hear that sound, they once again signal the nurse. The nurse records the length of time the client hears each sound. In the Weber test, the nurse strikes a tuning fork and places it on the middle of the client's head, and the client indicates where the sound is best heard: the left ear, the right ear, or both equally. A Snellen chart is an eye chart that can be used to measure visual acuity. An otoscope is an instrument designed for visual examination of the eardrum and the passage of the outer ear, typically having a light and a set of lenses. An ophthalmoscope is an instrument for inspecting the retina and other parts of the eye.

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 Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.