Chapters 26: health assessment

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 Auscultation of bowel sounds every 30 seconds Auscultation of gurgles and clicks Umbilicus centrally located

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.

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: erosion. ulcer. fissure. crust.

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 needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment? Penlight Stethoscope Visual acuity chart Tape measure

A penlight is used to test pupillary response to light and accommodation. None of the other items listed would be needed for this assessment.

A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use? Auscultation Palpation Percussion Inspection

Auscultation refers to the assessment technique of listening with a stethoscope to sounds produced in the body, such as bowel sounds. Palpation uses the sense of touch, percussion is the act of striking one object against another to produce sound, and inspection refers to observing.

An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use? Inspection Palpation Percussion Auscultation

Auscultation would reveal if the client's heartbeat is rapid or irregular, and if there are any additional heart sounds such as an S3, which could be an indicator of heart failure. Palpation and inspection may reveal an irregular heartbeat, but they will not disclose extra heart sounds. Percussion is a limited assessment that could be used to outline the cardiac boarder.

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

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 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? Provide a warm, quiet, dimly lit room Assess the cause of the client's wound Evaluate the blood pressure and pulse Interview to obtain the health history

Evaluate the blood pressure and pulse 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.

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action? Ensure that the preoperative check list is completed. Document that the preoperative medication was administered. Verify that the procedural consent form is signed. Locate the laboratory test results in the chart

Explanation: Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation? "How are you feeling?" "Have you been more confused?" "Do you know what day this is?" "Can you tell me where you are right now

Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

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

Explanation: 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 assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use? Palpation Inspection Percussion Auscultation

Explanation: 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 uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action? Encourage the client to increase food and fluid intake. Ensure that the scale is correctly calibrated and repeat the assessment. Report this finding promptly to the client's primary care provider. Increase the frequency of the client's weight assessments.

If weight varies by more than 1 kg, the nurse should check the scale calibration and the accuracy of the assessment before taking further action, such as reporting to the health care provider or altering the client's diet.

The nurse conducts a health history on a client who has experienced a 15-pound (7-kilogram) weight loss in the past 3 weeks. Which information would the nurse gather to determine the client's nutrition pattern? Weigh the client and measure the client's height. Ask the client for a 24-hour diet recall. Examine the hygiene of the client's teeth. Inspect the client's abdomen for symmetry

Interview questions that will focus on nutrition might include asking the client to disclose what the individual has eaten in the last 24 hours. Weighing the client would not provide good nutrition information because the nurse already knows the client has experienced a significant weight loss. A 24-hour diet recall would provide better information about the total nutritional pattern than merely examining the client's teeth or inspecting the abdomen for symmetry.

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 person, situation, and time oriented to hospital, person, and date oriented to person, place, and time oriented to person, place, and situation

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).

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as: ptosis. entropion. ectropion. miosis.

Ptosis is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. Outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. Reports of abdominal pain of 4 on a 0 to 10 point scale Hypoactive bowel sounds in all four quadrants The client states, "I feel nauseated." Peripheral pulses +3 Skin warm and dry Client informs the nurse there is a floater in the left eye

Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care

A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention? Assess capillary refill. Measure the pulse oximetry. Assess fluid intake. Limit the client's activity.

The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.

When percussing the liver, the sound should be: resonant. hyperresonant. dull. flat.

The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment? palpation percussion auscultation inspection

The thyroid gland is assessed by palpation, although it is not normally palpable in some clients. Percussion is a method of tapping on a surface to determine the underlying structure and is used in clinical examinations to assess the condition of the thorax or abdomen. Auscultation of the chest and abdomen is performed for detection of altered respiratory and bowel sounds, rubs, or vascular bruits. Inspection refers to findings on the surface of the body

While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is: clear. blurred. clouded. 20/20.

Visual problems with close objects occur more frequently after the age of 40