Comprehensive Physical Assessment of an adult

A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? A. Right upper quadrant B. Left upper quadrant C. Right lower quadrant D. Left lower quadrant

A. Right lower quadrant

A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A. A continuous sensation of vibration felt over the second and third intercostal spaces. B. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum. C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. D. A whooshing or swishing sound over the second intercostal space along the left sternal border.

C. A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line. *This is where you would inspect and palpate for the point of maximal impulse. Also called an apical pulsation, it occurs as the apex of the heart bumps against the chest wall with each heartbeat. The apical impulse is not always visible but can be felt as a brief thump. This is an expected finding and should performed when you are preparing to auscultate the apical pulse.

A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? A. Crackles B. Stridor C. D.

A. Crackles *Sometimes called rales, are wet, popping sounds created by air moving through liquid by collapsed alveoli snapping open on inspiration. They are most common at the end of inspiration of breathing.

A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take. A. Document accurate data B. Develop a plan of care C. Validate previous data D. Evaluate outcomes of care

B. Develop a plan of care *The first action the nurse should take using the nursing process is to assess the client and develop a plan of care. The nursing process follows the steps of assessment, analysis, planning, implementation, and evaluation.

A nurse is performing a complete, head-to-toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? A. Auscultation B. Inspection C. Percussion D. Palpation

B. Inspection *The nurse should begin a complete physical examination by inspecting the client's body systematically, observing for both expected and unexpected physical findings. Then assessing most body systems, the recommended order is inspection, palpitation, percussion, and auscultation.

A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? A. Lordosis B. Kyphosis C. Ankylosis D. Scoliosis

B. Kyphosis *"hunchback" curvature

A nurse is palpating a tender area of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? A. Borborygmi B. Rebound tenderness C. Tympany D. Abdominal guarding

B. Rebound tenderness *In the right lower quadrant at McBurney's point (1/3 the distance from the anterior iliac crest to the umbilical) is an indication of acute appendicitis.

A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingertips on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? A. Posterior tibial B. Popliteal C. Dorsalis pedis D. Femoral

C. Dorsalis pedis *Most common pulse tested in the lower extremities.

A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? A. Gait B. Hearing C. Vision D. Balance

D. Balance *Most common test for balance

A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve I is intact? A. The client can stick their tongue out. B. The client can smile symmetrically. C. The client can hear whispered words. D. The client can identify a minty scent.

D. The client can identify a minty scent. *Cranial nerve I = olfactory nerve *Controls the sense of smell. To test this nerve's function, the nurse should ask the client to identify a nonirritating aroma, such as mint or coffee.

A nurse is performing a general client survey and finds that the client has a body mass index (BMI). Which of the following should the nurse document? A. The client has no nutritional issues or deficits. B. The client is at high risk for obesity-related health problems. C. The client will need a referral to a dietician. D. The client has a BMI within the expected reference range.

D. The client has a BMI within the expected reference range. *BMI is a measurement of an adult's body fat based on height and weight. The expected reference range for a BMI is between 18.5 and 24.9, which indicates a normal body weight. Therefore, the nurse should document that the client has a BMI within the expected reference range for a client who has a BMI of 23.