Health and Physical Assessment

Which figure indicates that a nurse is performing a palpation of the popliteal pulse?

[behind the knee]

For which client(s) should the nurse consider family members as the primary source of information? Select all that apply.

Infant or child During traumatic emergency When critically ill, disoriented

A nurse is assessing an 89-year-old client with a history of severe congenital spinal deformity. Which condition would most likely describe the nurse's finding?

Kyphosis

Which site is best used to inspect a client who is suspected to have jaundice?

Sclera

Which of the following is a description of the percussion technique?

Tapping the skin with the fingertips to vibrate underlying tissues

A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student indicates ineffective learning?

"I'll perform painful procedures at the beginning of the examination."

A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms?

"What other discomfort do you experience?"

Which degree of edema will result in a 6-mm deep indentation upon pressure application?

3 +

A nurse is assessing a client's degree of edema and finds 8 mm of depth. How does the nurse document this condition?

4+

An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature?

38.5

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation.

Which clinical condition will result in changes in the integrity of the arterial walls and small blood vessels?

Atherosclerosis

A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find?

Brown or black mole with red, white, or blue areas

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

Clear breath sounds

A client who underwent a physical examination reports itching after 2 days. Which condition should the nurse suspect?

Contact dermatitis

While assessing the client's skin, a nurse notices a skin condition, the pathophysiology of which involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which condition is associated with this client?

Erythema

A student nurse is assessing the blood pressure of a client with the client's arm unsupported. What are the expected errors in the obtained readings?

False high reading

While assessing a client, the nurse finds bluish coloration of the skin. The nurse finds that this discoloration is due to cyanosis. Which condition may be suspected?

Heart disease

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply.

On the sternal area & back of the fore arm

Which client assessment finding should the nurse document as subjective data?

Pain rating of 5

Which assessing technique involves tapping a client's skin with the fingertips to cause vibrations in the underlying tissues?

Percussion

Which position is indicated to assess the musculoskeletal system and is contraindicated in clients with respiratory difficulties?

Prone position Rationale: Prone position is indicated to assess the musculoskeletal system in clients, but it is indicated with caution in clients with respiratory difficulties because they cannot tolerate this position well. Sims position is indicated to assess the rectum and vagina. Supine position is indicated for general examination of head and neck, anterior thorax, breast, axilla, and pulses. Knee-chest position is indicated for rectal assessment.

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply.

Ptosis may result from a loss of elasticity of the eyelids, which is a physiologic symptom of sleep deprivation. Decreased auditory alertness and blurred vision are also physiologic symptoms of sleep deprivation. Agitation, hyperactivity, confusion, disorientation, and increased sensitivity to pain are psychologic symptoms of sleep deprivation.

Which feature is characteristic of a risk nursing diagnosis?

The diagnosis does not have related factors.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion?

The nurse asks the client to explain the surgery.

A nurse is assessing a client who underwent abdominal surgery 10 days ago. The client complains of pain in the abdomen. What type of pain does the client experience?

Visceral pain

The nurse is assessing four infants. Which infant does the nurse anticipate to be of abnormal weight?

age = 5 months weight at birth = 3.3 kg current weight = 8.5 kg

A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition?

hypothalamus

Arrange the hierarchy of needs in ascending order beginning with the highest priority needs as defined by Maslow.

physiological, safety and security, love and belonging, self-esteem and self-actualization

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

planning

Which clients suffer from impaired near vision? Select all that apply.

presbyopia & hyperopia

What is the correct order of phases a client experiences in the event of a change in body image following an illness?

shock, withdrawal, acknowledgement, acceptance & rehabilitation

The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for?

skin turgor

Which parts of the body should be assessed for temperature in clients who abuse sedatives or hypnotics? Select all that apply.

thorax & forehead