Health Assessment Prep U

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

CN1

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? "This is nothing to worry about. I won't hurt you." "Some of the examination may be painful, but I will be gentle." "Let me tell you what I will be doing. It should not be painful." "I have to do this, so just relax and it won't last long."

"Let me tell you what I will be doing. It should not be painful." Rationale: Explaining the assessment in general terms can help decrease the client's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test.

A nurse is preparing to conduct the health history for a client new to the clinic. Which question would the nurse likely ask first? "How would you describe your health?" "Do you have any pain or discomfort?" "What brings you here today?" "What are your usual activities each day?"

"What brings you here today?"

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30 or 6/9. The client asks the nurse, "What does that mean?" How should the nurse respond? "You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." "Your vision is perfect; you can read the entire chart, and you do not need glasses." "Your vision is better than average; you can read from 30 ft (9 m) what a person with normal vision can read from 20 ft (6 m)." "Your vision in your right eye is slightly different than that of your left eye."

"You are able to read at 20 ft (6 m) what a person with normal vision can read at 30 ft (9 m)." Rationale: The 1st number= distance the person is standing from the chart. 2nd number=distance that a normal eye can see. It is not appropriate or correct to tell the client that vision is perfect, that one eye is better than the other, or that vision is better than average.

A nurse is teaching a client how to perform a self breast exam. Place the following examination techniques in the order they should be performed.

1.) Standing in front of a mirror, look at both breasts with the arms relaxed at the side, with the hands pressing on the hips, and with the hands elevated above the head looking for dimpling in the skin or retraction of either nipple. 2.) Lie down and place a pillow under the shoulder on the side where the first breast will be examined. 3.) Use the flat surface of the fingers in an up-and-down pattern from the underarm and across the breast from the clavicle to the base of the ribs to feel for changes in any area of the breast. 4.) Feel upward toward the axilla of each arm to determine if there are any lumps or hard or thickened areas. 5.) Squeeze the nipple gently between the thumb and index finger to determine if there is any clear or bloody discharge.

The nurse is assessing the legs of a client and notes fairly normal contour with a 4-mm indentation when pressing on the shin and calf of each leg. How should the nurse interpret these findings?

2+ pitting edema Rationale: With 2+ pitting edema, the legs are fairly normal contour and has deeper pit after pressing (4 mm) than trace or 1+ pitting edema. It lasts longer than 1+ pitting edema. It is not as severe as brawny edema.

During assessment of the lower extremities, the nurse notes that the bilateral lower extremities are pink, intact, warm, and soft to touch, as well as normal in contour with a 4-mm depression in the skin after pressing that returns after 2 seconds. Which is the correct interpretation and documentation of this result? brawny edema noted over bilateral lower extremities 2+ pitting edema noted on bilateral lower extremities bilateral lower extremities within normal limits 1+ pitting edema noted on bilateral lower extremities

2+ pitting edema noted on bilateral lower extremities Rationale: Depression of the skin with pressing is an abnormal finding. Brawny edema occurs when fluid can no longer be displaced secondary to excessive interstitial fluid accumulation, and there is no pitting, so the tissue palpates as firm or hard, and the skin surface is shiny, warm, and moist.

A nurse is examining a client with cirrhosis of the liver for edema. The nurse notes that the indentation remains for several seconds and the skin swelling is obvious on inspection. How should the nurse quantify the severity of the finding?

3+ pitting edema Rationale: Since the indentation remains for several seconds and a skin swelling is obvious by general inspection it's 3+ pitting edema 1+ pitting edema- a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30% above normal. 2+ pitting edema- indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours. 5+ brawny edema- there is no pitting, tissue palpates as firm or hard and the skin surface appears shiny, warm, and moist.

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 after having a stroke yesterday a client recovering from brain surgery for repair of an aneurysm a client with a brain tumor who is in the hospital because of respiratory depression a client in the Intensive Care Unit for acute pancreatitis asking for pain medications

A client in ICU for acute pancreatitis asking for pain medications Rationale: 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.

While assessing the characteristics of the skin of the client, the nurse observes a mouth slit at the aperture of the mouth. The nurse documents this finding as a fissure. What is a fissure? an open, crater-like area on the skin a mark left on the skin by the healing of a wound or lesion a crack in the skin, especially in or near a mucous membrane an area of the skin that has been rubbed away by friction

A crack in the skin, especially in or near a mucous membrane Rationale: An abrasion is an area that has been rubbed away by friction. A scar is a mark left by the healing of a wound or lesion. An ulcer is an open, crater-like area on the skin.

The nurse is performing a physical assessment of an older adult female client. The nurse documents scoliosis as part of the spinal assessment. What is scoliosis? a gentle concave and convex curve of the spine an increased curve in the thoracic area a pronounced lateral curvature of the spine an exaggerated lumbar curve of the spine

A pronounced lateral curvature of the spine Rationale: The normal spine appears in midline with gentle concave and convex curves when viewed from the side. Lordosis: A condition in which the natural lumbar curve of the spine is exaggerated, curves inward and the sacral region curves outward. Kyphosis: Causes an increased curve in the thoracic area. The shoulder and upper back curves forward.

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? Measure height and weight. Ask the client to empty her bladder. Warm the equipment. Place the client in a semi-Fowler's position.

Ask the client to empty her bladder.

When assessing the sensory skin perception of an older adult client, the nurse strokes the skin with a cotton ball at various places on both sides of the body. What information does the nurse obtain from this assessment?

Ability to identify fine touch Sharp and dull touch- uses pointed & curved ends of a safety pin Temperature changes- touches pt with warm and cold containers Sense vibrations- striking a tuning fork and placing the stem on bony areas (wrist or along the shin)

The nurse is auscultating the anterior chest of a client and hears gurgles. What is the nurse's appropriate action? Ask the client if they have any difficulty breathing. Ask the client to cough and auscultate the anterior chest again. Notify the health care provider. Document the findings.

Ask the client to cough and auscultate the anterior chest again. Rationale: Asking the client to cough or breathe deeply if crackles or gurgles are audible is a method that helps clear the air passages and open the alveoli. If the advantageous lung sound does not clear with coughing, further assessment is necessary, such as asking the client about breathing difficulties, documenting the findings, and notifying the health care provider.

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. Assess the client for cardiovascular disorders. Document a normal skin finding on the client chart. Report the finding as a positive sign for cystic fibrosis.

Assess the client for dehydration.

A nurse is assessing the pupillary response of a client brought into the emergency department with a head injury. Both pupils are round and react to light. What can the nurse interpret about the client's neurological status based on these data? The client should be referred to an ophthalmologist. Cranial nerve #1 is intact. Brain function is within normal limits. The client has 20/20 vision.

Brain function is within normal limits. Rationale: The nurse should observe the pupil of the stimulated eye, as well as the unstimulated pupil. The response should be the same. This assessment indicates the status of brain function. It will not provide information on visual acuity or CN1

Which technique should the nurse use to assess the pupillary light reflex on a client? Ask the client to follow the penlight in six directions and observe for bilateral pupil constriction. Have the client focus on a distant object, then ask the client to look at the penlight being held about 4 cm from the nose and observe for pupil constriction. Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Use an ophthalmoscope to focus light on the sclera and observe for a reflection on each eye.

Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction.

A nurse is auscultating a client's chest and notices adventitious breath sounds. The nurse suspects atelectasis and asks the client to repeat the word "ninety-nine." The nurse hears the sound louder and more clearly than normal. The nurse documents this as: Wheezes Bronchophony Crackles Egophony

Bronchophony Rationale: Bronchophony occurs when the word such as "ninety-nine" is stated by the client and is heard louder and more clearly by the nurse on auscultation. Egophony- Occurs when the client says "ee" and the nurse hears the sound "ay." Both of these occur when there is consolidation or atelectasis present. Crackles are high-pitched, discrete, and noncontinuous crackling sounds heard during the end of inspiration. Wheezes are musical noises like squeaks (fine wheezes) or snores (coarse wheezes).

During the physical examination of a client, the nurse uses the bell of the stethoscope to identify which sounds? Select all that apply. Bruits Bowel sounds S1 heart sounds S3 heart sounds Breath sounds

Bruits S3 heart sounds Rationale: The bell of the stethoscope is used to detect low-pitched sounds such as abnormal heart sounds (S3 or S4) and bruits. The diaphragm of the stethoscope is used to detect high-pitched sounds such as breath sounds, normal heart sounds (S1, S2), and bowel sounds.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response? Client reports breathlessness and productive cough. Client reports respiratory distress and frequent spitting. Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Client describes shortness of breath and increased sputum production.

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm." Rationale: The client's reason for seeking care should always be stated in the client's own words which should be document in quotations. This subjective data is important for all health care providers to review.

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply. Complete set of vital signs Description of client education Collection of subjective data Functional ability evaluation Goals with outcome criteria

Collection of subjective data Complete set of vital signs Functional ability evaluation Rationale: Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client. The development of the care plan, which includes goals with outcome criteria and client education, are done after the admission assessment.

A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action? -Complete an assessment. -Contact the health care provider. -Review the client's past medical records. -Assist the client with activities of daily living.

Complete an assessment Rationale: Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills and data collection- interviewing, observing, and examining the client, and in some cases, the client's family. Following the assessment, the nurse can use the client's medical record and contact other health care providers.

The nurse is performing the positions test on a client following a head injury. Which assessment would the nurse interpret as a normal finding? -Convergence of the eyes -Coordinated movement of both eyes -Nystagmus when looking in an upward position -Limited movement in one eye when moving from superior to inferior position

Coordinated movement of both eyes Rationale: Eye movements are controlled by several pairs of eye muscles. During the positions test, the nurse observes extraocular movements by asking the client to focus on and track an object as it moves 6 positions.

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings? Bronchovesicular breath sounds are audible in the posterior lobes. Crackles are audible in the posterior bases bilaterally, and they are abnormal. Gurgling is occurring in the lower posterior lobes, indicating that the client needs to cough. Pleural friction rub is occurring in the posterior middle lower lobes.

Crackles are audible in the posterior bases bilaterally, and they are abnormal.

A nurse is auscultating the lungs of a client during a physical exam. The nurse notes low-pitched, soft breath sounds over the posterior middle lobes with intermittent, high-pitched, popping sounds in the posterior lower lobes, primarily during inspiration. What is the nurse's correct interpretation of these findings? Gurgling is occurring in the lower posterior lobes, indicating that the client needs to cough. Crackles are audible in the posterior bases bilaterally, and they are abnormal. Bronchovesicular breath sounds are audible in the posterior lobes. Pleural friction rub is occurring in the posterior middle lower lobes.

Crackles are audible in the posterior bases bilaterally, and they are abnormal. Rationale: Crackles (rales) are intermittent, high-pitched, popping sounds heard in distant areas of the lungs, primarily during inspiration. They are attributed to the opening of partially collapsed alveoli (terminal air sacs) or the movement of air over minute amounts of fluid in the periphery of the lungs during deep inspiration. The other options are not the correct interpretations.

The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing? Impaired kidney function Decreased cardiac output Inflammation of a vein Hypertension and circulatory overload

Decreased cardiac output Rationale: Abnormal findings when assessing the peripheral pulses include an absent, weak, thready pulse- which may indicate a decreased cardiac output A forceful or bounding pulse- seen in hypertension and circulatory fluid overload A symmetric pulse- related to impaired circulation. Inflammation of a vein- would not result in a weak or thready pulse. Impaired kidney function- would not be related to the decrease in amplitude of peripheral pulses.

The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the primary care provider? Sinus dysrhythmia that increases with inspiration and decreases with expiration Visible pulsation through a thin chest wall Presence of an S heart sound Decreased heart rate

Decreased heart rate Rationale: Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound.

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? Assess for asthma. Recommend testing for pneumonia. Document normal breath sounds. Suspect an inflamed pleura rubbing against the chest wall.

Document normal breath sounds. Rationale: 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.

A nurse is assessing the skin of a client who had been on a hiking trip and developed a number of inflamed red patches on his hands and face as an allergic reaction. How should the nurse document this finding?

Erythema

A nurse is teaching a client about testicular self-examination. What should be included in the teaching? Squeeze each testicle gently, feeling for lumps twice a month. Examine testicles for lumps monthly while showering. Check the testes weekly for lumps while lying down in bed. Visualize the testes in the mirror looking for lumps monthly.

Examine testicles for lumps monthly while showering. Rationale: Male patients should examine the testes monthly at a time when the testicles are warm and positioned loosely within the scrotum, such as during bathing or showering. There is no need to visualize the testes in a mirror. Once a week is too frequent a time frame, and squeezing will not help identify lumps.

A nurse is inspecting the ear canals and tympanic membranes of an 18-month-old child. How would the pinna be moved to achieve better visualization? There is no need to move the pinna. Gently pull the pinna down and back. Pull the pinna parallel to the side of the head. Gently pull the pinna up and back.

Gently pull the pinna down and back. Rationale: To achieve better visualization of the ear canals and tympanic membranes of a child younger than 3 years of age, straighten the ear canal by gently pulling the pinna down and back. The ear canal of the adult is straightened by pulling the pinna up and back.

The nurse is preparing to perform a head-to-toe physical assessment. What approach will the nurse use? Perform the examination from the left side of the bed. Begin by examining the thorax and abdomen. Organize the assessment so the client does not change positions too often. Examine the structures in each system separately.

Organize the assessment so the client does not change positions too often. Rationale: Using a head-to-toe approach reduces the number of position changes required of the client. The nurse can still move around the client but typically has to move less. The examination begins at the head and groups structures together for easy examination.

While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? a narrowing of the upper airway air in the lungs narrowed small air passages moisture in air passages

Moisture in air passages Rationale: Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in small air passages and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs normally contain air.

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? on the mastoid area behind the client's head on the center of the head near the ear canal

On the mastoid area Rationale: Placing the tuning fork near the ear canal facilitates the testing of air conduction of sound in the tested ear.

Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing? Emergency assessment Comprehensive assessment Focused assessment Ongoing partial assessment

Ongoing partial assessment Rationale: An ongoing partial assessment is conducted at regular intervals during care of the client and concentrates on identified health problems and the effectiveness of interventions.

The nurse is palpating a client's precordium. Which result is an expected clinical finding? Palpable heave over the pulmonic area Palpable thrill over the aortic area Palpable pulsation over the mitral area Palpable vibration over the right sternal border

Palpable pulsation over the mitral area Rationale: A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.

Which technique should the nurse use when assessing the radial pulse of a client with a history of atrial fibrillation? -Palpate the pulse for 15 seconds and multiply by 4. -Palpate the pulse for 10 seconds and multiple by 6. -Palpate the pulse for 2 minutes. -Palpate the pulse for 1 minute.

Palpate the pulse for 1 minute. Rationale: If the pulse is irregular, such as in a client with atrial fibrillation, the nurse should palpate local peripheral pulses for 1 full minute, noting both rate and rhythm.

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

Palpation

The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which finding should the nurse document as an anomaly that may warrant follow-up? Decreased skin turgor is evident when the skin is folded and then released. The client states that a mole on his forehead has become larger in recent months. There are some raised, brown areas on the backs of the client's hands. Small, round, red spots are present on the client's forearms bilaterally.

Rationale: Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).

A nurse is testing the function of the spinal cord of a client who presents in the emergency department following a motorcycle accident. What would be the focus of this assessment? Reflexes Sensory abilities Motor ability Balance and gait

Reflexes Rationale: This is the initial assessment after a spinal cord injury; therefore, it would be the top priority to help determine the degree of injury by assessing for reflexes. Motor ability and gait cannot be assessed this soon after a spinal cord injury because further injury could result.

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

Rinne and Weber tests are performed in order to assess sound conduction with a tuning fork. 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. 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. Snellen Chart: Eye chart used to measure visual acuity. Otoscope- Instrument for visual examination of the eardrum and the passage of the outer ear Ophthalmoscope- Instrument for inspecting the retina & eye

A nurse is listening to the lung sounds of a severely dehydrated client. The nurse hears sounds that are described as grating or leathery. What type of adventitious sounds are these? wheezes gurgles crackles rubs

Rubs Rationale: Rubs are grating or leathery sounds caused by two dry, pleural surfaces moving over each other. Wheezes: Whistling or squeaking sounds caused by air moving through a narrow passage, heard during expiration or inspiration. Gurgles: Low-pitched, continuous, bubbling adventitious sounds, prominent during expiration and are heard in larger airways.

The nurse is preparing to assess a client's deep tendon reflexes. When evaluating the biceps reflex, the nurse would position the client in which manner? Sitting at the side of the exam table with legs hanging loosely over the side. Lying supine with the knee slightly flexed and foot dorsiflexed Sitting up with the elbow flexed, and forearm resting on the thigh, palm up. Sitting up with arm held across the chest, with the elbow flexed at a 90-degree angle.

Sitting up with the elbow flexed, and forearm resting on the thigh, palm up. Rationale: The triceps reflex- client's arm held across the chest, elbow flexed at a 90-degree angle and hanging forearm limply. Patellar reflex- client sitting up with legs hanging loosely over the side of the bed or exam table, or supine with the back of the knee supported while the leg is flexed at a 45-degree angle. The Achilles tendon reflex- client lying or sitting with the knee slightly flexed while the foot is dorsiflexed.

During the admission assessment of a new client, the nurse is preparing to assess the client's thyroid gland. How should the nurse perform this assessment? Auscultate over the client's trachea while asking the client to hold his breath. Lightly percuss slightly off midline over the client's trachea. Stand behind the client and palpate the sides of the trachea. Observe the midline of the client's neck while asking him to bear down.

Stand behind the client and palpate the sides of the trachea.

A nurse suspects that a client has abdominal ascites and prepares to assess the abdominal girth. How should this assessment be completed? measuring length and width of abdomen and documenting the anterior and posterior diameter measuring from the top of the pubic bone to the top of the umbilicus and marking the height stretching a tape measure around the largest diameter and making guide marks on the skin lying the client supine while percussing across the abdomen for dullness and marking the location

Stretching a tape measure around the largest diameter and making guide marks on the skin Rationale: If the abdomen appears unusually large, the nurse checks its girth (circumference) daily. To ensure that he or she always measures from the same location, the nurse makes guide marks on the skin with an indelible pen. The other options are inappropriate ways to complete the assessment.

Which of the following can a nurse assess by palpation? -Heart sounds, lung sounds, blood pressure -Vision, hearing, cranial nerves -Temperature, turgor, moisture -Tissue density, gait, reflexes

Temperature, turgor, moisture, texture, and shape Rational: Tissue density, gait, and reflexes use physical stimulation.

Palpation is the use of hands and fingers to gather information through touch. Different parts of the hand are more suitable for different tactile sensations. Which part of the hand is best for sensing temperature? the palm the dorsum the knuckles the fingertips

The Dorsum Rationale: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. Palm- Sensitive to vibration and is useful in locating a vibration associated with a heart murmur. Fingertips- Concentrated with nerve endings and can sense fine difference in texture and consistency. Knuckles are not used in palpation.

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. Rationale: The client's eyes should converge when the nurse moves a finger towards the nose. An older adult's pupils are pale and cloudy- Sign of cataracts

The nurse has palpated a client's radial pulses bilaterally and has documented the results of this assessment as "radial pulses 1+ bilaterally." How should this assessment finding be interpreted? The client's weak pulses may be indicative of cardiovascular disease The client has normal peripheral pulses. The client has increased radial pulses that may result from hypertension. The client shows no signs of a circulatory health problem.

The client's weak pulses may be indicative of cardiovascular disease

The nurse, after receiving a report on assigned clients, begins assessments of the clients. What is the primary purpose of assessing clients? Assessing the clients helps to identify the nurse's role in health care. The nurse is able to identify actual and potential health problems of the client. By completing assessments, the nurse is able to expand nursing knowledge and skills. This provides a basis for evidence-based nursing care.

The nurse is able to identify actual and potential health problems of the client.

A nurse is assessing the spine of a client with kyphosis. What would the nurse expect to observe about the client's posture? The sacral region tends to turn outward. The shoulder and upper back curves forward. A portion of the spine is curved to the side laterally. The lumbar region tends to curve inward.

The shoulder and upper back curves forward.

A nurse conducting physical assessment for a client is using the percussion technique. What is the purpose of using this technique? to assess the sounds from the heart, lungs, and abdomen to determine the location, size, and density of underlying structures to check the skin temperature and moisture to assess the mobility of normal tissues and unusual masses

To determine the location, size, and density of underlying structures

The client has requested a translator so that she can understand the questions that the nurse is asking during the client interview. What is important when working with a client translator? -It is always okay to not use a translator if a family member can do it. -Translators may need additional explanations of medical terms. -Talking loudly helps the translator and the client understand the information better. -Talking directly to the translator facilitates the transfer of information.

Translators may need additional explanations of medical terms. Rationale: All information is directed at the client and not the translator. There are certain circumstances where it is not appropriate to use a family member (emotional topics)

A nurse is conducting a physical examination and is percussing the gastric area of a client. What percussion tone is normally heard in this area? Tympany Dull Flat Resonant

Tympany- a loud tone heard normally over a gastric air bubble.

A nurse is planning to obtain a weight on an obese client who has a history of falls. What is the best way to obtain the client's weight? Transfer the client to a chair scale. Assist the client to stand on a scale at the bedside. Delegate this task to the assistive personal. Use an electronic bed scale.

Use an electronic bed scale.

The nurse is preparing to assess a client's visual acuity. How should the nurse proceed? Ask the client to read the print on a handheld Jaeger card. Use the Snellen chart positioned at 20 feet. Use a pen light to determine if the pupils are PERRLA. Perform the confrontation test.

Use the Snellen chart positioned at 20 feet. Rationale: The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision. Assessment with a pen light does not assess visual acuity.

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.

Vesicular- Soft, low-pitched, whispering sounds heard over most lung fields. Inspiration longer than expiration Bronchovesicular- Medium-pitched, medium-intensity, moderate blowing sounds, auscultated over the 1st and 2nd interspaces anteriorly and the scapula posteriorly, and mainstem bronchus. Inspiration equal to expiration. Bronchial- High-pitched, blowing, hollow sounds auscultated over the larynx and trachea. Expiration longer than inspiration. Rationale:. Sibilant Wheeze- Musical or squeaking sounds Sonorous/Coarse- Sounds with a snoring quality, sonorous wheeze Crackles- Bubbling, crackling, or popping sounds

A nurse performs a general survey on a client who is being admitted to the hospital for Chronic Obstructive Pulmonary Disease (COPD). Which components of this type of assessment will be a focus for the nurse? Select all that apply. Gait Body mass index (BMI) Breathing pattern Behavior Vital signs Lab tests

Vital signs Gait Behavior Body mass index (BMI) Breathing pattern Rationale: The general survey is the first component of the health assessment, beginning at the moment contact is made with the client. Information from the general survey provides clues to the overall health of the client. It includes observing the client's overall physical appearance, body structure, mobility, and behavior; and measuring vital signs, height, weight, and waist circumference; and calculating the client's body mass index (BMI). Laboratory assessments are included in the extended survey of the client.

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. Assist the client to a sitting position. Palpate the abdomen before auscultating. Uncover the client to expose the chest and abdomen.

Warm the diaphragm of the stethoscope. Rationale: Client comfort is essential when performing an assessment, especially when the assessment involves touching

A nurse is preparing to examine a client with a suspected sinusitis. What is the most appropriate action the nurse should take before performing a physical examination? -Put on gloves. -Wash their hands. -Assess the client's height and weight. -Assist the client to lie on the exam table.

Wash their hands. Rationale: The nurse should wash their hands before and after every physical patient encounter and before applying gloves. Gloves should be worn when there is potential contact with any body fluids. Hand washing would be completed before assisting the client onto the table and assessing height and weight.

A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify: muscle tenderness. density and location of lungs. normal breath sounds. masses.

density and location of lungs.

A nurse is completing an assessment on a client with no history of nutrition-related problems. Which activity should the nurse complete as part of an initial nutritional screening? abdominal girth vital signs height and weight calorie count

height and weight Rationale: The nurse documents the client's weight and height because these measurements provide more reliable data than a subjective assessment of body size, asking the client to provide the information, or measuring abdominal girth.

Following auscultation of a client's heart, the nurse documents grade III murmur. The characteristics of this type of murmur are: moderately loud. very loud, usually associated with a thrill sound. extremely loud. faint; can be easily detected.

moderately loud. Grade I murmur- So faint that it can be heard only with great effort Grade II- A faint murmur but one that can be easily detected Grade III- A moderately loud murmur Grade IV- A very loud murmur with a thrill sound Grade V- An extremely loud murmur Grade VI- An exceptionally loud murmur heard while the stethoscope is lifted off the skin.