Health Assessment: PrepU Chapter 1, 2, 3, 4, 13, 14, 15

The nurse working in a hospital assesses the respiratory status of a 64-year-old male client with a history of chronic obstructive pulmonary disease (COPD). Finish the following statement: Upon inspection, the client is in the (1) position, has a (2) chest, and the nails are (3). (4) are heard on auscultation.

(1) tripod (2) barrel (3) clubbed (4) crackles

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding? a) "Split sound auscultated over right carotid artery" (b) "Right carotid bruit auscultated" (c) "S2 sound heard over right carotid artery." (d) "Murmur heard over right carotid artery"

(b) "Right carotid bruit auscultated"

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? a) Hematochezia (b) Abdominal pain (c) Orthopnea (d) Tenesmus

(c) Orthopnea

A client presents with the following signs and symptoms: a 5-lb weight gain in the past week, coughing up pink-tinged sputum, crackles in bilateral lung fields, difficulty lying flat, and reports waking up in the middle of the night extremely short of breath. Based on these findings, the nurse suspects which of the following disorders? a) paroxysmal nocturnal dyspnea (b) orthopnea (c) heart failure (d) coronary artery disease

(c) heart failure Explanation: The client is exhibiting signs and symptoms of heart failure, which include unexpected weight gain (fluid), fluid in the lungs (backing up from the left ventricle, which is unable to pump the blood forward) causing pink-tinged sputum, orthopnea (difficulty lying flat), and paroxysmal nocturnal dyspnea or PND (waking up in the middle of the night very short of breath). Orthopnea and PND are signs and symptoms of heart failure; they are not disorders. Coronary artery disease presents with chest pain that is relieved with rest, shortness of breath with exertion, and fatigue.

When describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. Which heart sound would the instructor explain as being associated with systole? a) S3 b) S2 c) S4 d) S1

d) S1

T/F: Tobacco use is the leading cause of preventable death.

True

The nurse auscultates the base of the lungs to assess for what reason? a) It is where fluid occurs with pulmonary edema. b) It best reflects the health of the lungs. c) It indicates early infection.

a) It is where fluid occurs with pulmonary edema.

A nurse performs the Trendelenburg test for a client with varicose veins. Which action should the nurse take when performing this test? a) Legs should be elevated for 15 seconds b) Have the client stand upright after tourniquet removal c) Ensure that the client's legs are over the side of the bed d) Tourniquet should be put on before leg elevation

a) Legs should be elevated for 15 seconds

The nurse is preparing to assess a client's carotid arteries. Which of the following would be most appropriate? a) Palpate each artery individually to compare b) Palpate the arteries before auscultating them c) Use the diaphragm of the stethoscope d) Ask the client to breathe in and out deeply

a) Palpate each artery individually to compare

The nursing student demonstrates a need for further teaching when she states which of the following? a) Patients do not need to understand their problems. b) If a client is incoherent, a family member can help validate the problem. c) The client's diagnosis needs to be verified with the client and other health care workers caring for the client. d) Validation is also important for a client who has a collaborative problem.

a) Patients do not need to understand their problems.

Which characteristic associated with respiratory effort should be considered when planning care for a client diagnosed with a brainstem injury? a) There is loss of involuntary respiratory control. (b) The client will respond negatively to increased stimuli. (c) There is an increased level of carbon dioxide in the blood. (d) The client's oxygen levels in the blood will be increased.

a) There is loss of involuntary respiratory control.

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? a) To establish a database against which subsequent assessments can be measured b) To establish rapport with the client and family c) To gather information for specialists to whom the client might be referred d) To quantify the degree of pain a client may be experiencing

a) To establish a database against which subsequent assessments can be measured

The bicuspid, or mitral, valve is located a) between the left atrium and the left ventricle. b) between the right atrium and the right ventricle. c) at the exit of each ventricle near the great vessels. d) at the beginning of the ascending aorta.

a) between the left atrium and the left ventricle.

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem? a) left-sided heart failure b) palpitations c) hypertension d) dextrocardia

a) left-sided heart failure

During the interview process, the nurse obtains what type of data from the client? a) primary b) secondary c) objective d) oral

a) primary

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do? a) Collect the data b) Analyze the data c) Validate the data d) Organize the data

b) Analyze the data

An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. What would the nurse suspect? a) Musculoskeletal weakness b) Arterial insufficiency c) Diabetic neuropathy d) Venous insufficiency

b) Arterial insufficiency

A client has been admitted with new onset hypertension with a past medical history of asthma, type 2 diabetes, and hypercholesterolemia. After developing a nursing care plan, the nurse reports findings to the health care provider. After receiving medication orders from the health care provider, the nurse administers several medications for hypertension. What is the next best action of the nurse? a) Update the plan of care. b) Evaluate patient outcome. c) Develop a nursing diagnosis. d) Perform a comprehensive assessment.

b) Evaluate patient outcome.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings? a) Pigeon chest (pectus carinatum) b) Funnel chest (pectus excavatum) c) Barrel chest d) Thoracic kyphoscoliosis

b) Funnel chest (pectus excavatum)

Adventitious sounds are heard when auscultating a client's lungs. Which of the following would the nurse do first? a) Perform bronchophony b) Have the client cough, then listen again c) Auscultate for egophony d) Refer the client for further medical evaluation

b) Have the client cough, then listen again Explanation: If abnormalities are noted during lung auscultation, the nurse should have the client cough and then listen again, noting any change. Coughing may clear the lungs. If the sounds are still present after coughing, then the nurse would refer the client for further evaluation. Auscultating voice sounds would be done as part of any assessment of the thorax.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action? a) Encourage early ambulation. b) Notify the healthcare provider. c) Discontinue the indwelling urinary catheter. d) Assist the client to turn, cough, and deep breathe.

b) Notify the healthcare provider.

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? a) S1 b) S2 c) Preload d) Afterload

b) S2

A genogram is developed to visually show what? a) family tree b) family health patterns c) family relationships d) nationalities of family members

b) family health problems

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of a) patent ductus arteriosus. b) increased central venous pressure. c) diastolic murmurs. d) pulmonary emphysema.

b) increased central venous pressure.

Your client has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Data"? a) not recommended b) none currently c) not relevant to client's care d) nothing. enter as late entry

b) none currently

The nurse is admitting a new client to the unit. While reviewing old records of the client, the nurse knows that the data being gathered are what kind of data? a) primary b) secondary c) subjective d) objective

b) secondary

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the a) second intercostal space at the right sternal border. b) third to fifth intercostal space at the left sternal border. c) apex of the heart near the midclavicular line (MCL). d) fourth or fifth intercostal space at the left lower sternal border.

b) third to fifth intercostal space at the left sternal border.

_____________are musical respiratory sounds that may be audible to the patient and others. a) crackles b) wheezes c) egophony d) bronchophony

b) wheezes

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough? a) "Do you feel that you are under a great deal of stress?' b) "How much do you exercise during the week?" c) "Are you taking any medications on a regular basis?" d) "Have you changed your diet within the past few weeks?"

c) "Are you taking any medications on a regular basis?"

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? a) Listen with the bell for the high pitched sounds of normal S1S2 b) Elevate the head of bed until the examiner can comfortably reach the client c) Auscultate to determine the heart rate and if the rhythm is normal d) Stand at the client's left side and perform the entire assessment from this position

c) Auscultate to determine the heart rate and if the rhythm is normal

Upon entering the examination room, a nurse observes that the client is leaning forward with arms supporting body weight. The nurse would most likely suspect the client is compensating for what pathophysiological disorder? a) System lupus erythematosus b) Diabetes mellitus c) Chronic obstructive pulmonary disease d) Heart failure

c) Chronic obstructive pulmonary disease

Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process? a) Carcinoma of the lungs b) Pneumothorax c) Chronic obstructive pulmonary disease d) Tuberculosis

c) Chronic obstructive pulmonary disease

What will be the nurse's initial role when conducting a health assessment with a client reporting abdominal pain? a) Teaching the client to draw knees to chest to help minimize the pain b) Planning care to help minimize the client's pain c) Collecting data regarding the nature of the pain d) Identifying pain management interventions with input from the client

c) Collecting data regarding the nature of the pain

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency? a) Bilateral radial pulses of 2+ b) Epitrochlear lymph nodes not palpable c) Cool skin d) Capillary refill time of 2 seconds

c) Cool skin

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what? a) Invisible neck veins b) Distended neck veins c) Flat neck veins d) Round neck veins

c) Flat neck veins

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? a) Obstruction in the femoral artery b) Calcium deficiency c) Peripheral vascular problems d) Diabetes mellitus

c) Peripheral vascular problems

The nurse is collecting data from a client. Which of the following best reflects objective data? a) religion b) occupation c) appearance d) age

c) appearance

A client admitted with a pulmonary embolism has been receiving continuous IV Heparin for the past 48 hours. The nurse reviews the client's chart containing the following information: -- 0800 VS: temperature 98.7F, blood pressure 120/74, heart rate 88, SpO2 95% 2L NC -- 1200 VS: temperature 98.6F, blood pressure 100/60, heart rate 99, SpO2 94% 2L NC -- Laboratory values on admission: hemoglobin 15 g/dL, hematocrit 40%, platelets 275,000 mm3 -- Laboratory values today: hemoglobin 11 g/dL, hematocrit 33%, platelets 175,000 mm3 What step of the nursing process should the nurse perform next? a) intervention b) assessment c) diagnosis d) planning

c) diagnosis

A client comes to the health care provider's office for a visit. The client has been seen in this office on occasion for the past 5 years and arrives today complaining of a fever and sore throat. Which type of assessment would the nurse most likely perform? a) comprehensive b) ongoing c) focused d) emergency

c) focused

During an assessment, the nurse asks a client with low back pain if the pain is radiating. The nurse is asks this question to obtain assessment information for which category of the mnemonic OLD CART? a) treatments b) duration c) location d) onset

c) location

Which of the following would be most important for a nurse when developing critical thinking skills? a) quick decision making b) reliance on current situation c) maintenance of an open mind d) static knowledge base

c) maintenance of an open mind

After receiving morning report the nurse prepares to assess a client who was admitted the day before. Which type of assessment will the nurse complete at this time? a) initial b) focused c) ongoing d) emergency

c) ongoing

___________ occurs when air leaks into the pleural space. a) pneumonia b) COPD c) pneumothorax d) asthma

c) pneumothorax

During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client? a) well-placed phrasing b) close-ended questioning c) rephrasing d) active listening

c) rephrasing

The nurse is conducting an initial health history with a client. The nurse asks about the client's history of neurological, respiratory, cardiovascular, and musculoskeletal problems. Which part of the subjective health assessment is the nurse performing? a) health and lifestyle practices b) biological information c) review of systems d) family history

c) review of systems

When assisting a client with health promotion, what must the nurse also nurture? a) Knowledge of the Healthy People 2020 indicators b) Family communication c) School/work attendance d) A healthy environment

d) A healthy environment

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding? a) Heart rate is irregular b) Respiratory rate is too fast c) Heart enlargement is present d) Client has an increased chest diameter

d) Client has an increased chest diameter

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse? a) Give the client a printed diet. b) Inform the client that they can look up a diabetic diet on the internet. c) Call the physician and ask them to come and talk with the client about their diet. d) Make a referral to the dietician.

d) Make a referral to the dietician.

The nurse is exhibiting critical thinking in which client care situation? a) Transcribing medication orders onto the nurse's medication administration record. b) Notifying the healthcare provider of a critical lab result. c) Answering the client's call bell alarm while the nursing assistant is at lunch. d) Performing a focused assessment on a client who is complaining of shortness of breath.

d) Performing a focused assessment on a client who is complaining of shortness of breath.

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is a) increased secretions b) a severe cold c) exercise-induced asthma d) a foreign body obstruction

d) a foreign body obstruction

__________ is the most important examination technique for assessing air flow through the tracheobronchial tree. a) inspection b) palpation c) percussion d) auscultation

d) auscultation

When collecting data on the history of the present illness, it is appropriate to include what? a) Chronic childhood illnesses b) Treatment recommendations c) Reliability of information source d) Current medications

d) current medications

Total parenteral nutrition (TPN) has been prescribed for a client. After several hours of infusion, the nurse checks the client's glucose and it is elevated, requiring insulin. The nurse administers the insulin as prescribed. What step in the nursing process should the nurse take next? a) assessment b) diagnosis c) planning d) evaluation

d) evaluation

T/F: The anteroposterior (AP) diameter may decrease with aging, compared with the lateral chest diameter.

false

Unilateral __________ suggests a large pneumothorax or possibly a large air-filled bulla in the lung.

hyperresonance

Cyanosis signals __________.

hypoxia