NCLEX- Health assessment
A 52-year-old male client is seen in the health care provider's (HCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 feet, 8 inches (173 cm) and his weight is 220 pounds (99.8 kg). Vital signs are as follows: temperature, 98.6°F (37°C) orally; pulse, 86 beats/minute; and respirations, 18 breaths/minute. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question should the nurse ask the client first? 1. "Do you exercise regularly?" 2. "Are you considering trying to lose weight?" 3. "Is there a history of diabetes mellitus in your family?" 4. "When was the last time you had your blood pressure checked?"
"When was the last time you had your blood pressure checked?" Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client's major modifiable risk factors.
The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse should use which type of database initially to obtain information from the client? 1. An episodic database 2. A follow-up database 3. An emergency database 4. A complete health database
A complete health database Rationale: A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. The complete health database is used in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, women's health care agency, visiting nurse agency, or community health agency. An episodic database is used for a limited or short-term problem. It focuses mainly on one problem or one body system. A follow-up database evaluates an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of the data, often compiled concurrently with lifesaving measures.
Cerebellum
coordinates voluntary movements such as balance, coordination and speech
focused exam
does not include health history, usually done in ER
click
abrupt, high-pitched snapping sound
2-point discrimination
Gently pricking the client's skin on the dorsum of the foot in 2 places tests
cranial nerve 7
Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve.
tests cranial nerve 11- accessory nerve
Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve.
stridor
harsh sound due to obstruction
cerebellar ataxia
loss of balance and involuntary movements occur
Positive Brudzinski's sign
means that the client passively flexes the hip and knee in response to the neck being flexed and they are having pain in their vertebral column
proprioreception
moving finger up or down so they can sense relative position to one's own parts
A 1-cm hypertrophy of the right upper arm is
normal, means increased muscle size, on the client's dominant side of up to 1 cm is normal
conductive hearing loss
occurs from a physical obstruction, sensorineural hearing loss is from a pathological process in inner ear, cranial nerve, or defect in cerebral cortex
plantar reflex
this is tested when you firmly stroking the lateral sole of the foot and under the toes with a blunt instrument
Heart murmur
is abnormal and is faint or low blowing swooshing sound that can be high medium or low in pitch
sensory function
is tested by having pt close their eyes and you touch areas of their face (trigeminal- cranial nerve 5)
cranial nerve 7
puff cheeks out tests which Cranial nerve
The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply. 1. Allergy to pollen 2. History of headaches 3. Previous back injury 4. History of hypertension 5. History of diabetes mellitus
History of headaches Previous back injury History of hypertension History of diabetes mellitus Rationale: Previous neurological problems such as headache or back injury place the client at greater risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment for allergies is a routine part of the health history, regardless of the nature of the client's problem.
The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema? 1. Assess for drainage from the wound. 2. Assess for redness around the wound edges. 3. Palpate for swelling around the wound edges. 4. Palpate for increased skin temperature around the wound edges.
Palpate for increased skin temperature around the wound edges. Rationale: Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema
The nurse is performing an abdominal assessment on a client. The nurse determines that which finding should be reported to the health care provider (HCP)? 1. Absence of a bruit 2. Concave, midline umbilicus 3. Pulsation between the umbilicus and the pubis 4. Bowel sound frequency of 15 sounds per minute
Pulsation between the umbilicus and the pubis Rationale: The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the HCP. Bruits normally are not present. The umbilicus should be in the midline with a concave appearance. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute.
Cranial nerve 5-trigeminal
Separate the client's jaw by pushing down on the chin tests which cranial nerve
decerebrate posturing
abnormal extension when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed
Decorticate posturing
abnormal flexion when pt's upper arms are flexed and held tightly to sides of body and legs are extended to sides of body and legs are extended and internally rotated
snellen chart
tests visual acuity and tests cranial nerve 2 optic nerve
The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. 1. Sclerae 2. Tongue 3. Nail beds 4. Elbows and heels 5. Mucous membranes
Tongue Nail beds Mucous membranes Rationale: Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, nail beds, and mucous membranes. The sclerae are most useful in evaluating jaundice. Elbows and heels are not appropriate areas to assess for skin color changes.
A client experiencing "skipped heartbeats" is diagnosed with benign premature ventricular contractions and is placed on metoprolol tartrate. The client returns to the health care provider's (HCP's) office 1 month later for a checkup. The nurse should implement which type of database when performing an assessment? 1. Follow-up database 2. Emergency database 3. Complete health database 4. Problem-centered database
Follow-up database Rationale: A follow-up database is used in evaluating the status of an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of data, often compiled concurrently with lifesaving measures. A complete health database is the framework for a complete health history and full physical examination. The information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. An episodic (problem-centered) database is used for a limited or short-term problem. It focuses mainly on one problem or one body system.
The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? 1. Sclerae 2. Oral mucosa 3. Sole of the foot 4. Palm of the hand
Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would be best noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.
The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1. Over the second intercostal space at the left sternal border 2. Over the fourth intercostal space at the right sternal border 3. Over the second intercostal space at the right sternal border 4. Over the fifth intercostal space in the left midclavicular line
Over the fifth intercostal space in the left midclavicular line Rationale: The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space in the left midclavicular line. Therefore, the locations in the remaining options are incorrect.
The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? 1. Absent bowel sounds 2. Client complaints of wound pain 3. Pain with dorsiflexion of the foot 4. Crackles on auscultation of the lungs
Pain with dorsiflexion of the foot Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign. Wound pain and absent bowel sounds are unrelated findings. Crackles on auscultation of the lungs may indicate a respiratory complication.
After performing an initial abdominal assessment on a client, the nurse documents that the bowel sounds are normal. Which description best describes normal bowel sounds? 1. Waves of loud gurgles auscultated in all 4 quadrants 2. Low-pitched swishing auscultated in 1 or 2 quadrants 3. Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants 4. Very high-pitched loud rushes auscultated especially in 1 or 2 quadrants
Relatively high-pitched clicks or gurgles auscultated in all 4 quadrants Rationale: Although frequency and intensity of bowel sounds vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds.
asterognosis
inability to discern the form or configuration of common objects using the sense of touch.
nystagmus
rapid twitching of eyeballs
Positive Romberg's
when pt sways with their feet together and eyes close, they are not supposed to sway
Positive babinski's test
when you dorsiflex the ankle, the pt's big toe raises and the other toes fan out. It is only normal in babies and it indicates CNS disease
cranial nerve 2
which cranial nerve is responsible for visual acuity and you use a snellen chart
