PrepU Chap26: Health Assessment
A 56-year-old client with Mexican heritage has a diagnosis of heart failure. The nurse's morning lung assessment of the client reveals crackles in the mid to lower lungs and respiratory rate of 32. The nurse notices that the client is restless, and his skin has an ashen appearance. Which nursing action is the priority intervention?
Measure the pulse oximetry. Explanation: The focused assessment of the client's respiratory status indicates signs of respiratory compromise and possible hypoxia, as evidenced by the client's restlessness and the ashen appearance of the skin. To fully assess the respiratory status of the client, it is important to take the pulse oximetry. Capillary refill and fluid intake assessment do not address the primary problem of respiratory compromise. Limiting activity is not an assessment.
When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention?
Note the client's ability to swallow.
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. Explanation: Client comfort is essential when performing an assessment, especially when the assessment involves touching the client. To promote maximum client comfort, equipment should be warmed prior to touching the client. This assessment is done while the client is in the supine position, not the sitting position. Since physical assessment typically takes place while clients are undressed (or wearing only a loose examination gown), they generally appreciate being covered with a drape to provide modesty. The abdomen is always inspected and then auscultated (in that sequence) before using palpation or percussion techniques. Touching or manipulating the abdomen can alter bowel sounds, thus producing invalid findings.
A client is being treated for chronic obstructive pulmonary disease. The nurse auscultates the client's lungs following a period of coughing. The findings of this assessment are an example of:
objective data. Explanation: Objective data can be directly observed or measured, such as vital signs or appearance. The results of auscultation are considered to be objective because they do not depend on the client's subjective description. Baseline data is obtained on first contact with the client.
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 -Functional ability evaluation -Collection of subjective data
What percentage of weight change in 6 months is considered abnormal?
10%
A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale?
15 Explanation: The Glasgow Coma Scale (GCS) evaluates three key categories of behavior: eye opening, verbal response, and motor response. Within each category, each level of response is given a numerical value. The maximal score is 15, indicating a fully awake, alert, and oriented client.
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?
2+ pitting edema noted on bilateral lower extremities Explanation: Depression of the skin with pressing is an abnormal finding. 2+ pitting edema is a deeper pit after pressing (4 mm) and lasts longer than 1+ pitting edema, but the lower extremities are fairly normal contour. 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 assessing a client's level of consciousness using the Glasgow Coma Scale. The assessment reveals that the client opens the eyes to pain, exhibits abnormal flexion posturing, and produces sounds that are not identifiable. Which score would the nurse assign the client?
6
A nurse admitting a new client to the hospital needs to determine the client's needs and current problems. What is the priority action of the nurse?
Complete an assessment.
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?
Document normal breath sounds
The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?
Each lub-dub is one beat.
A nurse uses a bed scale to perform a client's daily weight. The nurse notes that today's weight is 3 kg less than the previous day's. What is the nurse's most appropriate action?
Ensure that the scale is correctly calibrated and repeat the assessment.
A client is admitted to the emergency department. He is bleeding from a cut on his head and his skin color is pale, with diaphoresis. What nursing action should be performed first?
Evaluate the blood pressure and pulse
A nurse auscultates the right carotid artery in an older adult client and identifies a bruit. What does this assessment finding mean?
It is distended. Explanation: Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.
A client has been reporting persistent headaches. Which is an example of subjective data?
Pain is 4 out of 10 on a pain scale.
The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which action, if observed, would require the charge nurse to intervene?
Palpation of both carotid arteries at the same time
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
The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply.
Reports of abdominal pain of 4 on a 0 to 10 point scale The client states, "I feel nauseated." Client informs the nurse there is a floater in the left eye Explanation: Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.
Which components are included in the integumentary system? Select all that apply.
Skin Hair Nails Sweat glands Explanation: The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands. Arteries are included in the cardiovascular or peripheral vascular systems, and muscles are included in the musculoskeletal system.
The nurse is using a bed scale to weigh a client, and the client becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?
Stop lifting the client and reassure him.
To assess subjective data related to a client's elimination pattern, the nurse:
asks the client about changes in elimination patterns.
A 7-year-old child is admitted to the emergency department with a tentative diagnosis of asthma. Which assessment requires a priority intervention by the nurse?
Stridor Explanation: Stridor indicates a narrowing of the upper airway (larynx or trachea) caused by an obstruction or edema and must receive priority of care. Intercostal retractions indicate increased respiratory effort. A snoring sound on inspiration indicates sonorous wheezes and is caused by air passing through or around secretions. Expiratory wheezing is caused by air passing through narrowed lower airways.
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?
The client makes noises when he breathes.
A nurse is completing a neurologic assessment of an 84-year-old client. Which principle should guide the nurse's interpretation of the results?
The client's reaction time will likely be slower than that of a younger adult.
The nurse is assessing the ear canal and tympanic membrane of a client using an otoscope. Which finding would the nurse document as normal?
The tympanic membrane is translucent, shiny, and gray. Explanation: The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.
The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding would require immediate action by the nurse?
Wheezing on auscultation
When percussing the liver, the sound should be:
dull
During a health assessment, the nurse uses deep palpation to assess a client's:
liver
A client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is:
subjective data.
A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?
tuning fork
Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?
wheezes
A nurse is assessing a new client's level of activity and exercise. What should be addressed with every client?
whether they have a program of regular physical activity
The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?
Ask the client about any usual genital observations.
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 dorsum Explanation: The skin over the dorsum of the hand is sensitive to temperature because it is thin and its nerve density is great. The palm of the hand is sensitive to vibration and is useful in locating a vibration associated with a heart murmur. The fingertips are concentrated with nerve endings and can sense fine difference in texture and consistency. The knuckles are not used in palpation.
A nurse is teaching a young female client about breast cancer prevention. The client asks at what age she needs to begin having mammograms. What is the nurse's best response?
"According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that."
An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?
"Can you tell me where you are right now?" Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.
The nurse is performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment? Select all that apply
"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?"
A nurse is preparing to assess a client with abdominal pain. Which statement is most appropriate for the nurse to use to gain cooperation from the client?
"Let me explain what I am going to do and how you can help." Explanation: The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation. Requesting to examine the client's abdomen without any explanation may cause anxiety and increase the client's pain and decrease the chance of cooperation. The results of the assessment should be reported to the health care provider. The nurse does not need to avoid conversation during the assessment.
The nurse at the neighborhood family clinic is teaching a 55-year-old client with hypertension and a family history of heart disease about reduction of risk factors. It is most important for the nurse to make which statement to the client?
"Take your blood pressure medications exactly as your doctor prescribed them." Explanation: Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s). Smoking is a contributory risk factor for heart disease, but hypertension is a major risk factor. Reduction of fats in the diet is preventive of atherosclerosis, and reversing a sedentary lifestyle by exercising is important, but controlling hypertension will reduce the risk of heart disease.
The nurse is performing an assessment for a 12-months-old child and observes pronation of the child's feet. The parent asks the nurse what is wrong with the child's feet. What is the best response by the nurse?
"This is an age-related variation for the child and should go away after about 30 months."
The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory?
"What are the month, date, and the year of your birth?" Explanation: Asking the client to explain the meaning of a common proverb allows the nurse to assess the client's abstract reasoning. The nurse needs to ask a question that may be corroborated to confirm a past or remote memory, so asking what the newly admitted client ate at dinner would not be able to be corroborated. The client's birthdate is available in the medical record and can be corroborated. Asking the client to repeat three objects that the nurse told the client earlier in the interview assesses recent memory.
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?
"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)." Explanation: The first number indicates the distance the person is standing from the chart; the second number gives the distance at which a normal eye can see it. 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.
The nurse cares for a client with chronic obstructive pulmonary disease. Which explanation does the nurse provide to the client's adult child, who asks, "How will we know if my parent is experiencing chronic hypoxia?"
"Your parent will exhibit clubbing of the nails." Explanation: Clubbing of the nails is a sign of chronic hypoxia. In clubbing, the angle between the nail bed and the finger flattens to 180 degrees or less. Hypoxia of the tissues changes normal, pink-color skin to a grayish or bluish color. A yellowish color of the skin reflects jaundice, a sign of liver impairment. Poor skin turgor is a sign of dehydration, normal aging, or weight loss. Cool skin may indicate poor circulation.
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.
-Soft, low-pitched, whispering sounds heard overmost of the lung fields -Medium-pitched, medium-intensity blowingsounds, auscultated over the first and secondinterspaces anteriorly and the scapula posteriorly -Blowing, hollow sounds auscultated over thelarynx and trachea
The nurse is caring for a client diagnosed with coronary artery disease after a cardiac angiogram. The client has a sandbag on the right femoral artery. Which assessments should the nurse choose? Select all that apply.
-Vital signs -Focused peripheral vascular assessment -General physical assessment
The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant?
An absent popliteal pulse Explanation: Priority assessments address the ABCs. Absence of a pulse (circulation) is a significant finding, which without intervention could lead to loss of limb. The other listed integumentary changes do not pose a short-term threat, even though they are clinically significant.
A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury?
An intact red area on the buttocks.
The nurse is assessing the glossopharyngeal nerve on a client diagnosed with a cerebrovascular accident. Which action should the nurse take?
Ask client to move tongue side to side Explanation: The motor function of the glossopharyngeal nerve can be tested eliciting a gag reflex by placing a tongue depressor on the back of the tongue and having the client move the tongue from side to side. Having the client open the mouth against resistance tests motor supply. Lightly touching with different sensations will test the trigeminal nerve (CN V) and observing the uvula tests the vagus nerve.
The nurse conducts a health history on a client who has experienced a 15-pound (7-kilogram) weight loss in the past 3 weeks. Which information would the nurse gather to determine the client's nutrition pattern?
Ask the client for a 24-hour diet recall. Explanation: Interview questions that will focus on nutrition might include asking the client to disclose what the individual has eaten in the last 24 hours. Weighing the client would not provide good nutrition information because the nurse already knows the client has experienced a significant weight loss. A 24-hour diet recall would provide better information about the total nutritional pattern than merely examining the client's teeth or inspecting the abdomen for symmetry.
A 55-year-old female client was admitted to the medical unit 2 days ago with liver failure secondary to alcohol use. She's on bed rest with bathroom privileges and has just been up to use the toilet. While helping the client to stand so she can wipe herself, the nurse notices a few drops of blood on top of the semiliquid, clay-colored stool in the toilet. What action should the nurse take next?
Ask the client if she has noted any blood in her stools lately.
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?
Ask the client to empty her bladder. Explanation: Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.
A 52-year-old male client is admitted to the medical-surgical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He tells the nurse that he hasn't seen any blood in his stool and that he usually drinks a six-pack of beer a day. In trying to pinpoint the cause of the client's pain, which action would the nurse take?
Ask the client to tell her more about the pain. Explanation: The nurse should ask the client to tell her more about the pain because an open-ended question would elicit more assessment information about the nature of the pain than a question that calls for a yes or no answer. Asking the client to compare this current pain to past experiences with pain or rating the client's pain level using a pain scale is useful only in determining the intensity of the pain—not the cause of the epigastric pain.
A 66-year-old female client is reporting abdominal pain. The nurse assesses the client's abdomen by first inspecting the abdomen. What should the nurse do next?
Auscultate the abdomen. Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.
A nurse is assessing the bowel sounds of a client who has Crohn's disease. What assessment technique would the nurse use?
Auscultation
An older client presents to the clinic with reports of dyspnea upon exertion and when lying down as well as feeling tired all the time. The nurse notes that the client's ankles and feet are swollen. What cardiac assessment technique would the nurse use?
Auscultation Explanation: Auscultation would reveal if the client's heartbeat is rapid or irregular, and if there are any additional heart sounds such as an S3, which could be an indicator of heart failure. Palpation and inspection may reveal an irregular heartbeat, but they will not disclose extra heart sounds. Percussion is a limited assessment that could be used to outline the cardiac boarder.
The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?
Auscultation of a bruit
The nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data would be important for the nurse to collect during the physical examination?
Bowel sounds Explanation: An abdominal assessment includes inspection, auscultation, palpation and percussion. Auscultating for bowel sounds is an objective assessment would be necessary for a physical assessment of the abdomen. Fatigue, pain, and nausea are subjective symptoms. This subjective data would be obtained during the client interview.
Which technique should the nurse use to assess the pupillary light reflex on a client?
Bring a narrow beam of light from the temple toward the eye, observing for direct and consensual pupillary constriction. Explanation: To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction. The diagnostic positions test and test for accommodation will not provide the pupillary reflex information.
The nurse is performing a respiratory assessment for a client and hears a high-pitched, harsh "blowing" sound, with sound on expiration being longer than inspiration. How will the nurse document this finding?
Bronchial breath sounds Explanation: Bronchial breath sounds are heard over the larynx and trachea; they are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration. Bronchovesicular breath sounds are heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration. Vesicular breath sounds are heard over most of the lung fields; they are soft, low-pitched, whispering sounds, with sound on inspiration being longer than expiration. Adventitious breath sounds are not normally heard in the lungs and result from air moving through moisture, mucus, or narrowed airways. These abnormal sounds also result from sudden opening of collapsed alveoli.
A gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply.
Bulge to the left inguinal area Scant yellow discharge Explanation: A bulge in the left inguinal area could indicate a hernia and needs further assessment. Yellow discharge could indicate an infection and requires further assessment. Decreased penis and testes size, less firmness of the testes, and decreased pubic hair are normal with aging of the male client's genitalia.
Mr. Martinez is a 55-year-old male who was brought to the emergency department (ED). He reports abdominal pain in his right lower quadrant (RLQ) and nausea without vomiting. The nurse performs a physical assessment on the client and documents the following: Neurologic status: awake and alert; Cardiovascular: radial pulses 90, bounding, and equal; Skin: warm and dry; Respirations: 24 and regular; Gastrointestinal: abdominal pain with rebound tenderness in RLQ; Musculoskeletal: sitting up in bed with knees bent. Identify which findings involved the assessment technique of palpation. Select all that apply.
Cardiovascular: radial pulses 90, bounding, and equal Skin: warm and dry Gastrointestinal: abdominal pain with rebound tenderness in RLQ Explanation: Palpation involves the sense of touch. The hands and fingers are sensitive tools and can assess skin temperature, turgor, texture, and moisture, as well as vibrations, pulsations, and shapes within the body. Neurologic assessment findings of awake and alert, respirations of 24 and regular, and musculoskeletal assessment of the client observed sitting up in bed with knees bent are examples of inspection.
The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?
Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.
A 7-year-old child suffered an injury on the playground at school that resulted in a fracture to the left forearm. The child reports to the nurse's office the next day for neurovascular assessment of the extremity. For each activity, click to specify whether it fulfills the circulation, motor function, or sensation section of the assessment.
Circulation- pallor, temperature Motor function- paralysis, pain Sensation- numbness
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 states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."
Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?
Cranial nerve I Explanation: Cranial nerve I is important for a person's sense of smell. Cranial nerves II, III, and IV are important for vision.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?
Crepitus
The nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?
Decreased cardiac output Explanation: 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), and an asymmetric 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 caring for a client with chronic obstructive pulmonary disease (COPD). What assessment data obtained by the nurse would correlate with this diagnosis?
Expiratory wheezes Explanation: Normal inspiration and prolonged expiration are heard to overcome the increased airway resistance of COPD. Wheezes are musical or squeaking, high-pitched, continuous sounds heard as air passes through narrowed airways. Fever may indicate a respiratory infection but is not a symptom of COPD. The cough of a client with COPD is productive and not dry. Rhinorrhea is not a symptom of COPD.
Upon assessment of an older adult, the nurse notes the client's skin to have a yellow color. The nurse interprets this finding as a result of which health condition?
Hepatitis Explanation: Jaundice is a yellow color of the skin resulting from liver or gallbladder disease, some types of anemia, and hemolysis. Hepatitis, inflammation of the liver, is a potential cause of jaundice. Appendicitis and diverticulitis do not typically result in changes in skin color, but will manifest as severe abdominal pain. Cellulitis would not result in yellowing of the skin, but as red and swollen legs.
A nurse is caring for a 44-year-old female who had a left total hip arthroplasty 3 days ago. Her postoperative course has been uneventful except for a urinary tract infection that developed yesterday for which she is receiving cefaclor 500 mg PO bid. The client tells the nurse that the backs of her legs and buttocks are "itching like crazy." Which action should the nurse take first?
Inspect the area of itchy skin.
The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first?
Inspect the left lower leg for areas of redness. Explanation: Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism.
The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order.
Inspection Auscultation Percussion Palpation Explanation: The order of the techniques for the abdominal assessment differs from that for the other systems. This is the preferred approach because performing palpation and percussion before auscultation may alter the sounds heard on auscultation.
The nurse is preparing to perform an examination of the abdomen of a 23-year-old male client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client?
Inspection, auscultation, percussion, palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation.
A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.
Irregular edges Larger than 1/4 inch in diameter Change in the mole Explanation: The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.
The nurse is palpating a client's precordium. Which result is an expected clinical finding?
Palpable pulsation over the mitral area Explanation: A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.
A 57-year-old male client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?
Palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.
The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?
Palpation Explanation: The thyroid gland is palpated for size, shape, symmetry, tenderness, and the presence of any nodules. If palpable, the thyroid gland should feel soft but elastic. Hypothyroidism may be caused by a goiter, which is an enlarged thyroid gland. Inspection, percussion, and auscultation would not reveal an enlarged thyroid gland.
A nurse needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment?
Penlight
Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?
Percussion
A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?
Pink labia lesions Explanation: Lesions on the labia may be the result of an infection such as herpes or syphilis, which is a concern. Coarse hair is to be expected, although the genitalia may be shaven. Clear or whitish vaginal discharge may be normal. Other signs would need to be present for this finding to be a concern. The vulva has more pigmentation than other skin areas and is often darker pink in color.
The nurse has performed a Romberg test in the context of a client's neurologic assessment. The client has failed the test. The nurse should consequently identify what nursing diagnosis?
Risk for Falls Explanation: Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.
Which statement accurately represents a characteristic of the third or fourth heart sound?
S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.
Mrs. Harris was admitted to the psychiatric unit 3 days ago with a diagnosis of major depressive disorder. The client answers assessment questions with barely audible "yes" or "no" responses and tells the nurse that she has been depressed for a long time. She wants the door closed and the curtains drawn to darken her room. She refuses visitors, eats only 25% of her meals, and tells the nurse that the food makes her nauseous. The nurse observes the client biting her fingernails. She cries often and sleeps a lot. The nurse documents which client actions as objective assessment data? Select all that apply.
The client answers questions in a barely audible voice. The client bites her fingernails. The client eats 25% of her meals. The client sleeps a lot. Explanation: Objective data are directly observed or elicited through physical examination techniques. Observing that the client talks in a low voice, does not eat all her food, sleeps a lot, and bites her fingernails is a means of attaining objective findings. Subjective data are experienced or known only by the client (e.g., pain and nausea) and are gathered by verbal report.
Which respiratory sound indicates an upper airway obstruction?
Stridor Explanation: Stridor is a harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction. Dyspnea is difficult or labored breathing and a term to describe difficulty breathing. Fremitus is a vibration felt on the client's chest during low frequency vocalization. A wheeze is a whistling or rattling sound in the chest as a result of obstruction in the air passages. Wheezing most often is caused by an obstruction (blockage) or narrowing of the small bronchial tubes in the chest.
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?
The client is dehydrated. Explanation: The nurse assesses for skin turgor by gently pinching the skin under the clavicle. This technique provides information about the client's hydration status as well as skin mobility and elasticity. Skin is less elastic with aging, but the turgor should remain normal (less than 3 seconds) and not tent, or remain in the pinched position. When a client is dehydrated, the skin will tent for more than 3 seconds. When a client is overhydrated, edema will be present with the skin, and the skin turgor would be normal, or taunt because of excess fluid.
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.
A client recently was diagnosed with Bell's palsy and is back to the clinic for a follow-up visit. What would the nurse observe during the assessment of cranial nerve VII if the client's symptoms are resolving?
The movement and appearance would appear symmetrical as the client smiles, frowns, and raises the eyebrows. Explanation: Bell's palsy is usually a temporary condition that presents with left or right facial weakness or paralysis. Cranial nerve VII controls the muscles of the face. Normal results would be symmetrical appearance and movement as the client smiles, frowns, and raises the eyebrows. Swallowing and speaking is demonstrated with cranial nerve X. Cranial nerve XII is assessed with movement of the tongue. The movement of shoulder muscles assesses cranial nerve XI.
The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?
Verify that the procedural consent form is signed. Explanation: Although the physician is responsible for obtaining the client's signed consent for procedures, it is most important for the nurse to verify that the consent form is signed and in the chart before the client goes to the operating room. Ensuring the completion of the preoperative check list, the presence of the lab results in the chart, and documentation that the preoperative medications were administered are not the most important nursing actions.
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 for acute pancreatitis asking for pain medications Explanation: 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.
The nurse should use the bell of the stethoscope during auscultation of:
a client's heart murmur. Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.
To obtain subjective data about a newly admitted client's sleep pattern, the nurse:
asks the client what promotes sleep.
A nurse assesses a client for blood pressure. Which technique would be used for this assessment?
auscultation
A client states during the interview that he has pain in his lower back. He states it is a 10 on a scale of 0 to 10 when he is asked to turn. The nurse should:
avoid a position change that requires turning. Explanation: Addressing pain early in the health assessment allows the nurse to individualize the rest of the assessment, avoiding positioning and techniques that are especially uncomfortable for the client
While assessing a 48-year-old client's near vision, the nurse can anticipate the client will state that her vision is:
blurred. Explanation: Visual problems with close objects occur more frequently after the age of 40.
Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:
chief concern. Explanation: The first subject discussed in a client interview is the client's specific reason for seeking care. The subject is often called the client's chief complaint or chief concern.
The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider?
circumoral cyanosis when the client is at rest Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.
When a client enters the acute care facility, the nurse should perform a:
comprehensive health assessment. Explanation: A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.
The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?
crackles
A nurse examining the lungs of a client percusses over the anterior thorax using the proper sequence. This technique helps to identify:
density and location of lungs. Explanation: Percussion over the lung fields helps identify the density and location of the lungs. Palpation assesses for masses, crepitus, muscle development, and tenderness. Lung auscultation assesses for normal breath sounds and for abnormal (adventitious) breath sounds.
A client is brought to the emergency department after being involved in a motor vehicle accident and sustaining a head injury. The nurse is performing a Full Outline of Un-responsiveness Coma Scale (FOUR) to determine the presence of increased intracranial pressure and client outcomes. What components of the assessment will the nurse document? Select all that apply.
eye response motor response respiration brainstem reflexes shape
The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of:
fissure. Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.
When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order?
inspection, auscultation, percussion, palpation
A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"?
oriented to person, place, and time Explanation: Oriented ×3 indicates that the client is oriented to person (one's own name, the names of significant others, or knowing the nurse), place (location, city, or state), and time (time of day, day of week, or date).
A nurse who works on a day-surgery unit conducts a thorough, head-to-toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's:
peripheral pulses.
Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:
ptosis
A 34-year-old client of Asian descent has been hospitalized for the past 3 days with a diagnosis of hepatitis B. The nurse is planning a head-to-toe assessment of the client and understands that the characteristics of an acute hepatitis infection are jaundice, nausea and vomiting, joint pain, rashes, and elevations in serum liver function tests. Where would be the best location for the nurse to observe jaundice in this client?
sclera of the eye Explanation: Jaundice can be observed in the face and body of people with very fair beige-colored skin with pinkish undertones, as is often seen in northern Europeans. The naturally fair skin of Asians has a yellowish undertone, as does the skin of southern Europeans, and some Hispanics and Black Americans. The best location to observe for jaundice in this population is the sclera of the eye. Jaundice in people with light brown skin with reddish undertones, such as Native Americans/First Nations, some Hispanics and Blacks, North Africans, and Arabians is best observed in the sclera. People with very dark brown skin with purplish undertones, such as sub-Saharan Africans, some Blacks, South Asians, and Native Australians often have normal yellow subconjunctival fatty deposits in the outer sclera. Do not confuse this with scleral jaundice. The best location to observe jaundice in this population is the junction of the hard and soft palate in the mouth, viewed with a non-LED flashlight. LED flashlights have an ultra-bright, bluish-white light that can alter color perception. The mucous membranes of the mouth is the location to observe for cyanosis.
