Vitals and physical assessment

What finding indicates that a child is receiving too much IV fluid too rapidly?

moist crackles in the lung fields

A nurse is assessing the lungs of a patient and auscultates soft, low-pitched sounds over the base of the lungs during inspiration. What would be the nurse's next action?

normal breath sounds

peristalsis sounds

normal sounds 4-32 per minute

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."

A nurse is completing a vision exam with the Snellen eye chart and records the client's vision as 20/30. The client asks the nurse, "What does that mean?" How should the nurse respond?

"You are able to read at 20 feet what a person with normal vision can read at 30 feet."Explanation:The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which 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.

The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The parents state that they began to notice the retractions a few days ago and wondered if it was significant. What is the best response by the nurse?

"Your child is having difficulty breathing and we need to determine why."

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

The nursing student is selecting a blood pressure cuff prior to obtaining a patient's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading?

40% circumference of the limb

Which of the following patient variables have the potential to result in either short term or longer term increases in blood pressure?

African american obesity older age

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?

Answer: B - rubs Rationale: Rubs are grating or leathery sounds caused by two dry, pleural surfaces moving over each other. Crackles are intermittent, high-pitched, popping sounds, which are heard in distant areas of the lungs during inspiration. Wheezes are whistling or squeaking sounds caused by air moving through a narrow passage, which can be heard throughout the chest during expiration or inspiration. Gurgles are low-pitched, continuous, bubbling adventitious sounds, which are prominent during expiration, and are heard in larger airways.

How would a nurse assess a patient for pupillary accommodation?

Ask the patient to focus on an object as it is brought closer to the nose.

To assess subjective data related to a client's elimination pattern, the nurse

Asks the client about changes in elimination patterns

A parent brings an infant to the health clinic for a well-baby checkup. During the assessment, the nurse measures the head circumference of the child and notes that there has been a rapid increase in size. What action should the nurse take next?

Assess for signs of increased intracranial pressure.

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. Percussion and palpation are done after auscultation because they stimulate bowel sounds.

The father of a neonate observes that the neonate's big toe dorsiflexes and the other toes fan when the nurse gently strokes the sole of the foot. How should the nurse should interpret this finding?

Babinski's sign A positive Babinski's sign involves dorsiflexion of the big toe and fanning of the other toes. Although normal in infants, this response is abnormal after about age 1 year or when walking begins.The stepping reflex occurs when an infant is held as though weight bearing with the feet on a surface and the infant steps along, raising one foot at a time. A plantar grasp reflex is characterized by flexion of the toes when a finger is placed against the base of the toes. A normal Galant reflex is initiated by stroking an infant's back alongside the spine. The hips should move toward the stimulated side.

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP.

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

Crepitus

A nurse is caring for an adolescent who has been diagnosed with a spleen laceration resulting from a skateboard accident. Which nursing diagnosis is the highest priority?

Deficient fluid volume Deficient fluid volume (hemorrhage) is of highest priority because the spleen is a vascular organ. Laceration may lead to hemorrhage. Confusion, dizziness, and increased heart rate may be initial symptoms. Pain and tenderness are normal after a splenic rupture and should be aggressively managed. Risk for injury and risk for infection are important, but the client does not yet have these issues. The nurse monitors and prevents injury and infection.

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.Fliver

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.

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. Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

Which action should the nurse take when suspecting that a child has been abused by the mother?

Ensure that any and all findings are reported to the proper authorities.

During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. This is a

Focused assessment

inflammation of the pleura asculatation sound

Friction rub

The nurse is inspecting the child's throat (see figure). How should the nurse proceed with the throat exam?

Guide the tongue blade while the child is holding it to depress the tongue to visualize the throat.

The nurse performs a comprehensive assessment of a newly admitted client. What is the primary purpose of this admission assessment?

Identify baseline data

entropion

Inward turning of the lower lid is termed

To assess a client's visual accommodation, the nurse has the client

Look at a close object, then at a distant object

S1

Mitral and tricuspid valve close. Aortic and pulmonic valves open. S1 heard best in the lower chest wall in the Tricuspid/ Mitral areas. HEARD AT APEX

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next?

No action is needed by the nurse because in an infant, the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1). As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

While examining a 2-year-old client, the nurse sees that the anterior fontanel is open. The nurse should

Notify physican because anterior fontanel closes between 12-18 months

While gently abducting the hips during a newborn assessment, the nurse hears a "click" as the femoral head slips into the acetabulum. The nurse interprets this as positive for which physical finding?

Ortolani's sign

ectropion

Outward turning of the lower lid is termed

You are palpating a patient's precordium. Which of the following is an expected clinical finding?

Palpable pulsation over the mitral area

Assessment of the pulse amplitude is accomplished by which of the following?

Palpating the flow of blood through an artery.

Upon assessment of a patient with myasthenia gravis, the nurse observes drooping of the upper eyelids. What is this finding is known as?

Ptosis

An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse?

Request that the child be screened for myopia.

You are preparing to assess a patient's cranial nerves. Which of the following techniques should you use to assess cranial nerve III?

Shine a bright light in the patient's eye and observe for bilateral pupillary response.

A 7-year-old child is admitted to the emergency department with a tentative diagnosis of asthma. Which observation 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 client states, "I have trouble sleeping. I only sleep about 2 hours and then I wake up." This is

Subjective data

The nurse is assessing an adolescent 1 hour after admission for a head injury. The nurse identifies that there have been changes since the baseline assessment, including apnea, bradycardia, and a widening pulse pressure. What is the primary reason for the nurse to notify the healthcare provider?

The changes suggest that the client's intracranial pressure is increasing. Cushing's triad (apnea, bradycardia, and widening pulse pressure) is a hallmark of increasing intracranial pressure

A nurse who provides care on a hospital unit has taken a patient's temperature this morning, yielding a reading of 37.6 C (99.7F) How should the nurse best interpret this assessment finding?

This body temperature may temporarily enhance the patient's immune function.

During measurement of a rectal temperature, the thermometer probe should be inserted about 1.5 inches (3.8 cm) in an adult and 0.5 inches (1.3 cm) in an infant.

True

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.

When assessing an infant with an undescended testis, the nurse should be alert for which symptom?

a bulging in the inguinal area

Which child most needs a screening for scoliosis?

a preadolescent client at the beginning of a growth spurt

The parents of an 8 month old have brought the child to the ER after falling from the high chair. The nurse assesses the child for increased intracranial pressure (ICP). Ifincreased ICP is present what signs would the nurse observe?

altered level of consciousness and sluggish pupils With increased ICP the child would have changes in behavior such as unconsolable irritability, an increase in sleepiness or lethargy, a cry that is shrill or high pitched, vomiting, and pupils which are sluggish to react or nonreactive. A depressed fontanel is indicative of dehydration and raccon eyes a skull fracture. A 3+ pupil size could be considerd normal. The child would have bradycardia, not tachycardia.

To assess subjective data related to a client's elimination pattern, the nurse:

asks the client about changes in elimination patterns.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse:

asks the client what promotes sleep.

Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?

auscultation of bowel sounds

Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?

auscultation of moist crackles`

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

listen with the stethoscope at the fifth intercostal space left mid-clavicular line

The patient's pupils should

constrict when looking at a near object and dilate when looking at a distant object.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will:

decrease the apical pulse.

The nurse assesses a child with ketoacidosis. What manifestations are supportive of the diagnosis of ketoacidosis?

deep, rapid respirations. The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations. Typically with ketoacidosis, the pulse rate would be more rapid and weak due to dehydration and loss of electrolytes. Typically with ketoacidosis, the skin would be dry due to dehydration. With ketoacidosis, hypotension results from the contracted blood volume secondary to dehydration.

When percussing the liver, the sound should be:

dull Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyperresonant, normal lung tissue is resonant, and bone is flat.

Outward turning of the lower lid is termed

ectropion

Eyes are Inward turning of the lower lid is termed

entropion.

bowel sounds occur

every 15-60 seconds. may need to listen 3-5 mins before concluding no bowel sounds.

A nurse assesses a patient's eyes by testing the cardinal fields of vision for coordination and alignment. What eye characteristic is being assessed by this process?

extraocular movement

bone is

flat

Inflammation of the pleura would result in

friction rub

A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position?

high Fowler's

A parent asks the nurse if the lesions around her child's mouth could be impetigo. What manifestations would verify the parent's suspicion?

honey-colored crusts, vesicles, and reddish maculae on the skin

hyperinflated lung tissue is

hyperresonant,

Upon assessing a patient who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs?

increased HR

Miosis

is constriction of the pupil, which is often caused by medications.

Miosis and Mydriasis

is constriction of the pupil, which is often caused by medications. Mydrialsis is dialation of pupil

A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting which finding?

less dyspnea

The nurse places a patient in experiences labored breathing in an upright position. The nurse notes that the patient is able to breathe more easily in this upright position and documents this condition on the chart as which of the following?

orthpnea

Nurse T. has auscultated Mr. Weinstein's apical pulse while a colleague simultaneously palpated his radial pulse. This assessment of Mr. Weinstein's apical-radial pulse indicates that the two values differ signifigantly, a finding that suggests which of the following health problems?

perphrial vascular diease

Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:

ptosis.

normal lung tissue is

resonant

When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts?

symmetry (comparison of bilateral body parts)

PMI=point of maximal impulse is at

the apex and 5th ICS at midclavicular line

Percussion of the abdomen is

tympanic

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?

wheezing

A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff. The nurse should recognize the client's peak blood pressure when what sound is audible?

A faint, clear tapping sound Korotkoff sounds have five unique phases. Phase I begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. When the first sound occurs, it corresponds to the peak pressure in the arterial system during heart contraction, or the systolic pressure measurement. This sound does not have the two-stage sound of a heartbeat.

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.

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.

Before a routine checkup, an 8-month-old infant sits contentedly on the parent's lap, chewing on a toy. When preparing to examine this infant, what should the nurse plan to do first?

Auscultate the heart and lungs.

A nurse is assessing the bowel sounds of a patient who has Crohn's disease. What assessment technique would the nurse use?

Auscultation

A nurse is caring for a 7-year-old client with Down's syndrome. How will the nurse implement care for the client?

Be mindful of developmental age

When performing a physical assessment on an 18-month-old child, which measure would be best?

Have a parent hold the toddler.

An infant is having a 2-month checkup at the pediatrician's office. The physician tells the parents that the infant is being assessed for Ortolani's sign. The nurse explains that the presence of Ortolani's sign indicates dislocation of the:

Hip To assess for Ortolani's sign, the physician abducts the infant's hips while flexing the legs at the knees. This is performed on all infants to assess for congenital hip dislocation. The examiner listens and feels for a "click" as the femoral head enters the acetabulum during the examination. This finding indicates a congenitally dislocated hip.

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

Ongoing partial assessment An ongoing partial assessment is conducted at regular intervals during care of the patient and concentrates on identified health problems and the effectiveness of interventions. A comprehensive assessment includes a health history and complete physical examination and is usually conducted when a patient first enters a healthcare setting. A focused assessment is conducted to assess a specific problem. An emergency assessment is a type of rapid focused assessment conducted to determine a potentially fatal situation.

The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?

The client is dehydrated.

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 2-year-old client is brought to the emergency department with suspected croup. The client appears frightened and cries as the nurse approaches him. The nurse needs to assess the client's breath sounds. The best way to approach the client is to

allow the client to handle the stethoscope before the nurse listens to the client's lungs.

A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding should be reported to the health care provider immediately?

moderate intercostal retractions

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

wheezing

The nurse is assessing a new patient's blood pressure using a manual sphygmomanometer. Which of the following sounds constitutes the patient's systolic blood pressure?

The first appearance of faint but distinctive tapping sounds.

You are assessing a patient's thorax and lungs. Which of the following findings would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure

When assessing the glossopharyngeal nerve, it is most important for the nurse to implement which intervention?

Note the client?s ability to swallow The motor function of the glossopharyngeal nerve can be tested by noting the client?s ability to swallow, eliciting a gag reflex, and having the patient yawn while observing upward movement of the soft palate. The sensory function of the glossopharyngeal nerve can be noted by testing for taste with various agents.

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The patient's pupils are black, equal in size, and round and smooth.

A nurse is assessing the thorax and lungs of clients visiting a physician's office. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply. A. softer auscultated breath sounds found in newborns and children B. children under 10 having a slower respiratory rate than an adult C. newborns and children using abdominal muscles during respirations D. older adults having an increased anterior-posterior (AP) chest diameter E. older adults having an increase in the dorsal spinal curve (kyphosis) F. older adults having increased thoracic expansion

Answer: C, D, & E - Newborns and children using abdominal muscles during respirations, older adults having an increased anterior-posterior (AP) chest diameter, older adults having an increase in the dorsal spinal curve (kyphosis)Rationale: Newborns and children use abdominal muscles to breath as opposed to adults, who use the thoracic muscles. Increased anteroposterior diameter of the chest is seen in older adults. Kyphosis is seen in older adults. Newborns and children have louder breath sounds and a higher respiratory rate than adults. Older adults have decreased thoracic expansion.

Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first?

Examine the fontanels and sutures.