Upon assessment of a client with myasthenia gravis, the nurse observes drooping of the upper eyelids. This finding is known as:
ptosis Is drooping of the upper lids and is an abnormal finding. Inward turning of the lower lid is termed entropion. The outward turning of the lower lid is termed ectropion. Miosis is constriction of the pupil, which is often caused by medications.
The nurse should use the bell of the stethoscope during auscultation of:
a client's heart murmur
What percentage of weight change in 6 months is considered abnormal?
A 10% change in weight in 6 months is considered abnormal.
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. A bruit may be heard in the presence of stenosis (narrowing) or occlusion of an artery. Bruits may also be caused by abnormal dilation of a vessel. The other findings are normal.
A nurse assesses a client for blood pressure. Which technique would be used for this assessment?
Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues.
The nurse examines the skin of a 29-year-old woman with light-colored skin who is reporting swollen and itchy hands and identifies a rash consisting of superficial, small, reddish, circumscribed, and solid elevations without blistering on the posterior aspect of both hands just below the wrists. What term most accurately describes this rash?
A maculopapular rash
Maculopapular: macules (distorted but nonelevated spots on the
skin) and papules (small, circumscribed, superficial, solid
elevations of the skin).Bullae: Presence of large
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. 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 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. Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.
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.
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. 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.
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. The ear canal should be smooth and pink.
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?
The nurse should stop lifting the client and reassure him. If the client continues to be agitated, the nurse lowers the client back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the client may result in injury. An order for sedation would only be requested if it was absolutely necessary to obtain the client’s weight at this time. Another nurse holding the client steady does not address the client’s agitation.
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 ×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 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. 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.
The nurse pinches the skin under the clavicle and it tents. What conclusion should the nurse determine from this assessment?
The client is dehydrated. 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 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. Reaction time often decreases with age, even in the absence of pathologic conditions. Each of the other listed findings would be considered abnormal, even in an older adult.
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. 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 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. 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 assessing the skin of a veteran who has returned from deployment overseas. Which response by the nurse reflects the best strategy to gain cooperation of the client?
“May I look at your skin to determine if there are any issues?”
Asking permission to look at the client’s skin and explaining why prepares the client for the assessment and may gain the clients cooperation. The nurse will need to consider the possibility of posttraumatic stress disorder (PTSD) or other emotional issues related to the client’s military service. By directing the client and not explaining the assessment it is likely the client will resist the nurse.
The nurse is conducting a health assessment on a client. Which subjective data would the nurse gather about the client’s sleep habits?
Client reports only sleeping 2 hours per night
Subjective data are those symptoms, feelings, perceptions, preferences, values, and information that only the client can state and validate. Frequent yawning, dark circles under the eyes, and a decreased attention span are objective data that may indicate a sleep problem.
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. 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.
When percussing the liver, the sound should be:
Dull. The percussion of the liver is dull. Percussion of the abdomen is tympanic, hyperinflated lung tissue is hyper resonant, normal lung tissue is resonant, and bone is flat.
A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?
Crepitus. Problems with the temporomandibular joint include pain or a grating feeling called crepitus
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. Inspecting the back of the client's legs and buttocks is the first step in determining the nature of the client's problem.
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. Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing.
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. Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse’s scope of practice. Asthma usually results in wheezing.
A nurse is assessing 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. Regular physical activity contributes to a person's physical and psychological well-being.
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. Romberg test assesses balance; an unsuccessful test constitutes a likely risk for falls. This test does not relate to the client's cognition.
The nurse must weigh a client using a bed scale. Place the following steps in the correct order. Use all options.
- Place a cover over the sling of the bed scale.
- Attach the sling to the bed scale.
- Balance the scale so that weight reads 0.0.
- Roll client back over the sling and onto other side.
- Gradually elevate the sling so that the client is lifted up off of the bed.
- Note weight reading on the scale.
Which components are included in the integumentary system? Select all that apply.
- Sweat glands
The integumentary system includes the skin, hair, nails, sweat glands, and sebaceous glands.
Which respiratory sound indicates an upper airway obstruction?
Stridor. Harsh inspiratory sound that can sound like crowing. It may indicate an upper airway obstruction.
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."
Hypertension is a risk factor for heart disease that can be modified and controlled with medication(s).
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
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. 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.
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
- Collection of subjective data
- Functional ability evaluation
- Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client.
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. 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.
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).” 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.
A nurse is caring for a postoperative client 1 day after coronary artery bypass surgery. Which nursing interventions demonstrate the skill of assessment? Select all that apply.
- inspecting the abdominal incision
- taking the client’s blood pressure
- reviewing morning lab results
Before the nurse can determine what care a person requires, the nurse must determine the client's needs and problems. This requires the use of assessment skills, or acts that involve collecting data, which include interviewing, observing, and examining the client.
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
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.
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.
The nurse should explain the assessment procedure which allows the client to be prepared and encourages cooperation.
When a client enters the acute care facility, the nurse should perform a:
comprehensive health assessment. A comprehensive health assessment encompasses the physical, psychological, social, and spiritual dimensions of living.
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. Bruits occur when the artery is partially obstructed or distended, which prevents blood flow from moving straight through the vessel.
The nurse is preparing to assess a client's abdomen. Arrange the steps of the assessment in the correct order.
The nurse is palpating a client's precordium. Which result is an expected clinical finding?
Palpable pulsation over the mitral area. A palpable pulsation over the mitral area is a normal finding (apical impulse). The other findings listed are abnormal.
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. 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 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. Any blood in the stool indicates an abnormal condition that needs to be assessed further. Clients with liver failure can develop coagulation problems that can lead to bleeding tendencies, such as bleeding gums. However, at this time it is more important to investigate the cause of the blood on the client's stool.
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.
Objective data are directly observed or elicited through physical examination techniques.
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. 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 enters the room of an older adult client diagnosed with Alzheimer disease to perform a head-to-toe assessment. What assessment findings by the nurse are reflective of the normal signs of aging? Select all that apply.
- Decreased near vision
- Increased systolic and diastolic blood pressure
- Decreased tissue elasticity
Decreased near vision (presbyopia), increased systolic and diastolic blood pressure, and decreased tissue elasticity are normal signs of aging.
The nurse is assessing a child for an underactive thyroid gland. Which assessment technique would the nurse use?
Palpation. 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.
The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first?
"What brings you here today? The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the “chief complaint” or “chief concern.”
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. 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 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. 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).
Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?
Cranial nerve I
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. To test the pupillary light reflex, the nurse should advance a light in from the temple and note the direct and consensual pupillary constriction.
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 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. If weight varies by more than 1 kg, the nurse should check the scale calibration and the accuracy of the assessment before taking further action, such as reporting to the health care provider or altering the client's diet.
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. condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider.
A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern?
Pink labia lesions. Lesions on the labia may be the result of an infection such as herpes or syphilis, which is a concern.
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. 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.