health assessment (lab) quiz 2

abdominal, nutritional, respiratory, cardiovascular, musculoskeletal and peripheral vascular assessments

A nurse is preparing to perform a complete physical assessment on a client reporting abdominal discomfort. In what sequential order should the nurse perform the components of the abdominal examination?

• A. Inspection, Palpation, Percussion, Auscultation

• B. Inspection, Auscultation, Percussion, Palpation

• C. Auscultation, Inspection, Palpation, Percussion

• D. Percussion, Inspection, Auscultation, Palpation

• B. Inspection, Auscultation, Percussion, Palpation

A nurse is caring for a client who recently returned to the unit following abdominal surgery under general anesthesia. Which nursing assessment is an absolute priority before allowing the client to consume oral liquids or food?

• A. Calculation of the client's baseline Body Mass Index (BMI)

• B. Assessment of the client's current weight and skin turgor

• C. Auscultation of bowel sounds and assessment of swallowing/aspiration risk

• D. Inspection of the client's surgical incision site for healing

• C. Auscultation of bowel sounds and assessment of swallowing/aspiration risk

A client admitted with pneumonia becomes restless, anxious, and exhibits a heart rate of 115 bpm and a respiratory rate of 26 breaths/min. The nurse recognizes these clinical manifestations as early signs of hypoxia. Which immediate intervention should the nurse perform first?

• A. Elevate the head of the bed to a high-Fowler’s position

• B. Obtain a sputum culture for laboratory analysis

• C. Administer a prescribed PRN sedative for anxiety

• D. Document the findings as a late sign of respiratory distress

• A. Elevate the head of the bed to a high-Fowler’s position

A nurse is auscultating heart sounds on an adult client and hears a low-frequency sound early in diastole at the apex that resembles the cadence of "Ken-TUC-ky" ($S_3$). How should the nurse interpret this finding?

• A. S1, indicating normal closure of the mitral and tricuspid valves

• B. S2, indicating normal closure of the aortic and pulmonic valves

• C. S3, which may be associated with heart failure in an adult

• D. S4, an atrial gallop normal in all older adults

• C. S3, which may be associated with heart failure in an adult

While conducting a peripheral vascular assessment, the nurse is unable to palpate the client’s right dorsalis pedis pulse. What is the nurse's immediate next action?

• A. Document the pulse strength as a Grade 0

• B. Use a Doppler ultrasound device to locate the pulse

• C. Notify the primary healthcare provider immediately

• D. Apply warm blankets to the client's lower extremity

• B. Use a Doppler ultrasound device to locate the pulse

The nurse is assessing a client's upper extremity strength. The client’s right arm exhibits slightly stronger resistance during push-pull testing than the left arm. What is the most appropriate action by the nurse?

• A. Immediately notify the physician of asymmetrical weakness

• B. Compare the finding to the client's dominant side

• C. Immobilize the left upper extremity in a sling

• D. Document muscle strength as 0 across both arms

• B. Compare the finding to the client's dominant side

A nurse is differentiating between arterial and venous insufficiency in a client’s lower extremities. Which clinical assessment findings are characteristic of arterial insufficiency? (Select All That Apply)

• A. Pale skin color (pallor) on elevation

• B. Warm and flushed skin temperature

• C. Absent or diminished peripheral pulses

• D. Loss of hair on the lower legs and feet

• E. Marked pitting dependent edema

• A. Pale skin color (pallor) on elevation

• C. Absent or diminished peripheral pulses

• D. Loss of hair on the lower legs and feet

• 
  

Auscultation

Listening to sounds the body makes to detect variations from normal

Body Mass Index (BMI)

Measures weight corrected for height (BMI= weight in kg/ height in m2)

Borborygmi

Loud (growling) sounds heard during abdominal auscultation.

Bowel sounds

Audible passage of air and fluid throughout the intestine

Dysphagia

Difficulty swallowing

Distention

Outward protuberance of the abdomen.

Hyperactive Bowel Sounds

Borborygmi; high-pitched, loud, and more frequent than normal; indicates increased gastrointestinal motility

Hypoactive Bowel Sounds

Decreased intestinal motility; fewer sounds than normal and faint (normal post-surgery due to anesthesia)

Ileus

Loss of function of the intestine that causes abdominal distention.

Inspection

The first step in abdominal assessment (observing contours, skin, and movements).

Percussion

Tapping the skin with fingertips to vibrate tissues and organs (tympany for air-filled, dull for solid organs like liver/spleen).

Peristalsis

The movement of contents through the intestines.

Striae

Stretch marks

Bruit

Turbulent or blowing/swishing sound of blood moving through a narrowed blood vessel.

Normal respiratory rate

Varies by age; Adults are 12 to 20 breaths per minute.

Adventitious Lung Sounds

Abnormal sounds resulting from air passing through moisture, mucus, or narrowed airways.

Dyspnea

Difficulty or distress with shortness of breath

Apnea

Cessation of respirations for 10 to 20 seconds or longer.

Bradypnea

Respiratory rate less than 12 breaths per minute.

Tachypnea

Respiratory rate greater than 20 breaths per minute.

Clubbing (nail)

Bulging tissues at the nail root with loss of normal nail angle/curvature; associated with chronic hypoxia.

Hypoxia

Inadequate tissue oxygenation at the cellular level.

Pursed Lip Breathing

Deep inspirations and prolonged expiration through pursed lips to prevent alveolar collapse.

Incentive Spirometer

Voluntary deep breathing tool providing visual feedback on respiratory volume

Barrel Chest

Anteroposterior diameter that equals the transverse diameter.

Cheyne-Stokes

Abnormal respiratory pattern with periods of apnea

Kussmaul Breaths

Abnormal respiratory pattern with increased rate and depth.

Fremitus

Continuous tactile vibration felt on the chest wall when a patient speaks.

Vesicular Breath Sounds

Normal soft, low-pitched, breezy breath sounds heard over peripheral lung fields.

Bronchovesicular Breath Sounds

Normal breath sounds combining bronchial and vesicular qualities.

Thrill

Continuous palpable sensation or pulsation (vibration) felt over a blood vessel or cardiac landmark

Murmur

Blowing or swishing sound heard during heart auscultation

Bradycardia

Abnormally slow heart rate (< 60 bpm).

Tachycardia

Abnormally elevated heart rate (> 100 bpm).

Dysrhythmia

Abnormal heart rhythm.

Perfusion

Delivery of blood and oxygen to body tissues

Angina Pectoris

Chest pain due to an imbalance between myocardial oxygen supply and demand.

Kyphosis

Exaggeration of the posterior curvature of the thoracic spine ("hunchback").

Lordosis

Increased lumbar curvature ("swayback")

Scoliosis

Lateral curvature of the spine.

Flexion

Movement that decreases the angle between two bones.

Extension

Movement that increases the angle between two bones.

Adduction

Movement that brings a limb toward the midline of the body.

Abduction

Movement that pulls a limb away from the midline of the body.

Pronation

Rotation of the forearm with palm facing downward.

Supination

Rotation of the forearm with palm facing upward.

Rotation

Turning of a body part around its central axis.

Osteoporosis

Systemic skeletal disease characterized by decreased bone mass and deterioration of bone tissue.

Gait

Style of walking with rhythm, cadence, length of stride, and speed.

Goniometer

Tool used to measure the precise angle of a joint.

Hypertonicity

Increased muscle tone characterized by resistance during passive movement.

Hypotonicity

Flaccid tone with little to no resistance during passive movement

Atrophy

Pathological reduction in the normal size of muscle fibers.

Active Range of Motion (AROM)

Patient performs joint movements independently.

Passive Range of Motion (PROM)

Nurse or examiner moves the joint while the patient relaxes

Edema

Swelling caused by fluid buildup in tissues

Blanchable

Visible skin redness that turns pale/white when pressure is applied