"Best bet" HA

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?

History of type 2 Diabetes mellitus

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years?

60 Packs Per Year

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Auscultate the apical pulse at the point of maximal impulse

When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?

Left fourth intercostal space, next to the left sternal border

The nurse is performing oral inspection of a client with dark pigmented skin. The nurse observes a patchy discoloration of the buccal mucosa. Which action should the nurse take?

Document this finding in the medical record

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Advise the client to see his healthcare provider for immediate evaluation

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

Examine the client's sclera for icterus (yellowing of the sclera)

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Instruct client to demonstrate activities of daily living

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

Empty your bladder just prior to the examination

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

What were you doing when you first noticed the problem

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Listen to the heart sounds using the bell of a stethoscope

The nurse observes that a client who is intoxicated has an ataxic gait. Which finding does the nurse expect to be positive upon further assessment of the client?

Romberg Sign

Assessed the client's lungs. Decreased lung sounds in the right lower base. Percussion reveals dullness over that same area. Using accessory muscles to breathe. Chest expansion is decreased on right side. Skin is warm to touch but is pale in color. Client says he has had a nonproductive cough for two days

Actions to Take:

-Auscultate the lungs for adventitious breath sounds

-Inspect the chest for lag on the affected side

Potential Conditions:

-Pleural Effusion

Parameters to Monitor:

-Cyanosis

-Respiratory Rate and Pulse

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider which pathology?

Aneurysm

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

Multiple maculopapular pustules over forehead and chin on an adolescent

A nurse performs a Tinetti assessment on an older adult client and calculates a balance score of 12 and a gait score of 8. Which do these results indicate?

Increased Risk for Falling

The nurse reviews a client's laboratory results for a client admitted with gastrointestinal (GI) bleeding who has no visible hemorrhoids on inspection of the anal area. Which laboratory test indicates that the client's bleeding is not yet resolved?

Reference Range:

Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)]

Prothrombin time (PT) [11.0 to 12.5 seconds (85%-100%)] Glycosylated hemoglobin (A1C) [4% to 5.9%]

Hematocrit changes from 36% to 32%

Which question by the nurse is likely to elicit the most information regarding a client's use of medications to treat a chronic cough?

What medications have you taken for your cough?

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Document the clients history that is directly related to current admission diagnoses

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

Increase sleep latency, and reduce total sleep time

A 20-year-old nulliparous female college student sees the nurse because she has missed her last two menstrual periods. She reports she has not had sexual intercourse in one month. The nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain?

Body weight, hirsutism, thyroid enalrgemnt

While completing an admission assessment for a client with rectal bleeding, the nurse observes dried, dark red blood on the surface of a purple, shiny tissue mass that extrudes from the anal opening. When documenting in the client's electronic medical record (EMR), which finding should the nurse enter in the client's physical assessment?

Dried dark red blood on swollen external hemorrhoids

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

Examine the testicles during bathing

The nurse learns in the report that a client is stuporous. Which assessment should the nurse perform to confirm this report? (Reduced level of consciousness)

Determine the response to stimuli

he client is a 73-year-old male with history of left sided stroke. Right side has increasing weakness and a decrease in range of motion (ROM). Lives in an assisted living facility. Has minimal confusion and is able to answer simple questions.

Wrist (Able to bend wrist back toward forearm): Flexion

Shoulder (Unable to move the arm away from the body): Abduction

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The left iris is "notched" and the pupil size changes minimally

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

Drenching night sweats

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

What does, "The early bird catches the worm" mean?

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

-Muscle tone

-Romberg's test

-Level of consciousness

-Pupil size

-Cranial nerves

-Glasgow coma scale

When assessing an older adult client, which finding is most indicative of dehydration?

Tenting noted in subclavicular area

While completing an admission assessment for a client with fatigue, weakness, and unexplained weight loss, the nurse notes scleral jaundice. Which finding during percussion of the abdomen should the nurse document indicating hepatomegaly?

Dull sound that extends downward below liver

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

The client is too obese

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Repeat vocalizing the letter "E" while the thorax is auscultated

A 16-year-old client with a history of chronic ear infections when younger comes to the clinic for a health exam. No ear pain, vertigo or hearing loss is reported during history taking. Inspection of the tympanic membranes (TM) reveals the presence of dense white patches on the TMs in both ears. Both TMs are a translucent gray with a light reflex at 5:00. All landmarks are visible. Based on these findings, which action should the nurse take next?

Record the findings in the clients record

When assessing an older adult client, which finding is most indicative of dehydration?

Tenting noted in subclavicular area

When assessing the left foot planter reflex of an adult client, the nurse observes an extension of the great toe and fanning of other toes. Which interpretation of this finding is accurate?

Pyramidal Tract Disease (Neurological conditions like stroke or MS)

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible findings? Select all that apply.

-Contracture

-Atrophy

-Kyphosis

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?

An expected vacation (Normal for older adults)

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

Periumbilical pain localizing to right lower quadrent

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

"I sleep on three pillows at night"

While obtaining the health history of a client, the nurse learns the client's father was diagnosed with schizophrenia in his twenties, the same age the client is now. The client hesitates to discuss the topic and answer questions about the father. Which approach is best for the nurse to use to interview the client about mental health concerns?

Begin with questions that are less sensitive in nature

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care?

Reference Range:

Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]

Imbalanced nutrition, less than body requirement's

While auscultating for bowel sounds in an adult client, the nurse notes a series of gurgles that last about 3 seconds and occur every 5 to 10 seconds in all quadrants. How should the nurse document this finding?

Normal bowel sounds

Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Rheumatoid Arthritis:

-Small joints of the hand

-Fatigue and fever

-Joint swelling

-Symmetrical involvement

N/A (Typically osteoarthritis):

-Morning stiffness that quickly resolves

-Herbeden nodes

-Pain increases with motion

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

Right breath sounds louder than left

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

Palpate the clients dorsalis pedis pulses

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Collect a urine sample and strain for granules or calculi

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Determine if the client has a history of heart disease

A client arriving to the emergency department reports trouble breathing and tightness in the chest that started while exercising at the gym. The nurse observes the client is afebrile, heart rate 96 beats/minute, respirations 32 breaths/minute, and pulse oximeter reading of 85%. Audible wheezing is heard on expiration with a decrease in tactile fremitus and bilateral breath sounds. The client displays intercostal retracting and prolonged expirations. Based on the findings, the nurse should recognize the client is exhibiting symptoms of which condition?

Asthma

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

Degenerative disease

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Petechiae

Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

-Wet the chest hair before auscultating

-Keep the examination room warm, and warm the stethoscope

-Reach under a gown to listen and take care that no clothing rubs on the stethoscope

-Ensure the room is as quiet as possible

An older adult client comes to the healthcare provider's office for a routine follow up exam for high blood pressure, osteoarthritis, constipation, and chronic sinusitis. The client recently had a cataract removed from the left eye. Which is most important for the nurse to address when obtaining this client's health history?

Conduct an assessment of functional capacity and environmental hazards

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Hearing loss

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines a client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Non-painful enlarged interphalangeal joints

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Assess the clients ability to read a Snellen chart from a distance of 20 feet

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Oxygen saturation of 85%

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Observe the specific location and appearance of the ulceration

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Collect information about the clients activities since surgery

A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is reporting pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?

Inspect legs for infection or trauma

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

Hyperactive response consistent with an upper motor neuron disorder

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

Numeric pain intensity scale

The nurse is assessing a female client who states that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the nurse implement to complete a focused assessment?

Position client in left lateral position to inspect perianal area for fissures or sacs

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

Complete a mental status exam

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Firm mass palpated at bottom of left rib cage

The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

Oriented x 2

The nurse examines a client admitted with a deep, constant pain in the abdomen that radiates to the back. Which finding is most important for the nurse to report to the healthcare provider?

An audible abdominal bruit

While assessing a client, the nurse observes that the client has a frequent productive cough. What follow-up assessment should the nurse evaluate first?

Sputum Characteristics

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

Large, flat, dark red irregular area on the neck

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Inspection

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

-Dyspnea

-Peripheral edema

-Jugular venous distention

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Position the client in high Fowler's position

While performing a health history the nurse asks the client, "You don't use recreational drugs, do you?" This approach is most likely to elicit which response from the client?

"No, of course not"

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Perform a hearing test

The nurse asks a 50-year-old female client what her natural hair color is. The client replies, "I've been dyeing my hair for so long, I'm not even sure... I just know that this month it's ravishing red." Based on this information, the nurse expects to obtain which finding when palpating this client's scalp hair?

Coarse, dry, brittle texture

The nurse is assessing older clients in a community health clinic. Which assessment finding is an indicator for immediate medical follow-up?

A change in awareness of surroundings

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

Pain in the neck, jaw, or medial side of the left arm

A client who recently underwent a routine surgical procedure made a dinic appointment. To elicit the most information, which question is best for the nurse to ask this client?

"What brought you to the clinic?"

The nurse is assessing a client with type 2 diabetes mellitus and observes an abnormal response when using a monofilament. Which finding should the nurse document that is consistent with an abnormal finding?

Loss of peripheral sensation

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

Extend arms up to 180 degrees beside the ears

During a routine health screening of an adult female, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

Decreased Height

The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

Loud at the apex, associated with a palpable thrill

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

"Should someone who lives in a glass house throw stones?"

The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

Condition of hair, nails, and skin

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

Nodes are non-palpable

When inspecting a client's skin, the nurse observes an area of erythema on the arm. Which follow- up assessment should the nurse complete?

Palpate the area for warmth and swelling

During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Ask about pain while bearing weight

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?

Usual bed time and time of awakenings

While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

Administer a respiratory aerosol treatment

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

An ulceration under the tongue that has been present for the last three weeks

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Document the presence of nailed clubbing

The nurse is assessing a client for goiter and is unable to observe the thyroid gland. Which action should the nurse take?

Ask the client to swallow while palpating along the sides of the trachea

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client reports that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

A weak urinary stream

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Gas

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Observe for eye opening to painful stimulus

To confirm the presence of steatorrhea, which action should the nurse take?

Observe the appearance of the clients stool

During a routine physical examination of a middle-aged female client, chest palpation is determined to be normal except for a 2 inch diameter area of crepitus over the upper right anterior chest. Which is the most accurate interpretation of this finding?

Crepitus is always abnormal and should be followed-up with a more detailed assessment

During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client's body mass index (BMI) as 16 kg/m2 (normal 18.0 to 24.9 kg/m2). Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition?

Trains for competition and runs 12 miles every day

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

Urine dipstick test

A client is concerned about developing carpal tunnel syndrome. Which screening technique should the nurse perform to provide the client with useful information?

Instruct the client to place the backs of the hands together and flex both wrists