health assessment study guide 1

After performing initial abdominal assessment on a client w/ nausea & vomiting, the nurse would expect what finding?

A. Waves of loud gurgles auscultated in all four quadrants

B. Low-pitched swishing auscultated in one or two quadrants

C. Relatively high-pitched clicks or gurgles auscultated in all four quadrants

D. Very high-pitched, loud rushes auscultated especially in one or two quadrants

A. Waves of loud gurgles auscultated in all 4 quadrants

A client with pneumonia is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history?

A. Focus only on the physical examination

B. Obtain all information from family members

C. Plan short sessions with the client to obtain data.

D.Use the primary health care provider's medical history.

C. Plan short sessions with the client to obtain data.

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse would instruct the client that while examining the left breast she would place a pillow under which area?

A. Left Shoulder

B. Right Scapula

C. Right shoulder

D. Small of the back

A. Left shoulder

Problem based assessment

involves a history and physical examination that is limited to a specific problem or client complaint and is most often used in a walk-in clinic or emergency department

Screening assessment

limited examination focused on disease detection

Complete Assessment

includes a complete health history and physical examination and forms a baseline database.It is performed on admission to a primary care or long-term care setting.

An episodic or follow-up assessment

done when a client is being followed up for a previously identified or treated problem.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

A. Poor Hygiene

B. Difficulty Walking

C. Fear of parents

D. Bald Spots on the scalp

B. Difficult walking

What position would the nurse place the client for the abdominal examination?

A. Left lateral position

B. Supine with the head and feet flat

C. Supine with the head raised slightly and the knees slightly flexed

D. Semi-Fowler's position with the head raised 45 degrees and the knees flat

C. Supine with the head raised slightly and the knees slightly flexed

pleural friction rub

It is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle

Wheezes

are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages.

high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway

Rhonchi

usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages.

Crackles

heard when a few strands of hair are rubbed together and indicating fluid in the alveoli or sudden opening of collapsed airways.

The nurse has obtained a personal and family history from a client with a neurological disorder. Which factors in the client's history are associated with added risk for neurological problems? Select all that apply.

A. Allergy to pollen

B. History of headaches

C. Previous back injury

D. History of hypertension

E. History of Diabetes Mellitus

B. History of headaches

C. Previous back injury

D. History of hypertension

E. History of Diabetes Mellitus

Client with hyperacusis, which would the nurse expect to note on assessment of the client?

A. Complaints of ringing in the ear

B. An excessive amount of cerumen in the ear canal

C. Intolerance for sound levels that do not bother other people
D. Complaints of dizziness and sensations of being "off balance"

C. Intolerance for sound levels that do not bother other people

Tinnitus

Ringing in the ear

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

A. The client's ability to ambulate

B. The intactness of the tympanic membrane

C. The intactness of the retinal structure of the eye

D. The functional status of the vestibular apparatus in the inner ear

D. The functional status of the vestibular apparatus in the inner ear

Romberg Test

assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.

A. Sclerae

B. Tongue

C. Nail Beds

D. Elbow and Heels

E. Mucous Membranes

B. Tongue

C. Nail Beds

E. Mucous Membranes

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?

A. Sclerae

B. Oral Mucosa

C. Sole of the foot

D. Palm of the hand

B. Oral Mucosa

In a dark-skinned client, petechiae are best observed in the…

Conjunctivae and oral mucosa

In a dark-skinned client, jaundice are best observed in the…

sclera of the eye

In a dark-skinned client, cyanosis are best observed in the…

palms of the hands and soles of the feet

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema?

A. Assess for drainage from the wound

B. Assess for redness around the wound edges.

C. Palpate for swelling around the wound edges.

D. Palpate for increased skin temperature around the wound edges

D. Palpate for increased skin temperature around the wound edges

Erythema

is a form of macula characterized by diffuse redness of the skin

A chest x-ray report states that the client has a left apical pneumothorax. The nurse caring for the client monitors the status of breath sounds in that area by placing the stethoscope at which location?

A. Near the lateral 12th rib

B. Just under the left clavicle

C. In the fifth intercostal space

D. Posteriorly under the left scapula

B. Just under the left clavicle

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S₁) the loudest?

A. Over the second intercostal space at the left sternal border

B. Over the fourth intercostal space at the right sternal border

C. Over the second intercostal space at the right sternal border

D. Over the fifth intercostal space in the left midclavicular line

D. Over the fifth intercostal space in the left midclavicular line

The weber test

• valuable assessment test when a client reports hearing that is better with one ear than the other.

• a vibrating tuning fork is placed on the client's head over the midline of the client's skull.

• should sound equally in both ears

The nurse is making an initial home visit to a client who was recently discharged from the hospital after treatment for a myocardial infarction. The nurse would use which type of database initially to obtain information from the client?

A. An episodic database

B. A follow-up database

C. An emergency database

D. A complete health database

D. A complete health database

complete health database

the framework for a complete health history and full physical examination.

episodic database

used for a limited or short-term problem. It focuses mainly on one problem or one body system

follow-up database

evaluates an identified problem at regular and appropriate intervals

emergency database

used for rapid collection of the data, often compiled concurrently with lifesaving measures.

The nurse is preparing to check the breath sounds of a client. When auscultating for bronchovesicular breath sounds, the nurse would place the stethoscope over which area?

A. The major bronchi

B. The trachea and larynx

C. The peripheral lung fields

D. The lower posterior thorax

A. The major bronchi

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

A. Presence of fasciculations

B. Muscle strength graded 5/5

C. Symmetrical movements bilaterally

D. Increased muscle size on the dominant arm

E. A 1-cm hypertrophy of the right upper arm

B. Muscle strength graded 5/5

C. Symmetrical movements bilaterally

D. Increased muscle size on the dominant arm

E. A 1-cm hypertrophy of the right upper arm

The nurse is performing an abdominal assessment on a client. The nurse determines that which finding needs to be reported to the primary health care provider (PHCP)?

A. Absence of a bruit

B. Concave, midline umbilicus

C. Pulsation between the umbilicus and the pubis

D. Bowel sound frequency of 15 sounds per minute

C. Pulsation between the umbilicus and the pubis

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds would the nurse expect to hear when performing a respiratory assessment on this client?

A. Stridor

B. Crackles

C. Wheezes

D. Diminished

C. Wheezes

Stridor

a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency.

Crackles

produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways.

Diminished lung sounds

are heard over lung tissue where poor oxygen exchange is occurring.

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

A. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet.

B. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

D.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The nurse is testing a client for graphesthesia and asks the client to close the eyes. The nurse would next ask the client to take which action?

A. Identify three objects placed in the hand, one at a time.

B. Identify three numbers or letters traced in the client's palm.

C. Identify the smallest distance between two skin pricks after pricking the skin with two pins at varying distances.

D. State whether one or two skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.

B. Identify three numbers or letters traced in the client's palm.

A clinic nurse is preparing to evaluate the peripheral vision of a client by the confrontational method. Which method describes the accurate procedure to perform this test?

A. The client is asked to discriminate numbers from a chart composed of colored dots

B. The room is darkened, and the client is asked to identify colored blocks and shapes when they appear in the visual field.

C. The examiner and client cover their right eyes and stare at each other's left eyes, and a small object is brought into the visual field.

D. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field

D. The examiner and client cover the eyes directly opposite to one another and stare at each other's uncovered eye, and a small object is brought into the visual field

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

A. Tapping the Achilles tendon using the reflex hammer

B. Gently pricking the client's skin on the dorsum of the foot in two places

C. Firmly stroking the lateral sole of the foot and under the toes with a blunt instrument

D. Holding the sides of the client's great toe and, while moving it, asking what position it is in

D. Holding the sides of the client's great toe and, while moving it, asking what position it is in

Proprioception testing method

is an assessment technique where the nurse holds the sides of the client's great toe and moves it while asking the client to identify its position.

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive?

A. Absent bowel sounds

B. Client complaints of wound pain

C. Pain with dorsiflexion of the foot

D. Crackles on auscultation of the lungs

C. Pain with dorsiflexion of the foot ( assessing pain in the calf area)

The nurse is testing a client for astereognosis. The nurse would ask the client to close the eyes and perform which action?

A. Identify an object placed in the client's hand.

B. Identify three numbers or letters traced in the client's palm

C. State whether one or two pinpricks are felt when the skin is pricked bilaterally in the same place.

D.Identify the smallest distance between two detectable pinpricks, made with two pins held at various distances.

A. Identify an object placed in the client's hand.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A. A defect in the cochlea

B. A defect in cranial nerve VIII

C. A physical obstruction to the transmission of sound waves

D. A defect in the sensory fibers that lead to the cerebral cortex

C. A physical obstruction to the transmission of sound waves

A client is diagnosed with external otitis. Which finding would the nurse expect to note on assessment of the client?

A. A wider-than-normal ear canal

B. A pearly gray tympanic membrane

C. Redness and swelling in the ear canal

D. An excessive amount of cerumen lodged in the ear canal

C. Redness and swelling in the ear canal

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse would expect to note which finding?
A. Rhythmic respirations with periods of apnea

B. Regular rapid and deep, sustained respirations

C. Totally irregular respiration in rhythm and depth

D. Irregular respirations with pauses at the end of inspiration and expiration

A. Rhythmic respirations with periods of apnea

Cheyne-Stroke Respirations

are rhythmic respirations with periods of apnea and can indicate a metabolic dysfunction in the cerebral hemisphere or basal ganglia.

Neurogenic Hyperventilation

is a regular rapid and deep, sustained respiration that can indicate a dysfunction in the low midbrain and middle pons

Ataxic Respirations

totally irregular in rhythm and depth and indicate a dysfunction in the medulla.

Apneustic Respirations

are irregular respirations with pauses at the end of inspiration and expiration and can indicate a dysfunction in the middle or caudal pons.

The nurse would perform which action to assess for a pulse deficit?

A. Count the carotid pulsations for 1 full minute.

B. Measure the blood pressure in both the arm and leg.

C. Auscultate the apical heartbeat while palpating the radial artery.

D. lace the diaphragm of the stethoscope directly over the skin at the mitral area.

C. Auscultate the apical heartbeat while palpating the radial artery.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

A. Lub-dub sounds

B. Scratchy, leathery heart noise

C. A blowing or swooshing noise

D. Abrupt, high-pitched snapping noise

C. A blowing or swooshing noise