Chapter 27: Health Assessment PrepU questions

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation?

"How are you feeling?"

"Do you know what day this is?"

"Can you tell me where you are right now?"

"Have you been more confused?"

"Can you tell me where you are right now?" is the right answer.

Explanation : Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 816.

A client has been reporting persistent headaches. Which is an example of subjective data?

Temperature is 104.1°F (40.1°C)

The client us slow to respond to questions

Pain is 4 out of 10 on a pain scale.

The client is oriented to person, place, and time.

Pain is 4 out of 10 on a pain scale. is the right answer

Explanation: Communicating the client's pain level is only something the client can state and validate. Subjective data are those symptoms, feelings, perception, preferences, values, and information that only the client can describe. The rest of the options can be directly observed or measured and are known as objective data.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, INTRODUCTION, p. 774.

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?

Warm the equipment.

Ask the client to empty her bladder.

Place the client in a semi-Fowler's position.

Measure height and weight.

Ask the client to empty her bladder is the right answer

Before palpating or percussing the abdomen, 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.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 808.

Which statement made by the client, regarding flat patches of brown skin on the face, demonstrates understanding?

A. "All of these spots are called seborrheic keratoses and they should be taken off."

B. "I know these spots are called senile lentigines and they are likely cancer."

C. "Older people often have splotchy skin due to seborrheic keratoses."

D. "These brown spots are senile lentigines and are common when you get older."

B is the correct answer.

Explanation: Benign skin lesions such as seborrheic keratoses (tan to black raised areas) and senile lentigines (brown, flat patches on the face, hands, and forearms) are common in older adults. Older people may have splotchy skin, but it is not attributed to seborrheic keratosis, as these spots are raised in appearance. The spots are not likely cancer and do not need to be removed.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 792.

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 compare this pain with the most severe pain he's ever experienced.

Rate the client's pain on a scale of 0 to 10, with 10 being the most severe.

Ask the client if there was ever a time during those 3 days when he did not have pain.

Ask the client to tell her more about the pain.

Ask the client to tell her more about the pain is the correct answer.

The nurse should ask the client to tell her more about the pain because an open-ended question would elicit more assessment information about the nature of the pain than a question that calls for a yes or no answer. Asking the client to compare this current pain to past experiences with pain or rating the client's pain level using a pain scale is useful only in determining the intensity of the pain—not the cause of the epigastric pain.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Focused Assessment Guide 27-1, p. 780.

The nurse is assessing the thyroid gland of a client. What action will the nurse perform?

Inspect closely for asymmetry or enlargement.

Ask the client to slightly lower the head.

Auscultate while having the client briefly hold their breath.

Palpate while the client swallows some water.

Inspect closely for asymmetry or enlargement is the correct answer.

Why? The nurse will assess the thyroid gland with the neck slightly hyperextended, not with the head lowered. The nurse will observe/inspect for asymmetry and visible masses. Asking the client to swallow can assist with inspection, but this is not done during palpation. Thyroid assessment does not involve auscultation.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 797.

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply.

Irregular edges

Larger than 1/4 inch in diameter

Change in the mole

Why? The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 790.

The nurse is assessing a 4-year-old child who has multiple bee stings. Which assessment finding requires immediate action by the nurse?

erythema at sting site

heart rate of 100 beats/min

wheezing on auscultation

crying with burning pain

wheezing on auscultation is the correct answer

Why? Wheezing is an abnormal breath sound that is commonly seen with allergic reactions. Signs of allergic reaction (anaphylaxis) to bee stings are potentially life-threatening and require immediate treatment. Erythema, or redness of the skin, is expected at the sting site. A preschool-aged child has a higher pulse rate (ranging from 80 to 120 beats/min) than an adult. Heart rate also increases when a child is crying. Burning pain is expected after multiple bee stings.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Conducting a Physical Assessment, p. 801.

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?

Ongoing assessment

Comprehensive assessment

Emergency assessment

Focused assessment

Comprehensive assessment is the correct answer

A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations.

Reference:

Taylor, C., Lynn, P., & Bartlett, J. L., Fundamentals of Nursing: The Art and Science of Patient-Centered Care, 10th ed., Philadelphia, Wolters Kluwer, 2023, Chapter 27: Health Assessment, Lifespan Considerations, p. 777.

A 57-year-old client is admitted to the medical unit with a 3-day history of sharp, non-radiating epigastric pain and vomiting. The client denies seeing blood in the stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

auscultation

percussion

palpation

inspection

palpation

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

ectropion.

entropion.

ptosis.

miosis.

While assessing a 58-year-old client's near vision, the nurse can anticipate the client will state that their vision is:

clear.

blurred.

clouded.

20/20.

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?

Suspect an inflamed pleura rubbing against the chest wall.

Assess for asthma.

Document normal breath sounds.

Recommend testing for pneumonia.

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take?

Request a prostate-specific antigen diagnostic blood test.

Ask the client about any unusual genital observations.

Call the health care provider and request diagnostic testing.

Insert an indwelling urinary catheter to ensure urine flow.

The nurse is asking admission interview questions and the client has explained the reason for seeking care. What is the most appropriate way to document the response?

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

Client reports breathlessness and productive cough.

Client describes shortness of breath and increased sputum production.

Client reports respiratory distress and frequent spitting.

The nurse is assessing a newly admitted client. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. How does the nurse document this finding?

crackles

sibilant wheeze

friction rub

sonorous wheeze

A client has just been admitted to the postanesthesia care unit (PACU) after having a procedure to have a neuroma removed from the left leg. Which assessment should receive the highest priority?

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"?

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

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?

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which is the appropriate action of the nurse?

The nurse should use the bell of the stethoscope during auscultation of:

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?

Cranial nerve function is important for normal sensory functioning. Which cranial nerve is important for the sense of smell?

A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response?

A nurse has explained her intention to conduct a Weber test and a Rinne test. Which pieces of equipment will the nurse require?

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 concern for care planning?

The nurse is assessing a client's thorax and lungs. Which finding indicates the need for further assessment?

A nurse is assessing the cranial nerves of a client who is recovering from Bell palsy. Which cranial nerves are important for the coordination of facial movement and reflex activity? Select all that apply.

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 the cooperation of 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?

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which sequence represents this order?

The nurse has entered the client's room to ask questions and complete the nursing admission database. The client is wearing a hearing aid in the left ear. Noise is emanating from the television set. What action will the nurse take to facilitate obtaining the history?

The nurse needs to obtain an admission weight for a client diagnosed with end-stage lung cancer. To obtain the client's weight, what should the nurse do first?

A community nurse is participating in a health promotion fair and has been asked by 47-year-old female client about recommendations for breast cancer screening. The nurse determines the client is at average risk for developing breast cancer. How will the nurse respond to the client's inquiry?

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?

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.

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 gerontologic nurse is inspecting the genitalia of an older adult male client. Which assessment findings are of the most concern? Select all that apply.

The nurse is preparing to perform an examination of the abdomen of a 23-year-old client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client?

The nurse is preparing a client for an emergency exploratory laparoscopy. Before the procedure, it is most important for the nurse to take which action?

The nurse is completing the admission assessment on a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most significant?

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?

The nurse is caring for a client admitted with a head injury. Which question should the nurse ask to determine the client's remote memory?

Upon admission to the hospital, the client states, "I am having surgery to correct my back. I have pain in the lower back and the doctor is going to do a lumbar laminectomy." This statement reflects the client's:

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?

The nurse is palpating a client's precordium. Which result is an expected clinical finding?

A client states during the interview that they have pain in their lower back. The client rates the pain as 10/10 when asked to turn. What action by the nurse is appropriate?

A nurse assesses a postoperative client's level of consciousness and documents the following: the client's eyes open spontaneously; the client accurately responds to instructions, converses, and is oriented to time, place, and person. What score would this client receive on the Glasgow Coma Scale?

The nurse conducts a physical examination of a client who reports moderate to severe abdominal pain. Which data should the nurse collect during the objective assessment?

Which respiratory sound indicates an upper airway obstruction?

The client, who is 8 weeks' pregnant from being a victim of sexual violence, tells the nurse, "I do not want to have this infant, but I have always believed that abortion is a sin. I do not know what to do." What nursing concern would be most appropriate for the nurse to formulate?

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing concern is most appropriate for the nurse to select?

A. ready to learn about childhood immunizations

B. ineffective health maintenance associated with lack of knowledge of childhood immunizations

C. infection transmission risk associated with lack of immunizations

D. complication risk associated with childhood illnesses

While caring for a client admitted with a Clostridioides difficile infection, the nurse notes that the client has had 3 loose bowel movements in 3 hours. What would be the most appropriate nursing concern to plan care for this health problem?